ARTICLE IN PRESS
Journal of Bodywork and Movement Therapies (2006) 10, 306311
SELF-MANAGEMENT: CLINICIAN SECTION
Functional problems associated with the
kneePart one: Sources of biomechancial
overload$
Craig Liebenson, D.C.
L.A. Sports and Spine,10474 Santa Monica Blvd., #202, Los Angeles, CA 90025, USA
Introduction
Rehabilitation of patients with knee problems
should progress from sparing to stabilizing to
functional integrated training (FIT) approaches.
A few of the most common clinical presentations
seen in practice include patello-femoral tracking
disorders, iliotibial band syndrome, post-operative
functional limitations after anterior cruciate liga-
ment rupture, partially torn medial meniscus, knee
osteoarthritis, and post-operative functional lim-
SELF-MANAGEMENT: CLINICIAN SECTION
itations after knee arthroplasty.
Sparing strategies include avoidance of valgus
overload due to medial collapse of the knee
secondary to subtalar hyperpronation or lack of
frontal plane stability of the hip (Trendelenberg
sign). Stabilizing strategies include training appro-
priate motor control of patello-femoral tracking
ensuring vastus medialis oblique (VMO) activation.
FIT includes upright single leg stance, stepping,
squats and lunges.
Sparing strategies
It has been said the knee has no place to hide.
Functionally its fate is often sealed by the foot or
$ shorter duration of gluteus medius activation in
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1360-8592/$ - see front matter & 2006 Published by Elsevier Ltd.
doi:10.1016/j.jbmt.2006.08.005
Journal of
Bodywork and
Movement Therapies
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hip to which it is linked in the kinetic chain (see
Fig. 1) (Griffin et al., 2000). Knee forces have been
characterized as slaved to the hip (Bobbert and
van Zandwijk, 1999). There are various sources of
biomechanical overload for the knee. One of the
most common is medial collapse of the knee
secondary to either subtalar hyperpronation or
frontal plane hip instability (e.g. Trendelenberg
position of the pelvis) (Hewett et al., 2005b;
McLean et al., 2005) (see Figs. 2 and 3). A key
factor in the lower quarter kinetic chain dysfunc-
tion is gluteus medius weakness (Powers, 2003).
Mascal et al. have demonstrated that a pelvic drop
and excessive knee valgus during a step down task
is indicative of contralateral gluteus medius weak-
ness (Mascal et al., 2003). Ireland (2004) has
showed this weakness is common in patients with
knee pain. Specifically, deficits of 26% in hip
abduction strength and 36% hip external rotation
strength were found. Reducing injury rates thus
relies on detecting and continually evaluating
people with relatively large valgus motions (McLean
et al., 2005).
The female athlete is known to be at greater risk
than the male for season ending knee injury (Nadler
et al., 2000). In particular, females with increased
dynamic valgus loads are at increased risk of ACL
injury (Hewett et al., 2005b). Females have a
stance, load-absorbing, phase during a cutting
manouvre (Kibler, 1999; Zeller et al., 2003).
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Functional problems associated with the knee 307

Figure 1 Knee slaved to hip (a) gluteus medius control

of knee in the frontal plane, (b) gluteus medius
insufficiency resulting in valgosity of the knee.

Figure 3 Trendelenberg sign and valgosity of the knee.

Reprinted from Fig. 4b, p. 250, Liebenson CS. Advice for
the clinician and patient: Functional training part one:
new advances. Journal of Bodywork and Movement
Therapies, 6;4: 2002.

SELF-MANAGEMENT: CLINICIAN SECTION

Figure 2 Subtalar hyperpronation and valgosity of the
knee. Reprinted from Fig. 7, p. 251, Liebenson CS. Advice
for the clinician and patient: functional training part one:
new advances. Journal of Bodywork and Movement
Therapies, 6;4: 2002.

Another source of biomechanical overload is

excessive anterior shear of the knee secondary to
a tight posterior hip capsule (see Fig. 4). Females
have been shown to utilize different muscular
activation patterns compared to males (i.e. de-
creased gluteus maximus and increased rectus
femoris muscle activity) during landing maneuvers
(Zazulak et al., 2005). Decreased hip muscle
activity and increased quadriceps activity were
concluded to be likely contributors to the increased
susceptibility of female athletes to non-contact
anterior crucial ligament (ACL) injuries.
A comparison of male and female healthy
collegiate soccer players demonstrated that fe-
males experience increased frontal plane moments
Figure 4 Patello-femoral anterior shear.
and decreased sagittal plane moments during early
deceleration of side-stepping manouvres (Sigward
and Powers, 2006). This dysfunction in tissue
sparing of the knee was termed an at risk
pattern in that frontal plane support of the knee
was lacking which could lead to overload the
anterior cruciate ligament. It was also noted that
the females exhibited increased quadriceps activity
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308 C. Liebenson

Table 1 Common dysfunctions leading to knee overload.

 Subtalar hyperprontation
 Insufficiency of the transverse arch (positive Veles test)
 Shortened soleus
 Shortened iliotibial band (ITB)
 Hamstring/quadriceps muscle imbalance (e.g. weaker hamstrings)
 Shortened iliopsoas or tight anterior hip capsule
 Shortened thigh adductors
 Shortened piriformis or tight posterior hip capsule
 Inhibited or weak gluteus maximus or medius

Figure 5 Psoas stretch.

SELF-MANAGEMENT: CLINICIAN SECTION

Figure 6 Ilio-tibial band mobilization.

Figure 7 Posterior capsule stretch: (a) supine and (b)

and smaller net flexor moments suggesting less
sagittal plane protection (i.e. increased tendency
towards anterior tibial translation).
Table 1 lists the most common dysfunctions which
may result in knee overload.
Distinguishing between cause and effect is
necessary to make an efficient rehabilitation
prescription. For example, tight hip flexors can
negatively influence the ability of the gluteals to
standing.
work through a full range and spare the knee (see
Fig. 5). Extensor mechanism disorders of the knee
such as quadriceps or patellar tendonitis related to
medial collapse of the knee (i.e. excessive
valgosity) are typically secondary to gluteus
medius insufficiency and iliotibial band tightness
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Functional problems associated with the knee 309

(see Fig. 6). Anterior knee shear when standing up
or sitting down is usually not a simple result of
weak quadriceps, but most likely due to stiffness in
the posterior hip capsule and related weakness of
the gluteus maximus. Thus, the sparing strategy
would be to stretch the stiff posterior hip capsule
and train the patient in how to perform a hip hinge
(see Fig. 7).
Since biomechanical overload of the knee is so
common the question of prevention arises. Children
under 7 years of age have been shown to have a
predisposition to faulty motor controlin particu-
lar, hyperprontationin the foot and angle during
gait (Ganley and Powers, 2005). It is suggested that
prepubertal or early pubertal female athletes
may benefit from biomechanical optimization by
reducing their future lower extremity injury risk
(Hewett et al., 2005a).
Stabilizing strategies
Terminal knee extension exercises (heel raise,
pillow push) have been recommended to train the
vastus medialis oblique (see patient self-help
figures). Heel slides have been recommended to
train hamstring/quadriceps co-activation (see pa-
tient self-help figures). Hamstring exercises (Fig. 8)
and gluteus medius training (Fig. 9) are important
basic training manouvres.
Functional training
Neuromuscular training has been shown to improve
performance and lower-extremity biomechanics
in female athletes (Hewett et al., 2002; Myer
et al., 2005; Paterno et al., 2004) (see Fig. 10).

Figure 8 Hamstring curls with the gym ball: (a, b) beginnerisometric, (c, d) intermediateisotonic curl, (e, f) SELF-MANAGEMENT: CLINICIAN SECTION
advancedisotonic inner-range curl.

Figure 9 (a, b) Clam shell exercise for the gluteus medius.

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310
Figure 10 (a, b) Crab exercisesquat with side steps.
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Figure 11 Functional (balance) reach.
Hewett et al. (1999) has shown in female collegiate
athletes that the introduction of supinatory train-
ing during plyometric squats prospectively reduced
the incidence of injury in the coming season. The
four main components of this training are plyo-
metric and movement, core strengthening and
balance, resistance training, and speed training
(Myer et al., 2005).
C. Liebenson
Gary Gray has pioneered exercises such as
balance reaches incorporating the Star Matrix (see
Fig. 11) (Gray, 2001; Risberg et al., 2001; Lieben-
son, 2002a, b, 2003a, b, 2006a, b; McGill, 2006). By
balancing or supporting on one limb while reaching
at different angles with the other limb tri-planer
movement in the sagittal, frontal, and transverse
planes can be trained. By adding upper quarter
movements to the activity functional activities
involving pushing and pulling such astennis,
baseball, golf, bowling, etc. can be facilitated.
References
Bobbert, M.F., van Zandwijk, J.P., 1999. Dynamics of force and
muscle stimulation in human vertical jumping. Medicine and
Science in Sports and Exercise 31, 303310.
Ganley, K.J., Powers, C.M., 2005. Gait kinematics and kinetics of
7-year-old children: a comparison to adults using age-specific
anthropometric data. Gait & Posture 21 (2), 141145.
Gray, G., 2001. Total Body Functional Profile. Wynn Marketing,
Adrian, MI.
Griffin, L.Y., Agel, J., Alborhm, M.J., Arendet, E.A., Dick, R.W.,
Garrett, W.E., et al., 2000. Non-contact anterior cruciate
ligament injuries: risk factors and prevention strategies.
Journal of the American Academy of Orthopeadic Surgery 8,
141150.
Hewett, T., Lindenfeld, T.N., Roccobene, J.V., Noyes, F.R., 1999.
The effect of neuromuscular training on the incidence of
knee injury in female athletes: a prospective study. American
Journal of Sports Medicine 27, 699706.
Hewett, T.E., Paterno, M.V., Myer, G.D., 2002. Strategies for
enhancing proprioception and neuromuscular control of the
knee. Clinical Orthopaedics and Related Research 402,
7694.
Hewett, T.E., Myer, G.D., Ford, K.R., 2005a. Reducing knee and
anterior cruciate ligament injuries among female athletes: a
systematic review of neuromuscular training interventions.
Journal of Knee Surgery 18 (1), 8288.
Hewett, T.E., Myer, G.D., Ford, K.R., Heidt Jr., R.S., Colosimo,
A.J., McLean, S.G., van den Bogert, A.J., Paterno, M.V.,
Succop, P., 2005b. Biomechanical measures of neuromuscular
control and valgus loading of the knee predict anterior
cruciate ligament injury risk in female athletes: a prospec-
tive study. American Journal of Sports Medicine 33 (4),
492501.
Ireland, M.L., Willson, J.D., Ballantyne, B.T., McClay Davis, I.,
2004. Hip strength in females with and without patellofe-
moral pain. Journal of Orthopaedic & Sports Physical Therapy
33, 671676.
Kibler, W.B., 1999. Unpublished data.
Liebenson, C.S., 2002a. Advice for the clinician and patient:
functional exercises. Journal of Bodywork and Movement
Therapies 6 (2), 108116.
Liebenson, C.S., 2002b. Advice for the clinician and patient:
functional training part one: new advances. Journal of
Bodywork and Movement Therapies 6 (4), 248253.
Liebenson, C.S., 2003a. Advice for the clinician and patient:
functional training part two: integrating functional training
into clinical practice. Journal of Bodywork and Movement
Therapies 7 (1), 2024.
 ARTICLE IN PRESS
Functional problems associated with the knee
Liebenson, C.S., 2003b. Advice for the clinician and patient:
functional training part three: transverse plane facilitation.
Journal of Bodywork and Movement Therapies 7 (2), 97103.
Liebenson, C., 2006a. Functional stability training. In: Lieben-
son, C. (Ed.), Rehabilitation of the Spine: a Practitioners
Manual, second ed. Lippincott/Williams & Wilkins, Baltimore.
Liebenson, C., 2006b. Functional training for performance
enhancement Part 1: the basics. Journal of Bodywork and
Movement Therapy 10 (2), 154158.
Mascal, C.L., Landel, R., Powers, C., 2003. Management of
patellofemoral pain targeting hip, pelvis, and trunk muscle
function: 2 case reports. Journal of Orthopaedic & Sports
Physical Therapy 33, 647660.
McGill, S.M., 2006. Ultimate Back Fitness and Performance,
second ed. Wabunu.
McLean, S.G., Walker, K., Ford, K.R., Myer, G.D., Hewett, T.E.,
van den Bogert, A.J., 2005. Evaluation of a two dimensional
analysis method as a screening and evaluation tool for
anterior cruciate ligament injury. British Journal of Sports
Medicine 39 (6), 355362.
Myer, G.D., Ford, K.R., Palumbo, J.P., Hewett, T.E., 2005.
Neuromuscular training improves performance and lower-
extremity biomechanics in female athletes. Journal of
Strength and Conditioning Research 19 (1), 5160.
Nadler, S.F., Malanga, G.A., DePrince, M.L., Stitik, T.P.,
Feinberg, J.H., 2000. The relationship between lower
extremity injury, low back pain, and hip muscle strength in
311
male and female collegiate athletes. Clinical Journal of
Sports Medicine 10, 8997.
Paterno, M.V., Myer, G.D., Ford, K.R., Hewett, T.E., 2004.
Neuromuscular training improves single-limb stability in
young female athletes. Journal of Orthopaedic & Sports
Physical Therapy 34 (6), 305316.
Powers, C.M., 2003. The influence of altered lower-extremity
kinematics on patellofemoral joint dysfunction: a theoretical
perspective. Journal of Orthopaedic & Sports Physical
Therapy 33, 639646.
Risberg, M.A., Mork, M., Krogstad Jenssen, H., Holm, I., 2001.
Design and implementation of a neuromuscular training
program following anterior cruciate ligament reconstruction.
Issue Series Title: Journal of Orthopaedic & Sports Physical
Therapy 31, 620631.
Sigward, S.M., Powers, C.M., 2006. The influence of gender on
knee kinematics, kinetics and muscle activation patterns
during side-step cutting. Clinical Biomechanics 21 (1),
4148.
Zazulak, B.T., Ponce, P.L., Straub, S.J., Medvecky, M.J.,
Avedisian, L., Hewett, T.E., 2005. Gender comparison of hip
muscle activity during single-leg landing. Journal of Ortho-
paedic & Sports Physical Therapy 35 (5), 292299.
Zeller, B.L., McCrory, J.L., Kibler, W.B., Uhl, T.L., 2003.
Differences in kinematics and electromyographic activity
between men and women during the single-legged squat.
American Journal of Sports Medicine 31 (3), 449456.
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