21 Sep How To Prevent Knee Valgus
Medial knee collapse, also known as knee valgus, is when the knee collapses or falls inward during any sort of weight-bearing activity, like a squat, during gait, or during sport-specific movements like cutting. Knee valgus is characterized by hip adduction and hip internal rotation in a flexed hip position. This position of the knee is most commonly associated with a non-contact mechanism of injury of the Anterior Cruciate Ligament (ACL), and occurs in the running or jumping athlete during the deceleration phase of a cutting movement. The gluteus maximus plays an interesting role in medial knee collapse and can help with preventing knee valgus. In this article, we will show you how to prevent knee valgus with gluteus maximus targeted exercises!
Common Knee Injuries Surrounding Knee Valgus
An ACL injury is the most common form of knee injury today in the United States, with estimates ranging from 100,000 to 200,000 per year. In addition to ACL loading, medial knee collapse also predisposes to lower extremity to a host of other orthopedic issues such as lateral hip pain, ITB stress, patellofemoral stress, MCL strain, and tibialis posterior stress (1). Any time our body develops a compensatory movement, it can lead to potential issues of pain and/or injury. Repetitive knee valgus can lead to overuse injuries at the knee. Below is a visualization of what knee valgus looks like.
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How To Prevent Knee Valgus: Understand The Role of The Gluteus Maximus
So you want to know how to prevent knee valgus? As mentioned above, medial knee collapse is characterized by excessive hip adduction and internal rotation. While the gluteus medius is the primary frontal plane hip abductor, and weakness of this muscle is clinically associated with knee valgus, one must not forget the important functional role of the gluteus maximus when considering impairments related to knee valgus. (We will devote our attention in this article to the gluteus maximus only, assuming the gluteus medius is functionally strong).
Gluteus Maximus Anatomy
The gluteus maximus is the biggest of the gluteal muscles that form the large majority of your butt. The gluteus maximus is also known as a “tri-planar muscle”, meaning that it has the ability to move the hip joint in all three cardinal planes. The gluteus maximus can extend the hip in the sagittal plane, abduct the hip in the frontal plane, and externally rotate the hip in the transverse plane. All three of these muscle actions counteract the motions associated with medial knee collapse: hip adduction, internal rotation, and flexion.
As the gluteus maximus is the main hip extensor, the body will naturally recruit and use other hip extensors, namely the hamstrings and adductor magnus, to compensate for its weakness. While hamstring and adductor magnus compensation will help hip extension, the additional recruitment of these other hip extensors actually further exacerbate medial knee collapse due to secondary actions of the hamstrings and adductor magnus. The hamstrings, while being a hip extensor, are also a hip adductor. The adductor magnus, while being a hip extensor, is also a hip adductor
Gluteal and Hamstring Anatomy
The combination of hamstring and adductor magnus overuse to compensate for gluteus maximus weakness drives the hip into more adduction, which will further exacerbate medial knee collapse! Of our body’s three primary hip extensors, two of the three actually adduct the hip instead of abducting the hip; thus, further emphasizing the importance of adequate gluteus maximus strength.
Interestingly enough, many individuals actually have more than adequate gluteus maximus strength, as evidenced by physical therapist-assisted manual muscle testing, or the ability to squat/leg press a lot of weight. Yet they still demonstrate medial knee collapse in functional activities. Why you might ask? These individuals lack proper neuromuscular control and the ability to adequately recruit their gluteus maximus.
The ability to properly recruit the correct muscles, in sequential order, is something that we not only take for granted but also seldom have to think about. When we walk, kick a soccer ball, or throw a football, we don’t think – we just do. Training your brain to turn on the right muscles can be a challenging process, but a quick fix might simply be adjusting your trunk angle! Leaning the trunk forward during squats, running, or sport-specific movements effectively increases the hip flexion moment while decreasing the knee flexion moment. This results in a greater propensity to activate the hip extensors with a forward trunk lean. A 2010 study by Pollard et al. found that greater utilization of the hip extensors was associated with decreased valgus moments and angles. The findings of this study are in line with the emphasis we place on the importance of the gluteus maximus and its role in preventing medial knee collapse (1).
How To Prevent Knee Valgus: Strengthen The Glutes!
There are a plethora of excellent exercises that you can work on to strengthen your glutes, specifically the gluteus maximus. We will show you some of them below! What is great about these exercises is that they can be modified to either be progressed or regressed based on your current fitness level! Always start with what feels best for your body and focus on the correct execution of the exercises to gain maximal benefit. In addition, if first starting out with these exercises, work on longer hold times, as this will prime the mind-body connection of activating the correct muscle groups!
Glute Focused Exercises: Bridges
- HOW: Start on your back with your knees bent and slightly spread apart. Tighten up your stomach first, then your glutes. Next, drive your heels into the ground and lift your hips up towards the ceiling. At the end position, your knee, hip, and shoulder should be in one straight line. Hold end position and squeeze the glutes, then slowly return to starting position.
- FEEL: You should feel your glutes work to control this motion. At no point should you feel your low back muscles doing the lifting motion. If you feel it only in your hamstrings, try bending your knees a bit more and repeat.
- COMPENSATION: Avoid arching at the low back as you perform this
Single-Leg Bridge – Band
Start on your back with a resistance band placed slightly above your knees. Bring one leg in towards your chest, with the leg on the floor drive-in with your heels to lift your hips up towards the ceiling. At the end position your knee, hip, and shoulder should be in one straight line. Hold the end position and squeeze the glutes, then slowly return to the starting position.
Begin by placing your upper back on an elevated bench surface. Your shoulder blades should be just above the edge. Have your feet shoulder-width apart and flat on the ground. Your knees bent with your feet slightly behind your knees. Push into the ground lifting your hips straight up. Stop when your hips are in line with your knees. Hold that position for a few seconds and then slowly return to the starting position.
Single Leg Hip Thrust With Band
Begin with your mid-back against a bench or elevated surface with your feet hip-width apart. Place a resitsance band just above your knees. Bring one knee up towards your chest to tension the resistance band. The elevated leg should be not only driving up but also slightly out towards your shoulder. While keeping your chin tucked, thrust your hips towards the ceiling. Focus on driving into the floor with your heel and tuck your tailbone. Slowly return back to the starting position and repeat.
Knee Valgus Prevention Exercises – Split Stance Lunge RNT
Reactive Neuromuscular Training (RNT) exercises are excellent to facilitate glute activation and prevent dynamic knee valgus! The video above and below are a couple examples!
Knee Valgus Prevention Exercises – Posterior Step Down RNT
The gluteus maximus is one of the most important muscles that prevents knee valgus. It is not always the case that this muscle may be weak, but it just may not be used as much as it should! It is important to include adequate gluteus maximus strengthening exercises when designing a specific program for each individual to ensure it is not being neglected. In summary, you must not forget to consider weakness or improper neuromuscular facilitation of the “tri-planar muscle”, the gluteus maximus, when addressing impairments potentially causing medial knee collapse!
- Pollard, Christine D., Susan M. Sigward, and Christopher M. Powers. “Limited Hip and Knee Flexion during Landing Is Associated with Increased Frontal Plane Knee Motion and Moments.” Clinical Biomechanics 25.2 (2010): 142-46.
- Powers, Chris M. “Abnormal Movement Mechanics and Injuries of the Lower Quarter: Proximal and Distal Influences.” University of Southern California, Los Angeles. 18 May 2015. Lecture.
- Powers, Christopher M. “The Influence of Abnormal Hip Mechanics on Knee Injury: A Biomechanical Perspective.” J Orthop Sports Phys Ther Journal of Orthopaedic & Sports Physical Therapy 40.2 (2010): 42-51.