I remember a few months ago I saw a fellow practitioner post the question “what is the most underrated joint in the body when it comes to rehab?” There were many responses including subtalar joint, C1/C2, proximal tib-fib, calcaneocuboid to name a few. These are all great joints, I love them all, but my thought process instantly went to the tibiofemoral joint. Maybe I was biased with my previous knee issues, but when I actually think about the question I still think that tibiofemoral joint mechanics are underrated.
Many people might not see it as underrated because it is a bigger joint that people can’t ignore and everyone knows a tibiofemoral joint that collapses inwards is bad….how could it be underrated? I think it is underrated because of it’s impact it has on the “kinetic chain”. So easily does the medial side of the joint become the path of least resistance during lower limb loading. If you have read my previous posts you know this often occurs due to inability to move at the ankle causing tibial external rotation on the femur. This then makes the femur in a position of relative internal rotation and results in medial instability due to the femur more easily caving into valgus. Medial joint instability also often presents itself with old knee injuries as well. It is an important area to assess because in my eyes it is the centre of rotation of the lower limb. It connects force produced at the ankle/foot to the hip and vice versa.
When it comes to knee pain and lower extremity function I think most people are going to be working on stiff ankles and stiff/weak hips, but often overlooked is the actual knee positioning and mechanics itself which is why I feel it is underrated. To me they all really go hand in hand. Hip pain? Is that femur constantly diving into internal rotation because of knee mechanics? Good luck stretching that out completely. Back/SI pain because of what appears to be a dysfunctional hip? What is making that hip dysfunctional constantly? Maybe it is the tibiofemoral mechanics and so often I find that to be true. Often times because of the inability to rotate at this joint people will struggle to create external rotation force in their hip which is all so important as we know.
As last weeks post discussed different ways to enhance ankle mobilizing, this weeks post will go over an exercise I like to give to actually work on tibiofemoral mechanics besides just working on the ankle/hip. Credit for this exercise goes to Dr. Michael Chivers who showed it to me last year. Dr. Chivers is one of the lead instructors for Functional Range Release which is a soft tissue release system I would recommend any practitioner take. If you are a trainer, I would recommend taking Functional Range Conditioning. Information can be found at their website here.
The exercise is Tibial Internal Rotation CARs (controlled articular rotations). The purpose of this exercise is to groove tibial internal rotation through out the range of motion of flexion/extension of the knee. As you will see in the video below my co-worker Minda is going to attempt to hold her tibia in as much internal rotation as possible while her knee is at 90 degrees. From there she is going to go into knee extension while trying to hold her tibial internal rotation position and not let her tibia spin out into external rotation like it so desperately will want to. This will take a lot of control through her medial hamstrings to eccentrically control this motion. As she is extending the knee she is going to do this slowly and make it difficult, should take at least 5 seconds for her to complete an extension. Then she is going to slowly bring her knee back into flexion while continuing to hold tibial internal rotation and focus on contracting more so with the medial hamstring group. While doing this all she is making sure her femur is being held in slight external rotation and she is going to avoid having the femur dive into inwards rotation. As you will see (and Minda is not even that bad), this exercise will cause a lot of shaking and quivering in the knee….which is awesome. To me that is a sign of re-education and motor learning! You are forcing your knee to do something it hasn’t known how to do before or you have lost the ability for it to do because of injury/compensation.
So sorry for the poor camera quality! No there was not a strobe light going off in my clinic room!
Along with ankle work and hip work this is a great adjunct exercise to get the middle man…the tibiofemoral joint. This will make “communication” aka force translation much easier between the ankle and hip. If your knee mechanics are faulty give this exercise a try, but make sure you do it with intent. As I mentioned last week in my ankle mobilizing article, every exercise has to be done with serious intent and that is even more so important with this exercise. Your knee should be shaking and it should be very challenging! If you do not find it so, then you are not doing it hard enough.
Thanks for reading guys! Let me know your thoughts and any questions you may have!