Knee pain is quite common among practitioners of the internal arts and is something I have struggled with myself when doing extended periods of zhan zhuang or qigong exercises that involve a lot of standing. Knee pain is usually experienced because of some incorrect alignment in your posture, though sometimes there are longer-term structural issues. In theory, these structural misalignments should resolve over a period of correct practice, but this may take some time and there may be specific exercises that can help. The purpose of this article is to highlight some common alignment mistakes that can result in knee pain, as well as talking briefly about some of the less common structural issues that can be involved.
The knee is designed to be a stable joint – the body weight should pass evenly through the knee joint to be transfered to the foot and the ground. If the knee joint is not stable and balanced, the force will accumulate in the knee, creating pressure on the joint.
Correct Alignment (standing)
- Keep your feet parallel
- The legs should be bent into an arch shape
- Make sure your knees don’t extend beyond the toes
- Keep your body weight over the Yongquan (Kid 1) point, behind the ball of the foot
- Bending from the kua, with sacrum neither pushed backward nor tilted forward
Common Alignment Mistakes
Knees beyond toes – usually more of an issue in lower stances, but make sure your knees do not extend forward beyond your toes. This will put pressure through the front of the knee.
Feet not parallel – this creates a twist on the knee and tends to drop one or both knees inward, putting pressure through the medial (inner) side of the knee.
Feet not level – this creates a twist on the pelvis and also tends to drop one or both knees inward, putting pressure through the medial side of the knee.
Both knees collapsed inward – most people have tightness in the kua (or groin area) – the leg adductors. When they completely relax into a standing posture, this tightness will tend to pull the knees inward, again putting pressure through the medial side of the knee. Although relaxing the body is vitally important in qigong, the muscles still need to be engaged sufficiently to maintain the correct structure.
Weight too far forward over ball of foot or toes – here the knees are not beyond the toes, but the body weight is distributed too far forward over the feet. This will not only fail to open the Yongquan (Kid 1) point, but may also put pressure through the front of the knee.
Resolving Common Alignment Mistakes
Use a grid – stand on a floor with tile squares, wooden beams or painted lines to ensure your feet are lined up level and parallel.
Use a mirror – check your knees aren’t dropped inward by practicing in front of a mirror (or video your practice if you are moving around lots).
Stretch out the kua – since most people have a tight kua, and this is not only useful for correcting postural errors but also for opening up these major energy gates, it is a good idea to stretch out the kua at least once or twice daily. Two simple stretches for the kua:
1. Each morning and evening, lie face up in bed with the soles of the feet touching and the knees bent out to the sides. Drape a heavy quilt or duvet over your knees to pull them gently downards.
2. Lie face down on the floor, with the soles of the feet together and knees apart. Use your body weight to gradually stretch the kua open and bring the body closer to the floor.
Other Structural Issues
Tight Iliotibial band / Tensor Fasciae Latae
The Iliotibial band (ITB) runs down the outside of the thigh, connecting the pelvis (via the tensor fasciae latae or TFL) to the shin bone. When this tightens up, it pulls on the lateral side of the knee.
Resolving tight IT band/TFL
1. Lie on your side on a foam roller or tennis ball and slide along the foam/ball so it presses into the tight tissue on the side of the thigh. Slide up and down for a couple of minutes to release the tightness in the tissue. Repeat every day.
2. Get some cupping / massage / acupuncture / rolfing regularly as these approaches may be able to draw out stagnation from deeper within the tissue.
Weakness of Vastus Medialis
The Vastus Medialis is the most medial (inner side) of the quadriceps (the thigh muscles). It is a key stabiliser of the knee and tends to become weak. This reduces the stability of the knee which can exacerbate other small imbalances.
Resolving Weak Vastus Medialis
Sit in a chair facing a wall, with one foot against the wall. Push forward with your toes for about 5 seconds. Rest for about 5 seconds, then repeat. Do 10 repetitions with each leg twice a day.
Weak gluteal muscles
The gluteal (buttock) muscles are a key stabiliser of the hips and lower back. When they are weak, this causes instability that can in turn affect the knees.
Resolving weak gluteal muscles
1. Lie on your side with your knees bent at about 90 degrees and hips at about 45 degrees, then raise your upper knee, keeping the feet together. Hold this position for a few seconds, then bring the knees back together. Do 10 repetitions with each leg twice a day.
2. Lie on your side with your legs straight, then raise the upper leg to about 45 degrees. Do 10 repetitions with each leg twice a day.
This refers to the arches on the medial (inner) side of your feet. Despite the name, they usually haven’t dropped so much as never really developed in the first place. This changes the angle of the ankle, causing the knee to drop inwards, the pelvis (and kua) to close and the piriformis (another muscle in the buttock) to tighten up.
Resolving ‘dropped’ arches
1. Squeeze your foot against the floor, aiming to bring the ball of the foot closer to the heel. Hold for a few seconds and do 10 repetitions with each foot twice a day. Try not to scrunch up the toes.
2. Practice picking up a towel with your feet.
3. When standing (especially when practicing qigong or other internal arts), aim to put your foot into the correct position as in exercise 1. Remember not to scrunch up the toes and don’t roll out onto the lateral (outer) side of the foot. You may need to engage the gluteal muscles to avoid creating a twist on the knee.
4. It is very difficult to build up arches if they haven’t developed properly at a young age, so unless you’re practicing for many hours a day, the exercises above may not be enough to put you into the correct position. Orthotics are special insoles for your shoes which can help by putting the foot into the correct position. Orthotics won’t help you build up your arch, but can alleviate many of the structural issues that happen further up the limb, including knee pain. You can buy off-the-shelf orthotics, which are probably okay for most people, or you can visit a podiatrist or other health professional who specialises in gait analysis for custom orthotics.
Knee Joint and Other Problems
There are also quite a few problems of the knee itself such as arthritis or bursitis, and back issues causing sciatica can result in pain in the knee, but generally these issues will be more noticeable during daily life as well and not just while you’re doing standing qigong or similar exercises.
There are quite a few causes of knee pain, and this article has only touched on some of the most common. Look at the common alignment mistakes first, ask your teacher for help and if you’re at all uncertain, it’s probably a good idea to get properly diagnosed by a professional. Physiotherapists, osteopaths or chiropractors are usually your best bet.