Recently several new students have presented with subtle, and more pronounced, signs of valgus knee. It is especially noticeable when doing any form of squatting or a dancer’s plié, where the arch appears to collapse and the knees fall inward creating what is commonly known as ‘knock knees.’ Naturally, this topic has become an interesting part of current reading materials and an emphasis in class formats recently. Within the scientific journal articles, it appears that the ‘jury is still out’ on a specific cause of valgus knee. Trainers have long attributed this dysfunction to weak gluteal muscles, overactive adductor muscles of the hip, and/or pronation of the foot; but recently, imbalances in lower leg muscles have also been studied with interest.
In an effort to understand the basic knee pain that students have reported, this investigation began with general look at the powerful quadriceps muscles at the front of the thigh. The four muscles are formally known as the quadriceps femoris group. They include the rectus femoris superficial to the vastus intermedius, centered along the femur bone; with the vastus medialis running along the anterior, inner side of the femur, and the vastus lateralis along the outside of the femur. While three quadriceps muscles originate from high on the femur bone, the origin of the rectus femoris attaches on the anterior inferior iliac spine (AIIS), low on the hip bone where it assists in hip flexion. All four quadriceps work as the powerful extensors of knee. The distal portions of all four muscles join into one important tendon. The tendon attaches to the sides and top of the patella, which then becomes the patellar ligament and attaches to the tibia (lower leg bone). The forces of the quadriceps muscles pull at the patella (or kneecap) and it slides in its ‘groove’ or ‘track,’ during movement at the knee.
Researchers continue to speculate why this perfect balance is impacted and how muscles’ direction of movements, specifically affect the knee. In general, the scientific method to measure forces at the patella is by assessing the Q-angle. This is the angle at which the femur and quadriceps muscles come from the hip and meet at the tibia bone (and patellar ligament). Normal Q-angle for men is about 14 degrees and for women is 17 degrees. Women typically have a higher Q angle due to a frequently wider pelvis. In taller people, the principles of biomechanics teach us that longer levers (femurs) exert greater force at the fulcrum (knees in this case). The patellar ligament usually maintains normal ‘tracking’ because it is guided on the outside by a bony ‘wall’ formed by a raised area of the femur bone (lateral femoral condyle) and along the medial side, the distal fibers of the vastus medialis are angled to pull the patella medially. Any one of these players can cause the ‘tracking” of the patella to malfunction which is a significant risk factor for patellofemoral osteoarthritis, or worse. A high Q angle often results in repetitive microtrauma to the tissues causing patellofemoral pain syndrome (dysfunctional patellar tracking also called “runner’s knee”), another form of damage occurs to cartilage behind the patella causing anterior knee pain known as chondromalacia, or anterior cruciate ligament (ACL) injuries.
Like snowflakes, humans are unique in our various sizes, frames and shapes as a result of nature’s design. Some individuals’ physical assets, including Q-angle, may prove more challenging or injury prone than others. As fitness professionals, we seek to understand not only how to assist individuals to maximize their health and journey toward their goals, but also we must educate ourselves. As movement experts, it is our duty to help mitigate any impending negative results of dysfunctional patterns as we strive to help all to “live better in our bodies”. In Part 2 on Friday we’ll ‘Confront the Q-angle Quandary’ with Therapy Ball techniques to help address the tissues involved, and in the meantime, watch this video below for Prasarita Lunges to strengthen the quadriceps muscles, glutes and outer hip:
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This is helpful information! Despite being a long distance runner for years- and having seen multiple clinicians over time for ‘knee pain” — I’ve never heard of the term “Q angle” prior to this article. It makes me wonder if I would still enjoy running (at all) now — decades later- had someone explained this anatomy and offered simple ways to strengthen the quadriceps, glutes and outer hips instead of rather than offer me temporary relief with shots of cortisone.
The Q-angle is a new term for me, and I’m grateful to know what it means now! Great breakdown of the anatomy here.
Understand the knee joint better. Good to know prasarita lunges are key in strengthening them.
As someone who suffers from patellofemoral osteoarthritis, the strengthening of the vastus medialis and vastus lateralis along with hip adduction muscles has helped to decrease knee pain and stiffness. Also have found appropriate lengthening of these muscles have helped to diminish some pain.
The rectus femoris group has grabbed my attention off and on for many years due to my own experiences with knee pain. Strangely when the pain subsides I fall off the wagon of my knee health practices?!?
Each time it reappears I receive new information from my own body as well as come across new information on how to treat it. What is shared here is another piece of my knee health puzzle, thank you.
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This article made me think about my knee and the recent issues that I have been having. I have never had knee pain before and so I really be ignoring it and deny the fact that my knees are achy in certain positions. It was really apparent when I was practicing the other day and we were doing danurasana with a blanket. Right away my right knee felt like pins and needles. It was pointed out to me that my quads may be the issue. Since then I started to look at how I stand and my knees are most certainly turned in and hip are a little internally rotated. I have been doing some self care for my Quads and external rotators and its working!. It was also interesting to learn about the Q-angle.
This hits right on a topic I was trying to work out with my guy earlier. He is studying for a different test and I am helping him with his anatomy as I learn myself. I know sonmany people that want to squat with heavy weight so badly, but they pay no attention to proper form for their own body and I just cringe and what it will look like long term.
Thank you for this! I’ll totally be using this technique with clients!
This is the first of a two part discussion of Vagus Knee. My personal tendency toward knock knees, their cause and possible antidotes led me to this Blog with its YTU Jill Miller demo of Prasarita Lunges—like a speed skater—warming up and pumping synovial fluid into the hip socket, strengthening glutes and outer thighs. The condition is more common in women due to generally wider pelvis and Q-angle of 17 degrees versus narrow pelvis and Q-angle of 14 for men. Diane informs us that the latest research is looking at the lower leg as a possible contributing factor in addition to weak glutes, overactive adductors and pronation
Great description anatomically that could even be used to explain to “regular folk” The Prasarita lunges are excellent to bring focus to the mobility and strengthening of hip and knee. Good reminder that bony alignment does come into play and it’s not always a muscle dysfunction. Proportions differ in people also and need to be acknowledged. Thank you
Merci pour cet article! tres enrichissant et en tant qu’entraineure je vois souvent ces problèmes, je me renseigne beaucoup au sujet des diverse causes de blessures au genoux et cet article m offre un nouvel éclairage.
I don’t know the actual degree of my Q angle but it’s pretty pronounced; I have had a couple of teachers comment that I tend to go knock kneed, from a quick visual. However I don’t believe that I really am going knock kneed – my arches don’t collapse, and my inner leg line stays strong… I also have never had any pain associated there because of this. The Q angle does give the appearance of being knock kneed though, particularly when my legs are straight. The angle is so pronounced that I can’t bring my lower legs or ankles to touch with straight legs. It’s quite frustrating at times.
It’s interesting that valgus knee can have so many potential causes. It really goes to show how every body is different and the causes of our pain / condition is so individual. I realize now that I have many dysfunctional patterns and weaknesses that have caused my valgus knees. I have been incorporating many glute and hip strengthening exercises into my routine and have stopped doing postures that promote that position.
Lots of interesting details in your article Diane! I see this happen when teaching yoga and people struggle with keeping the knee from falling in. You’ve provided some new terms that I look forward to researching to better understand. I do think the YTU poses are extremely helpful and will help students to better identify where they have weaknesses.
Thanks again for the great article!
Valgus knees is a very common problem seen in my kettlebell coaching practice, whether in deadlifts, swings, squats and lunges. So few people understand how to actively stop it from happening. I love this Prasarita lunges for it’s awareness boosting on how to stabilise the lateral hips dynamically while we push and pull with the legs.
Not only was this article super informative, the thread of comments also provided excellent information. As a yoga teacher, I find this particular situation tricky to teach in a group setting, since no two bodies are the same. Prasarita lunges are a great pose to experiment with since it can be done to work the adductors or the ABductors and strengthens the glutes, all contributing muscles to healthy knees.
This article very much resonates with me. I’ve had knee pain since adolesence and have been told contradictory from health professionals. The Q-angle is very interesting and I will read up on it. As for the Prasarita Lunges in the video: my knees felt great afterwards (not to mention my whole body)!
I very recently have become aware of how much instability I have in my knees. I knew it had something to do with an imbalance of strength and general leg weakness, but your explanation of the Q-angle and how it contributes to knee health and stability is really hitting home for me. I have disproportionately long legs and I think this combined with my lanky frame has been throwing off my angles!
Thank you for this informative post about the quadriceps and Q-angle. I especially appreciate your comment on Dec 15, 2013, in response to a question about the foot position in the Prasarita Lunge, further explaining that when flexing the hip under load, external rotation of the hip puts the joint into a more stable position. And that it is best to achieve that external rotation AFTER planting the foot (closing the chain) in a near-neutral position and, as you eloquently said, “mindfully ‘screwing’ the foot in an external rotation direction into the floor.” When I do the Prasarita Lunges with this closed-chain external rotation, I can really feel the external rotators of my outer hips engaging and my knees come apart significantly!
Diane, I love the way you describe humans as snowflakes – so true, especially when it comes to the unique quirks and anatomical makeup that each of us have! Great to be reminded of the Q angle and the implications of alterations in this. Recently, I have awoken my gluteus medius much more. I am very aware of valgus knees in both my yoga practice and weight training (squats etc.). The Q angle discussion reminded me in a different way of importance of alignment and awareness of body relative to itself.
Great article, this often comes up with my clients when discussing patella tracking!
Thanks Diane for this explanation as the knee is a delicate joint. I have never heard of the Q angle and I’m curious to see how they differ from each leg. My right knee and arch are clearly collapsed inward but the left seems more normal. I’ll have to look into this more. I was wondering if you use prasarita lunges with someone who has osteoarthritis of the knees?
Great description of the Q-angle and its relationship to potential knee injury. As a trainer, this is probably one of the main ‘issues’ we are taught to assess for in our clients. However, as you point out, the answer isn’t as easy as many training certifications make it out to be. Regardless, the first step is awareness and knowledge of the body- and knowing that what works well for one person may not work for another!
Hi Diane,
As someone who has suffered from runner’s knee, I was fascinated by this article. I’d never heard of Q-Angle and that runner’s knee is a precursor to other knee dysfunction. I also followed your advice to Susan on 12/15/13 and checked out Kelly Starret and learned even more about how to achieve external hip rotation using a table and with squats. Thank you.
I appreciated this detailed but succinct explanation of valgus knee. The explanation of the Q-angle was new to me and helpful to understand how the imbalance is assessed. The human knee takes on a great deal of force every day, and is stabilized by many muscles. It is no wonder why this problem is multifaceted and its origin is difficult to pinpoint.
Thank you for the Q-angle explanation. I did ballet for many years and now have a tendency to walk with turned out feet, in turn turning my glute med and abductors off. When I started running this turned into really bad knee pain when flexion at the knee joint happened, especially when going up stairs. I was able to fix this problem by rolling out my glutes and getting my quads smashed, no where near the knee but it worked!
Hi Garrett,
Thanks for your note. Interesting– without witnessing your squat mechanics– hard to say. However, in addition to perhaps needing more eversion action from the peroneals, your inverters (tib anterior) may be extra tight and inhibiting the eversion. To roll tibilais anterior, you can bend your knee and lay your shin onto the toted balls on a bench, ideally, or on a stack of books — allowing your foot to hang in neutral while you roll your shin north and south between the therapy balls and don’t miss the anterior side of the ankleto address a few tendons (including ant. tib). DM
Thanks for such an informative article Diane! I’ve been running into issues with my knees and squatting recently. My knees do not internally rotate, or knock in too much, but I do have a terrible time keeping the medial side of my foot planted when my feet are keep relatively parallel in my squat. I’m curious if part of the muscular action I might be missing is a stronger eversion of the foot to try and ground down that medial edge?
Very informative article! I had head the term Q-angle before but had never understood exactly what it referred to until reading this. The knee is so fascinating and complicated and certainly incredibly relevant as most people have at some point experienced knee pain! Sometime it seems the more I learn about it the more questions I have!
I’m working with a new client that has a mild to moderate knee varus condition, her knees like to go bow legged instead of knock kneed. I’m curious to know how that affects her Q angle. I have her perform Pasarita Lunges too, only with adductor emphasis and then we go into Monk Walks. We’ve found that the Pasarita Lunges help her “find” these stabilizing muscles for the Monk Walks – which she has learned to do so beautifully in a matter of a few weeks. Thanks for sharing!
[…] Q-angle, Patella and Quads, Oh My! | Yoga Tune Up http://www.yogatuneup.com/blog/It is especially noticeable when doing any form of squatting or a dancer's plié, where the arch appears to collapse and the knees fall inward creating what is commonly known as 'knock knees.' Naturally, this topic has … cause of valgus knee. Trainers have long attributed this dysfunction to weak gluteal muscles, overactive adductor muscles of the hip, and/or pronation of the foot; but recently, imbalances in lower leg muscles have also been studied with interest. […]
Hello,
I found this article and subsequent comments quite interesting because I suffer greatly from knock-knees. I played soccer as a young child and adult and following my third ACL reconstruction decided to leave the sport behind and give yoga a try. It’s a shame that I wasn’t introduced to yoga earlier in my life; through my practice I gained and continue to gain incredible insight into my own anatomy that could have reduced my risk of injury when I was playing soccer. Not only am I knock-knee’ed but I hyperextend my knees naturally. I have to constantly work during my asana practice at creating a microbend and opening my hips to prevent my knees from moving inward. I would love to have my Q-angle measured, because I imagine it’s larger than the standard for women. I know that strengthening my quads can help prevent further knee injury, but I had not considered strengthening my gluteal muscles, as the article mentions. I will give the lunges a try and hope they do some strengthening for me as well. Thank you!
Great post Diane. I definitely have a few clients with various degrees of valgus knee. You’ve done a great job to explain the issue, and made it easy to understand the need for strengthening and mobilizing. I can’t wait to share this, and your follow up article, with them. Thanks!
Great article. One of my students was an avid runner, and while her hip flexors and quadriceps are strong, the lateral movement in her hips is extremely limited. I’m looking forward to doing these with her in our next session. I’ve always been told the stability of the knee begins in the hips. I really like prasarita lunges. They are way more dynamic and fun than the “band walks” I’ve done in PT to address the same issue.
Snowflakes indeed! It seems like in a given class, something that I teach can be completely beneficial for one person’s knee health, and conversely, completely inappropriate for another student.
Thank you for suggesting the prasarita lunges to help strengthen glutes and hips. I was diagnosed with chondromalacia several years ago which started my hunt for holistic methods of addressing this condition. The prasarita lunges feel really good, thanks for the article.
I am planning a knee class for this coming week and this article was immensely helpful. I also read through the comments and found more ideas. It’s so interesting that when we feel knee pain we focus on the knees but it’s very important to see how other parts of the body are moving. I was thinking about how a clothesline comes off of it’s pulley, it’s not because the pulley (the knee) isn’t working but the tension and angle of the line (muscles) are off. Often once you fix the angle and the tension, the pulley runs fine.
I am constantly seeing the focus on squats as the “pose-du-jour” lately. So your posts on the Q angle couldn’t be more timely. Injury in this area is a tough fix. Using Prasarita lunges and Adductor slides are great exercises to strengthen the abductor group. I can the benefits of using bands to create tension and strengthen poses further. Great conversation everyone!
John– I appreciate the interesting posts! I do many gait assessments but have not used Farmer’s Carry— sounds like a great idea and I am going to try it next week!! Keep up the thoughtful creativity!! Thank you so much!!
Just read this article http://breakingmuscle.com/strength-conditioning/fixing-common-squat-and-deadlift-problems-with-bands
And it got me thinking about using bands in Prasarita Lunges, in the author’s words “as a tactile cue,” and to build strength in the abductor group.
I looped my left foot through the band and stood on it with the band under my arch, and looped my right leg through with the band resting above my knee. Then lunged to the right.
I have only one band, but I would imagine that this would work perfectly with two bands to make the movement dynamic.
Thanks for the article Diane!
I see Valgus knee all the time at the gym when I workout and at the CrossFit gym I teach yoga at.
My opinion is that it is exacerbated by the tendency to walk with externally rotated hips, thereby recruiting the Adductors and shortening and weakening the external rotators of the hip.
When I started with my personal trainer, she had me perform Farmers’ Carry as a means of assessing my gait. The load has a way of accentuating any dysfunctions or tendencies. I was aware of being watched and tried to walk my best, but the loaded movement overcame my self-consciousness. This exercise made me aware of my tendency to externally rotate my hips, particularly my left hip.
I’ve been addressing this by “ninja walking,” as my trainer calls it. Basically it’s just a silent and slow walk with the intention of propriocepting hip rotation.
Hi Susan. These are important questions. First regarding foot distance- your joint stacking alignment sounds good. Effort includes keeping the bodyweight over the heels and not the hands, but you want to separate your feet wide enough apart to safely challenge your abductor (outer hip) and adductor (inner thigh) muscles also. Now- the foot turnout question is more complex and an excellent lesson. During daily activities we often externally rotate our hips/feet unnecessarily – creating avoidable joint stressors. I’m often helping students correct this habit. “Slight” foot turnout on this move is Ok because we are loading the hips in flexion, but please read on: When loading the hip (or shoulder) in the flexion position, with compression forces (full bodyweight in this case), the effort to create a torsion force in the joint (twisting=torque) by adding external rotation helps the surrounding tissues create joint stability. External rotation offers the best safety effort for flexion moves with a load. However, we obtain the best potential torque (rotation) force for joint stability, not by placing our foot in a completely externally rotated position already, but by planting it close to neutral and mindfully “screwing” the foot in an external rotation direction into the floor. I hope this helps. If it is not clear, Kelly Starrett DPT of MobilityWOD has videos on Youtube that may help demonstrate the science:) Thank you for bringing up a key biomechanics question!!
Thank you for a very interesting article! One question related to foot position with prasarita lunges: When I do this, it is much more comfortable if my feet are pointed slightly out, and I take my feet just wide enough apart so that during the lunge, my knee ends up approximately over my ankle. If my feet are any wider, the knee is uncomfortable. Can you comment on my knee and foot alignment observations?
Thank you Diane M. Very helpful!
Hi katie. Great question. Prasarita lunges are an excellent dynamic exercise to balance hip strength and mobility. The lateral strengthening AND stretch/mobilization movements gained from this activity bring a direction of movement/strength that is often missing. The glutes are comprised of 3 muscles; Gluteus Maximus, Medius, and Minimus. Prasarita lunges strengthen primarily the 2 smaller but important gluteal muscles (Medius Minimus) and the larger Gluteus Maximus is only acting as a helper/synergist on the abduction movement (during the ‘pushing away’ phase). In order to strengthen the larger Gluteus Maximus, the hip needs to move into extension (think of reaching your leg out behind you). In Yoga Tune Up, we do a version of “walking lunges” called Monk Walks which are excellent for the gluteus maximus, but any version of lunges executed with proper alignment will work. Another good option requiring less balance is Bridge lifts. And…. YES. Longer legs = longer “levers” in physics biomechanics. This means your longer bones can put more force or torque on your joints. Modification for this intensity is to ‘shorten’ the long lever to relieve some force on the joint by bending knee ( or elbow to lighten shoulder forces). Hope that helps!
Hi Yvonne! I live in “Hockey country” near Canada — and love the sport! I have repeatedly seen hockey players’ unbalanced lateral/coronal VS sagittal mobility. Today’s Video for lower legs is perfect for them!! In addition to what is already stated – I also like YTU Moon Rises and Leg Stretch Series- with closed chain strap for these issues. They are lucky to have you!!
good article. I do a small number of prasarita lunges daily and although I find them helpful, I don’t feel my glutes strengthening or working that hard. Am I missing something? Also, I’m tall for a female, 5’9″, long legs. Is my height playing a role in it’s effectiveness? thanks so much.
After reading your interesting article, I find myself wanting to know more, especially about the Q-angle. I teach hockey players who complain of knee pain…as do my runners. I love Prasarita lunges and Adductor slides. As Diane commented I will make sure to consider the lower leg and foot. Looking forward to Part 2.
Hi Helen:) I agree with your comments… In addition to so many YTU exercises that can help folks with Hip/glute strength — and yes the postural alignment…. consider our lower leg/foot releases too. Sitting Seza and Dandasana with Inversion/Eversion, and anything to enhance dorsifleexion and inversion… Much can be accomplished with this dysfunctional pattern by working below the knee also. Mahalo nui loa<3
Awesome article Diane. In Jazzercise I see this when doing plie’s and such involving external rotation of the hip and flexion of the knee…students struggle with keeping the knee form falling inward… work has to be done to strengthen medius minimus and max and external rotation . And then of course teaching them alignment and their own bodies blindspots.… Thank you and I am looking forward to part two! Those prasarita lunges work well to really feel the movement I need to get more of those Jazzercise girls in my Balance in motion/YTU® classes to understand their bodies better…what muscles behind the movement? XO