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Episode 78: Behemoth Knee Myths
1.3k Plays3 months ago
Welcome to Episode 78 of the Movement Logic podcast! In this episode, Laurel and Sarah discuss what current science, versus outdated advice and conventional wisdom, have to say about the knees—namely whether “bone on bone” is a thing, and if deep squats, knee valgus aka “knee cave”, or high impact are inherently bad for your knees. Learn what research has to say about some of the most common fragilizing beliefs people hear about their knees, and why these scary tales are just plain wrong. In this episode you will learn that:
- The knee is strong and adaptable, capable of handling various loads with training.
- The knee has a wide range of safe positions, especially with progressive exposure.
- Knee pain doesn’t always mean injury, and injuries can heal with proper care.
- The knee isn't a simple hinge; it allows rotational and lateral movement.
- The kneecap doesn’t always need to face forward in standing.
- Knees can lock or hyperextend without causing harm, depending on the person.
- The knee can safely move past the ankle and toes during squats or lunges.
- Running and landing don’t require the knee to track perfectly forward.
- Knee valgus is not inherently dangerous.
- Deep squats, high-intensity exercise, and running do not cause arthritis or "wear and tear"; they strengthen the knee.
- Strength training and running thicken knee cartilage compared to inactivity.
Sign up here for our FREE Live Strength Class (and sample our Bone Density Course) on September 19th at 8:30am PT/11:30am ET with free replay!
Analysis of the load on the knee joint and vertebral column with changes in squatting depth - PMID: 23821469
Positive effects of moderate exercise on glycosaminoglycan content in knee cartilage - PMID: 16258919
Thickening of the knee joint cartilage in elite weightlifters as a potential adaptation mechanism - PMID: 24648385
Exercise for osteoarthritis of the knee: a Cochrane systematic review - PMID: 26405113
Knee alignment does not predict incident osteoarthritis - PMID: 17393450
Gluteal muscle weakness on joint kinematics - PMID: 37309814
The effect of experimentally induced gluteal muscle weakness on joint kinematics - PMID: 37309814
Impact of Three Strengthening Exercises on Dynamic Knee Valgus - PMID: 34068810
Anteromedial versus posterolateral hip musculature strengthening with dose-controlled in women with patellofemoral pain - PMID: 33689989
Kiss goodbye to the 'kissing knees' - PMID: 33906580
Research on Crossfit injury risk - PMID: 24276294, PMID: 28253059, PMID: 32343082, PMID: 33322981
Instagram post about Sharon Lokedi
Low Prevalence of Hip and Knee Arthritis in Active Marathon Runners - PMID: 29342063
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Transcript
Introduction and Dance Class Excitement
00:00:00
Speaker
Noisy knees. Crikey, cracky, clicky, clacky, snap, pop, pop, pop, pop, pop, pop, pop, pop, pop, pop, pop, pop, pop, pop, pop, pop, pop, pop, pop, pop, pop, pop
00:00:19
Speaker
my knees a noisy mane and noisy is this bad is this a red
00:00:26
Speaker
Welcome to the Movement Logic Podcast with yoga teacher and strength coach Laurel Beaversdorf and physical therapist, Dr. Sarah Court. With over 30 years combined experience in the yoga, movement, and physical therapy worlds, we believe in strong opinions loosely held, which means we're not hyping outdated movement concepts. Instead, we're here with up-to-date and cutting-edge tools, evidence, and ideas to help you as a mover and a teacher.
00:01:01
Speaker
Welcome to the Movement Logic Podcast. I'm Laurel Beiberstorff, and I'm here with my co-host, Dr. Sarah Court. We are together. Yay! And we are going dancing tonight. We are going dancing tonight. Which I'm excited and a little bit nervous about.
00:01:17
Speaker
Yeah, I mean, I haven't been. we're So we're going to a dance class with our friend, Trina Altman, and with Adam Macatee, and some other people that I don't know that I know. But Trina is like the gatherer of people. like she's so so She's so much more social than I am. yep She's like, I want to go to this class, and here's 10 other people that I know. And I'm like, ah do I know 10 people? Not let alone 10 people that want to go to a dance class.
00:01:39
Speaker
I tried to get my boyfriend to come. He said, no, thank you, which I understand. But yeah, I haven't been to a dance class since before the pandemic. Like a lot like in person live dance class. I'm very excited. I think Nathan and I tried to do some salsa dance classes way back in the day. fine And that's the last dance class I've been to. Nice. Yeah. So are we going to look like, as Nikki, no, Levi likes to say, a bunch of popsicle sticks? Flying through the air. Flying through the air? Correct. We're going to be great. Yes.
Free Class Announcement and Bone Density Benefits
00:02:08
Speaker
Sarah, tell us about this free class we have coming up. Yeah, so we did this last year before we launched our first bone density course. And essentially, we're doing it again this year because it's a way for people who are maybe interested in the course or curious and want to see what it's like. We're going to teach a live class.
00:02:24
Speaker
the same way that we teach class during our program. so And it's actually the first class of the program. That is going to be on September 19th, which is a Thursday at 8 30 in the morning, Pacific time 11 30 Eastern time. So what happens in the class is you get the zoom link, you show up, you can, we're going to be teaching with barbells. If you don't have barbells, no sweat. You just use whatever weight you have available.
00:02:49
Speaker
But you'll get a sense of like, what is this kind of a class like? And I think the other thing that it helps people realize is because sometimes I think there's a bit of a disconnect when like, how am I going to do this online? We have both been teaching online for many, many years now. And I think we're pretty good at it. I think so. And I i think we're awesome. Yeah. So what will happen? So what will happen in the class is, you know, if you feel self-conscious, leave your camera off.
00:03:14
Speaker
If you want us to give you feedback on your form, leave your camera on. If you have questions about things, we'll answer them. And you basically get a chance to just kind of get ah a sample, a taste test. It's like one of those little spoons of ice cream at the ice cream store where you're you're going to get a little spoon of strength training and feel what it feels like because I don't know if you know this, Laurel, but ah heavy strength training and impact training are really the only really well-documented and proven methods to improve bone density. Nice. Did you know that? Yes. And to get strong as fuck. Yeah. I mean, the other side effects is you'll be strong as hell. You are going to be like... The one thing that we both love so much that happened to the last group is they all got like huge confidence boosts out of it. Like I almost cared about that more than anything else, right?
00:04:05
Speaker
So anyway, you're going to get a chance to do all of that. So the way you get into that class is you sign up at the link in the show notes, or if you're on Instagram, the link will be in the bio. Sarah, tell us about this program. Oh, so artt you mean our bone density course, Lift for Longevity? Oh yeah, that one. That one.
00:04:22
Speaker
It's awesome. ah we This is our second time doing it. We did it last year. We had a great time. We had 90 women show up, which has blew us away, and we got all of these 90 women who were working out in their bedroom or their dining room or their living room. Some of them were going to the gym, but we got them confident and comfortable with using barbells specifically to get stronger because One of the things that you know didn't really occur to me until I started lifting barbells is if you're lifting dumbbells, you're going to really pretty quickly not be able to keep strengthening your lower body. yeah because For example, I can put a 100-pound barbell with weights on my back and do back squats, but I cannot pick up two 50-pound dumbbells and get them ... I mean, I would have to do a biceps curl. I can't. I literally cannot.
00:05:12
Speaker
so it's a It's an incredibly easy tool to use and much easier than I think a lot of women have been led to believe. Yeah, and so we have this six month barbell course that we're going to be running in early October and we've got a free class that you can take to get a feel, to get a taste of what this course will be like in addition to the live classes, which you will get a taste test of in this free free class.
00:05:38
Speaker
There's also ah many, many hours of pre-recorded content that you get to keep forever. So come to the free class and find out if this way of getting strong as fuck is for you, if this course might be for you, and we'd love to see you there.
Exploration of Knee Misconceptions
00:05:55
Speaker
All right, today we're talking about Nemeths. Behemoth Nemeths.
00:06:01
Speaker
This is the title, you guys. This is the title that when I saw it, I was like, I might as well just like hang up my shoes and give up on titles because, fucking behemoth-nemeths. I've just been walking around for two days going, behemoth-nemeth, behemoth-nemeth, behemoth. I don't even know what kind of like,
00:06:19
Speaker
savant level, like moment of genius. It's just so good. I love that you love this title as much as you do. So we are going to be talking about some behemoth, nemeth, and smaller ones too, around certain bigger knee topics. We'll just call them, okay? So these topics include knees over toes or knees past toes. Should you do that? Knee valgus, aka the knee boogeyman, or as Adam Meekins calls it, knee-bola.
00:06:48
Speaker
Maybe more commonly you've heard this described as knee cave in strength training or knees collapsing inward, knock knees in yoga or in life. Additionally, we'll talk about knee arthritis or wear and tear or bone on bone. yeah So Sarah, paint me a picture. Let's use broad brush strokes.
00:07:10
Speaker
We'll fill in the details in a moment, but on the most general generic level possible, what are in your mind the most common negative pessimistic default assumptions people make about knees? Well, I have people come into the clinic and they'll tell me things like, I've got weak knees, which I'm always a bit of like, your knee's a joint. how is it like you might have Your muscles might not be that strong, but your knees themselves, like this idea that oh they're they're just going to give out at any moment, like that they're fragile somehow.
00:07:36
Speaker
Uh, and then also, you know, knees must always track in a straight line forwards, right? That's, there's, that's the only safe place for your knee, right? You've got to keep your knee safe because you've got to keep it just pointing straight forward. Um, and that knee pain means that there's something wrong with your knee when in fact, I mean, sometimes it does, but sometimes it means something's going ah funky above it or below it. Right. And it's just the knee is taking the brunt of the force that it can't handle. And that's why your knee is hurting.
00:08:05
Speaker
Yeah. Yeah. I heard a lot that knees don't heal that because the a lot of the tissues that make up the knee are a vascular that like if you injure your knee, it's game over. Wow. That's really in intense. Super pessimistic, right? I actually, um, when I had my hip replacement, so this is in 2013 or something.
00:08:24
Speaker
I start, right after I had the hip replacement, I started having knee pain. And I was like, mother fucker. I just had a like one joint replaced and now another joint is a problem. And so when I went to my PT, she watched me walking and she was like, oh no, you're just not moving your ankle very much right now. And that's why your knee is hurting. And she fixed my ankle and my knee pain went away. So yeah.
00:08:45
Speaker
ah yay So, knees can heal. They sure can. That's what you're saying. That's good. So, there are also some anatomical or maybe biomechanical misunderstandings about the knee. Do you want to talk about some of those? Well, that the knee is just a hinge. Right. It's just flexion in the next sense. Yeah. All it does is flexion extension movement in that sagittal plane forwards backwards. Which is not true. It's not true.
00:09:10
Speaker
what is What does it do? ah It is a what's called a modified hinge, which means it can actually do some rotation under. Oh, are you a horse?
00:09:24
Speaker
And then the other, this horse is very excited about the potential neat knee rotations that it's about to be able to do. There's also this idea that you should never lock your knee, that that's bad, or that you should never, like your knee can't twist, right?
00:09:37
Speaker
Or hyper-extend. Or hyper-extend, right? That all of those things are wrong. Wait, so they're not? but Yes. The locking and the hyper-extending is not wrong? It's it's fine. Wait a second. Yes. Wait a second. But I'm experiencing so much cognitive dissonance because I heard that my knee, when it's locked or hyper-extended, is more at risk. At risk for what?
00:10:02
Speaker
exactly never healing oh wow this sounds really terrible right and like you should never get up again I think it's true in all seriousness that it's not always the best position for every single person in every single activity to have their knee fully locked or hyper extended, but maybe we could talk just for a second about One of the biggest advantages of having a knee that can fully straighten or even straighten past straight or you know lock like Why evolutionarily speaking are we able to do that if it were so bad in other words? We probably would have evolved to never be or not be able to straighten our knees, right? Yeah um Why is it an advantage to be able to straighten or lock our knees? Well, it actually does a lot of what's called energy conservation because then you're not
00:10:49
Speaker
uh the muscles around the knee are not having to work so hard i learned this recently when i went to this motorcycle dirt dirt bike training And one of the things they teach you is how to stand up on the bike, which is moderately terrifying in the beginning. And then you realize it's actually super fun and it's a lot like when I used to stand up on my bike as a kid. But one of the things they they were like, the the instructor kept saying is like, get your knees all the way straight because that position on a dirt bike is what they call their energy conserving position. But you're not conserving energy if you're like partially squatting for 10 minutes. yeah That sounds exhausting. Yeah. um I've heard, correct me if I'm wrong, that
00:11:26
Speaker
five to 10 degrees of hyperextension is actually considered to be normal. Yeah. I mean, I think as well, there's not this idea of like the knee is supposed to be at zero degrees and only there, so like not past it and not in front of it. You know, there's, I think there's a much ah more generous range between, you know, what we might call like ah microflection, right? So like five degrees of flexion to, you know, five or 10 degrees of hyperextension that in that window,
00:11:56
Speaker
is normal and fine. That's so good to know. It is. All right. But Sarah, I find that knee managing happens a lot in all kinds of movement contexts, maybe for beneficial purposes and maybe not. I was, I think, taught more to micromanage people's knees in yoga and to watch everyone's knees like a fire ranger in a tower looking for smoke. If I saw the knee of a student deviate outside of this very narrow range of safe positions relative to the hip, relative to the foot. Basically anything outside of flexion and extension where the knee was over the ankle, definitely not past the toes, tracking in line with the second and third toe, never hyperextended, right? I assumed it was either pain or an injury, which just waiting to happen. And so I would swoop in to rescue or, you know, put out that fire, which is actually a phrase I used.
00:12:52
Speaker
Hence the Fire Ranger reference. I basically made it my mission and brand, alignment-based teacher here, to educate students on quote, good joint mechanics, quote, safe movement, safe postures. And this included, of course, the knees. In fact, in my 200 and 300 hour teacher training, we were taught that the knee was actually one of the three risk factors of the body. Wait, sorry. Sarah, keep it together. sorry Yeah, risk factors, you know, like smoking or a parent who had cancer or high blood pressure. No, but so just having a knee is a risk as a risk factor for what? Knee explosions? For knee problems. Oh. It was basically an area we were taught to pay wait what were the other two a lot of attention to was the neck and the lower back.
00:13:39
Speaker
were also considered risk factors. Just having them. Just having them. Just that there were joints jointing about, you know, doing their joint thing, letting us move. Oh my God. Yeah. Yeah. So that that language, right? I feel like it's just very representative of the type of language you hear about the knee, which is usually pretty pessimistic, pretty dismal. I mean, you know, when I was a yoga teacher as well, like I absolutely thought I was saving lives.
00:14:06
Speaker
By making people's knees stay right over their ankle and not go in or out or if their knee was hyper extending or a little too I didn't like what the way it looked making them you know micro bend it in like triangle pose right where your leg is straight.
00:14:22
Speaker
I now hate the word slash, ver I don't even know if it's a real word, microbend. I wanna throw it in the trash and set the trash on fire. I just hate that word so much. But yeah, this idea that like, neat, like people are gonna hurt their, and you gotta you gotta get in there and like prevent, like put the fire, like you said, put the fire out, right? um And i you know I think we all did that. I mean, I have a story from a friend of ours who's a teacher where,
00:14:49
Speaker
You know, she spent so much time putting this one student's knee in the right place that he then just would like wait for her to do it. That was his expectation as part of the classes. He would look at his knee and he would look at her and she'd run over there and put the knee in the right place. I know. that is All right, so generally again, because we do, Sarah and I really do like to untangle the ways that aesthetics, okay, get conflated with other things like capacity, function, pain, this trio capacity, function, pain, I think we could put under the single umbrella term of health, right? We we often see a conflation of aesthetics with this trio under the umbrella of health.
00:15:34
Speaker
Paint us a picture of what are the ways people conflate how the knee is supposed to look or move on an aesthetic level with knee health according to you know conventional wisdom. Yeah. Well, so when you're standing, your your patella, your kneecap is supposed to point straight ahead.
00:15:54
Speaker
Right? But I mean, I've done this in the yoga teacher trainings where I teach anatomy. I'll have someone come to the front and I'll be like, all right, well, sure, let's make their knees point straightforward. And then we make their knees point straightforward and then their feet are now turned in. And I'm like, all right, well, now how are we going to fix their feet? So let's turn their feet forward and then their knees point out. And I'm i'm like, well, which one is it? And the students look very confused because they're like, uh-huh. And I'm like, no, here's the point is that there's so much variation in the torque of like your tibia, right? The rotation through the bone and your femur. Your patella and your feet can point any goddamn way they want. and And there's something called a screw-home mechanism. Yes. Where when the knee extends, starting at some position close to extension and leading fully through extension, that there is rotation that does have to happen at the knee for the knee to lock it. Like there's a key turning in a lock basically. yeah
00:16:47
Speaker
Yeah, cool. What else? So that's one, ah you know, we talked about micro bending already a little bit, like you should never lock your knee, you should never hyperextend your knee. And, you know, as someone who has hyper mobility
Personal Stories and Knee Myths in Yoga
00:16:59
Speaker
in various joints in my body, I tend to habitually not lock my knees backwards because it starts to feel kind of achy at this point. I'm basically almost 50. Can you believe it? um No.
00:17:17
Speaker
What am I supposed to say? I don't know. What's the right answer? ah but yeah i mean it's not It's not illegal for your knees to go into a locked position. You may choose if you are a chronic hyperextender person like me to just build strength all the way around the knee so that it's supported in all of the positions. but Again, we talk about this idea of locking your knees as an energy conserving practice. So we don't want to not do it. um So then the other one is when you bend your knee, it shouldn't go past your ankle, right? And it definitely shouldn't go past your toes. And that's very often the cue that we hear in like warrior two or any of those front leg bent poses, side ankle pose, things like that in yoga.
00:18:00
Speaker
But there's also other yoga poses where your knees are allowed to go well past your ankles, like malasana, your deep squat or chair pose, right? So why is the physics true at one point in the class, but not true in the other part of the class? And then also like, I dare you to go through your day and not let your knees go past. You can't get out of a chair.
00:18:20
Speaker
if your knees don't go past your toes. But if you don't believe me, give it a go. Yeah, and also pick up heavy box up off the floor while you're at it, yeah or maybe go up the stairs. I mean, yeah, a lot of things would not work. um And then, yeah, this idea that your knee always needs to be centered over your foot, it always needs to be tracking over your foot, it's just not true. And so when earlier, when we were saying the the myth about that the knee is just a hinge, when your knee is flexed, you then can rotate your knee So your knee can do internal and external rotation in flexion. It can't when it's fully extended. Right. When it's fully extended, it's in that locked out position. It can't as soon as you start to bend it, it can't. So if it couldn't, like I want you to try to imagine like actually like going for a run and not having any anything available to your knees, but just literally flexion extension. Like if you really tried to do that, you probably would have to just like land on ah like a smack
00:19:16
Speaker
flat foot. like yeah It doesn't permit proper ankle movement. Well, I got into trail running and I'm probably going to be betting back into trail running because I'm apparently doing a race so soon. So should probably start that. um And when you're running on trails, there's so much in your way and it's so uneven and it's it would be impossible not to fall on your ass every 10 steps if your foot wasn't allowed to interface with the ground and of course the foot is incredibly wonderfully flexible but in part because your knee rotates you're able to meet the ground at varying different angles. Yeah. Just make it so hard also to pivot or cut in sporting movements like. Yeah. Yeah. A lot of things would be basically impossible. Go watch some professional baseball players. Or basketball players. That's the one I meant to say. Baseball and basketball. But I was thinking basketball and I said baseball. Right. Or soccer. Or basketball.
00:20:11
Speaker
But yeah, just go watch some professional athletes playing a ball sport. Tennis. Volleyball. um ah What's the one with shuttlecock? What's that one called? Badminton. That's a ball sport. Ping pong. Badminton is actually not a ball one. It's a birdie one. Shuttlecock.
00:20:33
Speaker
Anyway, go watch all those people and then see if see what you think. So the last one is like landing from a jump, right? or Wait a second. You're saying that the knees can track inward when landing from a jump? yeah Oh, what? yeah Wait, that's wrong. No, it's not. It must be. But it's not. How's your brain? Is it feeling conflicted? It feels tight. Are you feeling uncomfortable? Yes. That is cognitive dissonance, friends. You better get used to it.
00:21:01
Speaker
All right. Well, Sarah, do you here's another question. It's a little off topic. Do you ever feel like a broken record? Sometimes I feel like a plastic bag.
00:21:11
Speaker
Isn't that the Katy Perry song? Do you ever feel like a paper bag? Ah, paper. Something, something, something. I really should have worked on that. I like plastic bag though. Yeah. No, I often feel like a broken record. I feel like I'm saying the same thing over and over and over and over again with a different photo, a different video, a different carousel. I know, I know. You and I, we've been in this process of deprogramming old outdated beliefs, fear-mongering, pessimistic dismal beliefs about posture and pain, and then, of course, replacing those with more evidence-based optimistic
00:21:44
Speaker
empowering beliefs, you know, I'm pretty sure that other teachers around us who might be in our sphere, like on social media or whatever are doing the exact same thing. And so I'll say something for the one billionth time and be like, Oh, shut up. Like everyone knows this now. Like it's time to move on. Right. And yet it's really amazing to me how often with my work with one-on-one personal trading clients, especially where I will encounter these old outdated beliefs still to this day. And they're still floating around out there in the general public. And I feel like it's something that it's easy to overlook if you work with teachers a lot. Like what is the, what actually is floating around right what non-teachers are thinking exactly. yeah Exactly. And so let me give you an example. I was working with a one-on-one client with knee osteoarthritis.
00:22:35
Speaker
And we're trying to find some good exercises for her quads that are tolerable for her. And so I actually recommended softly that she maybe look into getting a gym membership so that she could get access to the knee extension machine there because it's open chain. So unlike all the exercises we've been doing that are more closed chain where her foot is in contact the floor, things like sit to stands mostly, right? Um, I thought maybe that would be an option that would be less, uh, pain provoking. And.
00:23:02
Speaker
Oh, by the way, i yes, I do fully believe a gym membership is well worth accessing one machine, just even if it's just one machine. Of course, you'll use more than one, but um if it's a crucial machine.
00:23:14
Speaker
get the membership. For example, I will probably always have a membership to a gym now that I've discovered the calf raise machine and the hamstring curl machine. I'm not sure I will ever be able to live without them. But anyway, this woman was shocked when she heard that she should do the knee extension machine. And she was like, I've always been told that knee extension machines are completely off limits and are dangerous for my knees. Like open kinetic chain. The extension was just bad and like the worst thing you could do.
00:23:42
Speaker
And I was like, in my head, I was like, Oh my God, people still believe it. Instead, I was like, Oh no, that's not true. That belief was floating around out there and I didn't go in the nineties, but the early two thousands, but instead I was like, yeah, I used to float around out there and and it turns out that, you know, newer evidence is showing.
00:24:02
Speaker
The knee extension machine is not only okay for your knees. It's actually a really good way to strengthen the quads and it's even the tool of choice for some types of rehab. So she seemed okay with that answer. um For background though, the belief that knee extension machines were harmful did stem from a concern about shear forces on the tibia and stress on the patellar femoral joint. So the knee joint is ah the space between the tibia and the femur as well as the patella and the femur which is the kneecap and the femur. The tibia is the lower leg, femur is the thigh, patella is the kneecap.
00:24:43
Speaker
And so there was this concern about sheer force where stress would be too much for the patellofemoral joint for it where the kneecap meets the femur. That doesn't even make sense. Well, that's what they thought. And it led clinicians to advise against the exercise, especially for those with knee injuries. So this woman, you know right rightfully she had osteoarthritis, she's concerned about it. And of course, because shit flows downhill, this caution then spread to the broader fitness community who also then started to fear monger in the knee extension machine.
00:25:12
Speaker
and make fun of people who did it, who used it and were like, you use machines, you're weak. You should you should only do back squads for your quads, which is just like another example of rampant dogma flying around like feces being thrown from trees. If you have any poo, fling it now. However, recent studies show- Do you know where that's from? No.
00:25:34
Speaker
that's from Madagascar. You're just waiting for me to have any amount of pop culture knowledge, and I'm letting you down each and every time. I mean, a lot of my things that I say are a little obscure. I don't expect most people to get them. ah So, no, I didn't expect you to get them. Okay, good. I've never even seen the movie. hu Is it a good one for kids? Oh, yeah. Okay, I'll see it. And also super fun for adults. Okay, gonna do it. they so So is Inside Out. Yes. They talk about flinging poo. Okay.
00:26:04
Speaker
That's kind of what ah dogma in the fitness community feels like sometimes. I go to cross a CrossFit gym and a guy there wears a shirt. and um in front of the shirt and bowl that says, you use machines. And I'm like, I do. And in fact, I do. In fact, I do. Yeah. um yeah So recent studies have shown i mean studies that have been around actually, frankly, for a long time, that loaded appropriately, the new extension machine is safe and beneficial, especially for ACL repair.
00:26:34
Speaker
And they're excellently simple, so if someone is struggling with the mechanics of a squat, because there's a lot more complicated than any the extension machine, it might be a wonderful option. I personally love the knee extension machine that I use, and I've just regularly implemented it into my next training block, because I've decided I'd like bigger quads, Sarah. Thick thighs save lives. That's right. Now, I didn't say any of what I just said to this student. No. Like, none of it, because I don't think that it would have been helpful to do that. We'll talk more about TMI or TMTI, too much technical information when talking to students. But before that, what are some of the deepest rooted fears
00:27:13
Speaker
People have about their knees and I think it's important to to empathize with people who are rightfully concerned about their knees because they've experienced pain. Knee pain can be a real pain in the knee. I was gonna say pain in the ass and I was like, that doesn't work. No.
00:27:28
Speaker
um Yeah, I mean, people have ah an extraordinary amount of concern about their knees a lot of the time, and I'm not and entirely sure why. I think it feels like but your ankle feels kind of solid, and your hip feels kind of solid, and your knees just in the middle there just batting back and forth all over the place, being like whipped sideways at the slightest you know high wind or something. yeah Um, so, so there's all of this fear around needing to like keep your knees safe and protect them and be careful. Uh, people, I have a client right in a patient right now who is about to go in and get a knee replacement. Uh, it is appropriate for him. He's not getting it for no reason, but when he came in, he was like, yeah, the doctor told me my knees are bone on bone. And I'm just so tired of that phrase because it's not even accurate. It's just terrifying. Can I tell you just interject here? Please. Similarly, Nathan had some knee pain.
00:28:20
Speaker
went to the doctor and he looked at his knee, bent it and straightened a few times and went, you have no cartilage. I think you're going to need knee surgery. That is literally how- Just from moving his knee. That is literally how it went. Wow. That guy's psychic, huh? I was like, was he a surgeon? Because it seems like he really wanted to get into your knee and open it up and do surgery on it.
00:28:44
Speaker
Cause how the fuck would you draw that conclusion? I have no idea. Oh man. Based on bending and straightening some of me. Uh, yeah. And there's also this idea that like anything that's like high intensity or high impact, like running, that that's going to cause like too much wear and tear. It's going to give you arthritis. Or if you do like, you know, what we call the Astagrass squat, like deep squats, that that's going to just mess your knee up automatically. Those are some things.
00:29:10
Speaker
Yeah. And, but here's some more cognitive dissonance producing fun facts that we're going to get into in this episode, which is that, okay, if all of this is the case, that we have all of these fears about our knees and all of these movements are off limit and all of these maybe exercise formats are off limit, like high impact, for example, or heavy squats or deep squats, right? Or knees past toes. Oh God.
00:29:33
Speaker
Why is it that the knee cartilage of people who lift heavy is thicker than those who don't? Or why is it that people who run long distances recreationally, running is an impact activity, have lower incidences of arthritis than those who don't run at all? Or why is it that there is hours and hours and hours of video footage of elite athletes whose knees cave in a lot during their sporting movements, during their squats, during their running,
00:30:03
Speaker
And yet they're operating at the highest possible level of athletic prowess. I mean, these people purportedly have quote shitty knee mechanics and yet they are the best of the best in their sport. I just don't get it. Something's not adding up. And so there are a lot of behemoth knee myths. I just do that to watch Sarah lose her shit and smaller ones too that we're going to talk about. And we'll look at three big ones in this particular episode.
00:30:31
Speaker
And then we're also going to touch on some teaching tips or maybe attitudes or ways of communicating with students around each of these myths ah so that rather than talking someone's ear off about the evidence, right, we can really just adopt an attitude for them to help them feel safer in the needs that they have and the movement that they're doing. And I want to I want to share these in our role playing scenario, but at the time of writing this,
00:30:54
Speaker
outline I couldn't remember the name role-playing so instead I was thinking play acting because I'm a former actor and Sarah's done some acting as well and so we're gonna Sarah and I do some play acting where she's gonna pretend to be either a PT or a movement teacher I'm gonna pretend to be the student or vice versa I'll be I won't be a PT but I will be a strength coach potentially Sarah will be a student and we'll talk through with our quote student some of their concerns about their knees and I think this is important because again, it can be very tricky as teachers, we try to teach from an evidence-based place, but that doesn't always mean that we need to overwhelm our students with the evidence.
00:31:32
Speaker
yeah amen It's really tough too because sometimes we're in our own little teacher bubble where everybody's on the same page, we all have updated our beliefs, but then we encounter, you know, Susie from HR who still thinks that her you know noisy knees or her ah you know knees are bone on bone or whatever. and and And we're like, I don't even know how to talk to you, because I thought we were past that. um And so, you know, it's it's really, I think, easy to almost sound dismissive of people's fears. You know, I don't think we want to do that, or to science them, which can, I think sometimes feel like being gaslit. ah Kind of what has happened to lots of people in a doctor's office where
00:32:18
Speaker
Oh, it's all in your head and here's, you know, my scientific expert opinion on what's actually happening and you're wrong. Or you're just, you know, maybe they don't trust you because you are saying the opposite of what they've heard so much of. And so now you're some rogue bucking the status quo, apparently, AKA full of shit, maybe just making things up. um You are now a know-it-all who likes to hear yourself talk and that's off-putting, or I think I'm very guilty of just too much technical information, like keep it simple, stupid, right?
00:32:48
Speaker
And so hopefully in our in our little play acting, Sarah and I will be able to kind of act out what the tone could be instead of a long lecture. I am hoping to get an Emmy nomination for this performance, so I'm looking forward to it. Okay. All right. And the star of Behemoth Nemeth, Sarah Kort. Thank you. Thank you.
00:33:09
Speaker
And the Academy Award goes to Sarah Kord. Oh, I'd like to thank my something. Team? The Academy. The creator of Behemoth Nemeth. That's right. ah So me? Yes. Okay. Ultimately, all of this neat myth busting, the Behemoth Nemeth busting is so that we don't unbeknownst to us become ah just another person creating fearful beliefs and narratives in our students' minds about their knees.
00:33:36
Speaker
which we know can increase their pain and actually cause them to avoid exercise. All right, let's fucking go. Knee topics we are going to cover include, should the knees always stay over the ankles? Should they never go past the toes? Knee valgus or knee cave, is it ever an acceptable position to be in? Knee arthritis, the idea that movement, especially certain types of movement like impact or high intensity causes it. And then a subtopic of that one,
00:34:05
Speaker
um want to talk about is crackly noisy poppy knees and if that's bad okay knee over ankle or knees never pass toes this i feel is a good starting point because it's kind of like what i like to think of as low hanging fruit i think that well i hope that we're moving beyond this myth above all other myths i think this is the one that even the general population knows is probably not the case but let's discuss why this belief that the knee must stay stacked over your ankle in yoga poses or that the knee should never go past the toes maybe in strength training. What's the problem with these myths? Where do they kind of break down?
00:34:44
Speaker
Well, I mean we mentioned it a little bit earlier, but how there's various yoga poses where your knees do in fact go past your toes. So why is it one rule at one point in the class and then 20 minutes later that rule disappears?
00:35:00
Speaker
That doesn't make any sense. the Your knee, as we said, goes all over the place. like If you just imagine stepping into a car, right your knee is doing all kinds of like in and out and over your toes and straight. like It's going all over the place and you're not thinking about it at all right because it's not a problem. But suddenly we're in an exercise setting and all of a sudden like the rules of physics change.
00:35:22
Speaker
and God forbid your knee goes anywhere else, right? And then if we're talking about strength training, like this whole idea of like your knee shouldn't go past your toes, like like I don't know how to do an Astagrass squat without my knees going past my toes, yeah frankly. So again, it's like there's no, it's just this like idea floating in space with no context, right? The forces on your knee when they go past the toe is not automatically higher.
00:35:47
Speaker
right it's not and No, it's not as it turns out. Shut the front door. I wish I could.
00:35:57
Speaker
Yeah, so I think this is a great moment in our discussion to talk about the difference between two very technical sounding terms. which are kinematics versus kinetics. When we're talking about the knee past the toes in a squat, for example, we're talking about kinematics. When we're talking about the knee coming inward toward the inside of the foot or past the inside of the foot, right we're talking about kinematics. But when we're looking at why people get injured or even why they have pain, we're not just talking about kinematics, we also have to take into account
00:36:32
Speaker
ah kineic So kinematics and kinetics are both branches of physics that study the motion of objects but they differ in their focus. So kinematics is the study of motion and it does not consider the forces that are causing the motion. It's sometimes called the geometry of motion.
00:36:48
Speaker
Kinetics, on the other hand, studies how forces affect the motion of objects or the cause behind the motion, right? So kinetics would explain how a body responds when a force or torque is applied to it. So when we're discussing whether or not it's dangerous for the knee to go past the toes or even the ankle, we're really just having a conversation about kinematics. But what causes injury?
00:37:16
Speaker
would be forces. Yes. And when we want to look at what forces the knee is having to manage, we have to get a lot more specific about what is happening in the scenario, where the knees are going past the toes. Can I give you an example of that in action? Yes, please. My father, when he was in college, was a football player, American football. Oh my gosh. For our non-American listeners.
00:37:35
Speaker
Uh, and so one time during a game, I think it was like it had been raining. It was very muddy and his foot got stuck in the mud and his knees started to move in. And that wasn't a problem. The problem was the person who then came and tackled him around the knees. So a huge amount of force pushing his knee even more sideways and causing a lifetime knee injury. Right. And so we we do want to look at both kinematics and kinetics to understand injury. By the way, you do need some pretty fancy lab equipment to understand like what is kinetically, kinetically even happening here. But we can't just look at alignment. We can't just look at posture. We can't just look at movement quality and figure out whether or not the knee
00:38:23
Speaker
is even dealing with a higher force or a lower force in any given position. This is where research can be helpful because research is often done in labs with fancy equipment that can measure kinetics. They have those tools. And so, guess what? What? Oh, it's actually, this is very counterintuitive, it's actually been found that it's between 60 and 90 degrees of motion of knee flexion.
00:38:46
Speaker
where the knee will experience the highest. Retro patellar forces. Okay, so Sarah, tell us what would 60 to 90 degrees of knee flexion look like? And then what are retro patellar forces?
00:38:57
Speaker
So if we're starting with that, like we can all get around the idea that that's 90 degrees. If you start with your knee bent like that and then start to straighten it, now you're going towards this 80 degrees, 70 degrees, 60 degrees. So it's actually higher forces with your knee less bent, why not with your knee going past 90 degrees into the 100, 110 range. I cannot compute. I know, but it's true.
00:39:21
Speaker
Yeah. And retro patellar just means retro means behind and patellar is your kneecap. So it means behind the kneecap, which is like your knee. Your freaking knee. youre The whole of your inside of your knee. your knee A systematic review from 2013 showed that based on biomechanical calculations and measurements of cadaver knee joints, the highest retro patellar compressive forces and stresses were seen at 90 degrees.
00:39:47
Speaker
The systematic review is titled, analysis of the load of the knee joint and vertebral column with changes in squatting depth and weight load. This is a summary of the study. Concerns about deep squats causing knee injuries led to recommendations for avoiding deep flexion. However, this recommendation ignored factors that this review uncovered, like the wrapping effect,
00:40:09
Speaker
which is when soft tissues wrap around bones towards the bottom of the squat and this distributes loads differently so that there's less force on the knee, less load on the knee, as well as the way the back of the thigh and lower leg come into contact with each other at the bottom of a deep squat again to alter load distribution resulting in lower forces placed on the knee. A literature review of over 164 studies Laurel, does that count as a fuck ton? I think so. Found no evidence that deep squats increase injury risk compared to half or quarter squats. In fact, deep squats may lower retropatellar compressive stresses, the part of the knee behind the patella, and enhance joint health through proper load distribution and adaptation. With correct progressive training, deep squats are effective for injury prevention.
00:40:59
Speaker
ah Yeah, look at that. So in fact, the research proves the exact opposite that deep squats may actually be lighter on your knees than holding it in that 90 degree position. And there's certainly not a problem and you should do them and get strong. Right. And also holding your knee in a 90 degree position isn't a problem either. Right. Our point is just that more knee flexion does not mean more forces on the knee. Right. And more forces on the knee also don't mean knee injury.
00:41:23
Speaker
I mean, do you think that we've were are you still hearing people say, keep your knee or at 90 and don't let it go past your toes? like Is this something that you think people are still believing? No, but I'm cautious to say that it's like a you know um mainstream understanding because again, I tend to be in the working with teachers bubble a lot. I mean one of the things I do when I go to teach anatomy is I'll do a warrior too and then I'll be like look you guys look at all these other places my knee can go and I'll take it too far forward or I'll take it in and sometimes there are audible gasps it's very entertaining and so yeah I mean a lot of what I do in that training at this point is just myth bust yeah I feel like it's a lot of what I do basically all the time like you tease them and torture them too I do all right um no I I think
00:42:10
Speaker
One thing that I do still hear bandied about is this idea of quad dominance though. Quad dominance isn't completely what we're talking about right now, but for example in a deadlift, if you were to be in a squadier deadlift, which it's sometimes called, you would be more quad dominant in the performance of that deadlift.
00:42:30
Speaker
And so what that would maybe look like is your knees are coming further past your ankles, probably not past your toes, but further past your ankles, your trunk is more upright and you almost look like you're squatting while pulling the weight off the floor. And so sometimes that will be called a quad dominant deadlift. And I think what is intended oftentimes there is just to help somebody find more of a hinge so that their hips are flexing more than their knees are. And there's nothing wrong with that. Cause then they can maybe target their quads and hamstrings more, but that's,
00:42:58
Speaker
not the end of where this narrative goes because then what this turns into is that, okay, well, if we see people doing this, it must mean that they are, quote, quad dominant. So the instance in which they're doing the exercise becomes who they are as a person. Okay, now you're quad dominant. Okay, okay. It's also possibly true that we're all gonna approach an exercise differently and some people will have a higher tendency of being more, okay, quad dominant in a deadlift, right? And we could maybe train them out of that or maybe not. and Fine, but then that's not all because the narrative keeps going and this is really where it goes awry that this then means that the person who's quad dominant must have inhibited glutes and hamstrings. That's why they're quad dominant is that their hamstrings and glutes are asleep.
00:43:49
Speaker
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00:44:28
Speaker
the person who's quaddominant must have inhibited glutes and hamstring that's why they're quadal that their hamstrings and glutes are asleep And this here keeps going. This puts them at risk. They're not safe now. And their knee might become injured because their glutes are asleep, their hamstrings are asleep, all because of their quad dominance. And so this can even result in some trainers or physical therapists actually purposely trying to make people's quads less strong by advising that their patients or clients don't strengthen their quads anymore because you're already quad dominant.
00:45:06
Speaker
because then it might be you know ah a situation where the quads are too strong, and then the glutes and hamstrings are even more inhibited by the strength of the quads. That's not how it works. But yeah, I've definitely heard that narrative still floating around out there. I don't think when people use the word quad dominant, they always mean the full extent of that narrative, but I know that they sometimes do. What do you think are the most important muscle groups to make strong for the knee to be healthy, happy,
00:45:35
Speaker
Uh, injury free, Sarah. I mean, one of them is your quads. Okay. Thank you. And the other is the other ones. Yeah. All of them. Yeah. And there's nothing wrong with having strong quads.
00:45:49
Speaker
and it strikes me as bizarre that you would purposefully try to weaken a muscle versus if you've got this idea that like oh the quads are too dominant then why don't we just like make your glutes and your hamstrings stronger like why are we trying to Huh? Yeah. Yeah. I don't know. All right. So Sarah, now we've determined that knees over or even past heels and toes is not dangerous. Let's go with the more extreme range. Is knees past toes actually accessible to everyone? Like should we expect everyone to be able to take their knees past their toes?
00:46:28
Speaker
And, you know, why or why not? Well, you know, the problem with becoming sort of medically, clinically brained is you never say anything is for everyone, even when it is actually for the vast majority of everyone. For the vast majority of everyone, yes, it's totally acceptable and fine. um You know, I start to think about people who can't do it, and that's why it's not happening, because they can no longer do it, because of some other disease state that they might have.
00:46:53
Speaker
but for the most part, for people who are generally healthy and don't have any underlying condition that for some reason might make it not a good idea to move your knee in that way. I can't even really think of what that would be at the moment, but let's just say. But could you see someone has pain in that position? Well, yeah. I mean, if you have pain doing it, then we need to pause and figure out why the pain is happening. But that doesn't mean we can't fix the pain and that you get you to do that move. It doesn't make the movement permanently illegal for you. Or even illegal, you could just reduce load, you reduce range of motions, build up from there. Yeah.
00:47:24
Speaker
Cool, let's do our play acting. Great. Okay. I'm a student. Yep. And what's your issue? Hello. Hello, coach. Laurel. Hi, student. Okay, let's be real. Okay. Hey, Sarah. Hi, Laurel. What's going on? Well, i i you're my new coach and I'm really excited to work with you, but i my the coach I had before, um he told me that I have, like, my knees are bad and that squats are dangerous for my knees. So i one thing i I cannot do is squats.
00:47:52
Speaker
Let's talk about it. Have you been having some knee pain recently? Um, no. Have you had any knee pain in the past? um Yeah, sometime. I mean, maybe. Okay. You can't really remember exactly. Well, no. Okay. No, but I just, my knees are weak. I have weak, bad knees. Okay. Um, I, I mean, I think it's totally reasonable to be concerned about your knee safety. They're very important joint. The cool thing about squats though, is they actually make your knees stronger because they strengthen the muscles that are really big powerful muscles of your knees, namely the quads. The thing about deep squats is we don't actually have to start with deep squats either. That's really good news. We could start with a little bit shallower squat, like almost like coming up out of a chair. Coming up out of a chair is actually a squat. Oh, no way. I never thought about that. It totally is. yeah hu so We can start with what are called sit-to-stands. ah This is basically where you're going to sit down and then stand up. and As your knees
00:48:43
Speaker
seem to be doing well with that if you have any pain we'll figure out maybe another option but if that's okay feeling good yeah that's getting stronger we might sit down and get up out of a chair holding a weight and if that's going well then we might lower the seat of the chair we don't have to do any of this but if you're open to trying it's a really great way to maintain your ability to get up and down off the floor or out of a chair and also just be a general badass in life You sound great. Let's do it. And scene. And scene. All right. So yeah, I didn't list off the six studies showing that deep squats are OK. I didn't say that our coach was an idiot. I didn't say any of that. Sometimes people say things that are like, in your mind, crazy. Oh, yes. But you have to just redirect. Yep. Don't just keep out on the inside. That's inside, brain.
00:49:40
Speaker
Not outside words. yeah All right, knee arthritis. Okay, there's this idea that deep squats and other movements we'll talk about can lead to knee arthritis. Like running, you know, knee valgus is also a culprit, apparently.
00:49:55
Speaker
But before we get into knee arthritis, I actually think it's important to dispel a few osteoarthritis myths. So when we talk about bone on bone wear and tear, we're we're we're talking about osteoarthritis. There are many different types of arthritis. And osteoarthritis
Osteoarthritis Myths and Strength Training Benefits
00:50:08
Speaker
is not what most people think it is. I think that This is very common to believe that osteoarthritis is this bone-on-bone thing and it's the case that it's actually not. Sarah, we actually do need to do an osteoarthritis episode. Put it on the list. Okay. I think most people think osteoarthritis is due to some type of grinding or rubbing happening inside the joint at the joint surfaces.
00:50:36
Speaker
And then the story goes that this rubbing causes the cartilage to wear away from overuse or quote wear and tear. And then suddenly because of that, we now have bone on bone. So the articular cartilage wears away and now the bone itself is rubbing on the other bone and that causes bone spurs. So now we've got these bumps on our bone, which causes even more grinding because the surfaces are bumpy.
00:51:00
Speaker
and that the movement is not smooth. And so it's just absolutely terrifying. it's probably It's painful to think about. And I've had many people online comment in the comment section that, oh, no, no, no, I can't do heavy strength training. I can't do heavy squats because my knees are bone on bone. And we've had several people say this to us, but is it true, Sarah? I mean, can your knees be bone on bone physically? No.
00:51:29
Speaker
What? Yep. No.
00:51:34
Speaker
I'm going to let you make that face for a while. so i mean I hate that phrase, bone on bone, and I hear it from so many patients coming in who might be you know getting getting ready to get a knee replacement or you know they don't want to do surgery or their doctor said, time to do PT first or whatever. But they'll be like, my doctor said my knees are bone on bone. And I'm like, for fuck's sake. Do we not do people not understand about no SIBOs?
00:51:59
Speaker
No, they don't. That's the thing. I feel like almost movement teachers are getting more wizened up to it than doctors are. I hope so. Do you think that's the truth? Yeah, probably. Well, we spend more time having like actual long-term interactive relationships. You know, the doctor sometimes sees you 15 minutes twice a year. Yeah. So, but anyway, that's an aside. So, people, you know, you have arthritis, osteoarthritis, your knees hurt or your whatever hurts.
00:52:23
Speaker
You don't want to move because you think it's going to hurt, but the the in fact is that, generally speaking, movement makes your joints feel better. and and Especially for people with osteoarthritis, it's well documented that movement and e and exercise is one of the best way to reduce your pain symptoms.
00:52:43
Speaker
and so Yeah, but the this story of like, well, I'm already bone on bone, so if i'm if I'm moving my knees, then surely the bone is grinding against the bone, and it's just more bone on bone, and it just all sounds horrible. It's like a like when you hear a car that is like trying to start, and it won't, itly like and like, that's what you think is happening. theres Here's a paper.
00:53:05
Speaker
So we found a randomized control trial that shows that the knees of people who exercise have thicker knee cartilage than those who don't. And this is the articular cartilage, right the surfaces of the bone, not the meniscus, just to be clear. And so the title of the paper is Positive Effects of Moderate Exercise on Glycosaminoglycan.
00:53:30
Speaker
Okay, so the title is actually Positive Effects of Moderate Exercise on Glycosaminoglycan Content in Knee Cartilage. a four-month randomized controlled trial in patients at risk of knee osteoarthritis. And so, yeah, what it found was that people who exercise actually end up getting thicker cartilage, which totally refutes this idea that your cartilage is just going to wear away, wear away, and that exercise is going to make it worse, and the grinding, so much grinding.
00:53:59
Speaker
Osteoarthritis is is a really complex disease yeah of the joint. Tell us about it. What it is it? It affects way more than just the bones, right? It affects all of the tissues around your knees. So the ligaments, yes, the bones, your meniscus, the joint capsule, the muscles. It's a whole series of biological processes that ends up disrupting the balance between the cartilage breakdown and the cartilage repair. It's basically a low-level inflammatory condition.
00:54:27
Speaker
And what's interesting is that athletes like recreational runners have lower rates of knee osteoarthritis compared to sedentary people. Real risk factors that are modifiable are things like your weight, specifically your weight that you're holding around the middle of your body. So not like the weight of your body on your knees, but like a type of fat. A type of weight. Central adiposity, right? A type of weight because central adiposity evidently triggers a systemic inflammation.
00:54:57
Speaker
or something like activity level, that's a modifiable risk factor. There's also non-modifiable risk factors like genetics, age, gender. Okay. All right. So back to this idea that deep squats are bad for knees and can lead to arthritis. If you have bought into this bone on bone or wear and tear narrative, which is very provocative and very scary and easy to latch onto,
00:55:18
Speaker
and a hard bell to un-ring, I can see why you would think that deep squats are problematic. I mean, when you look at a squat, the knee flexes a lot, it squeezes the knee. You feel squeeze, right? You feel stretch and squeeze. There's maybe a rotational movement that you're noticing. And we think it's, oh God, causing the bones to press together. But as the study earlier that we mentioned showed, there's this wrapping effect that's actually happening.
00:55:44
Speaker
actually unloading the knee a little bit as we take our knee into more flexion. The soft tissues are actually taking on some of that load. They wrap around the knee. And so it's just not the case that a deep squat is loading the knee more than a 90 degree partial range of motion squat. But also, but also, but also specifically people who strength train research has shown. So Sarah shared about exercise in general.
00:56:11
Speaker
But they've looked specifically at people who strength train. And it shows that they have thicker knee cartilage as well. And that may be protective against OA. And this again is particular cartilage and not the meniscus.
00:56:25
Speaker
So a randomized control trial showed, here's the title, thickening of the knee joint cartilage in elite weightlifters as a potential adaptation mechanism. This study aimed to determine if elite weightlifters, so we're probably talking very high loads, do they have thicker knee cartilage compared to inactive men? on And so MRI scans of the knee showed that weightlifters had significantly thicker cartilage in most regions analyzed, including both weight-bearing and non-weight-bearing areas. Also, this is cool, the duration of training didn't correlate with how thick their cartilage is or was, but it was whether they started training earlier in life that was linked to thicker cartilage. So there's no earlier time to start than now, if you're listening.
00:57:15
Speaker
and you currently don't strain train, start now. Cause that's earlier in life than you'll ever be able to start. It's never earlier than right now. It's never earlier than right now. Oh, this suggests that, uh, sports like weightlifting, which are high strain, right? What does that mean? High strain. They stretch your tissues. Okay. When you come into a deep squat, the tissues around your knee are stretching that they may lead to cartilage thickening as a form of functional adaptation to mechanical loading. It's also been found, so we talked about how exercise can thicken articular cartilage, strength training with heavy loads specifically, can thicken articular cartilage, but also people with osteoarthritis already whose strength train tend to have less pain. This study was a systematic review france by Fransin et al. in 2015 called Exercise for Osteoarthritis of the Knee. It's a Cochrane systematic review. Can you tell us about the Cochrane review, Sarah?
00:58:13
Speaker
Yeah, Cochrane reviews are basically the absolute highest level of evidence because they're very thorough in the evidence that they include or exclude and they also give the evidence a rating, like other studies they'll give it a rating on like how good it is. Yeah, cool. And this is not the only, by the way, this is not the only review that found.
00:58:33
Speaker
this similar conclusion, right, which is that there is overwhelming evidence supporting the benefits of exercise, particularly strength training, for managing knee osteoarthritis. Among the most compelling is this Cochrane review, which systematically animalized? Animalized. I love it. That's like something I would say. Yeah. Systematically analyzed 54 randomized controlled trials involving over 5,000 participants.
00:59:00
Speaker
This Cochrane review found that strength training along with other forms of exercise significantly reduces pain and improves physical function in individuals with knee osteoarthritis. All right, it's time to play action. All right. Okay, so I get to be a patient or student. You're my patient because you're coming into my PT clinic. And I'm really, really worried. Okay, so here we go. Okay, hi. Hi, welcome. Yeah. What brings you in today? Yeah.
00:59:30
Speaker
Well, I have a problem, which, okay. I have knee osteoarthritis, as I mentioned, and I'm pretty sure I know how it came about, oh which is that I have what's called dead butt syndrome, which I'm sure you've heard about. And, and so I'm pretty sure that my knees just aren't getting enough support maybe from my hips. I don't know. My, my glutes and hamstrings are just not working.
00:59:55
Speaker
And so I'm concerned because I did start to strength train and the trainer wanted me to do squats. And I'm like, Oh, you know what? My knees are bone on bone and I've got this dead butt syndrome. So I'm probably going to be really quad dominant. And I'm just, I'm just concerned. I'm, I'm hoping that you can teach me. I think the exercise is like a clamshell or something. I heard those are supposed to be good for my dead butt syndrome and my knee osteoarthritis.
01:00:22
Speaker
um Okay. Can you imagine if you had a patient come in and just say that to you? Laurel, no joke. People say shit like that to me all the time. They come in and tell me what's wrong. They also tell me what the solution is going to be. I'm glad. I'm glad. I'm like, well, why do you need me if you know what to do already? I feel like as I was talking, I was like, this is so unreal. It is like nobody would say this. What's wild is that it's deeply realistic. Good to know. Good to know.
01:00:47
Speaker
um So that I mean all of those things they that sounds really scary. Here's the thing. There's actually so much that we can do to make your knees feel better. The way that we can do it is just very kind of systematically and thoroughly.
01:01:01
Speaker
we're gonna work on getting muscles strong actually all the way around your legs. So absolutely we're gonna strengthen your glutes. We might use some clams if that seems like the right exercise and we might find something else, right? What we're gonna look for together are exercises that help you get stronger but don't bother your knees. Okay, so not the ones that are gonna make my knees go boneon bone on bone.
01:01:20
Speaker
Well, the thing with ah this idea of bone on bone is it's this kind of colloquial term that is actually not really accurate at all. Wait, wait, wait. You mean my bones, my bones aren't like grinding against each other. No, no, no, no. It feels that way though. it's I can feel it them grinding and they're popping too. Well, probably what you're feeling actually the pain that you're feeling is much more likely coming from the soft tissue around your knees.
01:01:41
Speaker
oh and that they're getting irritated. So a lot of it has to do with just kind of figuring out exercises that at the moment make your knees not hurt more, right? And then as you get stronger, your tolerance for different kinds of exercise is going to increase. And then so we'll sort of just very steadily and in a programmatic kind of a way work through ways to keep you as strong as you can be and to keep you out of as much pain as possible. How does that sound? Good. Do you think that I probably should probably shouldn't squat though? Well, we're if you're worried about squats, I'm not going to make you squat today. And I'm not going to make you do anything you don't want to do. But I think if we just start working together and getting you stronger, I think what's actually going to happen, because I've seen this happen, is that squats aren't going to bother your knees anymore. Really? Yeah.
01:02:31
Speaker
Amazing. Yeah. Yeah. We're just going to find a way to make you feel better. My knees feel better already. Yeah. Isn't that funny? Yeah. Okay. I mean, I literally have that conversation all the time. I was like, Laurel, this is ridiculous. No, it is not ridiculous. I thought it was like SNL level. But apparently not. It is not at all. Is that because you work in LA?
01:02:55
Speaker
What? That people are so crazy? ah I don't know. but Let's ask our friend Caitlin who works in New York. Caitlin, did the same thing happen to you? Please comment somewhere. Yes. Thank you, Caitlin. She's probably running right now. um All right. Hopefully running and laughing. Yes. Okay.
01:03:11
Speaker
Ni-valgus. This is our third. This is our third and last. Myth. Ni-valgus. Ni-bola. I didn't get the Ni-bola joke for a while because what I went to in my head is this thing called a tambola. Oh. Do you know what a tambola is? Is it an instrument? Do I know what a tambola is? Hang on. it It's from my, mr not misspent youth, it's from my English youth. It's a kind of bingo.
01:03:34
Speaker
Oh! Yeah. A raffle in which usually numbered tickets are drawn at random. No, we're talking about the deadly disease, Ebola. Right. That makes a lot more sense. The virus. I was like, why are my knees are tumbling around and I'm getting... Yeah. Anyway. It's a Adam Mechansism. Are we going to mention him in every single episode now? It's likely. Okay. Just wanting to adjust my expectation level. Okay. I'm sure he doesn't mind. Hi, Adam.
01:04:03
Speaker
Okay. Thee valgus is often seen as a major culprit in knee issues, but the term is vague. We're going to get into it a little bit. And its involvement in injury is misunderstood. So essentially, valgus technically means, and I got this from Eric Mera. We'll link his stuff in the show notes. Great blogger, PT, I believe a researcher as well.
01:04:30
Speaker
writes about the DLI. And so it technically means outward from center. And in the context of the knee, that would mean that the knee could somehow abduct, right? The tibia, the lower leg bone could move outward from center at the knee as the, for example, similar to how the thigh can move outward from center at the hip. Of course we know, Sarah, right? The knee cannot abduct. That is a good thing. um So it doesn't actually do that. but So in other words, what we're actually talking about is dynamic valgus, which is the relative
01:05:05
Speaker
internal rotation of the lower extremity against a relatively fixed foot and pelvis. So if your foot is fixed on the ground and then your knee is bent a little bit and your entire lower and leg and your thigh move inward at that fixed foot, that knock knee, that inward knee movement is called valgus. It's really dynamic valgus technically. And this dynamic valgus can contribute to ACL tears, especially in field sports where there's a lot of cutting maneuvers. That's when an athlete is running in one direction, decelerates,
01:05:40
Speaker
plants a foot into the ground, changes direction, and usually the knee is flexed. But typically, um when they tear their ACLs, it's happening under 30 degrees of flexion, and forces are very, very high because the speeds are high.
01:05:57
Speaker
So what happens when the ACL tears? By the way, can we talk about what the ACL is real quick? Sure, it's your anterior cruciate ligament. It's one of the ligaments inside your knee. You've got four of them. Great. Okay, so because the knee in this scenario where it's typically a cutting situation where there's high forces, the knee's under 30 degrees flexed, okay, that it can't for some reason absorb shock effectively and then the load shifts to the ACL and the ACL gets injured.
01:06:25
Speaker
Okay, and this so this involves both the kinematics of the way the movement looks itself, but also the kinetics,
Dynamic Valgus and ACL Injury Risks
01:06:31
Speaker
the forces. What is going on when the knee is in this position? It's not just when the knee is in this position, everyone's ACL is at risk. It's when the knee is in this position and all these other things are happening, right? In addition to the athlete's history of injury and everything else that influences when someone or why someone gets injured. So wild dynamic valgus certainly is a factor in many instances of ACL tears in athletics, especially it's just not the sole cause of this injury.
01:06:59
Speaker
And so it's also the case, and we must also always remember, that the body can adapt to dynamic knee valgus and get better at managing those stresses with proper conditioning.
01:07:14
Speaker
And so maybe it's the case that for athletes and non-athletes, rather than eliminating dynamic valgus and saying that is an off limits movement, we should never do it. By the way, good luck with that. The focus should be instead on building strength and load tolerance to prevent this injury mainly And this is Eric Mera's perspective, make the quads as strong as possible because they are very good contributors to the shock absorption that needs to happen at the knee. The knee is a great shock absorber because of the meniscus, because of the way it's designed, because of the way it moves, but the quads are like this main muscle that we need to rely on for that ability to slow down knee flexion and cut, right? yeah Make them strong.
01:08:00
Speaker
Yeah, so when we're talking about valgus, what we're talking about is internal rotation and adduction of your thigh bone, and then also some pronation of the foot while the knee is flexed. And some of the mean names given to this are things like knock knees, or kissing knees, or you said this one, pencil skirt. I hadn't heard that, but I can visualize it.
01:08:22
Speaker
And faulty mechanics, right? Faulty mechanics. Everyone's mechanics are faulty. So places that we see it sometimes are like if you're doing a squat under load. Certainly this happens to me. As I go down and up, my knees go whoop in and whoop back out again, just too all on their own. ah You might see it in a lunge pose or in one of the warrior poses or in standing yoga poses. You might see it on the reformer when somebody's doing footwork and you're you like, oh my god, their knees go in and out.
01:08:50
Speaker
or any of the standing ah movements that you can do with the performer, you might see it when someone lands for ah from a jump. Oh, no. Yeah. And you might see it when people run. Yeah. I mean, I used to run with a really big knock-kneed gate, and I've since stopped for some reason, but I still think I have a little bit of it. So when we're talking about knee valgus, we still are in this like headspace of, ooh, bad knee alignment. It could wear down your joints too soon or in in in a non-optimal way. So some of the joint might be getting worn out more faster than the other part of the joint because your knees are knocking in, right? So bad knee alignment could cause osteoarthritis and yet
01:09:36
Speaker
There's a study called knee alignment does not predict incident osteoarthritis, the Framingham osteoarthritis study. And so it looked at varus, which is the opposite of valgus is when your knees bow out, varus and valgus misalignments and found that they were not a cause of arthritis, osteoarthritis, but rather a result of having osteoarthritis. Oh, so are we again focusing on the wrong thing?
01:10:04
Speaker
We are. And the one that I like, what I'd like to add to this season of mantras is you are a lot finer than you think you are. Oh, thank you. Yeah. Oh yeah. You are fine. Yeah. I also have this pimple on my face. Am I still fine? Yes. Okay. I have one on my neck. I hate those. What is going on? I don't know. Acne. I mean, let's talk about something more important.
01:10:24
Speaker
i You know, Valgus is considered, like people think, oh, Valgus, it's suboptimal, you know, or it's dysfunctional, or it's like an energy leak. That's my least fit energy leaks. I'm not a goddamn battery. Peter Atiyah. Anyway, and other people, not just him.
01:10:43
Speaker
So these words, like subop like what does suboptimal mean? Who the fuck knows? Or functional. Yeah, functional or dysfunctional. Who knows what they mean? they're They're usually used as a way just to market something like, oh, you're doing that? It's not functional. You better come over here and do my functional three-word course. I think there are suboptimal things. I think pain is suboptimal. I think it's suboptimal if I want a donut and I don't have one. I agree.
01:11:09
Speaker
ah
01:11:12
Speaker
and Do you agree that pain is suboptimal? Oh, yeah. pain is is ah agree pain Pain is suboptimal. Yeah, for sure. But here's the thing. Would it then also follow? If pain is suboptimal, we can all get behind that. If exercise reduces pain, it must be optimal or functional? Sure. Right. Well, here's the deal. Any exercise can reduce pain. Yeah. So does that mean any exercise is optimal or functional? It's both. Quite possibly. like It's a yes and. Individual by individual. It depends. But any exercise could be functional or optimal.
01:11:42
Speaker
if we think pain is suboptimal. yeah okay I also think that stalling in progress is suboptimal. So if your exercise offers you room for improvement or a path toward mastery, I say it's functional or optimal. And the only type of exercise that I've ever found that doesn't offer improvement toward mastery is exercise in humility, because that would be very un-humble to be a master at exercise in humility. This is for my brain.
01:12:10
Speaker
behemoth, nemeth. I think getting injured is suboptimal. Yeah, it's not the best. Yeah. So, if your exercise system bolsters your resilience in some way, I say it's optimal. I say it's functional. Word. And the only exercise that fails to bolster your resilience is the type that's inappropriately dosed.
Fear Mongering in Movement Education
01:12:29
Speaker
Underdosed or overdosed? And here's what else I think. Similar to what you said, Sarah.
01:12:35
Speaker
I think fear mongering and instilling scary narratives in our students about their bodies or knees is dysfunctional. I think that's what's dysfunctional because it's literally creating a dysfunctional relationship with their body. It's causing them to believe they're weak and fragile. They're always at risk. And ironically, as you noted, I think that these self-proclaimed functional movement systems that teach you to move optimally with optimal joint mechanics I think a lot of the times they also love to fearmonger other movement systems that are not doing what they think is functional and optimal. And in fact, I also think it's often the case that when people use functional in the title of their movement system, they're low-key broadcasting the fact that they probably also regularly fearmonger movement.
01:13:23
Speaker
100%. Which is so ironic. Yeah, i mean I remember somebody one time was like, well, why would you do triangle pose? I mean, it's not functional. right And I'm like, well, neither is a lot of things according to you. Right. But if triangle pose feels good and gets me out of pain, yeah if I can get better at triangle pose and it experience the pleasure of like getting better at something. Yeah, if I like yoga. Right. and Or if triangle pose held you know, in a the particular way that I'm holding it is helping me to improve some capacity that's helping me in my life. It's fucking functional. I agree. Sorry, not sorry.
01:13:54
Speaker
If we're making progress without pain, I say that's pretty dang functional. I say that's optimal. So let's discuss what assumptions people make about knee valgus so that we can can be
Debunking Knee Valgus and Squat Misconceptions
01:14:06
Speaker
ready for them. So generally, what do we assume or even cue? When we notice, for example, in a squat or a lunge, okay this can be a yoga or strength, right? The warrior poses are kind of like lunges. Maloscent is a squat. Strength training, we've got the squat, the deadlift.
01:14:18
Speaker
ah Sorry, we got the squat, the deadlift too. We've also got lunging movements. What do we cue? What do we assume when the knee dumps inward of the center of the foot? Well, that's the worst possible thing that could happen. Shouldn't do that. So what should happen is that your knee should just track straight ahead. It shouldn't waver. Like if you're doing a movement like coming in and out of a squat, it shouldn't go in and out. It should stay on that same path.
01:14:43
Speaker
If it goes in, we should push it out. In fact, I mean, Kelly Starrett was the mastermind behind the whole like knees out thing, as far as I understand, because that's where who I heard it from. ah To the point where I think he even went like, hey people, not everybody needs to be like going so ham on this. like Everyone, let's just calm down.
01:15:06
Speaker
Right. But there's this idea that like, oh, we want to make sure that the knees in doesn't happen. So we should preemptively push them out. Ideally push them out into a band, even, even better. Right. So that's, you're going to wear a band around your thighs while you're squatting so that your knees don't cave in. Okay. So it's often thought as well that the reason why you have a knee valgus is because you have weak glutes, or maybe so more specifically is because you have a weak. Glute need, right? Your lateral glute muscles, because since they're not strong enough, yeah your femur, your thigh bone is now internally rotating and that's forcing your knees together. And so people sometimes are told if they do a squat in their knees cave in, oh, it's your weak glutes and we got to make your glutes stronger. But this is fast. I found this fascinating. So it's just not born out in the research. So there was this study that was done where they took 10 healthy adults
01:16:01
Speaker
and they induced weakness in their glute muscles. They did nerve blocks, which I would love. I just feel like that's like hilarious. I'm trying to imagine them like walking in the room with like paralyzed butts. But anyway, so they induced weakness of the gluteal muscles with a nerve block and then they had them perform deep squats. There was a loss of joint reactive force, right? The ability to produce produce force. but it didn't change anything significantly in the hip, knee, ankle, or pelvis kinematics. Kinematics is that joint geometry, right? So we know glutes are strong glutes are important for strength, sure, but it's not important to the kinematics of your squat, and in particular to whether your knees go in. Right.
01:16:49
Speaker
There's also this randomized controlled trial titled impact of three strengthening exercises on dynamic knee valgus and balance with poor knee control among young football players, a randomized controlled trial. And the aim of this study was to assess the effectiveness of three exercises in strengthening the muscles, one of which was the gluteus medius. There were 45 participants aged 12 to 15 and the participants were assessed with 2D video kinematic analysis during a single leg squat to assess the knee valgus angles and they found there was no significant interaction between groups the control group or the exercise group and time the baseline and then after six weeks the
01:17:34
Speaker
No significant in her interactions between groups were noted for dynamic valgus for the left and right knee. So in other words, what that's saying is that strengthening the gluteus medius did nothing for the knee valgus.
01:17:53
Speaker
all right It's so good. It's like if you turn it off, it does nothing. If you turn it on, it does nothing. yeah like it doesn't it Don't do nothing. Don't do nothing, but then does it does it potentially reduce our knee pain if we strengthen the glutes? Well, maybe not, because not necessarily the glutes, okay, because there was a randomized control trial that it was both anterior medial, that's front and inside of the hip, versus posttero lateral, back and side of the hip musculature.
Nonspecific Knee Pain and Exercise Variety
01:18:24
Speaker
um The title is anterromedial versus posterolateral hip musculature strengthening with dose controlled in women with patellar femoral pain, a randomized controlled trial. And it found there was no difference between the addition of anterromedial or posterolateral hip muscular strength, musculature strengthening.
01:18:43
Speaker
to knee strengthening in improving pain and function in women with patellofemoral pain. In other words, what that's saying is you can strengthen your adductors, you can strengthen your hip flexors, you can strengthen your abductors, you can strengthen your hip extensors and you could pick one or all and they might all reduce your knee pain. You don't just have to strengthen the backside of your hips. But why then are we always given clamshells?
01:19:12
Speaker
Why aren't we given? Copenhagen's. Knee raises. Why aren't we? Yeah. Anything. Literally anything else. Adductor slides. Sure. All right. Sarah, there's there's a phrase I've heard. I don't know if it's like a clinical phrase, but there's something called non-specific low back pain, but also I've heard non-specific knee pain. Yeah. that like You can have knee pain and not necessarily need to find the exact mechanism of it? Yeah. Well, sometimes your knee pain is because there's something funky going on in your foot or your hip and nothing thing at all going on in your knee. And sometimes you'll never find the mechanism of your pain. You're just, your knee has pain. Yeah. you You maybe need to do a little exercise of some kind. Maybe your knees hurt cause you don't move enough. And maybe it'll feel better. Exactly.
01:19:53
Speaker
Or maybe you're moving too much in one particular way all the fucking time. Like you only do, I'll raise my hand, yoga for eight years. And then you're you're like, shit. Maybe I should do something else. Okay. I think basically the good news is that we have lots of options. A lot of the time when we have some discomfort, we don't just have to go to one muscle group. Okay. Back to banded knees while squatting.
01:20:15
Speaker
Do you notice that people like to wear bands around their knees when they squat, Tara? I sure do. Or they just like to shove their knees out, even before they start moving. Their knees are out and then they're bending. Can you think of or share some drawbacks of this always being the way we try to squat?
01:20:32
Speaker
The thing about the band or the pushing out is that you're forcing a trajectory for your knee that might actually not be the most mechanically advantageous to your knee. You might actually be giving your knee a harder task by not letting it just track wherever it would naturally track.
01:20:50
Speaker
You're also exaggerating the import of those abductor muscles and possibly not able to get as much out of, let's say, your adductor muscles, right? Which some of them, like your favorite muscle, adductor magnus also do hip extension, but now suddenly I'm like not allowing it to function as well, right?
01:21:10
Speaker
and One of the things you can think about as well is like, I'm now wasting energy or wasting force pressing out into this band that I could otherwise be using to push down into the ground and stand up with out of my squat, right? And then there's also the issue of foot pronation, which everyone is... I think we have to do an episode on foot pronation as well. Yeah. It's when it's when your're your medial arch moves down into the floor. It's o okay. Quai ror. What? Horor. Isn't that how you say it in French? Quai ror. Quai ror.
01:21:37
Speaker
um
01:21:39
Speaker
and thought you I'm deeply sorry if I'm offending anyone who's French. Sorry. I'm not French and I'm offended. OK. Yeah, I mean, pronation of the foot is a natural, normal movement of the foot, and it's probably going to happen when you squat. And if you're shoving your knees out, you're not letting it happen,
Reconsidering Knee Valgus and ACL Injury Links
01:21:55
Speaker
right? So you're giving away some of your strength for something that you don't really need. Can I ask though, I mean, let's go back to foot pronation. Why would would would i why would would I want the medial arch of my foot to move into the ground for a squat?
01:22:06
Speaker
My understanding is that then you're getting more contact surface with the ground, right? Oh, shit. That's a good point. Right. And then you're able to push off. You have greater ability to push off, right? To stand up. Yeah. The one thing I will say is like, let's say, you know this is we're talking about like healthy pain-free people who are forcing their knees in a place for no real reason. Sometimes for someone who's coming in and let's say they have some hip pain or hip arthritis or something, it feels more stabilizing to engage that um ah abduction.
01:22:36
Speaker
While they're doing their hip flexion and extension because it's not wrong. Yeah, it's not wrong to do But you don't need to do it if there's no problem, right? Yeah. Okay, but is it okay for everybody? Is there ever an instance where we might want to change this pattern of the knees coming in Sarah? Sure um If there's pain Probably would be the only reason I do it. Mm-hmm. Yeah, I don't think bands are a bad choice inherently But I don't think you need to change If someone's knees come in a little while squatting, that doesn't mean you immediately need to change that. And you don't necessarily need bands to change that. But surely, Sarah, surely landing from a jump. Don't call me Shirley. Surely. I mean, Sarah landing from a jump and knee valgus is bad. I mean, if I jump off of a box and land and my knees come in, that must be bad, right? No.
01:23:31
Speaker
What? yeah That is very, very cognitive dissonance creating. Well, what you're going to do is kiss goodbye to kissing knees. It's one of those ah study titles. Yeah, it's one of those study titles where they're like, you know we just want to make it a little bit funny. So this study is called Kiss Goodbye to Kissing Knees. I wish they could say, it's time to donate your pencil skirt. No, that doesn't make sense. Sorry.
01:23:59
Speaker
Anyway, kiss goodbye to kissing knees. no association but what no kiss goodbye to the kissing knees No association between frontal plane inward knee motion and risk of future non-contact ACL injury in elite female athletes.
01:24:18
Speaker
This study aimed to determine if frontal plane knee and hip control in single leg squats or vertical drop jumps with an overhead target predicted future non-contact ACL injuries in elite female athletes. In in other words, Alona Mera is not ramming into your knee.
01:24:33
Speaker
while you're landing on it. Or like what happened to your dad. Right, exactly. Non-contact. This is not a contact situation. No, this is not an external force shoving your knee somewhere. Yes. So analyzing 722 non-injured and 56 injured participants, we assessed lateral pelvic tilt, knee projection angle, medial knee position, and side-to-side asymmetry from 2D videos at baseline. None of these variables differentiated between injured and non-injured athletes.
01:25:03
Speaker
Yeah, and there's been a lot of other studies that have corroborated this, and it's now being recommended that we move away from valgus as a way to screen for future
CrossFit Myths and Technique Adaptability
01:25:12
Speaker
ACL tears. In other words, you can't look at someone landing from a drop-jump and watch their knees go valgus and go, you will eventually have an ACL issue. Because remember, there is a very specific context in which it happens typically at the low 30 degrees cutting type movement, right? Also, it depends on how adapted someone's knees to that action. and When I took the CSCS exam though, I had to answer a lot of questions about watching a video of somebody landing from a jump, their knees would go valgus. I would notice like of the four videos, this one's knees are going in and I had to mark that as the correct answer to like, what's what's the problem here? Because it was always the problem. The knee valgus was always the problem. And the CSCS exam is
01:25:56
Speaker
considered to be for personal training assets, the most reputable cert that you can take in the US. But even the CSES is outdated, right? And so it needs to be updated. But what makes it so good is because they're constantly updating their textbook and their tests based on newer evidence. um But it takes time to make these updates. And you also want an overwhelming amount of evidence before you make those updates. So research is expensive. It takes time.
01:26:20
Speaker
Yeah, so bad technique in general is not associated with increased risk of injury. And I know that sounds really counterintuitive, but if bad technique were associated with increased risk of injury, we'd probably see that CrossFitters have higher injury rates than other people whose strength train. CrossFitters lift at high intensities under a lot of fatigue. Ask me how I know. And yet, injury rates in CrossFit are about the same as in other lifting styles that are supposedly safer or use more optimal technique.
01:26:49
Speaker
There are multiple studies that will link in the show notes showing this is the case. And at this point, there's been consensus around the fact that CrossFit is just not as dangerous as people want to make it seem. The thing is, is that motor patterns change as intensity and fatigue build. This is normal and it's also a good thing, right? As you fatigue, your body, your brain really is going to find other muscles to recruit in different patterns of recruitment so that you can keep doing the thing you're doing.
01:27:16
Speaker
So no, not every rep needs to look the same. Just watch how elite runners look while running at the start and the end of a marathon. Or look at how me, a non-elite runner, looks starting a 5K and then ending a 5K. Some of us are hobbling to the finish line. I mean, I would be hobbling for sure if I even tried that. Yeah. and This is going to allow us to even finish the race because the patterns that worked at the beginning no longer work because we're tired. so Let's talk actually about running. Is it bad for your knees generally to run? It's common knowledge or rather, I should say, conventional wisdom that it is.
01:27:59
Speaker
How many times have you heard running a wreck your knees? a A million, gabillion times. Yeah, and and also if you run with valgus, which I i used to in a very pronounced way in like elementary school, my feet would like be flying out to the side as I was running. um I also sat in the W-sit, right so I have like a lot of internal hip rotation.
01:28:20
Speaker
and I was one of the fastest runners in my class and I looked weird running, but I could run fast and I never had any knee pain or any pain, so to speak, at all in my lower extremities. Even if you run with valgus, I know I'm just one person, but studies have shown as well that Again, running technique doesn't necessarily equal a sentence of knee pain. We can look at another very elite runner, Sharon Leketi, the winner of the New York Marathon in 2022 and recently fourth place finisher in the Olympics. She pretty frashed. She displays very pronounced dynamic knee valgus and I'm sure
01:29:03
Speaker
You looked at the comment section of the social post we're sharing in the show notes and what are people saying about Leketi's knee valgus? I mean, they're saying everything from like, that's a, you know, knee surgery waiting to happen. She's going to blow her ACLs or just that looks ugly or it hurts me to look at it. Just all this kind of like fear mongering language around knee valgus. Yeah, and yet she is operating at the highest possible level as a runner. And so what are these people basing these predictions off of? Probably a lot of outdated beliefs. By the way, I can maybe, maybe run for about 20 seconds as fast as Leketi can run for 26.2 miles on a good day.
01:29:47
Speaker
ah Just check out her marathon time and ah you'll understand that that this woman is faster in a marathon as most people are in a sprint. If we were to suddenly go in and start trying to change her gait, there's a very high likelihood her running times would decrease and there's also a very high likelihood that she would end up with some type of an injury.
01:30:10
Speaker
The mechanics of her run are what her body has naturally selected to be the most efficient for her.
Running Technique Myths and Arthritis Prevalence
01:30:19
Speaker
And so if we go in and we start saying things like, you know, push your knees, I don't even know how you would, what you would say to try to make her run differently. But if we start messing with the mechanics of her run,
01:30:29
Speaker
It's going to now put pressure on other tissues in some way that her body has not selected as the most optimal. I remember reading this article a while ago about elite runners and how a lot of them, you know quote unquote, run ugly. But when people would go in and try to correct what their whatever their running technique was, like it wasn't the you know standardized textbook, this is how you should run, they'd go in and try to correct it and it would just mess everything up. Yeah.
01:30:56
Speaker
there is There are definitely arguments for changing running gait, and so one of them that I've encountered is to change cadence, which is how many times your foot is contacting the ground in a span of time, right? You can speed up your cadence, you can slow down your cadence, you can shorten your stride length, you can lengthen your stride length, and these can be wonderful ways to change running in a very simple way that can reduce sensitivity. But it doesn't mean that one cadence or one stride length or one gait pattern in running is correct or incorrect. It just is going to be a case-by-case situation where if someone does have pain in running, you can make these simple tweaks. like Just run at a faster cadence or relax a little bit more.
01:31:43
Speaker
right With Leketi and that dynamic knee valgus, she's got her running style dialed into the point where she's now winning marathons and beating the fastest people in the world. Until she has knee pain and is seeing a physical therapist or ah What are they called? Sports rehab, right? Specialists sports rehab specialists for her, for her issues. We don't need to go in there and change anything. Thank you very much. yeah There was a cohort study called low prevalence of hip and knee arthritis and active marathon runners that I found very interesting. So an international survey of marathon runners, 675 participated assessed hip and knee pain, arthritis prevalence, and various risk factors.
01:32:28
Speaker
The average age of participants was 48 years old. They were running a mean of 36 miles per week. Wow. I know. Over 19 years and completing an average of 76 marathons. So an average means a bunch of people did a lot more than 76 marathons. That's right. Holy cannoli. Yeah. Results showed that 47% reported hip or knee pain and 8.9% had arthritis.
01:32:57
Speaker
Okay, notably, US marathoners had an arthritis prevalence of 8.8%. This is significantly lower than the 17.9% prevalence in the general US population. hu So risk factors for arthritis include age and family or surgical history, but it turns out that running duration, intensity, mileage, and marathon count did not significantly affect arthritis risk.
01:33:27
Speaker
That's fascinating. Now, I have also seen other studies showing that elite marathoners may have higher rates of arthritis than the general US population. But recreational marathon runners have lower rates of arthritis.
Knee Sounds and Reassurance
01:33:43
Speaker
So if you're listening and you are a recreational runner or want to be a recreational runner, it turns out that that might be a really good choice for your chances of getting arthritis, knee arthritis specifically.
01:33:55
Speaker
Okay, time for play acting. Sarah's the client, her knee hurts while squatting. Begin. Hi, my knee hurts when I squat. Oh, well let's take a look at you squatting. Squat, knees out. Oh, okay. So I'm watching Sarah squat and I noticed that she initiates the squat with a very aggressive knee out position. That's what I'm supposed to do, right? Well, there are- Kelly Starrett said it. m Yeah.
01:34:25
Speaker
i I think he's actually walked it back. Have you heard that? No. Yeah, I think that he sort of walked back that advice. It's maybe not the best for everyone. It could be that it helped you for a while and then it's no longer helping you and we can maybe scale back the degree to which you're pushing your knees out. In fact, I wonder what would happen if we tried squatting and you just let your knees do what they wanted to do.
01:34:50
Speaker
Okay. Let's see how it feels, and if it doesn't feel good, we'll keep playing with it. Squat. Oh, wow. That feels a lot better. Interesting. Okay. Why don't we try this for a while? Nothing is ever set in stone. We don't need to do something forever. um But I suspect that the knee out thing maybe just has become a little too well worn in your body, and we can try a different pattern and see if it feels better. Huh.
01:35:13
Speaker
Yeah, thanks, Laurel. You're welcome. OK, so notice how I wasn't like, oh my god, Kelly Starrett. I wouldn't take everything he says as law. ah Sarah. Yes. Noisy knees. Cricky cracky, clicky clacky, snap, pop, pop, pop,
01:35:43
Speaker
My knees are noisy. My knees are noisy. Is this bad? Is this a red flag? Why do my knees pop and snap? Does it mean I might have bad knees or am I destined for pain? and They don't hurt when they pop and snap, but will they someday? Well, the there's a few different things that can cause noisy noise or noisy knees.
01:36:09
Speaker
One of them is when you go to go from a like a standing position to squatting down, for example, the space inside the joint expands. And when it does that, it pulls the oxygen that has been absorbed into the fluid out into a gaseous form.
01:36:28
Speaker
And that's the noise that you're hearing sometimes. Like if you do an experiment where you you know come down, you hear your knees go pop, come back up, do it immediately again, they if that's what the noise is from, they're not going to make that noise again because it's already happened. And then over time, the ah gas gets reabsorbed into the liquid. And then however many minutes later I don't know, you can make them make noise again. That's one reason. Another reason, and i this is just sort of what I've understood.
01:36:56
Speaker
I don't have evidence to to back this, but what I've understood is that as we age, you know we end up we've got that space with the synovial fluid in the joint. It ends up with a bit of flotsam and jetsam floating around in there. Maybe like little tiny microscopic bits of cartilage might have like popped off. or you know Just kind of not as, ah to use the words of Stu McGill, pristine, as it may have been when we were born. And so then as we move our knees around, some of the sound that we might feel, sometimes we just kind of feel it as a vibration or sometimes we can actually hear it, is just those bits of flotsam and jetsam rubbing up against each other. Okay. Play acting. All right. So I'm coming to Sarah's yoga class and my knees are clicky.
01:37:42
Speaker
Hey, so glad to be here. Great to have you. My name is Laurel. Hi, Laurel. I just want to let you know before we start class that my knees are really noisy, and they click, and they kind of crackle a lot. And i'm when I go to other teachers' classes, and my knees are super noisy, I'm always wondering, like is this bad for my knees to be doing the like warrior poses? Or if we come into that deep squat, what is that one called? Malafina? That one, yeah.
01:38:09
Speaker
um I'm just not sure if like it's okay that they're like really loud. So my first question to you is going to be, do you have any pain when your knees are making those noises? No, I don't, but I'm worried that I will if I keep making those noises with my knees. Well, here's the good news. Those noises are not going to lead to pain. Oh. There's some very natural things going on in your knees. There's a couple of different things. You should listen to a podcast I did called Behemoth Nemeths.
01:38:37
Speaker
He just said that weirdly. we with meanhe and ne The crackling noises are nothing to worry about. It's not going to create pain in the future.
Conclusion and Listener Engagement
01:38:47
Speaker
If you have knee pain, definitely come and tell me and we'll figure out what might actually be causing that, but it's not going to be the noise coming out of your knees. Nice. Yeah. All right. I'll stop worrying about it. Great. Cool.
01:39:00
Speaker
All right. I think that was a lot of behemoth nemeth. So many. And we're ready for the conclusion. Sure. What are we conclusioning? I hope you enjoyed this episode and you feel well equipped to go out into the world and fix everyone's bad knee alignment or else. Just kidding. Please check out our show notes for links to references we mentioned in this podcast. There is going to be an FT of them.
01:39:28
Speaker
Yes, that's a ah metric fuck ton. I think we have to change it to MFT, so it's a metric fuck ton. There is an MFT of links in our show notes to references we mentioned in this podcast. Finally, it really helps us out if you like this episode to subscribe and then rate and review on Apple Podcasts. I know that we say this a lot, but we are in a bit of a rating and review drought on Apple Podcasts, and I would like to go to my Apple Podcast and look at a new review Laurel loves the reviews. It makes my day. And so when there's a drought, it just makes her really thirsty. I want to drink your review. So that my throat is parched send reviews and dryness in my throat. Yeah, and the stars are like the electrolytes. They keep me hydrated as well. Ah, nice. I need lots of stars. Yeah, you do. OK. And then take our free class. Woo, woo, woo. September 19th at 8.30 Pacific AM. That's AM.
01:40:26
Speaker
And 1130 a.m. Eastern, we are teaching a sample workout from our barbell course. Yes we are. The intensity course, Lift for Longevity. You can come as you are with what you have. If you have weights, bring weights. If you have a dowel, have a dowel. If you have barbells, bring your barbells and see what it's like to be live online with Sarah and I and a bunch of other women looking to get strong AF. You also get a replay if you can't attend live.
01:40:50
Speaker
And you can keep your camera on and get live feedback, or you can leave your camera off and just go anonymous, which is my favorite thing to do. Nice. So that's also in the show notes. Click it. We are holding this free class on September 19th. See you next week.