<b>Do Your Knees Knock?</b>

<span style="font-weight: 400;">Only during Halloween? Haha no I mean during exercise or your chosen sport…</span>

<span style="font-weight: 400;">Something prevalent in observing our client’s knees during movement is knock knees, otherwise known as knee valgus.</span>

<span style="font-weight: 400;">Now while looking at the mechanics of the knee, during gait for example, what we see in simple terms is knee flexion and extension, but it is a bit more complex than that.</span>

<span style="font-weight: 400;">For the purposes of this article I am going to keep it simple but, if looking at what happens intrinsically during knee flexion and extension does excite you as much as it does me, and you want to find out more, just leave your email below and I can get in touch about our knee &amp; foot biomechanics workshop.</span>

<b><span style="color: #008080;">Ligament Dominance</span></b>

<span style="font-weight: 400;">Now if we are truly following The Integrated System idea that people have talked about for years (but often still don’t </span><i><span style="font-weight: 400;">really</span></i><span style="font-weight: 400;"> practice), it goes without saying, there are likely to be both ascending and descending biomechanical influences upon human movement.</span>

<span style="font-weight: 400;">Last week we discussed just one of the possible ascending biomechanical issues in the blog </span><b><i>‘Over Pronation or Late Supination’</i></b><span style="font-weight: 400;"> that may affect your client's movement, but this week we will be discussing a potential descending influencer.</span>
<h3>The Problem</h3>
<span style="color: #008080;"><b>Ligament Dominance</b></span>

<span style="font-weight: 400;">Ligament</span> <span style="font-weight: 400;">dominance occurs when your client allows the knee ligaments, rather than the extremity musculature, to absorb a significant portion of the ground reaction force, during their chosen activity or an exercise you have given them. (</span><i><span style="font-weight: 400;">Hewitt TE, Paterno MV, Myer GD. Strategies for enhancing proprioception and neuromuscular control of the knee. Clin Orthop 2002</span></i><span style="font-weight: 400;">).</span>

<span style="font-weight: 400;">Typically during single-leg landing, pivoting or declaration (all common Anterior Cruciate Ligament (ACL) injury mechanisms), your client may allow the ground reaction force to control the direction of motion of the lower extremity joints. This motion is especially evident at the knee; which is not only influenced by direct external moments (the floor), but also by the ankle and hip internal moments. (</span><i><span style="font-weight: 400;">Winter DA, Biomechanics and Motor Control of Human Movement 2</span></i><i><span style="font-weight: 400;">nd</span></i><i><span style="font-weight: 400;"> Ed. New York, NY: John Wiley and Sons; 1990). </span></i><span style="font-weight: 400;">In these instances the neuromuscular and ligamentous control of the joint is unbalanced</span><i><span style="font-weight: 400;">, (Hewett TE, Myer GD, Ford KR, et al</span></i><span style="font-weight: 400;">).</span>
<h3>So What?</h3>
<span style="font-weight: 400;">Measurement of neuromuscular imbalances allows individuals who are at potential risk of ACL injury to be identified. A client may display techniques that place them at an increased risk because of one or more imbalances. During single-leg landing, pivoting or deceleration, the motion of a </span><i><span style="font-weight: 400;">ligament dominant knee</span></i><span style="font-weight: 400;"> in a client may be directed by the external ground reaction forces, rather than by their musculature.</span>

<span style="color: #008080;"><strong>A Runner</strong></span>

<span style="font-weight: 400;">For example the client who wants to train with you to prepare for a race will ultimately need to practice running, of course. However it would be prudent to identify if they have any knee stability issues while running, because if they do, they may require bespoke strength work to reduce their risk of injury. As we know, the impact and repetitive nature of this kind of activity, has a high instance of ‘overuse’ symptoms. This force of landing transfers up *The Integrated System, through the pelvis and spine, at which point there is a rotational force too. If the ligaments are dominate in taking the impact, rather than the lateral hip muscles, this ‘shock’ can stress not only the knee, but also the body higher up.</span>

<span style="font-weight: 400;">So if we can assess, monitor, exercise, re-assess and create more stability with smart individualised programming, your client will be a more efficient runner, with a reduced risk of hurting their knee.</span>

<span style="font-weight: 400;">*See more detail below about further considerations </span>
<h3>How To Identify If Your Client Is Ligament Dominant</h3>
<span style="font-weight: 400;">The evaluation of a client’s level of </span><i><span style="font-weight: 400;">ligament dominance</span></i><span style="font-weight: 400;"> can be accomplished using a 31cm box-drop test combined with a maximum effort vertical leap. (</span><i><span style="font-weight: 400;">Ford KR, Myer GD, Hewett TE. Valgus knee motion during landing in high school female and male basketball players. Med Sci Sports Exerc. 2003</span></i><span style="font-weight: 400;">).</span>

<img class="aligncenter size-full wp-image-1802" src="https://www.biomechanicseducation.com/wp-content/uploads/2017/05/Screen-Shot-2017-04-25-at-07.39.55.png" alt="" width="612" height="318" />

<span style="font-weight: 400;">When dropping from a box, a </span><i><span style="font-weight: 400;">ligament dominant</span></i><span style="font-weight: 400;"> client displays substantial medial knee motion in the transverse plane which is visually identified upon the point of the foot contacting the floor. </span>

<span style="font-weight: 400;">Medial knee motion may be related to an overall dynamic knee valgus ie; femoral adduction, femoral internal rotation in relation to the hip, tibial external rotation in relation to the femur with or without foot pronation.</span>

<span style="font-weight: 400;">Movement patterns that place your client in positions of high ACL load (excessive external knee abduction moments), combined with a low knee flexion angle, may well increase the risk for ligament injury or failure (</span><i><span style="font-weight: 400;">Lloyd DG</span></i><span style="font-weight: 400;">).</span>
<h3>Now It’s Your Turn</h3>
<span style="font-weight: 400;">So using your slow motion setting on your phone or camera, squat down in front of your client and ask them to let one leg hang off the box. Then ask them to drop onto the hanging leg allowing the knee to flex to 30 degrees upon landing. Now watch back the slow mo and notice the exact point the foot comes into contact with the floor and notice what action occurs at the knee. </span>

<strong><span style="color: #008080;">You can see an example of the drop box test in action here:</span></strong>

<iframe src="https://www.youtube.com/embed/1dZ_Ta3S00U" width="560" height="315" frameborder="0" allowfullscreen="allowfullscreen"></iframe>

<span style="color: #008080;"><b>Ask yourself;</b></span>

<span style="font-weight: 400;">Does the knee ‘flick’ inwards?</span>

<span style="font-weight: 400;">Does the knee land medially?</span>

<span style="font-weight: 400;">If you answer yes to one of these then the test is positive and this would indicate an unstable knee which increases their risk of injury. Always reassure your client this is quite common and more often than not, a simple bespoke exercise programme will address it.</span>
<h3>The Solution</h3>
<span style="font-weight: 400;">If we consider that the ligaments are taking the force, then the muscles that would limit this knee valgus would logically produce the opposite movement.</span>

<span style="font-weight: 400;">What is knee valgus in terms of </span><i><span style="font-weight: 400;">movement?</span></i>

<span style="font-weight: 400;">Well if the knee is dropping inwards in terms of </span><i><span style="font-weight: 400;">analysing the movement</span></i><span style="font-weight: 400;"> this would be hip adduction and internal rotation of the hip. This movement comes from the pelvis of course but what this means is there are simple ways of strengthening the hip that will contribute to a more stable knee upon landing and taking load.</span>

<span style="font-weight: 400;">The opposing movements to hip adduction and hip internal rotation would be hip abduction and hip external rotation.</span>

<span style="font-weight: 400;">So any strengthening exercises for these 2 movements individually or combined would likely contribute to improving ligament dominance and therefore create a more stable load through the knee.</span>

<img class="aligncenter size-large wp-image-1804" src="https://www.biomechanicseducation.com/wp-content/uploads/2017/05/Screen-Shot-2017-05-01-at-20.58.33-1024x416.png" alt="" width="840" height="341" />

<span style="font-weight: 400;">This is just one of the knee assessments we teach during the </span><b>Knee and Foot Biomechanics workshop</b><span style="font-weight: 400;"> and we should always take into account The Integrated System when it comes to assessment and exercise prescription for true long term objectivity in improving human movement.</span>

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<p style="text-align: center;"><b>If you are interested in learning more about this 2-day workshop; fill in your details below and we’ll get in touch to tell you more.</b></p>
<img class="aligncenter wp-image-1801" src="https://www.biomechanicseducation.com/wp-content/uploads/2017/05/Screen-Shot-2017-05-01-at-20.49.59-1024x508.png" alt="" width="600" height="298" />

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<b>Other References</b>