Last week I looked into why knee pain is so common and how the Bar Method can help students who have knee issues. To recap, if your knees hurt because of ligament damage or moderate arthritis, The Bar Method workout can help you regain stability in the joint by strengthening and balancing the major muscles that extend across your knee, principally your quads, calf muscles, and hamstrings.
The cause of your knee discomfort could also be a matter of having leg muscles that are of uneven strength and length. In that case you will need to use some minor modifications during the workout in order for your knees to feel comfortable and get better. This problem arises when the muscles on the outside and front of your legs become very strong but those on the inside of your legs don’t, an imbalance that causes your stronger muscles pull your kneecaps off track towards the outside of your legs during exertion. Runners and dancers can both suffer from this problem for different reasons. Runners are prone to IT band syndrome, which involves a tendon on the outside of the leg becoming too tight and pulling on the knee. Both runners and dancers can suffer patella displacement by developing strong quads while letting their hamstrings and inner leg muscles remain relatively weak. If you think you have one of these conditions, here are some modifications you can try:
• Instead of the narrow V position, do “parallel thigh.” If needed, bend your knees to a lesser extent as I’m showing in the photo. This adjustment prevents your stronger outer quad muscles from over-engaging. In this position you can also squeeze a ball, small mat or cushion between your legs to help strengthen your inner quads (see last week's blog for details).
During standing seat-work:
• Instead of bent-knee standing seat, do straight knee standing seat. Under normal circumstances standing seat is a great stretch for the quad muscles, which have just been worked. The reason the exercise might be uncomfortable for you is because your outside leg muscles might be not only stronger but also tighter than those on the inside and so are pulling your kneecap outwards. Until your leg muscles regain more evenly balanced strength and length, simply keep both legs straight in this exercise.
Now we come to students who have more problematic knee issues, those that involve something going on inside the joint itself. Here are a few of these conditions:
Meniscus tears: You have two menisci in each knee. They’re a kind of cartilage but with a specialized cushioning and stabilizing ability. A sudden twist is what often tears a menisus, usually causing enough pain and disability to need medical treatment before you return to exercise. When you do come back to class, after your initial treatment the exercises can help you strengthen your knee if you take it easy at first.
Patellar tendonitis: Your patella or kneecap kind of floats inside your quad tendon, a big tendon that extends across your knee and fastens to your shinbone. (Your kneecap itself has a smaller tendon of its own.) Patellar tendonitis, which you get when these tendons become inflamed, is a stubborn condition that doesn’t go away easily. It causes pain and swelling in the front of your knee when you bend it. If you have this condition, some thigh exercises will be uncomfortable for you.
Hamstring tendonitis: You have three hamstring muscles, the tendons of which stretch across the back of your knee. These tendons can also become inflamed (another obstinate problem) and cause pain in the back of your knee.
Bursitis: Your knee has three bursae whose function it is to help lubricate the joint. When your bursa is inflamed, usually from kneeling for long hours, your knee will experience swelling, tenderness and redness. Excess swelling around the bursa will cause an accumulation of synovial fluid behind the knee, a condition known as “Baker’s Cyst.”
Obstruction in the knee joint: Your knee might have an obstruction in the joint due to a piece of cartilage, menisci or other tissue stuck between the bones. Obviously in this situation you wouldn’t be able to straighten your knee without a lot of pain.
Greater than average “Q angle”: Women’s “Q angle,” that is, the angle between the quad muscle and the patellar tendon, which is greater than mens’ due to a wider pelvis. Women’s knees are beset by this issue because evolving humans found it to their advantage to produce ever smarter babies with bigger heads. Women’s knees have as a result ended up with “a narrower femoral notch, increased 'Q angle,' and increased ligamentous laxity” according to James A. Nicholas, M.D., the founding director of the Nicholas Institute of Sports Medicine and Athletic Trauma, thereby making women’s knees inherently more vulnerable to injury.
The issues listed above of course require medical attention. Meanwhile, provided that you’re being treated and are on your way to recovery, can you take the Bar Method? The answer is a qualified yes. If your doctor says it is safe for you to do strengthening and stretching exercises you can take class by using some modifications during some of the exercises. Here are some substitutions you can try:
During thigh-work: Knee problems vary, so try the following substitutions and see which ones work best for you:
• Instead of parallel, leg-together and narrow V thigh work, do “chair.” This position keeps the feet flat on the floor and the knees right over the ankles. It’s also great for distributing the effort from your quad muscles evenly across your knees.
• Instead of “diamond thigh” and “second position,” both of which are performed in a wide turn-out, do “second position” with your feet flat on the floor. Like chair, this position allows you to keep your heels down and your knees over your ankles.
• When all else fails, you can always do leg lifts during thigh-work. Leg lifts work your thighs with no weight on your knees. You can do leg lifts both in a parallel position and with your legs turned out (always keep your leg directly in front of your hip, whether the leg is “parallel” or turned out).
During stretches that involve kneeling or bending your knee:
• Your knees might be simply sensitive, or you may not be able to bend them completely. In these cases, you can modify the leg stretches in a number of ways. Here are two modifications for example that you can use during the thigh-stretches.
• Throughout the whole class anyone with limited flexion in a knee can keep it straight during any stretch or perform the stretch standing while holding onto the bar.
In the long run, finding a way to workout rigorously without joint pain will help your knees. In my view the Bar Method is an ideal workout choice first of all because its tight structure enables you to anticipate each next position and adjust accordingly, and also because its modifications accommodate as many knee issues as possible.
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Read more about exercise and the human body: EXERCISE AND EVOLUTION: THE COMPLEX, MOBILE AND BEAUTIFUL SHOULDER
Bar Method students with knee issue fall into three groups: those whose knee pain lessens or disappears after a few months of classes; those whose knees improve when they use Bar Method modifications during class that are specially designed for their particular condition; and those who have knee disorders that need a doctor’s care. This third group can benefit from taking the Bar Method. However, they need to use more specialize modifications during class, and their knee issues will take longer to resolve.
The reason there is so much variation in the way knees respond to exercise is that the knee is simply a very complicated joint. A lot of very different things can go wrong with it, and in recent years knee injuries have become so widespread that they are now the most common musculoskeletal complaint that people bring to their doctor. Two trends have converged to cause this recent surge. First, collegiate and amateur sports such as soccer, skiing and off-road biking have become more competitive. Second, the people signing up for these sports have become less fit. In the last ten years for example, the number of high school age girls who play soccer has doubled while the overall level of physical fitness in this age group has declined. Today girls are five times more likely than boys to injure their knees while playing this sport.
Fortunately most students with knee issues fall into the first group, the one that responds quickly to the Bar Method workout. These students’ knees simply lack stability due to loose or damaged ligaments or arthritis. Such conditions usually originate from sports that involve jumping, executing sudden turns such as soccer or repetitive high impact movements such as running. The Bar Method workout addresses such problems by firming up and balancing the muscles that run across the knee, thereby giving the joint the added stability via a strong girth of muscle. The Bar Method's exercises were designed in conjunction with physical therapists with this express purpose in mind. Countless Bar Method students with ligament injuries or moderate joint degeneration have told me that their pain goes away after a few months of classes.
The second group of students usually have muscles running though their knees that are of unequal length and strength. When they bend their knee with a certain amount of muscle power, their muscles pull the knee cap to one side as shown above (usually in an outward direction) causing pain. Runners and dancers for different reasons come down with these conditions more so than other athletes. My favorite modification for this problem, shown to the right, is for students to do thigh-work with just a slight bend in their knees while squeezing a ball or small mat between their thighs. This position helps them to strengthen and tighten their inner quad and leg muscles, helping eventually to make them as strong as those in their outer quad and leg muscles.
The students in the third group, the ones who need additional modifications during class, have a wide range of conditions, each with its own set of causes and symptoms. Before I describe the modifications that these students would use, I want to explain why there are so many kinds of knees injuries. The reason in brief is that the human knee consists of a greater number of parts than the average joint. If just one goes awry, the rest of the knee is affected. Since the knee supports almost the entire weight of the body, when something goes wrong, the situation can deteriorate pretty quickly.
The knee, unlike most joints is composed of not two but three bones: the thigh bone, the shin bone and the knee cap (the patella). These bones are bound together by four major ligaments. Next, numerous tendons run up, down and across all sides of it. (Tendons are the ends of the muscles that operate your knee.) Finally, deep inside the knee joint is cartilage, meniscus, which is kind of sliding cartilage, and several bursae, which serve to reduce friction.
All of these components can misfire, wear out, or get tweaked, creating a multitude of knee issues that, should you have one, will affect your workout in different ways. It's important to note that if you happen to be someone whose knees are bothering them, it’s important that you see your doctor if you’re feeling persistent joint pain.
Next week, I'll describe some of the knee disorders that need special attention when you work out, and I'll give you step by step instructions on how to modify The Bar Method exercises for these conditions.
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This morning while I was taking the 7 am class, I noticed two students, Raymonde and Rose, who were working across from me. The three of us are regulars at this hour, so I’ve had the pleasure of watching Raymonde and Rose develop from struggling beginners into students with good form. Their improvement has been especially satisfying for me to watch because their height could have interfered with their progress had they not been at the Bar Method. Both are on the petite side, especially Rose, and Raymonde also has delicate shoulders. Here their stature and joint sensitivity are not a problem due to the availability of “riser mats,” a piece of equipment that you can find in every Bar Method studio. Riser mats are two inches thick and filled with dense rubber. Students who are petite or have sensitive shoulders can sit on “risers” so that they can reach up to the bar from below without straining their necks and shoulders. Raymonde as you can see is also using a stretching strap to hold her leg elevated, which helps her do the exercise without running the risk of overworking her hip-flexors.
The idea to make riser mats an essential piece of equipment came from The Bar Method’s long-standing effort to make its workout as safe as possible. When your joints are comfortable, you can concentrate on your muscles, not to mention that you feel intrinsically safer. With this aim in mind The Bar Method has developed not only its risers but a variety of equipment that contributes to its goal of creating a workout that is gentle on its students joints, the better to be challenging to their muscles.
Rubber Underlayment: On first sight a Bar Method studio looks like a normal carpeted room. In fact, the flooring in the room is quite unusual. Under the carpet lies not regular carpet padding but rubber underlayment that is three-fourths-of-an-inch thick. Walk into a Bar Method studio in your socks and you’ll notice that your heels sink down slightly with each step. During class this underlayment gives extra protection to students’ feet, knees, elbows and hips.
Large Mat: Yoga mats are popular in many exercise studios but can feel uncomfortable during strengthening and stretching exercises. The Bar Method’s mats are filled with dense, inch-and-a-half-thick foam that protects students’ spines and hips during ab work.
Small Mat: During thigh-work students sometimes press The Bar Method’s small mat between their thighs to tone their legs. The main purpose of the small mat however is to protect two particularly boney parts of the body. First, students with sensitivity around the balls of their feet can place it under their feet during thigh-work. Second those with stiff or delicate backs can tuck it under their ribs as shown above during ab work. If you want a small mat to use at home, you’ll be able to buy one on our website in late October along with the new Bar Method DVDs, “Dancer’s Body,” “Beginner’s Workout,” and “Pregnancy Workout,” all of which use this piece of equipment.
Riser Mat: As I mentioned earlier in this blog, riser mats come in handy if you’re petite or have sensitive shoulders and you’re doing “round-back” (shown above) or “flat-back” (similar to round-back but with a straight, vertical back). Its biggest success however has been with students who have hip issues. When these students sit on one or two risers during “flat-back,” their feet drop lower down than their hips. This adjustment makes their legs easier to lift and their hips experience less strain – while still offering plenty of challenge to their abs.
Stretching Strap: The Bar Method’s stretching straps mainly make hamstring stretching more doable. Students with shoulder issues have also found them useful during “flat-back,” which Heather is demonstrating. By looping two straps over the bar and holding onto their ends, students can perform this challenging exercise while keeping their upper arms lower than their shoulders.
How much of a difference does all this equipment make? One student named Jen who emailed me awhile ago put it this way: “I have joint problems and arthritis from numerous sports injuries, and this is the ONE workout that actually makes my legs, hip and back feel better. Thanks again.”
Read here how exercise itself helps keep your joints safe: Why People Need Muscle
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Four million years ago, our ancestors stood up and walked on two legs. Now our two knees, which are the body's largest joints, do the job that four knees used to do and they help keep us in balance, which is an issue when you're more vertical than horizontal. Our knees need all the muscles around them to be as strong and balanced as possible.
By systematically strengthening all three muscles groups that run through the knees - the calf muscle, the quads, and the hamstrings - Bar Method students keep them strong and pain free, which may be especially important for runners or participants in other high impact sports. Here's part of a blog that I happened to run across:
"My current fitness obsession is The Bar Method. Check out Burr Leonard’s Exercise blog at http://blog.barmethod.com/. I have Burr’s two CDs and do the workouts at home. At one point I plan to sign up for classes too – the studio is comfortably close to the Embarcadero Bart station in San Francisco. The effect on my abs and lower back is astonishing, and my genetically weak knees do not bother me anymore." (Click here to read the entire blog
Even if you are not an athlete, the health of your knees is important. Knees carry the weight of most of the body with every step we take. Keeping them strong and youthful requires a pretty simple formula: strengthen and balance the muscle groups that extend across the knee joint.
The long calf muscle (the “gastrocnemius”)is the first of three that
intersect in the knee. You can see them toward the bottom of the picture to the right. This muscle enables us to come up onto the balls of our feet in what could be thought of as a "high heels" position. The great thing when it comes to knee stabilization is that the calf muscles extend across the back of our knees, thereby helping to hold them aligned and straight.
If you have an ACL (anterior cruciate ligament) injury, the gastrocnemius can stabilize the back of the knee in its place. This is why physical therapists give calf strengthening exercises to their patients with ACL injuries. The Bar Method’s starts its leg-exercises with heel lifts for this reason.
Above the knee on the back of the body are the hamstrings. The picture above shows this group of muscles (the biceps femoris, semitendinosus, and the semimembranosus.) The Bar Method is know for it's “seat-work,” which is really a series of exercises for the backs of your upper legs including the glutes. These exercises target your hamstrings, the third major muscle group that extends across our knees. Feel those kinds of sharp cords that run across the backs of your knees. Those are your hamstring tendons. When your hamstrings are strong, they help hold your knees in place. When these muscles aren’t toned, our knees get less support. A side benefit of strong hamstrings is the beautiful slightly rounded shape of the back of fit thighs.
The quads are the muscles in the fronts of our thigh and happen to be our bodies’ largest muscle group. The quads extend across the front of our knee. The intense, non-impact plies, little knee bends where the muscles stay engaged that we do in a Bar Method class, are tremendously effective to strengthen and balance the quads. The Bar Method’s knee bends are safe because students do them while bringing their heels up off the floor, thereby engaging the calf muscles to lock the knee in place.
Every Bar Method class includes at least three different sets of these plies with the quads at slightly different angles. These multiple positions assure that the quads get worked evenly. The four muscles in the quads include the vastus muscles and the rectus femoris as you can see in the picture to the left. Runners, tennis players and athletes in other sports tend to use their outer quad muscles (vastus lateralis) more than their inner one (vastus medialis). That can ultimately pull their patellas to the side with flexion, causing pain. The Bar Method emphasizes inner quad work to help address this issue.
This blog is the fourth in a series on special challenges we humans face due to our evolutionary journey from four legged creatures to bipeds. Shoulders, backs, and knees changed radically as we stood up, walked, and used our arms to reach over our heads. We can stay supple and healthy by producing and toning muscle around these especially vulnerable areas. Click on any of the links below to read other sections of the series.
The theory that the knees should not go forward of the toes during exercise has long been discounted by fitness experts. Squatting, a form of which students practice during Bar Method’s thigh work, is actually one of the best and safest knee strengthening exercises we can do, according to many recent studies. One research center, Cambridge Consultants based in the UK, found that: “squatting actually often puts less strain on internal knee ligaments, compared with conventional and popular isometric and isokinetic knee-flexion and knee-extension exercises.” Doing non-impact, controlled quad exercises that bring the knees forward of the toes functionally strengthen and stabilize the knees.
I've been keeping track of students' feedback on how their knees do after taking class, and most Bar Method students with knee problems have reported significant improvement after taking class regularly for a few months. The reason the Bar Method helps most knee issues, including arthritis, is that its small, non-impact moves strengthen and balance the quads, hamstrings and calf muscles, which we methodically work in Bar Method. These muscles all extend across the knee joint and, as they become stronger, your knees do, too. A Chicago resident named Christina, for example, discovered that the Bar Method helped her to exercise without knee pain. “I’ve had problems with running and many other exercise forms due to a previous knee injury,” she wrote me, “and this has been pain-free for me.” (Read about how Bar Method sculpts a dancer's body
There are however several knee conditions that, if you have them, call for some modification of Bar Method's thigh-work, at least temporarily. You have a small chance, for example, of there being a slight malformation in your patella or knee cap, giving it a tendency to scrape against your knee cartilage during exercise. If you’re a Bar Method student and think you have this kind of patella, you’ll probably need to limit your thigh-work section to the following positions: “chair,” "second position," and "leg lifts.” (see below for details.) You can also restrict the thigh-work section to “holds” rather than the little down and up moves that are usually part of every thigh routine. These modifications will enable you to do the workout with no “bad” pain, plus they will add more strength and stability to your knees.
Another reason you might feel your knees during thigh exercises is that your outside quads are tighter and stronger than your inside quads. A lot of athletes such as former runners and tennis players develop excessively tight outer quads because they use them so much. As a result, bending their knees during thigh strengthening exercises pulls their knee caps out to the side and causes pain. Fortunately, this condition is correctable over time, and the Bar Method can help. If you suspect you’re one of these students, first go to your doctor and get a diagnosis along with a rehab routine. You can then speed up the healing process during your Bar Method workouts by squeezing a ball or a piece of foam between your legs during thigh-work, ab-work and “back-dancing.”
Whatever the reason for experiencing knee pain in or out of class, make sure to tell your teacher about your problem and ask her or him to help you to do the modifications that are right for you. If you use the Bar Method dvds, try holding the thigh poses rather than moving within them for a few weeks. You’ll know that the modifications are working when you start to feel intense muscle burn in your quads and no discomfort in your knees.
A note to dvd users: Watch for the upcoming thigh-work modification section on our website.
Joint injuries can happen to anyone. My accident took me by surprise three years ago when I fell off a ledge onto some debris tearing an acl and some cartilage in my hip. My ensuing journey through treatment and recovery took months.
Along the way, I learned an intriguing fact about how our muscles behave, one that my former, healthy self would never have guessed: The muscles around an injured joint will not respond to exercise, even if pushed. Before I found this out, I thought “no pain, no gain” was how it worked. Now a team of doctors was telling me that even if I fought my way through workout after workout, my injured leg would get weaker and weaker until its underlying joints healed. My orthopedist explained this to me after measuring my thighs. I have a “one-inch atrophy of the right thigh,” he told me, “which is significant.” The reason, he said, was “pain.“
My injured joint was in effect putting the break on the
development of my quads because of pain, whether or not I paid attention to it, and causing them to atrophy. Later during rehab, my physical therapist confirmed this interrelatedness between joint pain and muscle strength. “The pain in your joint will not allow your muscles to recruit,” she said.
Undoubtedly this reluctance on the part of muscles to perform when the joint they surround hurts would be news to the runners who are often seen limping along roads with
bandaged knees. Are healthy runners who haven’t yet experienced problems also at risk for future joint deterioration? Several studies have found a correlation between osteo-arthritis (joint erosion) and running. In one especially creative experiment, different sports were compared on how much they break down cartilage – a bad thing - and “remodel”, or repair, bone – a good thing. Rowing, a non-impact sport, turned out to be the best sport at both minimizing joint erosion and re-building bone, running the worst. (Click here to read how in some cases exercise can be used as physical therapy
So far no studies have turned this equation upside down and looked at the possibility that high-impact sports build muscle more slowly due to their impact on joints. What we can be sure of is that high-impact strength exercise will eventually take its toll on joints. And since healthy joints are a pre-requisite for muscle building, non-impact workouts like the Bar Method will not only keep joints healthier longer but will also give the bigger bang for the buck when it comes to building sculpted, strong bodies.
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