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Friday, September 7, 2012

Friday Q&A: Knee Restrictions

Q: I have chondromalacia from an untreated sprained knee that I got 5 years, at 2 months post partum. Once I finally had it diagnosed, I needed nearly a year of physio for my knee to become 95% functional. So today, I cannot hyperflex, or sit on my knees, or go on all fours. Because I am very interested in practicing yoga now, I need to adapt several poses. Some impossible positions for me are the child's pose, the lotus, and anything stemming from those poses. I wonder if you have any advice to offer regarding adaptation as I follow videos and don't attend a formal yoga class. Many, many grateful thanks to you for your help!

A: Thanks for your very interesting question. Since chondromalacia of the knees is a fairly common condition, especially for younger women, I am excited to talk a bit about the condition and then share some general ways of modifying your poses to enjoy the bigger benefits of yoga while keeping that knee happy!

So let’s start off by defining chondromalacia, or what is also known as patellofemoral syndrome (PFS). The NIH website defines it as follows: “Chondromalacia of the patella —the softening and breakdown of the tissue (cartilage) on the underside of the kneecap (patella). The pain associated with this condition is often felt at the front of the knee or kneecap (patella).” Another common cause of pain in this area of the knee is runner’s knee or patellar tendonitis. Because chondromalacia involves actual breakdown of the healthy cartilage that lines the back surface of the knee cap, recovery times, as you have experienced, could be a lot longer than those for inflammation of the patellar tendon, which connects the quadraceps muscle to the front shin bone, via the knee cap.  Runner’s knee usually refers to the section of tendon between the patella and the tibia or anterior shinbone.

It is always helpful to have a sense of how this could come about. Normally, the kneecap sits in front of the lowest part of the upper leg bone, the remur bone, when you leg is straight at the knee joint. Once you bend or flex the knee to 90 degrees and beyond, the kneecap ends up in front of the bottom of the femur bone. The patella has a midline raised grove on its backside like the hull of a sail boat, and the bottom of the femur bone has a groove in it that the patella normally slides on, like a perfect channel for the bottom of the boat. Both surfaces of these bones are normally coated with smooth, slick, cushioning cartilage, so movement proceeds smoothly, silently and without much of any sensation. So how do things go wrong?  Again, according to the NIH:

“Anterior knee pain (such as PFS) begins when the kneecap does not move properly and rubs against the lower part of the thigh bone. This may occur because:
  • The kneecap is in an abnormal position (also called poor alignment of the patellofemoral joint)
  • There is tightness or weakness of the muscles on the front and back of your thigh
  • You are doing too much activity that places extra stress on the kneecap (such as running, jumping or twisting, skiing, or playing soccer)
  • You have flat feet”
Because deep bending of the knee joint brings the kneecap and the thighbone into close tighter proximity of one another, inflammation and pain can ensue when PFS is present. So, it is not surprising that you experience pain (I am assuming that is why you are avoiding these poses) in poses like Child’s pose, where not only are you deeply flexing the joint, but you are also putting your full body weight right over that knee. And Lotus involves not only deep flexion of the knee, but also a spinning outward of the shin bone in order to get your foot on you opposite thigh, adding another 3D challenge to an already sensitive joint.

In general, I’d recommend avoiding the deep fold of the knees in poses like Child’s pose and Hero pose (Virasana). One way to do Child’s pose is just flip it upside down, lying on your back, with your hands behind the knee joint to encourage a bit of space in the joint.  For Hero pose, a block on its highest height under your hips could relieve the intensity of the fold and allow for a modified version. Instead of Lotus pose, substitute Cobblers pose (Baddha Konasana), where you can keep your feet further away from your pubic bone and control how deep of a fold of your knees you can do without precipitating pain.

For straight leg standing poses, like Triangle, if it is the knee of the front leg where you experience pain if the knee hyper extends, then there are ways to train yourself to find more even alignment of the femur and lower leg bones, so you can still practice the standing poses with out aggravating your knee.  One use of props that some find helpful is to angle a block just behind your front shin so that it pushes up and forward against the back of your calf at just the point your knee would be going to far toward hyperextension.  It takes some playing around to find just the right spot for the block, but it can start to train your joint receptors to tell you where straight is. Once you know that spot or alignment, you can take the block away.

An experienced yoga teacher could also share many ways to modify poses so you could begin to feel more competent in caring for yourself with the basic yoga postures, and eventually could set the stage for you feeling safe to try a regular class. And always keep in mind that accomplishing challenging yoga poses is not really the goal of yoga, and that you always want to create a practice that serves your bigger goals, such as mental equanimity and clarity, while honoring the unique challenges that each of our body’s will continue to dish up.

—Baxter
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