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Feldenkrais Method

Knee Dysfunctions

Anatomy Overview, Degenerative Joint Disease, Patellofemoral Injuries/Chondromalasia, Meniscal Wear and Tears

Anatomy Overview

The knee joint is a fairly complex joint. The primary movement seen is bending and straightening. In order to bend, the lower leg bone (tibia) must glide around the rounded end of the thighbone (femur). The bottom of the tibia is covered in hard cartilage (See ill. 5) Two cartilaginous discs (menisci), act as shock absorbers as well as friction-reducing spacers that allow the end of the thighbone to glide smoothly on the lower leg bone (See ill. 1).

Disc material is tough yet somewhat elastic and is held in place on the tibia by coronary ligaments around the edges (See ill. 2). As the knee is bent and straightened during walking there is a small degree of rotation between these two bones (See clip 1 and 1.5). The discs follow this motion. There are two cruciate ligaments that provide forward/backward stability between the femur and tibia (See ill. 1.5). When standing with the knee straight, the anterior cruciate resists hyperextension (See clip 2). When kneeling the posterior cruciate resists backward sliding of the tibia (See clip 3). Medial (inside) and lateral (outside) ligaments support the knee side to side (See ill. 3 and clip 4).

Degenerative Joint Disease (DJD) is a very common problem in the knee. Normally as the knee is bent and straightened the kneecap should ride smoothly in the center of the groove of the thighbone. (See clip 4.5). When DJD occurs either between the cartilage of the kneecap and the front end of the thigh bone (femur) it is called Patellofemoral Chondromalasia. See site: DJD can also result from the wearing down of the discs (menisci). Of the two discs the medial (inside) one is more susceptible to wear and injury as it is the less mobile of the two and takes more of the pressure. When the discs are worn thin or partially torn, the femoral cartilage moves on top of a non-smooth tibial surface and becomes scratched.

This becomes painful and the condition is called osteoarthritis of the knee. Osteoarthritis is inflammation from mechanical wear of the joint surfaces as opposed to rheumatoid arthritis where bone becomes soft and deformed. See site:

Causes of DJD

Very commonly excess body weight can cause accelerated wear of the knee cartilage. Most doctors advise knee pain sufferers to lose excess weight.

A fall or blow to the knee may injure the cartilage between the kneecap and femur (Patellofemoral injuries).

A sudden forceful start into running especially in the cold can cause the kneecap to jump up and grind on the edge of the groove of the femur causing cartilage injury. I can attest to this. One subzero night, I quickly ran across the street and wow, what a jolt of pain I felt. It took 2 weeks for that moderate pain to subside and several months before it was back to normal. In some cases Patellofemoral injuries can take a year or two to heal completely. Superficial scratches in our cartilage heal themselves all the time. Larger ones can fill in as well, but constant friction can make for slow or poor healing. This is why protection and rest are key elements in the healing of cartilage injury.

Walking, Running and Working in the cold can accelerate knee wear. Synovial fluid is the body's joint lubricant and is found in all true joints. The knees, being bony and prominent, are very exposed in the cold and wind, so it is wise to keep them warm with an extra layer if you run/walk or stand in the cold. Cold joint fluid doesn't lubricate the joint well, just as motor oil doesn't protect an engine until it is warmed up. Synthetic joint fluid, injected into a joint can help reduce the progression of early DJD. (See conservative management)

Constant kneeling on hard surfaces can irritate the infrapatellar bursa causing a condition called "housemaid's knee" (see ill. 4).

This also is hard on the cartilage. My suggestion is to wear pants with soft knee cushions inserted in the front of the legs. These do not cut and restrict circulation like wrap-around or slide-on kneepads. See site for MN DTPro Pants 85322, and 85324 bibs: Also prolonged, fully bent kneeling is just not good for the knee discs because they get overstretched in one direction. In general to reduce knee and back problems it is advisable to vary the tasks for any job, shifting position and activity frequently. Taking the stress off of the knees and resting various muscle groups helps to avoid constant strain on the same tissues.


People with more knocked knees and low arches may have a high "Q-angles". This can make a person more prone to chondromalasia. The Q-angle is made between the lines drawn from the ASIS to the kneecap and from the kneecap to the patella-tibial attachment. (See ill. 5) A large Q-angle causes excess sideways (lateral) pull of the kneecap in the femoral groove, thus causing excessive pressure and wear on those surfaces. When the angle is extremely high the force can cause dislocation of the kneecap. With chondromalasia, a rough sandpaper or loud crunching/cracking noise (crepitus) will be heard/felt in the kneecap while straightening the knee from the bent position.

Typically, having low arches increases the strain on the inside of the knees, causing excess lateral pull and wear on the kneecap. Other chondromalasia sufferers may have an oddly shaped kneecap or inner kneecap surface, causing the kneecap to ride poorly in the groove and ultimately make it more susceptible to dislocation. (See site illustration. Strengthening of the VMO (vastus medialis oblique see ill. 6) portion of the quadriceps muscle is of particular importance for anyone with tracking problems, chondromalasia or patella dislocation/subluxation problems. (See Exercises under General Treatment Strategies.)

Meniscal Tears can occur suddenly with or without traumatic injury. (See site illustration

Non-traumatic tears: For example when walking down a set of stairs there may be knee locking and pain for no apparent reason. An overstretched meniscus may not be well centered and can become trapped, clipped and torn during bending and straightening. Thinning edges of a meniscus may become torn in a similar fashion. Non-traumatic tears of the disc do not cause bleeding but it is not uncommon to see synovial fluid swelling in the joint within a day or two.

Traumatic tears of the meniscus commonly occur during forceful twisting and sideways movement of the knee.

Although the knee and the menisci have some flexibility, once the knee is pushed beyond the limit of the tissue, a meniscus can get caught and torn on the ridge between the two discs. Some torn menisci cause a locking of the knee, although some do not. A springy blocked feeling at the end of knee extension can also accompany the tear. The locking of a torn disc may self-resolve as the disc moves back into place. The McMurray test is a manipulation technique that can diagnose certain types of tears and is considered positive when a characteristic "click" is heard/felt at the end of the test manipulation. Persistent joint line pain is also characteristic of meniscal tears.

Although MRI and x-rays are helpful in diagnosis, the true extent of a suspected meniscal tear is usually determined during Arthroscopic Surgery. (See site illustration:

Surgical repair of the meniscus via suturing or pinning can sometimes be done. Often arthroscopic removal of the damaged part or whole of a disc can provide improvement. The extent of the disc removed often determines the long-term prognosis. Remember, discs are there to provide cushion and friction-free gliding of the surfaces and without that smooth disc more degeneration is likely to occur over time. If swelling, pain and locking subside with rest and protection, surgery is often postponed and the knee monitored.

Some doctors are also using Prolotherapy (proliferative) injections for conservative management of meniscal tears and knee joint hypermobility. This involves multiple injections of an irritant into ligaments that help stimulate the formation of new collagen fiber. The combination of injections and nutritional supplementation helps grow new, stronger connective tissue. A series of injections are generally given about a month apart and may involve 3-6 months of treatment. (See Dr. Hauser's web site:

General Treatment Strategies:

An experienced orthopedic surgeon should assess traumatic injuries of the knee, severe pain or knee problems that are not resolving with conservative management.

Minor Soft Tissue Injuries should be respected and treated with PRAICE: PROTECTION, REST, ANTI-INFLAMMATORIES, ICE, COMPRESSION, ELEVATION

PROTECTION: Protect the knee as long as there is pain or hyper-mobility (excess play in the joint). Wear a support when you feel a definite injury has occurred and you need stability while walking, standing or bending. The maximum support is a knee immobilizer (a cast is really maximum, but I'm not referring to fractures, dislocations, or ruptured muscles/ligaments here,

they usually require casting). (See Products.)

A knee sleeve offers support particularly for minor strains but may not provide enough protection to prevent more moderate re-injury. Sleeves with cutout hole or rubber donuts around the hole are helpful to stabilize the kneecap and keep it tracking properly. A support must not restrict circulation, particularly in the back of the knee. I prefer knee sleeves that have a Velcro wrap-around so the tightness can be adjusted.

Some sleeves have hard plastic stays or metal hinges to help with medial/lateral support. Hinges are more bulky so if you don't need the stability you may not want that type or on some brands they are removable.

See Products under Royce Medical and Saunders, but consult with your therapist or doctor as to which support may be right for you. Custom-made plastic knee supports can be made by an Orthotist in cases of chronic instabilities due to injury, DJD or while an injury is healing.

Taping can be done to temporarily stabilize a joint while it is healing and or being strengthened. Tape helps resist the direction of the injury. For example for a knee cap that tends to sublux to the outside, the tape would be applied and pulled to the inside, resisting the subluxation. A pulled hamstring can be taped in the back of the knee with the knee slightly bent to protect it from full extension.

Taping a plantar fasciitis can also help take the strain off the fascia while it is healing. Taping should only be done by trained professionals and when swelling is minimal. Some people get an allergic reaction to certain tape adhesives, so a layer of under-tape is used by professionals to avoid skin irritation.


Avoid prolonged standing especially with weight on the one knee.

Avoid doing more than necessary stair climbing especially step over step.

Avoid lifting or pushing heavy loads (it goes to the knees).

Defer running, dancing, exercise class and full arc knee bending/extending exercises.

Avoid crossing your knees and or the ankle over opposite knee.

Avoid kneeling or squatting.

Be sure to wear supportive shoes to avoid low arches and medial knee strain.

Rest also means that if the pain is severe you use crutches/walker to reduce the weight bearing on your knee, distributing it to your hands and other knee.

ANTI-INFLAMMATORY MEDICINE, either homeopathic or allopathic should be taken to reduce pain and inflammation. Take the maximum recommended dose and frequency for the most severe injury. Ibuprofen, naproxin (Aleve) and aspirin are all anti-inflammatories, but remember they need to be taken with food, plenty of water and may require checking with your doctor to see if there may be contraindications, particularly if you are on other medications, have stomach problems, or are not to take blood thinning medications. These non-steroidal anti-inflammatory medicines are not meant to taken for more than a month. They may in fact have a destructive effect on cartilage if taken long term. Remember acetaminophen (Tylenol) provides pain-relief and lowers a fever; it doesn't reduce swelling and inflammation.

ICE should be used within the first 24/48 hours and if there is warmth and or swelling. For stationary ice packs, a thin, moist, protective layer against the skin is advisable. This could be a paper towel or bath towel.

Warmth can be used if swelling is gone, 48 hours after pain/strain. (See site for Bed Buddy microwavable moist heat packs)

Thermal therapy may be used for 20 minutes at a time and after that as frequently as every two hours if needed. Alternating heat 10 minutes with cold 10 minutes is also helpful after the first 48 hours has passed.

COMPRESSION: When swelling is present use a 3-4" wide Ace wrap. Apply in a figure eight fashion, starting 6" below the knee and extending to 6" above the knee. Each pass of the bandage should over-lap slightly. The wrap should be less tightly wrapped as it goes upward. This provides a slight upward pressure differential to move swelling upwards.

Remember, do not wrap too tightly, circulation may become compromised. Remove and reapply if any discomfort develops, and look for any swelling below the wrap and or redness of the skin as an indication that the wrap is too tight or wrinkled.

ELEVATION: When swelling is present or when pain is felt while a limb is pendent, elevation is helpful. For legs and feet it is sufficient to have the limb horizontal or slightly higher than horizontal. Because veins in the back of the calf, knee and thigh draw venous blood upwards it is important not to have the leg heavily resting on the calf, back of knee or thigh. This can occur on the leg rests of many recliners.

A soft pillow under the heel/calf and another under the knee/thigh prevent occlusion of these veins. Be careful not to merely jack up the heel on a surface higher than the knee, leaving the knee unsupported because you can cause hyperextension and strain of the back of the knee. Injured limbs can get stiff if left in any one position too long so it is best to vary the position every 30 minutes. For example if you have your knee extended too long it may be hard to bend, if bent too long it may not straighten. You can also vary things by lying on your non-swollen side with a pillow between the legs varying the knee bent or straight.

Kurashova Tissue Re-education Techniques are very effective for 1) reducing any swelling whether it be superficial or deep 2) reducing pain 3) bringing circulation needed for healing 4) normalizing tissue elasticity 4) normalizing knee-cap mobility. It can be started soon after an injury or surgery.


Most knee pain, even when lasting only a week, begins to create disuse atrophy of the quadriceps muscle. Once the quadriceps muscle is weak, patella-tracking problems can develop. It is very important that with any injury (except for quadriceps tear/ruptures repairs, knee cap fractures and post-surgical contraindication by your doctor), the quadriceps muscle strength needs to be maintained, especially the VMO (vastus medialis obliquus). The VMO helps the kneecap ride centered in the groove.

The safest exercises to do for most knee strains are:

Gentle, isometric quadriceps tightening, emphasizing contraction of the VMO, muscle above and inside of the kneecap (see ill. 6)
Straight leg raises (post-surgically you must have your doctor's permission)
If allowed some active movement, small arc (30 degrees) of knee straightening.

Full range quadriceps strengthening (straightening from 90 degrees of bending) should be done only when there is no DJD, when the knee is not painful and when your doctor allows it post-surgically.

Conservative Management Approaches:

Dietary Changes

For anyone experiencing degenerative changes in a joint, I recommend consulting a nutritionist who can make dietary recommendations and provide high quality supplements. Calcium and Magnesium citrates are easily absorbed forms of both calcium and magnesium. Getting 20 minutes of morning or late afternoon sun will also help give you the vitamin D needed to keep bones healthy. In the winter in areas above the 40th latitude the sun does not provide UV, so dietary supplementation may be required.

Glucosamine/Chondroitin/MSM is recommended by many doctors to help reduce inflammation as well as build cartilage. See Dr. Williams for more nutritional approaches to bone and joint health. Email Dr. Williams Whenever a woman 40 or older has degenerative joint problems, having a baseline bone density scan can be helpful in monitoring bone health.


Making sure that you get 8-10 glasses of pure water each day is very important for maintaining healthy cartilage. When the body is well hydrated, the cartilage has a protective layer of moisture that makes it more resistant to wear.

Unfortunately the body can become accustomed to low hydration, so the normal thirst mechanism doesn't alert you like it should.

I have observed that if I am well hydrated and drink 8 ounces of water it goes through me in about an hour or two. Good times to drink water are between meals but no sooner than an hour after eating and 1/2 hour before eating. The lining of your digestive system is also more protected from irritating acids when better hydrated; however, following the above rule prevents over diluting the digestive juices.

Have pain? Check shoes... With any back, hip, knee or foot pain it is important to notice undue wear on the bottom of the shoes. Worn shoes can cause strain up the entire linkage of the lower extremity and back. Inspect and replace worn heels and/or soles. Normal wear is on the outside of the heel and under the fall of the big toe. Replace when this wear is between 1/8 and 1/4 inches.

Arch Supports

If your arches are low, consider getting arch supports not only to support your arches but also to support your knees. Excess flattening of the arches is a common cause of medial knee strain.

It can be tricky to get just the right amount of support using the right materials for your feet but don't give up. Often several adjustments to the orthotics are needed to get you pain-free. (See Arches).

Structural Balance

A person having a "short leg" (whether the leg itself is truly short or whether it is short due to a musculoskeletal imbalance) will stand and walk with excess weight on one leg. This excess weight bearing on one side can cause uneven, excess wear of the hip or knee over time.

A truly short leg is called a "structurally short leg". Common causes are: having a broken or injured leg as a child, childhood growth plate problems, scoliosis, injury or surgery that leaves the hip or knee permanently bent. Sometimes there is no discernable reason.

More commonly people have a "functionally short leg". It can be caused by imbalances either in their skeletal alignment or weakness in ligaments and muscles. Poor standing habits, hyperextension of the knee, a fallen arch, misalignment of the first cervical vertebra, pelvic torsion problems or a sprained sacroiliac joint can all contribute to a functionally short leg. Not only the hip can suffer but knee and foot problems all may also result from imbalanced forces acting down through the weight bearing joints. (See ill. 5)

It is commonly thought that most people have some asymmetry and that a short leg of 1/8 to 1/4 inch is no big deal. If a person is having symptomatic neck, back, hip, knee or foot pain structural alignment needs to be evaluated. If left uncorrected it may cause considerable problems over a lifetime. The Leaning Tower of Pisa may have started out with a small structural fault but over the years the result has become very obvious.

Assessing and Attaining Structural Balance

When I see a patient I evaluate them for structural imbalance. Are the shoulders level? Is the pelvis level? Hips, knees are they level? Is the head to one side? Is there a visible Scoliosis? Is the person standing with one knee slightly bent, the other straight? How high are the arches? When lying down are the leg lengths equal?

If the history indicates any injury-related reason for an asymmetry, then that is treated first. If there is no obvious cause, I begin by teaching a procedure for balancing the pelvis (see On the Level), along with some gentle stretches. I let these work over a period of about month and keep checking the pelvis, re-balancing it again if needed and this is accompanied by work to neck and cranium. Most often the imbalance can be corrected or partially corrected. If some imbalance remains then I refer my clients to a NUCCA practitioner for evaluation of their first cervical vertebra (C1).

I would not have believed it if I had not experienced myself the instant effect of a C1 adjustment. Legs become equal length, the pelvis is level and weight becomes balanced through both legs as soon as the first cervical is put back into correct alignment. Read more about NUCCA at Find a practitioner in your area

Occasionally I do recommend a shoe lift, but only if a person has had a C1 correction and they still show a true shortness in their leg. Then, it is best to start with half the shortness and then increase it incrementally as tolerated.

Synvisc, Artificial Synovial Joint Fluid Injections

Synvisc is an artificial joint lubricant similar to that found in young healthy joints. It has been injected in knees to help reduce pain and friction related arthritis for many years. It may reduce the progression of early DJD.

The Alexander Technique teaches improved overall use of one's self. Greater self-awareness helps a person notice early signs of fatigue and strain before more serious damage occurs. The Alexander Technique addresses and improves standing, walking and running biomechanics, thereby indirectly reducing the strain on the knees.

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MovementWise Christine Inserra P.T.
Certified Teacher of the Alexander Technique & Feldenkrais Method
Physical Therapy serving Chicago and the Greater Chicagoland Area