Knee exercise

You asked about exercises…

I am not a doctor or physio, but have had problematic knees for a very long time, seen many physios (and doctors) and offer these exercises for you to consider.

Only do the exercises slowly and carefully, making sure you have good technique - get a physio or other qualified person to show you if you can. Don't do anything that hurts. Remember to build up exercises gradually. If in doubt, leave it out.

I also strongly suggest you wear a support whenever you are playing soccer or any other sport. If you want more info on supports or on how to use tape or bandage as a support for your knee, post back; it’s better to see than read, but reading is better than nothing.

There are exercises you can do to strengthen your quadriceps (four thigh muscles), especially the VMO – vastus medialus oblique (small tear or pear shaped thigh muscle on inside of leg just above knee). The VMO helps to hold your kneecap in place. It is important because it pulls the kneecap towards the inner side of your leg and most people’s kneecaps dislocate by going toward the outer side of the leg. If possible it is ideal to have your VMO as strong or stronger than the outer muscles, however this is very difficult because the outer muscles are naturally a lot bigger and stronger (in fact biggest in your body, they go right up to your hips in a wrap around line) and much stronger than your VMO. Having better tone and strength in any of your thigh muscles will help, but VMO is the most important to reduce risk of further dislocations.

There are lots of different exercises.

1 A very good exercise to get your VMO working, and to recognise and train yourself to work on it, is the 5 by 5 by 5 VMO activation exercise (that’s what my physio called it, don’t know if it is a recognised name). You need to be able to bend your knee to 90 degrees to do this exercise.

Sit on a chair, bend legs to 90 degrees with your bare feet flat on the floor so that your thighs are at right angles to your shins. Turn your feet so that the heal of one foot pushes against the arch/instep of the other. Put your hand over the VMO you want to exercise (can do either leg in this position). Tense your VMO muscle as hard as you can, while pushing that foot into the other foot, should feel the VMO tense under your hand, try not to allow any other muscles to tense – especially the muscles on the outer side of your thigh. Can tap or rub your VMO muscle with your hand to help it initially contract (supposed to help your brain to be aware of muscle, isolate muscle, help to concentrate on it etc – once you can contract it in isolation you don’t need to tap or rub it, but still good to put hand over it). Tense the muscle hard for a count of five. Relax the muscle for a count of five. Repeat so you have tensed and relaxed 5 times in this position. Now, move your feet further out, but still on the floor with feet interlocking, so your legs are at about 110 degrees. You will probably need to sit further forward in the chair to do this. Put hand over VMO again. Tense VMO muscle for count of five, relax for count of five. Do five times. Move feet further out, so your legs are at about 130 degrees. Repeat 5 lots of 5 second tension and relaxation of VMO as before. Move feet further out, so your legs are at about 150 degrees, repeat 5 lots of 5 second tension and relaxation of the VMO. Move feet further out, so your legs are about 170 degrees (almost straight), you will need to be perched on the end of the chair to do this, repeat 5 lots of 5 second tension and relaxation of the VMO.

2 A really simple exercise that you can do – to some extent, even if have very limited mobility, is simply to contract the thigh muscle (trying to focus on VMO) as much as you can. Have your legs straight (you can sit or lie down), and tighten your thigh muscle, trying to push your kneecap down (you don't actually move the leg). Try to turn your foot outwards so that your VMO is uppermost (turn leg from hip). You should be able to feel the thigh muscles working, try to focus on VMO and tighten as much as possible (can put hand over, especially to start with, if sitting and is comfortable, will help to start to work the VMO more). Build up repetitions to over a hundred repetitions at a time (but start slow). You can do this exercise while watching TV or anything so long as your leg is straight, can do while standing as well - weight bearing or not (eg while washing dishes).

3 Another simple low risk exercise to strengthen these muscles is straight leg raises. Lying down, with both legs straight (can bend other leg if muscles are too weak), lift leg while keeping it straight, so your heal comes up about 30cm (one foot), do as many repetitions as you can, start with about ten or twenty and gradually build up. Turning your foot outwards, so your toes are toward the ground, away from your body, while doing this exercise helps to tighten the inner thigh more (which you want). If you're getting tired and want to turn it inwards, don’t - stop and rest. If you are doing really well, you can add small weights (~1kg) to your feet while doing the raises.

There are many variations to straight leg raises, I’ve written four below.

3.1 Tighten while leg is straight, hold muscle tight and raise (about 30cm), lower to surface (but keep tight), raise again, hold for 10 seconds, lower to surface, relax 10 seconds, repeat whole sequence multiple times – all with leg straight.

3.2 Raise straight leg, move straight leg in pattern (eg draw a square with your foot), then lower straight leg. Can do with any shape – eg circle, triangle etc. Can do clockwise or anti-clockwise. Can do alternately with plain straight leg raises or alternately with variation 1 above.

3.3 Can raise straight leg, then hold thigh still while bend lower leg so foot touches bed, then raise lower leg back up (leg now straight and in air), then lower whole straight leg. That exercise bit more difficult/ risky because knee is bent while upper leg is unsupported.

3.4 Variation of that exercise (variation 3 above) is to prop your upper leg to about 40 degrees (with pillows, cushions, whatever), then raise and lower your lower leg.

4 You can also do knee bends which is still fairly low risk, but you are moving the knee so only do if you are confident. Sit on a chair (or table, bench, stool – whatever), bend leg to 90 degrees then straighten, do in repetitions starting with about 10, don't overdo, but eventually, over a few weeks or more build up to over a hundred, you can add weights to your feet/ ankles to work the muscles harder.

5 Hydrotherapy, exercise in water, is also really good. The buoyancy of the water takes a lot of the weight and strain out of the exercises, so you can work your muscles harder, and do higher risk exercises in water with lower risks (but still be careful what you do). Even just walking in water forwards is good for your knees (walking sideways and backwards is also beneficial). Kicking your legs (small kicks, scissor motion) is also good but does not focus on VMO, builds up whole thigh and calf). For other exercises consult a physio (PT), and make sure they watch you doing the exercise so you know you are doing it correctly. Hydrotherapy is often used after surgery or extended immobilization, but you can also use to build up your muscles to help prevent dislocations.

6 Lunges work your thigh hard, but are hard to do, and higher risk – only do slowly and if confident, watch knee alignment during movement Can do in water to reduce risk. Do not do if not confident or muscles not strong enough.

7 Squats are very demanding. Can start off against a flat surface (eg wall), and slide down and up carefully. Watch back and knee position. Can do in water to reduce risk. Do not do if not confident or muscles not strong enough.

8 Stairs are also demanding but not as high risk as squats or lunges. Many people with dislocation problems find stairs painful – especially upstairs. Avoid if painful. Always make sure you are holding onto or close to a rail. If doing on a makeshift stair – eg a box, block of wood or bricks, make sure it is stable and safe, and that you have something you can lean on for support if necessary (even a wall is better than nothing). Step left foot up one step, then right foot up to same step, then step left foot down to floor, then right foot down to floor. Repeat sequence (build up to about 50 repetitions). Then repeat, starting with right foot up, then left foot up, then right foot down, then left foot down. Repeat sequence multiple times.

Stability is also very important, better stability helps proprioception - your awareness of body position, which helps you to be less likely to put in bad positions, to be aware of risky positions quicker and to change position quicker. This means you can compensate quicker and therefore helps to reduce risk of further dislocation.

9 Simplest balance exercise is to stand on one foot for as long as you can, start off for ten to fifteen seconds and try to build (will take time and practice) to about one minute or so. When you are confident, do the same thing but with arms by your side and entire body perfectly still. When confident with arms by side, do with your arms crossed over the front of your body (hands on opposite shoulders). When confident with arms on body, do balancing with your eyes closed - starting with simple standing on one leg using arms to balance as necessary, then hands by side, the arms up. If you have access to a trampoline (any size) and if you feel confident, you can repeat exercise on the trampoline (start eyes open through each stage of difficulty, progress to eyes closed for each stage of difficulty). Can do all in water to make harder (especially if there is movement in the water).

Avoid twisting, turning, pivoting, slopes etc (and if have to make these movements do with knee support only).

Happy exercising!

Hope all goes well.

Liana.