From Chapter 3. The Knee

Making our way up the body, the knee is the next major joint we come to. The femur and tibia, the two longest bones in the body, meet here to create one of the more complicated joints. Knee pain and dysfunction are almost as common as good old back pain. But what else should we expect from a joint that has to perform the type of demanding tasks that we ask of it?

In every workshop I have ever done, the knee is high on people’s priority list. I can’t say I blame them, since the ideal image of yoga in most of the world is someone sitting in Lotus. Therefore, Padmasana becomes a measuring stick for a person’s yoga practice. Of course, there is nothing less in line with a true yoga practice than a determined beginner trying to get into this pose and destroying their knee(s) in the process.

As my teacher John Scott points out, yoga has been plucked out of its cultural context and placed here in the West. In India, sitting on the floor has been a way of life for a long time. Although this is slowly disappearing with Western influence, you still regularly see women squatting to cook, or workers squatting to build things. And let’s not forget the Eastern toilet: beautifully laid porcelain in the floor requiring that you squat to use the toilet! With all of this squatting and sitting in everyday life, Indian hips and knees stay more flexible than ours in the West. Therefore, it is practically assumed that Lotus can be done. Lotus variations are the norm in the culture in which yoga was created.

In the West you will find something completely different. Unfortunately, the transplantation of yoga into our culture often results in suffering knees. It doesn’t mean that we can’t do yoga or Lotus, of course. It just means that we may want to keep cultural differences in mind as we try to plant our own Lotus seeds. We have a different culture, and Lotus is not a natural part of it. It is important to understand all the components of the posture, work with them over time, and let your Lotus grow at its own pace.

The Broader View

The knee is highly influenced by and connected to the joints above and below it, namely the foot and ankle joint below and the hip joint above. Often when injury occurs at the knee, there is some level of dysfunction (excess tension or weakness, or even a previous injury) in one or both of these surrounding joints.

The leg can be described as a kinematic chain. This means that the functions of the three main joints that comprise the leg are linked. Stand up for a moment with your book in hand and bend both knees at the same time; notice how the ankle and hip joints also move to accommodate the bend in the knees. Through its role as the central link in the kinematic chain of the leg, the knee is responsible for guiding and directing the movements of the leg in our daily activities, something as simple as walking or as complex as doing advanced asana.

The knee plays two somewhat contradictory roles: first it must be strong, because a great amount of our body weight passes through it. In addition to strength, it must also be flexible enough to deal with the adaptations of the ankle and foot, which change shape and position. It also must adapt to the hip and its role as we walk. When the balance between these joints and their roles (strength and flexibility) goes awry, the knee often receives the forces.

The Knee and Posture

We started with the foundation of our standing posture, the feet. If there are dysfunctions at this level (for example, flat feet), the ankles, knees, and hips (the joints above it) will have to compensate. Now let’s look at the second link in the chain, the knee.

A simple observation to make when studying the knees is to note the direction in which they face. You could look at the kneecaps as headlights and observe where they’re “shining their light.” Whether in Tadasana, Down Dog, or Triangle Pose, the knees tell a story. It may be a story about themselves, but it’s more likely a story about the hip, ankle, foot, or a combination of them all. As we mentioned in the last chapter, problems below have an effect above. The knee is, therefore, the first joint to feel the effect of a fallen arch or pressure from an ankle that is stuck in Lotus.

Let me share with you my own foot/ankle and knee relationship. Remember my story of breaking my right femur playing soccer? I kicked the soccer ball at the same moment that my much larger neighbor was kicking it in the opposite direction. From my recollection, the soccer ball didn’t move and I was vibrating like a cartoon character. The force of that mutual contact actually broke my femur. I wish I still had the x-ray to share with you here, but it has been lost over the years.

That event influenced that side of my body. My legs are slightly different lengths, which you may observe in an image of me in Headstand (see Figure 3.2). This could be a result of a stronger anterior tilt of the right side of my pelvis. My longer leg may be creating, or may be the result of, the slightly compressed arch in my right foot. This arch is visibly lower and more compressed looking. Who knows? My point is that there is an obvious relation between my foot, the arch, where my knee likes to point, and the tilt in that side of my pelvis; whether or not I can pinpoint the cause isn’t important.

Of course this can change on a moment-to-moment basis. If you look closely, you may be able to see a twist below my knee, essentially between the knee and the foot/ankle. If I add a bit of an arch to my foot, you can see how the direction of the knee changes (see Figure 3.3). Thus, due to the knee’s relation to the joints above and below it, it often reflects what’s going on (tension, weakness, injury, or other converging histories) in the joints surrounding it. This is a great example of the integrated nature of our bodies. Looking at the knee by itself does not give you the whole picture any more than feeling the trunk of an elephant gives you a clear idea of what an elephant looks like. To get the whole picture, we must also look at what is influencing it. This doesn’t just mean the foot, ankle, and hip joints, but also the muscles that cross these joints and their influence.

Basic Anatomy of the Knee

Three bones come together at the knee: the femur, tibia, and patella (kneecap). The technical name for the “knee” is the femoro-tibial joint. It is the connection between the rounded ends of the femur and the relatively flat surface of the top of the tibia. Between and around these two bones are the meniscus, the cruciate ligaments, and the collateral ligaments that help support movement and stability around this joint.

The shapes and angles of the bones are part of the determining factor of the function of this joint. We do not often realize the shape of the femur until we take a close look at it. . . .

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Integrating Anatomy into Your Practice

We’re all familiar with the advice to bend our knees when stooping down to pick up a heavy box. We do this to help distribute the weight from the lower back into the legs. This same concept can be used in our transition in and out of standing postures. Straight-legged standing postures themselves do not call for bending the knees, but in a standing forward bend, Triangle Pose, or any other straight-legged standing pose for that matter, bending the knees distributes the weight in the legs.

Play with entering and exiting a number of standing poses with the legs straight and then with the knees bent. Compare the difference. Bending the knees to transition between postures can be extremely helpful to students with SI, lower back, or knee problems. Once in the final pose, however, you should at the very least be trying to straighten the knees.

Your knees may be indicative of what is happening at the joints and structures that surround them. Take a look at your knees in a simple Downward Facing Dog and see where they point. Bend them slightly, and see if they point straight forward, inwards, or outwards. Better yet, lift your toes and see if this has any effect on your knees. Is there a connection between the feet and the knees?

Try this one. Step into a simple Triangle Pose, and before your reach out to move into the posture, notice where your knee tends to point. Chances are it points inwards. If you bend the knee slightly, you’ll notice that it unlocks the hip and brings the knee to point straight forward over the foot.

Pain in Your Knee During Lotus?

At a workshop, when I ask who has knee pain, approximately 80 percent of those who complain about knee pain in a Lotus type of posture (where the leg is flexed and rotated) say they experience pain on the inside (medial) of the knee. Approximately 10 to 15 percent complain about pain on the outside (lateral) of the knee. The rest usually complain about pain through the centerline of their knee or around the kneecap. All three areas express stress in the knee in different ways.

Pain on the inside of the knee is the most common knee pain associated with the leg being in Half- or Full-Lotus Pose. Using statistics from my own personal observations, I’ve come up with a working hypothesis: the most common cause of pain on the medial knee is compression of the medial meniscus. Please note that I am not suggesting that all pain on the inside of the knee is coming from the medial meniscus. Nor am I saying that pain on the inside of your knee during Half- or Full Lotus means you have already torn your meniscus. You may simply be irritating it. There are other structures in this area that can get inflamed or irritated and cause pain on the inside of the knee. For instance, the MCL and various muscles crossing the inside of the knee, and even the joint capsule itself, can get compressed and irritated.

One reason I first suspect medial meniscus compression is that I’ve heard stories of many people who complain about pain on the inside of their knees who eventually experience a “pop” in Lotus position. Swelling in the back of the knee and sometimes a regular clicking sound follows the pop. It is also possible that the knee will lock intermittently after the original pop occurs. All of these are classic signs and symptoms of a meniscus tear. The best way to confirm if the meniscus has torn is to go to the doctor and have an MRI scan taken.

Lotus can involve the two movements which, when combined, put the most amount of pressure on the medial meniscus: flexion of the knee and internal (medial) rotation of the tibia. Instead, what we want is for both the femur and tibia to rotate externally. If the tibia doesn’t have enough outward rotation, there could still be enough in the hip to make up for it, or vice versa. If, however, both the tibia and the femur lack the ability to rotate externally, you end up with more internal rotation, which can put pressure onto the medial meniscus. When you combine this with a flexed knee, as in Lotus, you end up with even more pressure on the medial meniscus. If the hips are tight, it is common to feel pressure in the knees.

There are two ways of dealing with this. The first is an immediate response: the moment you feel the sensation of pain, place one hand on your thigh near your knee and the other on your calf muscle.

Try externally rotating both of them, as if you are creating space between the ends of the two bones rotationally. You could also prop the knee higher with a block or a bolster to see if that alleviates the pressure or pain.

The long-term solution is to lengthen the tissues in the hip that are restricting external rotation of that joint. (See Chapter 4, pages 106–107 for specific stretches to lengthen the muscles around the hips.)