Sometimes It’s Simple

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I’ve taken lots of courses, read lots of books and articles, listened to podcasts, and attended seminars dedicated to helping my clients move better and get out of pain. I’ve spent time and money learning about so-called corrective exercises. I’ve learned that rarely is the site of pain the site of the problem. I recognize that the body is a highly interconnected system of systems and that what happens at one end can have powerful effects way out at the other end. I’ve tried to absorb and apply all sorts of complex information and sometimes, my brain gets in the way and I overlook simple solutions.

Patty is one of my senior clients. We’ve worked together for several years. She has intermittent knee pain on both, but mostly her left knee. It’s not terrible but it bothers her after tennis games and often while climbing and descending stairs.

It’s important to recognize that the knee is caught between the hip and the ankle. Rarely is it the fault of the knee that’s causing the knee pain. (An obvious exception would be an acute injury like a ligament sprain or some sort of impact to the knee.)

I’ve had her do all sorts of exercises and mobility drills for her hips. We’ve done glute drills in all three planes of motion. We’ve done all sorts of lunges in all sorts of directions. We’ve done a bunch of ankle and foot mobility work too. In the past, I spent way too much time giving her a bunch of instructions to squeeze the glutes when she walks and to try and make her leg do this or that as she moves. (These are examples of intrinsic cues. They’re usually not the best cues.)

Sometimes her knee(s) feel better but for the past several weeks she’s reported fairly consistent knee pain, particularly on stairs. This was frustrating to me in that last week we did a variety of drills and exercises such that she was able to take the stairs without pain. I was hopeful though. If we could eliminate her pain last week then we could do it again.

We went to the stairs. I planned to review a couple of things we did the prior week. My mind filled with cornucopia of lunges, stepping drills, and ankle mobility exercises. How would I tweak the exercises? How would I load them? There were many options. My brain started to overheat as I tried to contemplate them all.

Then I paused and thought, “What’s the simplest possible way to find success?”

Coach her to walk the stairs differently. No drills, no exercises, nothing special. I would give her a minimum of instructions on how to walk the stairs in a different way than when she arrived.

There were two tactics from last week I wanted to try. If those didn’t work then we could move to all the wacky, exotic stuff. The two main instructions were these:

  1. Ascending: Lean forward a little. By leaning forward I expected the glutes to work more than if she stood fully upright. It didn’t need to be a big lean forward, just somewhat of a lean. Don’t think about the glutes either. Jus lean forward.
  2. Descending: Let the heel of the rear foot stay flat longer. That way the ankle would dorsiflex more thus taking some of the load from the knee. Also, try and descend softly. Try not to slam and clunk down to the next step. My hope was that this would prompt a controlled descent as opposed to a sort of lurching slam into the step.

(I’ve seen this ankle/knee relationship several times in the past. A few of my clients have presented with knee pain and limited ankle dorsiflexion. The knee pain diminished or vanished once dorsiflexion was restored and then used during gait.)

Both strategies worked immediately! How cool! For the next 5-10 minutes I had her practice the new stair walking strategies. The only time the knee pain popped up was when she let the heel rise too early during the descent.

I didn’t tell her anything about her glutes or her knee or any other muscles or joints. Just, “lean forward,” and “keep your heel down longer.” I need to remember that sometimes giving simple cues can do world of good. I don’t always need to go through a rigamarole of creative exercises to help someone move and feel better.

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