The origin of (most) knee pain

The knee is the punching bag for the foot and the hip“.

A wise man once told me that the majority of non-traumatic sporting injuries that occur at the knee originate due to a weakness above or below the knee itself.

When the knee is under load, its position is determined by various muscles around the core, the hip, the shin and the foot. They all work in unison to keep our knee in the optimum position. The classic way to determine if your knee is in the correct position is to draw a line from the bony part on the front outer edge of your hip, down through the centre of your knee cap. A line is then taken along the tibia and drawn back upwards. Where the two lines intersect, an angle is taken which determines what is called the Q angle (See image below).

The normal Q angles are:
For men: Anything +/- 3 degrees either side of 14 degrees
For Women: Anything +/- 3 degrees either side of 17 degrees

When this angle is outside of the normal range, a variety of different knee problems can occur.

I personally dont tend to use the above method to identify dysfunction, as it does not take in to account how the body reacts during weight bearing or when running. One good way to see if you have an increased Q angle yourself is to try doing a few unsupported single leg squats in front of a mirror (dont hurt yourselves!). Perform this to see whether your knee ‘kicks in‘ or if your ‘hips shift‘ outward. Being able to keep your pelvis level and having your knee bend over your 1st to 3rd toes indicates a reasonably happy knee joint. If this is not the case then its worth seeing a good manual therapist to determine where the weakness may be coming from.

Clinical tip: A good indication to figure out if you are seeing a good sports therapist is to see if they check the lower back, hip and the foot as well. Not just your knee ;-)

Talking of Punching bags, its Pacquiao vs Mayweather this weekend!

Have a good one,

Injury relapse prevention- Habits and Rehabilitation

Injury Relapse

owen injury2

The word ‘Relapse’ to a health care professional is not a very nice one to hear, it means that for some reason, the client has re-injured themselves in the same place either during or after recovery. Michael Owen is a classic example of a person that had a lot of injury relapses, in this England striker’s case it was his Hamstring. We hate to see it happen as understandably it can be very disheartening for the client as they are often doing really well when the injury occurs.

In some cases however, the occasional relapse is expected.

Some injuries are very prone to relapses. The most well-known of these injuries that is prone to this is a ‘disc bulge’ or ‘slipped disc’ as it is commonly known. Disc bulges usually occur over a long period as the discs between the vertebra slowly fail as they are loaded incorrectly (usually by sitting poorly for prolonged periods of time). Once the tissue that causes an injury has failed, the tissue is then susceptible to re-fail, especially during the healing phase. Probably the most common reason for a relapse is due to a client falling back in to bad habits, the original cause of the injury.


We are creatures of habit, from the moment we wake up, to the routine we have when we go to sleep, we are dictated by our habits.

The habit loopOnce a bad habit is identified, and is thought likely to have led to the injury, we ask the patient to avoid or correct the habit. As your body heals, you become more comfortable and mobile. Unfortunately though this means that the bad old habit can sometimes return (usually subconsciously), often leading to re-injury. The habit can be movement based or even due to something you enjoy (such as a hot bath).

To help avoid these injuries recurring, it is best to ensure good habits for the injury are retained and bad habits avoided. However, this alone is not enough, rehabilitation exercises are also required to strengthen the area of injury once it is healed. Until the area is correctly supported it will be more prone to relapses



Research shows that any joint that has been injured becomes prone to re-injury again, this is because the muscles and tissues around the joint have become weak and are not feeding back information about themselves to the brain as effectively as they were before (known as proprioception). Rehab exercises are the final stage of treatment, rehab is the proverbial ‘fork in the road’ between a client that is content being pain-free, stops following advice and does not want to do rehab exercises, leading to a good chance of the injury relapsing. Versus a client that engages with rehab, continues to follows advice and has a much lower chance of their injury relapsing. As we say in clinic “When the pain is gone, it does not mean that your body’s function has improved”. Which rehab exercises to perform depends on many factors which a manual therapy professional should be able to help you with.

Thankfully we don’t see that many relapses in our clinic as we tend emphasise these points from the beginning during our Report of Findings. Though being aware of these factors is important for you to understand that there are some injuries with which a lot of care must be taken when avoiding bad habits.

Note: some habits can be resumed once the injury has subsided, such as hot baths. ;-)

The role of the Pelvic floor in core stability

The pelvic floor’s role in core stability

The Pelvic floor is crucial for many reasons, many mothers will be told to do their pelvic floor exercises after giving birth. Some mothers will also be recommended to do some Pilates to help strengthen their core.

There are a large group of females out there who suffered back pain during and after their pregnancy, the pelvic floor muscles are one contributing factor as to why this can happen. The pelvic floor is not just important for females after giving birth, it is important for everyone to work on, especially if you have had recurrent episodes of back pain.

To engage your pelvic floor, all you have to do is engage the muscles that ‘stop yourself peeing’. To ensure these muscles stay on, you must keep them engaged while challenging you body in different positions. You are not looking to stop yourself peeing forever, you are looking for these muscles to be more turned on so that they will be recruited by your body when the lower back and pelvis are in a challenging position.

To ensure this happens, keeping you pelvic floor engaged during gentle movement based activities such as Pilates or Yoga is perfect. You will have to engage the pelvic floor muscles consciously to begin with, though after a few weeks of challenging them, it will become a subconscious activity which you will experience as having the muscles become ‘easier to engage’. Along side your pelvic floor, having your lower abs engaged to activate your core muscles, keeping your pelvis in a ‘neutral’ position and breathing correctly using your diaphragm. You should start to experience a lot better results from your Pilates/Yoga. You’ll find, this will benefit your body when playing more vigorous sports, as the foundation of your back (The Thoraco-pelvic canister) is stronger.

Last point, please make sure you are performing Pilates/Yoga at a level that is suited you as these principles will not work if you are performing them at too higher level of exercises, technique and patience is key. If you have ever played golf you’ll know what I mean, e.g. in golf, if your hands, feet, head, hips etc are all not in the right position before you swing to hit that tiny ball, the shot will be terrible. When improving your backs core strength, unless you have all the right muscles engaged correctly, there is no point in even trying to move as the object of the exercises is lost. Your instructor or practitioner should be able to help check if you are engaging your key lower back muscles correctly.

Remember, even the best, strongest athletes can still get a weak back. Everyone should aim to keep a strong Thoraco-pelvic canister.

Thoughts and a book review: The power of habit

Self discipline is something I thought I had in abundance. That was until I started following some of the top Chiropractors in Canada and the USA. It is incredible at how often they read to further themselves and how self disciplined they are with what they say they will do and then carrying it out.

One of the best Chiropractors I follow is a guy called Jason Ross, he stated at the start of the year that he would do a blog every day as his new years resolution and he has stuck to it. I didn’t think it would be possible as I find it hard to do one a month at the rate I am going.

One of the tips I learned from Jason is to read at least 20 minutes a day, this helped me a lot as I have been using the excuses of time and a new relationship to explain why i haven’t posted or read enough recently. However by doing little bits at a time I have been able to achieve a lot more. I love reading as knowledge is power and little chunks at a time have been an amazing way of helping me finally finish some books I have been unable to complete for a while.

The power of habit was one of these (ironic I know), this book helps you understand exactly how we form habits and how to create and break good and bad ones.
The power of habit

By adopting the above system and repeating it over and over you can form a new habit, this can be positive or negative. An example of how it is used is smoking, see the packet, smoke the cigarette and your senses get the reward. Stop the cue or replace the routine and you can form an alternative to a bad habit. This can even be a positive change as your reward may not even lie in the chemical reward from a cigarette, it could just be that you want to be social. In which case, go chat to someone at their desk instead of going for a social cigarette and see if that social reward solves your ‘craving’. you’d be surprised at how the reward you are looking for can be misunderstood.

I love books like these, ones that take a topic and use others experiences to explain the details. A highly recommended read, you never know, this could be life changing for you or your sport. I’m gonna work on writing my posts more regularly (Gulp!).

As Aristotle once said “We are as we repeatedly do”.

What is the best way to strengthen the core muscles?

How do I strengthen my Core?

Apologies for not posting sooner, it has been a hectic couple of months!

So then! If you have ever had repetitive lower back pain and have seen a professional or rehab specialist to try to address the problem, then you may have been told you have a “weak core and it needs strengthening”?

Unfortunately, in my opinion and experience, the word ‘Core’ gets used far too much by people that don’t truly understand it. The classic mistake is that some professionals generally view the abdominal muscles as being the core of the body and that by strengthening these muscles, your core will be ‘stronger’ and lower back pain will cease. As you may have already found, abdominal strengthening exercises such as planks and sit-ups do not solve repetitive lower back pain and can make it worse, here is why.

To truly strengthen your core, you have to make sure the muscles that make up the thoraco-pelvic canister (TPC) (described by Dr Evan Osar in his book ‘) are activated at all times to support your lower back. The TPC is best explained using the analogy of a tin can representing your abdomen and the muscles that make it up. The top being the diaphragm, the bottom being your pelvic floor muscles and the sides being your abs, internal and external obliques, Quadratus Lumborum etc..

I address the muscles of the TPC using exercises that address these 3 areas:

i) 25% of abdominal contraction engages a good amount of the core to stabilise the TPC. Therefore use progressed Dead bug and Bird Dog type exercises, then into activity specific strengthening. this is To strengthen the sides of the tin can.
ii) Progressed pelvic floor stabilisation exercises To strengthen the base of the tin can.
iii) Progressed Breathing correction exercises (use principle muscles (diaphragm etc) and not accessory muscles) To strengthen the top of the tin can.

All areas must be worked for endurance type strength and not for power, therefore lots of repetitions which are gradually and gently progressed and challenged. Also, they must be worked in various positions that we adopt each day: Standing, sitting, lying down (although sitting in chairs is always bad for the back). By working these three areas your core will be super strong and you should find episodes of lower back pain and even episodes of recurrent neck pain should also decrease (due to deactivation of accessory muscles).

Stay tuned for future posts on exercises to help strengthen each of the 3 areas of the TPC.

How to improve hip strength

The hips are an often over looked and under utilised part of the body, yet I can’t stress just how important they are. When not correctly strengthened they can often be the origin of a lot of knee and lower back pain and if severely functioning incorrectly, can lead to early hip arthritis.

However, when functioning well, can lead to a vast improvement and cessation of many knee, hip and lower back complaints. In an athlete they can lead to a large improvement in performance and injury reduction.

The hip is similar to the neck, lower back and shoulder in that it has its own ‘core’ muscles that are responsible for keeping the hip in the middle of the joint, or ‘centrated’ as it is known. ‘Centration’ is a very important thing to understand, the hip is a ‘ball and socket’ joint as you can see in the picture below, where the head of the femur (upper leg) is the ‘ball’ and the cup in which it sits in the pelvis is the ‘socket’.
There are many structures that keep this joint in position such as ligaments and a capsule called the acetabular labrum. However, to ensure the joint is allowed to move evenly throughout the joint, the joint must be in the correct position within the joint to allow even force distribution to decrease wear and tear and ensure best function. The muscles responsible for this are the ‘deep rotators of the hip’. These form the base level muscles around the hip and are often responsible for buttock, hip, leg, knee and back pain if tight and weak. To ensure they are functioning correctly, they must first be lengthened and then strengthened. To strengthen them, a set of exercises that can be done at home are called ‘clam shells’. The Clam shell routine is designed to strengthen up key musculature around the hip including the most important part, the deep hip rotators. Once these are strengthened you effectively have a solid foundation upon which to work.

The next stage is to strengthen the ‘global muscles’ that overlay the deep rotators, the most important ones being the Gluteus Medius and Gluteus minimus.

These muscles effectively brace over the hip downwards, preventing the hip from collapsing sideways. These muscles are also prone to tightness (a tight muscle is a weak muscle), this can lead to compensations such as TFL and Glut Max tightness that when overused and tight can effectively cause Iliotibial band tightness and common problems such as ‘runner’s knee’ and problems in other areas. Glut Min and Med are strengthened using a piece of light to medium strength Theraband and the X-walk and monster walk,  there are many variations of this exercise on Youtube so I combined the best pieces from each into the above word document. These exercises alone will not be any where near as effective as they can be without strengthening your Thoraco-pelvic canister (TPC), the TPC is made up of your Diaphragm, core and pelvic floor muscles all working together to support your pelvis and lower back (a functional body).

There are progressions of these hip exercises to make them more challenging such for the athletic individual, however when in the rehab phase after an injury these exercises are great. I will at some point start doing my own Youtube videos as I find technique lacks in a lot of the videos currently available.

Performing these exercises regularly when the hips are not in pain can help prevent hip osteoarthritis. If however, the hips are already painful it is best to stretch and use lots of ice packs (10-15 mins every 2 hours) to calm the musculature down before attempting any strengthening routines.

A simple way to improve hip rotation

A simple way to improve hip rotation

Before I get into the meat of this post, I’ll quickly explain why hip rotation is so important.

Without good hip rotation the forces from your lower limbs cannot be distributed throughout your hips and the tissues around them in the way that they were designed. This leads to more force being applied to either the hip joint itself (rather than the soft tissues) or into the lower back, causing lower back issues. There is very reliable evidence that links a loss of internal hip rotation to lower back pain.

Hip rotation is a key aspect of many sports, I found that my decreased internal hip rotation as a result of playing football prevented me from efficiently “popping up” onto a surfboard when surfing.

The solution to my problem was the simple use of a tennis ball to massage the hip region while laying on my back. It is also worth working on the other hip musculature in the region as compensations are likely to occur from daily life and sports with non-rotational muscles also getting tight in the hip region. I find using a tennis ball a lot more efficient as you can easily hit the spots that are tight rather than using a stretch as stretches tend to be quite global and tend to miss key areas of tightness within a muscle.

The routine I recommend, I refer to as “search and destroy”. Locate your hip by feeling the side of your leg till you find a bone that is the size of a small tennis ball. This is your landmark to work from as the majority of the musculature in the hip region attaches around this point. Roll the ball side to side in the buttock region from the hip and then roll it up and down above the hip. If you find a sore spot, stop and hold it for up to 1 minute and then continue self massaging with the tennis ball for a few minutes until the whole area feels looser.

In the next post I will explain how to rehab and strengthen up the hips so they function more efficiently to decrease tightness in the future. Remember “you cannot have stability without mobility” so by improving the hip musculature you will decrease your chance of a hip operation and help prevent lower back and knee problems.