Have you ever seen someone squat in the gym with their knees about to touch? What about that time you were running behind someone and watched their knees give in whenever their foot hit the ground? A voice deep inside of you says that doesn’t look right. Their knee is basically caving in. Then, you are at the gym one day and record yourself squatting or watch yourself squat in the mirror, and then suddenly you realize YOUR knees cave in too! Is this normal??
The short answer is no – as this movement pattern has been highly correlated with an increase in both traumatic (ex: ACL tear) and non-traumatic (ex: patellar tendinosis) injuries. However, this movement pattern is so common, some might consider it normal. Let’s first talk about what’s going on here. Firstly, this movement pattern is known as dynamic knee valgus, also referred to as valgus collapse or knee caving. The knee joint functions generally as a hinge joint; however, it also rotates subtly both in internal and external rotation as we flex and extend out leg. This mild rotation cannot be overlooked. If we develop excessive amounts of rotation in either direction, shear forces increase, and pain can result.
Knee valgus occurs when we combo this excessive rotation with hip adduction and often opposite side pelvis/hip drop. Now, many athletes will display this movement pattern without pain – this relates directly to their tissue tolerance. These athletes haven’t created enough shear yet to reach the pain threshold, and often they can get away with it, sometimes for a long period of time. However, if left untreated, it can lead to patella-femoral pain syndrome, IT band syndrome, patellar tendinosis, hamstring tendinopathy, meniscal tears, ligamentous injuries and a host of other issues up and down the chain.
So what causes excessive rotation at the knee?
For starters, women are more likely than men to display this movement pattern during activity, much of which is related to their anatomy (wider hips and “Q” angle – see below). It’s also commonly seen in sports or activities that require ‘toeing out’ such as with ballet dancers, soccer, basketball, and ice skaters. Some people may have structural factors such as natural bone structure in their hips, knees, and ankles which may predispose them to have more knee valgus than others. However, the knee valgus we refer to the most is dynamic knee valgus which occurs during movement, and often due to a variety of modifiable risk factors. It’s often correlated with squatting, jumping, running, lunging, but can be present anytime we bend our knee while weight bearing.
Here are the top reasons dynamic valgus can occur:
Knee valgus could initiate from a combination of these factors, but once it “sets-in,” it becomes a brain/nerve problem (muscle memory) and not just a strength or flexibility problem. Therefore, you’ll always have to re-groove squat patterns even after restoring impairments or imbalances.
If your dealing with this movement pattern, you need to put in effort to correct it. Understand that just because you may not have pain at the moment, it doesn’t mean that its normal. Making efforts to keep your knees in relative alignment with your hips and ankles when your workout can go a long way. First see if you can correct the movement pattern by simply paying more attention to your technique. If it still feels very difficult, it may be related to your mobility (hips and/or ankles) or your strength balance (glute max and glute med primarily). Check out our YouTube channel for great hip and ankle mobility exercises. For strengthening; exercises like deadlifts, lunges, step ups, side steps, or KB swings – all of which target the glutes – are great options. If you’re dealing with knee pain and want the fast track back to 100%, we can get you there. E-mail firstname.lastname@example.org or click the button below to get started!
Thanks for reading,
Edited by Dr. Andrew
The diaphragm plays a major role in trunk stabilization and posture by creating and modulating the correct amount of IAP to minimize excessive spinal motion during movement in sports. As the intensity of any activity increases, the tendency is for less diaphragmatic activity and increased thoracic breathing, or "chest breathing.” Chest breathing is produced by the accessory muscles of respiration, which includes the upper traps and many of the neck muscles. It becomes problematic during breathing when these dominate over the lower muscles such as the diaphragm. Over-activity of these accessory muscles have been also linked to many postural and motor control issues, especially in the neck and shoulders, and reduces the ability to produce sufficient IAP for proper stability during activity.
Okay, so what exactly is diaphragmatic breathing?
Let's first talk about what it’s not. Diaphragmatic breathing is NOT the same as belly breathing. When someone takes a deep breath and you see only their belly rise, many people think this is the proper cue because it appears they are using the diaphragm correctly – but it’s actually incorrect.
The key to proper diaphragmatic breathing is what we call 360 breathing – where you get 360 degrees of abdominal expansion. We don’t just want a forward distention of the belly as in belly breathing, we want a 3 dimensional expansion – forward, backward, and side-to-side. We want to see this without too much upward movement of the chest. 360 breathing is key for IAP development, and that’s true core stability. The better you can perfect 360 breathing, the more effective those big breathes prior to a 1RM squat will be, and the more efficient your CrossFit workouts will become.
When it comes to our CrossFit and weightlifting workouts, we need to be able to do 2 things well. We need to achieve what the experts call: (1) synchronization with movement and (2) coordination during recovery.
Synchronization with movement is basically the ability to have the diaphragm create the necessary IAP to provide core stability for that specific movement demand. For example – when you are doing a heavy lift, let’s just say a deadlift. Prior to the lift, you inhale. As you initiate the lift, which is typically the heaviest part, you hold that breath which creates your IAP to stabilize. Some people maintain this hold throughout the lift, and some people slowly exhale throughout the lift. Doesn’t matter. The most important aspect was the synchronization of the most IAP with the most difficult part of the lift, which was the initiation. Ideally, we want really good synchronization of breathing during any kind of performance. A great example is the barbell thruster. You all know how important it is to exhale in rhythm at the top of the lift. The key is to take that same concept and apply it to all our movements.
In regards to coordination during recovery, this refers to recovery both during our CrossFit workouts, and afterwards. The goal is to maximize the total amount of air we breathe both in and out as much as possible, which will allow the most oxygen intake and carbon dioxide output. This occurs if the diaphragm is allowed to move through the zone completely….which means minimizing chest breathing.
SO during our workouts we need focus on controlled 360 diaphragmatic breathing, not just when were tired, but from the get-go. Remember – the diaphragm is a muscle, so it responds to stimulus and it can be trained. The more you practice, the better it will function and the better you will feel!
Thanks for reading,
Other than bracing for a heavy lift, most CrossFit athletes don’t pay much attention to the way they're breathing—inside or outside the gym. How many times a day do you think we breathe? Typically over 20,000 times! Breathing is a foundational movement that plays a critical role in not only oxygen in and carbon dioxide out, but..
Shallow breathing, which is using the chest and not the diaphragm, is a very common dysfunctional breathing pattern that doesn't allow you to get as much oxygen as you otherwise would — it mimics the type of breathing common during stressful situations.
You see this all the time in athletes. They will perform a tough workout, and they will partially hinge over, hands on their knees, and drop their head down and try to catch their breath. And you will see their shoulders are up by their ears. I’m guilty of this at times as well – over the past few months as I’ve revisited these concepts I’ve been able to adjust my ability to recover through proper breathing, and it’s made a HUGE difference. There's nothing worse than being dead out of breathe during these workouts without muscle fatigue.
Okay so what exactly is going on here? Well, dysfunctional breathing can have many negative consequences on respiratory chemistry which can have a huge effect on a wide range of system functions….. respiratory chemistry meaning the balance of chemicals in your lungs and breathing systems:
1). Chest breathing causes an increased amount of CO2 in your body, which increases the acidity of your blood. The more acidic your blood becomes, the more inefficient your muscles will be, and overall performance will suffer.
2.) Elevated CO2 levels also put your body in what's called a “fight or flight” state -- which is a stress response that occurs in your body during a threatening situation. This can increase HR, increase anxiety, increase stress, impair reflexes, and impair focus.
3.) Speaking of focus – How many of you have pile-drived through a workout and midway through suddenly can’t remember what round you’re on or what your rep count is? Breathing affects this as well. Being focused on the task at hand is just as important as performing the task.
Focusing on breathing correctly (think quality vs quantity) will create:
Now, we talked a bit about performance, but what about injury? Dysfunctional breathing patterns have been shown to play a significant role in posture, technique, and movement control associated with back, neck, hip, and shoulder pain. Here are some examples:
The spine is one of the most frequently injured body regions in CrossFit. There are a few things happening here with excessive chest breathers (these are related to non-acute injuries):
It’s important to recognize that dysfunctional breathing has been recognized for many years as a potential source of a wide variety of unexplained symptoms. If you're one of those people that’s had continued issues in any of these areas, you’ve received treatment, but things still linger or come back, I highly recommend you consider your breathing patterns and implement some of the concepts I'm about to talk about.
What’s also important is to recognize that your breathing patterns play a crucial role in core stability.
Core stability must come from the inside out, not the outside in -- such as weight belts for example.
A healthy spine is dependent on strong core stability and the dynamic coordination of many muscles especially the deep abdominal muscles. Are you familiar with what IAP is? – it’s that big breathe you take prior to big lifts, and it’s the smaller controlled breathes you take to do burpees for example so you don’t flop like a worm. Simply put, it’s the pressure your body generates from within to keep you safe during workouts.
Intra-abdominal pressure (IAP) is an important parameter that influences spinal mechanics and stiffness….. And its generated by the muscles of respiration aka breathing. What muscle is main key driver of breathing?
Check out Part 2 to find out, AND learn how to breath correctly to boost performance!
So you’ve been crushing it at the gym over the past few months. Your body is getting stronger and your conditioning is improving. You can do a ton more now compared to when you first started working out. You’re finally starting to feel like an athlete! Until one day you begin to notice some nagging pain after your finish up a workout. At first it's not bad and you ignore it, but then it starts to progress and interfere with your lifts. All the sudden you’re modifying all your workouts and you’re experiencing pain through non-gym activities as well. Now a couple of weeks have gone by and your shoulder continues to get worse. You’re frustrated!
You’re also not alone. By some estimates, as many as 67% of people experience shoulder discomfort at some point over the course of their lives. It's also the most commonly injured body region in CrossFit athletes. And by all accounts, I agree. 3 out of the last 4 new patients that have come to see me were for shoulder issues. Below I listed some things to consider if you’ve been dealing with nagging shoulder pain -- check them out, and make adjustments as needed.
Do you have an appropriate balance of shoulder mobility and stability?
First things first, let’s clarify what these terms mean. “Mobility” refers to the ability for you to access a particular range of motion, whereas “stability” refers to the ability to be strong and sturdy throughout the range of motion, including end range (ex: when the arm is fully overhead). CrossFit, for example, is a unique sport in that not only demands extreme end-range mobility, but also adequate stability at those end ranges to handle heavy loads. If you lack the appropriate mobility to get your shoulder into the positions required to perform the exercise -- don’t force it! While i’m certainly an advocate of working into an exercise with a limitation (ex: front rack position), you don’t want to force it, repetitively, under load, during a high intensity workout. That’s just a recipe for an injury.
Do you have balanced programming?
Whether you design your workouts yourself, or follow a gyms programming (such as CrossFit or weight lifting), its very easy to develop strength imbalances between opposing muscle groups. The two most common shoulder imbalances that arise are pushing vs pulling strength and “large muscle” vs “smaller muscle” strength, so let’s talk about each.
Pushing exercises include those that push weight away from you -- the push-up, bench press, shoulder press, push press, etc. Pulling exercises are just the opposite; those that pull weight towards you -- pull-ups, rowing, power cleans, deadlifts, etc. If you’re programming has a tendency to overwork one particular direction, imbalances can develop over time and pain can arise.
Another important imbalance involves over-dominance of the larger muscle groups -- particularly the lats, pec major, and teres major. A healthy shoulder is one where the ball (upper arm bone called the humerus) stays centered in the socket (shoulder blade, aka the scapula) during movement. When these larger muscles over-dominate over the smaller ones (specifically the rotator cuff and scapular muscles), the ball moves and glides excessively, failing to stay centered in the socket, and often leading to impingement and pain. While the “beach” muscles are fun to train, attention needs to also be directed towards stabilization and accessory exercises of the little guys.
Do you sleep on your shoulder?
Our bodies heal and recovery while we sleep. If you’re dealing with nagging shoulder pain, the last thing you want to do is sleep on it. Studies have shown that sleeping on your shoulder literally cuts off the blood supply to the rotator cuff tendons, which commonly are the irritated structures that cause shoulder pain. Make it a point to not sleep on your shoulder at night, or on your stomach with your arm overhead for that matter (just as bad, if not worse). Try sleeping with your injured shoulder towards the ceiling and a pillow between your arm and your body. You should wake up everyday feeling refreshed and pain free. If this isn’t the case, adjust accordingly!
Do you also have neck pain or pain that radiates down the arm?
Most shoulder pain results from an injury or condition in the shoulder itself. However, pain in the shoulder region can also stem from elsewhere in the body, especially the neck. If your shoulder pain is also accompanied by neck pain or stiffness, it may be the neck that’s the primary issue, particularly if your pain is located in the upper trap, near the shoulder blade, or radiates down the arm. Each area of the body requires different treatments. To help you better pinpoint what the source of the problem is check out these lists below:
When the shoulder is the suspect:
When the neck is the likely culprit:
So what should you do if you’re dealing with a shoulder injury? The best answer is to get yourself checked out before starting some significant training. The shoulder is one of the most common areas of the body we treat. If you’re in the Charlotte area and you’ve been dealing with a shoulder injury, give us a call. We can help get you back to do what you love faster than any other medical group in the area.
This is where we share our expert opinion on hot topics in physical therapy, injury prevention, sports performance, strength and conditioning, nutrition, and sometimes other random thoughts. Enjoy.