Friday Q&A: Alignment of the Knees

Q:  Here is a question for you.  I was practicing Utkatasana Tuesday and as I sat down into the pose I got a twinge in my inner left knee.  (Slightly forward of the seam line, between the upper and lower leg bones.) I straightened up and repeated the pose squeezing a block between my knees. The little pain was gone. How did squeezing a block between my knees change the alignment of the knee?

A:  Utkatasana, mistakenly called “Chair Pose” by some, comes from the Sanskrit root word utkata, which Richard Rosen defines as “exceeding the usual measure, immense, gigantic; richly endowed with, abounding in; drunk, mad, furious; excessive, much; superior, high, proud, haughty; uneven; difficult” (from his book Original Yoga ).  If you have spent any time in this pose, you can certainly get behind the difficult part, but we try to avoid it feeling uneven. (We like to call it "Powerful pose.")

Whenever you have pain in a joint in a yoga pose, look not only to that joint, but also one or two joints above or below that one as you look for an explanation of your pain. Not being able to see our questioner in person, it is hard to say why the pain showed up in the first variation, but any time you are standing and bearing weight on your legs, and you bend the knee joint, there is the potential to compress the joint in an uneven fashion that could result in pain. As I have discussed elsewhere regarding arthritic joints and creating space in the joint, creating a feeling of lift of the femur bone (the upper leg bone) away from the lower leg bones is always a good starting place to see if you can eliminate the pain.

In this situation, placing a block between the thighs and squeezing has many effects, any one of which could have alleviated the knee pain. Squeezing the blocks may change the way the feet are aligned, as they may come closer together, and the weight might shift more towards the inner foot. So, if the feet were the underlying cause of the knee pain, the block squeeze could re-balance the feet.  When looking at the knees, if someone is a bit knock-kneed, with the knees dropping toward one another, the block could move the knees outwards slightly and make more space in the outer knee joint and bring the inner knee joint closer together. If the knees are a bit bow legged, the block squeeze could bring the knees closer together, opening the inner knee joint and narrowing the outer knee joint.  Again, these shifts could alleviate pain in the pose.

If the inner thigh muscles are weak, the squeeze of the block is going to contract them more actively using the five adductor muscles, and this could bring the vertical alignment of the thigh bones back towards even if one is bowing or sagging in or out through the femur bones. And if the outer buttock and hip muscles are really tight and pull legs apart or tend to roll the femurs out a bit into external rotation at the hip joint, the squeeze of the block could help internally rotate the thigh bones to help them adduct a bit closer together, resulting in better alignment at the knee joint. Finally, the block also can activate the quadriceps muscle that tends to be weakest, the vastus medialis (which I believe is discussed in one of my earlier posts on knees). This can help balance out the stronger vastus lateralis, which would tend to pull the femur to the side and roll it out a bit at the knee.

And although this list of possible effects of blocks between the knees is not exhaustive, as you can see there are many potential impacts that could have led to the disappearance of your knee pain.

If you have pain in Utkatasana every time you do it without the block, I’d suggest you use the block regularly for a while, then try it without the block, but with the same alignment and muscle work that you feel when the block is in place. Hopefully this will resolve any pain in this pose, which is one of the original asana that Richard Rosen identifies in his book. He has other useful suggestions for Utkatasana in that book, which is a must-read for any yoga enthusiast!

See Featured Pose: Powerful Pose (Utkatasana) for our instructions on how to do this pose.

—Baxter

Balance and Strength

Today we’re pleased to present a second interview with Shari Ser, a practicing physical therapist and yoga teacher. This time we asked her about strength and balance, as a follow-up to our original conversation about balance in general (see here). 

Nina: Why is strength an important factor in our ability to balance?

Shari: Balance and strength need to go hand in hand like cookies and milk! Muscle strength has to be present in sufficient amounts for us to resist gravity and move our bodies through space, allowing us to sit, to stand, and to walk efficiently. When we are weak, we can’t move efficiently and smoothly, and our effort is often more than the effects we can produce. Strength also has to be reproduce-able and renewable. But muscle strength is very concrete, and it is something that can be improved. Just the act of standing up from a chair 10 times will build your strength. Learning to use your legs instead of your arms to stand from a chair builds strength.

Repetition of effort with your current range of motion builds strength. From coming up from a chair with no arms, you can progress to Powerful pose (Utkatasana) to build back strength as well as arm and leg strength (see here). Using a wall to pike forward over bent knees to come down into Powerful pose is easier than fighting gravity to come up into the pose. But how you use gravity will work differently on your strength. Powerful Pose trains muscles differently depending on how you do it.

For good balance, your muscles have to be both strong enough and coordinated enough to fire on demand, not with a lag time till “everything is set up just right.” So isolated strength training doesn’t translate to improvement in balance. Smoothly transitioning between positions with repetitions will build strength better. Think sun salutations, with countless modifications.

Nina: Are there particular muscles we need to keep strong?

Shari: In order for us to maintain our balance, all our postural muscles need to be kept strong. But gastroc-soleus (one of the calf muscles) is a really big deal in balance, as are hamstring and quadriceps (the backs and fronts of our thighs), quadratus lumborum (a lower back muscle), and the hip abductors, and hip adductors (the inner and outer thighs). And we need the strong back extensors to keep us upright (which is especially important if there is a pendulous abdomen pulling us forward). 

Nina: Can you list some of the key yoga poses for building strength, and explain why you've chosen those particular poses?

Shari: I have touched on Powerful pose already and mentioned Tree pose in a previous post (see here). Warrior 1 and Warrior 2 (see here) are also favorites because any standing pose that puts you into an isometric hold position with a bent knee is going to build strength in the legs. And any pose where a limb is raised up is going to build strength in that limb, and both Warrior poses have raised arms. Warrior 1 is also a backbend, which helps strengthen back extensors.

Nina: This is one of the many reasons why yoga is so wonderful. A well-rounded yoga practice, with an assortment of standing poses, backbends, and twists, helps strengthen the postural muscles you need to maintain good balance as you age. Add to this moving smoothly between poses in some form of sun salutation or moving with your breath between two poses (viniyoga style), and you’re all set!

Shari Ser has over 25 years of orthopedic experience as a physical therapist and has been teaching yoga for a wide range of medical conditions since 1999. She graduated from The Yoga Room Advanced Studies Program in 1999, and was certified as a “Relax and Renew” teacher by Judith Hanson Lasater. She currently  teaches ongoing beginner level and back safe yoga classes, and co-teaches Yoga for Chronic Health Issues at The Yoga Room in Berkeley, California. For information see here.

Featured Pose: Powerful Pose (Utkatasana)

by Baxter and Nina

In his post “Come On, Stand Up, Get Outta that Chair!” (see here), Baxter recommended that Powerful pose (Utkatasana) was one of the most helpful poses for maintaining the ability to move with ease from sitting to standing. And in Shari Ser's workshop on yoga and balance that Nina attended, Shari recommended Powerful pose for balance because it strengthens the thighs and the muscles around the knees (see an interview with Shari here). In addition to improving balance and building leg strength, Powerful pose also opens the upper back and shoulders, as well as strengthening the arms. And the variations described below make this pose accessible to almost anyone.

Powerful Pose (Utkatasana)

Baxter prescribes Powerful pose for:

• improving knee strength and patella tracking
• recovering from illness that resulted in fatigue and weakness (helps you reclaims leg strength)
• preparing for intense physical activity, such as skiing and hiking
• improving balance when you can’t balance on one foot or building leg strength to maintain balance
• improving shoulder mobility

General Instructions:Stand with your feet parallel to each other and hips-distance apart, with your hands on your hips. Keeping your thighs parallel, slowly bend your knees directly forward until your knees are either in line with your toes or just past them. Make sure that your heels do not come off the floor. Tip your hips slightly forward so your torso leans forward over your legs but keep your back elongated (in the same alignment as in Mountain pose).

Now inhale and raise your arms forward and up. If your shoulders are tight, keep your arms parallel to the floor. If your shoulders are more flexible, keep your arms in line with your ears, as shown in the drawing above. To come out of the pose, release your arms, then straighten your legs.

Recommended Timing:30 seconds (6 to 8 breaths) for beginners, working up to 1 minute (12 to 16 breaths).

Some Helpful Variations:

1. To strengthen the muscles of your inner thighs and around your knees (muscles that are weak in many people), use a block between your knees. Use the narrow side of the block (and step your feet a bit closer if necessary)

2. If the full pose is too difficult for you but you wish to practice in the middle of the room, you can bend your knees only slightly, keep your back vertical, and place your hands on your knees.

3. If you have balance issues or are weak, you can work at the wall. Start with your buttocks on the wall but your feet about six inches away from it.

4. If you want focus on strengthening for your thighs and knees, work at a wall as above, but allow yourself to drop lower in the pose. Intense!

If you’d like to see a video that shows how to do this pose, here is a link: