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Knee Rotation Exercises – Part 2: Knee Internal Rotation

In my last article we started talking about the importance of knee rotation, which is an absolutely critical yet often neglected fundamental motion. There we covered why knee rotation is so important, and reviewed assessment strategies to go through with your patients or clients. You can check out that article here is you missed it or need a refresher.

To make things a little more digestible Part 1 focused primarily on corrective exercises for knee external rotation. Here in Part 2 we will cover exercises for knee internal rotation.

And remember, if you are a My Rehab Connection subscriber you can find all of these exercises in My Exercises Library.

Training Control of Knee Internal Rotation

To train coordination and control of the knee we are going to use active range of motion exercises with a very specific rotational focus. (If you are familiar with the Functional Range Conditioning System these would be an example of a Capsular CARS exercise.)

The way I typically start with most patients is to have them seated in a chair with their foot flat on the floor. For this to work best you want the foot to be able to slide, so doing this on a hardwood or tile floor and putting a towel under the foot will help.

From here what we are going to ask our patient or client to do is simply rotate their lower leg and foot internally and externally. Motion of the toes outward and the heel inward is knee external rotation. As the toes go in and the heel goes out, this is knee internal rotation. Depending on the presentation and exercise goals you can either move and forth, or you can bias the movement towards internal or external rotation. 

Keep in mind that our aim here is to isolate movement at the knee, so we really want this rotation to occur exclusively through the tibia. To help with this we need to make sure the foot stays flat on the floor. This will help prevent compensatory inversion/eversion motion at the foot and ankle.

It is also helpful to focus on moving the heel and forefoot in opposing directions. For example, during knee internal rotation we want to slide the heel out as the forefoot comes in. 

The other common compensation that you’ll see all the time will be movement of the thigh back and forth. To prevent this we can lock the thigh in place by holding a yoga block between the knees, or by placing a stiff strap around the distal thigh.

As a side note, the way I like to use these blocks is that if the knee thigh has a tendency to fall in, I like to use the strap and have the patient lightly press out against the strap to create tension in the abductors. In this way it becomes more of an active block. Likewise, if the tendency is for the thigh to go outwards I will lean more towards using the block and having the patient or client squeeze into the block to activate the adductors.    

Developing Knee Internal Rotation Flexibility

If we find that flexibility (PROM) of knee internal rotation is limited, we need to plug something into our treatment program to help improve this findings. In the majority of these cases we can use manual therapy therapy techniques to help with this, but we also want to be able to give our patients something they can do at home.

Here we’re going to talk about how to perform a PAILS exercise for knee internal rotation. These exercises, which stands for Progressive Angle Isometric Loading, are an integral component of the Functional Range Conditioning system, which incorporates isometric contraction into a stretched or endrage position. Not only do these contractions influence passive tissue components, but will also affect the neurological components such as the stretch reflex and muscle spindle sensitivity. In other words, it will help improve stretch tolerance. 

When training knee internal  rotation we are going to start with the outside of our foot against a wall. Once we’re in this position we’re going to place a heavy kettlebell against the inside of our heel.  This kettlebell isn’t absolutely necessary but does help to provide something to push against when we get to the contraction phase of the exercise. 

With our foot in place we can then start to turn our hips towards the wall, but will start to create internal rotation at the knee.

You need to be very careful with this motion, especially when dealing with knee pain or injury, but if this position is tolerated we want to relax into and hold this position up to 2 minutes.

Following this passive stretch we can then start to incorporate some contraction. In this example, to help improve knee internal rotation we want to contract into external rotation. To do this we can start to rotate our forefoot into the wall and our heel out against the kettlebell. 

Remember, we want to be careful not to strain or irritate the tissue, so start easy. Once you establish the desired intensity you can then hold the contraction from 10-30s, then slowly relax and if possible let turn in a little farther towards the wall to establish the next tissue barrier.  Relax into this new position for 10-30 seconds, then perform another contraction. You can repeat this 3-4 times.

Knee Internal Rotation Mobilization with Band

Another option to help improve knee internal rotation is to perform an Active-Assisted mobilization using a resistance band. Here we can start in a kneeling position with a relatively stiff resistance band wrapped around the back of our heel. To promote internal rotation we want the other end of the band to be secured so the band is running away from our body.

With the band secured around our heel we want to first rotate our heel inwards to engage the rotational muscles around the knee. Then we want to slowly rotate the heel outwards, which starts to rotate the knee internally. During the first part of the movement we are working to eccentrically control the rotational moment created by the band. As the knee moves farther into external rotation we want can then transition into more of a concentric contraction. Here the band acts as assistance and helps to achieve a greater range. 

We can hold the end position for a few seconds then slowly rotate in the opposite direction again. We can slowly perform 10-15 repetitions. 

Training Knee Internal Rotation Strength

Once the knee has sufficient flexibility and control, we can then start to progress to higher level loading and strength exercises.

One option that I often use in my clinic is to train knee rotation from a kneeling position using a stiff resistance band or cable. To train knee internal rotation we’re going to set this up by wrapping the band around the outside of our heel with the band running across our body. From here we are going to slowly pull heel outwards against the resistance of the band. 

As we do this we want to keep the forefoot flat, almost as if we are pivoting from the ball of our foot. We want to firmly hold the contraction in this end position for a few seconds, then slowly rotate the heel inwards. Remember we want to move slow and control this motion to accentuate the eccentric phase of the movement.

Sets and Reps

Remember, if the goal is to promote strength we want to provide stimulus to actually get the tissue stronger. But at the same time, we are often prescribing these exercises as part of a rehabilitation program, so we also need to respect the potential for easily irritable or healing tissue. 

So we may need to ease into these exercises and initially keep the resistance low. But once tolerance has been established I will typically have patients perform anywhere from 3-5 sets of 6-10 repetitions. And they will typically perform these two to three times per week. But these need to be very deliberate sets and reps. Remember, it is not easy to get strong. If someone goes to the gym and does a few sets of biceps curls, if they’re not fatigued after those exercises they probably didn’t work hard enough to create a change. And that’s what I tell most of my patients. If I tell them to do sets of 6-10, I expect those last few reps to be challenging. If they get to 10 repetitions but feel like they could have done more they need to increase the resistance. 

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Knee Rotation Exercises

When we think about the knee we conceptualize it as a hinge allowing large ranges of flexion and extension.  But the knee does not behave like a conventional hinge you would find in a door. The knee is actually classified as a modified hinge, and this hinge allows for rotation to occur as the knee. 

Yes, the knee is supposed to rotate. In fact, the ability of the knee to rotate is an absolutely critical motion if we want our knee (or our patients knees) to get and stay healthy. But despite it’s importance, knee rotation is often neglected in knee training and rehabilitation programs.

So let’s spend the rest of this article discussing knee rotation, including what it’s so important, how we can assess it, and then we’ll review some knee rotation exercises that I often use in my office when treating knee pain patients.

The critical importance of knee rotation

Your lower extremity is regularly subjected to rotational stresses. This occurs with sports such as tennis and golf, but really any time you twist or turn some of this rotational stress filters down to your knees. 

But it’s not just during these obvious examples where knee rotation is important. The ability of the knee to rotate is also essential for overall joint health.

Remember as stated above, the knee is not a true hinge like you would see in a door. Instead of pivoting around a fixed point it actually glides along the rounded femoral condyles as it flexes and extends. As it does this it needs to be able to rotate internally and externally. Biomechanically this is referred to as the screw home mechanism, and it is essential for knee health. 

When this rotation does not occur properly it will change how the knee moves. This has the potential to create abnormal stress and shear patterns through the knee and, over time, may lead to accelerated tissue breakdown or repetitive strain injuries in and around the knee.

Before we discuss strategies to improve knee rotation, we need to consider how to assess knee rotation. We need to know if knee rotation is even an issue that needs our attention.

Testing Knee Rotation Flexibility

The first thing we need to assess is rotational flexibility. This is a measure measure of a joint’s basic ability to move through it’s “normal” range of motion.

To test rotational flexibility of the knee position your patient/client supine with their hip and knee flexed to 90 degrees. From here we can assess passive flexibility by turning the tibia internally and externally. 

As far as what we are looking for or what is considered normal, most sources suggest knee internal rotation should be somewhere around 20-30 degrees, with external rotation being around 30-40 degrees.

But in practice it is difficult to accurately measure these ranges.  So really what we are looking for is whether or not the knee moves freely and fairly easily, and is able to move approximately 20-30 degrees into internal rotation and a little more than this into external rotation.

If we find that flexibility is lacking, we make note of this finding. One of our treatment goals is now improving rotational flexibility.

From here we can move on to testing coordination.

Testing Knee Rotation Coordination and Control

Next we can assess coordination and control. What we are really looking for here is whether our patient is able to actively move the knee into internal and external rotation. We want to know if they are able to actively contract and control the muscles around the knee that are responsible for knee rotation.

To test coordination and control of knee rotation we can keep the patient lying on their back with the hip and kneed bent 90 degrees. But now instead of us passively rotating the lower leg in and out we can ask our patient to perform the motion actively.

As our patient does this we are looking for two things. First, we want to simply see how well the patient is able to perform this movement. Are they able to isolate movement at the tibia, or do we see compensatory motions at the foot and ankle or at this hip and thigh?

Second, how far can they move. Is it the same or at least very close to the ranges available passively? Or is it less? 

If either of these areas are deficient make note of these findings. One of our treatment goals is now improving rotational coordination and control.

Testing Knee Rotation Strength

Finally, we want to assess strength. Remember, as important as mobility is, joints rely on muscular forces to create the stiffness and stability needed to resist stress and prevent injury. 

To test strength of the knee in internal and external rotation we can again keep the patient in the position used when testing flexibility and coordination. From here, what we want to do is test the ability of the knee to resist rotation.

To test the strength of knee internal rotation we can wrap our fingers around the outside of the patients’ heel and our forearm around the patients inner forefoot. From here we are going to start to very gently pull the heel in with our fingers as we push the forefoot outward with our forearm. As we do this we’re going to ask the patient to rotate the lower leg inward against pressure. They are trying to actively hold the knee/lower leg stable against our pressure.  

As we apply pressure we are going to do so very gradually. We do this first and foremost to be careful not to overload the knee, especially if we are dealing with a sensitive or injured knee. But going slow also provides a more accurate assessment of strength (as when we go too quickly we often miss the point when the knee starts to “give” against our pressure).

We can measure external rotation the same way, but we change our body position so we are standing on the opposite side of the patient. Now we are able to hold the inside of the heel with our forearm along the outside of the forefoot. And of course our pressure/resistance is into internal rotation.

With respect to strength, what is considered normal vs abnormal is not always black and white. This is a measure that is difficult to accurately quantify in the clinic.  And even if we could, knowing how much strength is actually needed will vary based on individual needs. 

So to simplify this what I am really looking to see is whether or not the patient can hold the knee stable against a moderate to heavy overpressure.  If they can’t, one of our treatment goals is now improving rotational strength.

Knee Rotation Exercises

Knee Rotation Exercises to Build Control and Coordination

NOTE: Remember if you are a My Rehab Connection Subscriber all of these exercises can be found in My Exercise Library

To train coordination and control of the knee we are going to use active range of motion exercises with a very specific rotational focus. (If you are familiar with the Functional Range Conditioning System these would be an example of a Capsular CARS exercise.)

Now there are several ways to do this but the way I typically start with most patients is to have them in kneeling lunge position (if kneeling is uncomfortable seated in a chair will work as well). For this to work best you want the front foot to be able to slide, so doing this on hardwood or tile floor and putting a towel under the foot will help.

From here what we are going to ask our patient or client to do is simply rotate their lower leg and foot internally and externally. Motion of the toes outward and the heel inward is knee external rotation. As the toes go in and the heel goes out, this is knee internal rotation. 

Keep in mind that our aim here is to isolate movement at the knee, so we really want this rotation to occur exclusively through the tibia.

To help with this we need to make sure the foot stays flat on the floor. This will help block compensatory inversion and eversion of the ankle, which is a very common compensation seen with limited knee rotation.

I also find it helpful to focus on moving the heel and forefoot in opposing directions. For example, during external rotation we want to bring the heel in as the forefoot moves out, and then for knee internal rotation we want to slide the heel out as the forefoot comes in. 

The other common compensation that you’ll see all the time will be movement of the thigh back and forth. To help minimize this we can block this by placing a block between the knees, or by placing a stiff strap around the distal thigh. The main goal here is to lock the thigh in place to focus motion at the knee. 

As a side note, the way I like to use these blocks is that if the knee thigh has a tendency to fall in, I like to use the strap and have the patient lightly press out against the strap to create tension in the abductors. In this way it becomes more of an active block. Likewise, if the tendency is for the thigh to go outwards I will lean more towards using the block and having the patient or client squeeze into the block to activate the adductors.    

Knee External Rotation Flexibility Exercises

Option 1: Knee External Rotation PAILS

If we find that flexibility (PROM) of knee external rotation is limited, we need to plug something into our treatment program to help improve this findings. When we see these cases in our clinics there are of course manual therapy options we can use, but we also want to be able to give our patients or clients something they can do at home.

Here we’re going to talk about how to perform a PAILS exercise for knee external rotation. These exercises, which stands for Progressive Angle Isometric Loading, an integral component of the Functional Range Conditioning system, which incorporates isometric contraction into a stretched or endrage position. Not only do these contractions influence passive tissue components, but will also affect the neurological components such as the stretch reflex and muscle spindle sensitivity. In other words, it will help improve stretch tolerance. 

When training knee external rotation we are going to start with the inside of our foot against a wall. Once we’re in this position we’re going to place a heavy kettlebell against the outside of our heel.  This kettlebell isn’t absolutely necessary but does help to provide something to push against when we get to the contraction phase of the exercise. 

With our foot in place we can then start to bring our knee in towards the wall, which will create external rotation at the knee.

You need to be very careful with this motion, especially when dealing with knee pain or injury, but if this position is tolerated we want to relax into and hold this position up to 2 minutes.

Now following this passive stretch we can then start to incorporate some contraction. In this example, to help improve knee external rotation we want to contract into internal rotation. To do this we can start to rotate our forefoot into the wall and our heel out against the kettlebell. Remember, we want to be careful not to strain or irritate the tissue, so start easy. Once you establish the desired intensity you can then hold the contraction from 10-30s, then slowly relax and if possible let the knee move farther toward the way to establish the next tissue barrier.  Relax into this new position for 10-30 seconds, then perform another contraction. You can repst this 3-4 times.

Option 2: Knee External Rotation Mobilization with Band

Another option to help improve knee external rotation is to perform an Active-Assisted mobilization using a resistance band. Here we can start in a kneeling position with a relatively stiff resistance band wrapped around the back of our heel. To promote external rotation we want the other end of the band to be secured so the band is running in front of our body.

With the band secured around our heel we want to first rotate our heel outwards to engage the rotational muscles around the knee. Then we want to slowly rotate the heel inwards, which starts to rotate the knee externally. During the first part of the movement we are working to eccentrically control the rotational moment created by the band. As the knee moves farther into external rotation we want can then transition into more of a concentric contraction. Here the band acts as assistance and helps to achieve a greater range. 

We can hold the end position for a few seconds then slowly rotate in the opposite direction again. We can slowly perform 10-15 repetitions. 

Knee External Rotation Strength Exercises

Once the knee has sufficient flexibility and control, we can then start to progress to higher level loading and strength exercises.

One option that I often use in my clinic is to train knee rotation from a kneeling position using a stiff resistance band or cable. We’re going to set this up by wrapping the band around the inside of our heel with the band positioned away from us. From here we are going to slowly pull heel inwards against the resistance of the band. 

As we do this we want to keep the forefoot flat, almost as if we are pivoting from the ball of our foot. We want to firmly hold the contraction in this end position for a few seconds, then slowly rotate the heel outwards. 

Sets and Reps

Remember, if the goal is to promote strength we want to provide enough stimulus to actually get the tissue stronger. But at the same time, we are often prescribing these exercises as part of a rehabilitation program, so we also need to respect the potential for easily irritable or healing tissue. 

So we may need to ease into these exercises and initially keep the resistance low. But once tolerance has been established I will typically have patients perform anywhere from 3-5 sets of 6-10 repetitions. And they will typically perform these two to three times per week. 

But the execution of these sets and reps need to be very deliberate. Remember, it is not easy to get strong. To make this point with my patients I often use the example of someone going to the gym. If someone wants to build bigger and stronger biceps, they can go to the gym and do some biceps curls, if they’re not doing enough curls, and if they’re not fatigued after those exercises they probably didn’t work hard enough to create a change. So I instruct my patients to do sets of 6-10 repetitions, they should expect those last few reps to be challenging. If they get to 10 repetitions but feel like they could have done more they need to increase the resistance. 

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I Hurt But Didn’t Do Anything?

Unfortunately, pain and injury are an inevitable fact of life. In some cases this pain occurs following a traumatic event such as rolling over on an ankle or falling on an outstretched arm. Of course we aren’t happy about these injuries, but at least they make sense….. “I’m in pain because of the trauma I experienced”.

But this is only one type of injury. In other cases you can hurt and be in pain without undergoing a specific injury or accident. Maybe you just noticed some minor symptoms one day that got worse instead of better with time. Or maybe you started feeling pain after doing a routine activity that you have done countless times before.  Perhaps your back hurts after simply bending forward one day, or you knee hurts after a run even though you have been running for years.

These “injuries” can be equally as painful, but seem to not make any sense…“I Hurt But I Didn’t Do Anything?”

Let’s take a few minutes to talk about this type of “injury”.  

As a side note… Please consider that this brief article talks about pain that arises from some form of tissue injury. But keep in mind that pain is a complex and often poorly understood entity. Pain can also be driven by other mechanisms, such as medical/non-musculoskeletal problems, or in some chronic pain situations can occur even in the absence of tissue injury. What I am talking about here is pain that occurs as a result of tissue damage (which which accounts for the majority of cases we see in our office).

Understanding Pain And Injury

To understand any injury we must first understand that all of the tissues in our body (and here I mean any biological tissue such as muscle, tendon, ligament, bone, joint cartilage, and even our nerves) have what is referred to as a “load tolerance”. This is the amount of stress any particular tissue can withstand before the tissue yields. For example how far can a ligament be stretched before damage occurs, or how much force can a bone withstand before it breaks.

Simply stated, if your body is subjected to forces that are beyond a tissue’s tolerance level, that tissue sustains damage. Of course this will make perfect sense when talking about a traumatic injury such as an ankle sprain. Image yourself running along and you catch your shoe on some uneven ground. The forces associated with all your body weight coming down onto your twisted ankle is more than the muscles and ligaments can handle and tissue damage occurs.  

But what about those times when pain and injury occur but there is no specific trauma or single precipitating event?

Interestingly, in non-traumatic injuries (the “I hurt but didn’t do anything” type of injuries) the injury process is the same, but instead of the  overloading forces occurring all at once they occur as a result of long-standing, low-level forces accumulating over time.

All injury follows this same basic formula…. When load exceeds tolerance tissues become injured

In other words, instead of a single traumatic event, repeated “sub-threshold” forces can slowly disrupt and damage tissue over time. If this process continues at some point the tissue yields, leading to pain and symptoms.

Understanding Non-Traumatic Pain and Injury: A Simple Illustration

To appreciate how this actually works realize that our bodies are under continual physical stress throughout the day with activities such as standing, walking, bending, lifting, and even sitting. Fortunately these stresses are typically well below our tissues’ tolerance levels, meaning our bodies can easily withstand these loads without incurring any significant damage.  Essentially there is a “margin of safety” or buffer between the stresses our bodies are subjected to and our bodies capacity to tolerate that stress. 

The key phrase here is “any significant damage”. Even though these lower level loads are well below the failure stress of any individual tissue they can still still create low level micro-damage. Under normal circumstances the body is easily able to repair and recover as these stressed are removed.

Exercise is a good example of how this principle works. When we go the gym and lift weights we are selectively and purposefully stressing our muscles. As we remove these stresses (i.e., when the workout ends) and when we allow the necessary time for recovery our tissues adapt by getting stronger. Our tissues are then better able to tolerate the stress if and when it occurs again. We have thus improved the tolerance of those muscles. It is now able to tolerate more stress. It becomes more resilient.

But here’s the critical factor…. 

For this positive adaptation to occur we must allow adequate recovery time between training sessions. That is why we don’t typically train the same muscle groups everyday.

But imagine we were to violate this principle and we  went to gym and did biceps curls every day. Without the needed recovery between workouts microtrauma would start to accumulate. Instead of getting stronger the health and integrity of the tissue starts to slowly deteriorate. If this continues at some point the damage will build up to critical mass at which point pain and symptoms develop. Maybe some symptoms just shown up on day, or maybe your feel a pain in your biceps after lifting up your kid or opening a heavy door. Either way, tissue damage has accumulated to the point of injury, but as you can see this “injury” has actually been slowly building for some time.

So What Do Biceps Curls Have to Do Your My Injury?

So what does all this have to do with why you hurt? Simple. Just replace “biceps curls” with any sort of activity you are doing on a regular basis. Maybe your a runner, swimmer or crossfitter who one day starts to hurt even though you’ve been training for months or years. Or maybe you do a lot of bending or lifting at work and suddenly one day your back hurts. When this happens more often than not it probably means you’ve been flirting with that buffer – that ever narrowing “margin of safety” between what you need to do and your body’s capacity to do it safely. Just like the example above, you’ve been doing too many biceps curls without the needed recovery.

 

Treatment = Building The Buffer

Treatment and rehab can can a complicated topic, but let’s simplify this by returning to the idea that injury occurs tissue stress exceeds tissue tolerance. In other words, when we lose the “buffer” between what any particular tissue can tolerate and the stresses imposed on that tissue.

So in this context treatment is directed at restoring and increasing that buffer. This is done by addressing both the injured tissue itself, as well as the addressing the offending mechanism of stress/overload.

Improving Tissue Strength and Capacity

As for the injured tissue itself we need to both guide the healing process to ensure that the heals as quickly as possible, and heals properly. Depending on the degree of symptoms and the extent of the injury this may include some basic range of motion exercises and isometric contraction exercises to help manage pain and guide tissue healing. These exercises are critical to prevent the area from further tightening up and to guide the cells into laying down new collagen fibers in the right areas and directions.

As healing continues higher level exercises can be prescribed to strengthen the area. Essentially we are trying to improve the capacity of the tissue. Remember injury occurs when the capacity of a tissue is less that imposed demands. So we don’t just need to get the pain to improve. We also need to improve the capacity of the tissue to meet the demands that caused the injury in the first place. Just because symptoms improve does not necessarily mean that the tissue is healed and ready to resume full activities.

Reducing Stress / Load

In addition to dealing with the injured tissue, we also need to address the offending mechanism of stress/overload. In other words, we need to try to reduce the load/stress on the tissue. Some of this may be done in a short term capacity, for example temporarily reducing running mileage or avoiding certain things at work or at the gym.

It is also common for biomechanical issues to need to be addressed. For example, heel pain may be related to a restricted ankle or foot joints that may be putting more stress on the plantar fascia. Knee pain may be related to tight or weak hip. When this is the case, correcting these offending biomechanical issues can be a critical step in reducing stress, getting the patient back to full activities as fast as possible, and helping to minimize re-injury.

 

 

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Adductor Stretches

 

Hip adductor stretches and mobility exercises are a major component of hip and lower back rehab and flexibility programs. Here are a few great options to help target this critical (and very commonly tight) muscle group.

Adductor Roller Release

Self myofascial release techniques utilizing foam rollers, lacrosse balls, or massage sticks have become popular in recent years. While there is still some debate as to the utility and best practices of these techniques, these practices do appear to help improve mobility. This effect seems to be most pronounced when combined with more traditional stretching and ROM exercises.

Therefore, utilizing some form of self myofascial release prior to the performance of other mobility exercises can be a great addition to an overall mobility program. Here’s a simple way to do this for the adductors.

Begin on the floor with the leg flexed to your side and your inner thigh resting on a foam roller. Slide back and forth so the roller moves up an down along the inner thigh. Feel where the tight spots are and hover over those spots a little more for a better release.

Be sure to keep the leg relaxed. You want the roller to sink into the muscle. Slowly move back and forth over the roller for 1-2 minutes.

While the foam roller is probably the easiest and most effective way to get at the adductors, another option is performing a self-release with a massage stick. While this is note quite as effective (hard to get as deep on the tissue), this is a option for those patients who have trouble getting getting onto the floor or into the position needed for the roller.

 

Standing Lateral Lunge Adductor Stretch

The lateral lunge stretch is one of the most classic adductor stretches. One of the reasons I like this stretch is it’s easy to do, and the patient does not need to get on the floor to do it. That means they can do it a bunch of times throughout the day.

But there are a few things to keep in mind to make this stretch as effective as possible.

First, begin in a standing position with a wide stance.  The biggest mistake most people make with this stretch is not getting their feet wide enough. The key is to start with almost all of the slack out of the adductors. This way only a very small movement is needed to generate a stretch.

The other major error with this stretch is that as the adductors pull tight they often pull the pelvis out of position. To prevent this it is often helpful to hold a posterior pelvic tilt and abdominal brace during the stretch.

Once the right starting posture is met, bend one knee and slide the hips to one side. This should create a stretch on the inside of the opposite thigh. Hold the stretch for 1-2 seconds then return to the starting position to release the stretch (you can also increase the hold time if needed).

 

Adductor Lunge Stretch

In addition to limiting hip abduction, tight adductors (especially the adductor magnus) can restrict hip flexion. When this is the case this “Adductor Lunge” stretch can be a great way to help restore this motion.

Begin kneeling on the floor in a lunge position. Bend your trunk forward to bring the outside of your shoulder towards the inside of your lead knee. Now lunge forward so your hips slide forward. You should feel a stretch along the inside of your upper leg (on the forward leg). Hold the stretch for 2-3 seconds then release. Perform 10-15 reps.

Adductor AIS Release

Active Isolated Stretching (AIS) utilizes the contraction of opposing muscles groups in combination with passive assistance to achieve a deeper stretch. I often used these stretches with muscle imbalances where there is a tight agonist along with a weak antagonist. In this case, when the adductors are tight and the lateral glutes and weak / inhibited.

To perform an AIS stretch for the adductors begin in a supine position with a stiff strap around one foot. The other end of the strap is held in the hand. Now actively slide the foot outwards. The key is to SLIDE the foot, don’t lift it or the hip flexors will contract. At the end of the motion gently pull the foot further outwards with the strap. You should feel a stretch in the adductors and a contraction in the abductors.

Hold for 2 seconds then slide the leg back in. Perform 10-15 repetitions.

 

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5 Simple Quad Stretches

Tight quadriceps are a common finding with knee pain, as well as lower back and pelvic pain. In this brief article I outline five simple exercises that can help improve mobility and flexibility of the quads.

Note: If you are a My Rehab Connection subscriber, these stretches can be found in the My Exercise Groups section under the “Group: Quad Mobility”. Each stretch can also be accessed in the My Exercise Library section.

 

Kneeling Lunge

The Kneeling Lunge is a classic hip flexor stretch. But because the knee is flexed it tends to bias the stretch towards the rectus femoris muscle.

As long as the patient does not have issues with putting pressure on the knee this is usually my go to stretch for the quads. Not only is it a great stretch, but is teaches the patient how to move through the hip. It also serves as a great precursor to the lunge exercise, which is often dysfunctional and needs to be retrained when the quads are tight.

To perform the stretch correctly it is important to make sure motion is coming from the hip. The two most common faults patients will use to get around the hip are to tilt the pelvis anterior and hyper-extend the lumbar spine, or to lean forward with their entire trunk. Having the patient perform a posterior pelvic tilt and abdominal brace will help prevent this first fault. Instructing the patient to keep the shoulder stacked over the hips can help with the second fault.

In most cases I prefer to have the patient shift forward until they feel a light stretch on the front of the thigh, hold that stretch for 1-2 seconds, then shift back to release the stretch. I have them perform 10-15 repetitions. Having them hold the last stretch for 15-30 seconds is another option.

5 simple quad stretches - kneeling lunge quad stretch

 

Kneeling Lunge with Quad Focus

The classic Kneeling Lunge Stretch can easily be modified to increase the intensity of the stretch and to shift the focus even more towards the quads. This can be done by elevating the back foot. This stretch can be particularly effective where there is restriction between the rectus femoris and vasti group.

The additional knee flexion will further load the quads and create a deeper stretch. You can vary the height to which the foot is raised to match the capacity of the patient. Other than the raised foot, the execution of the stretch is the same as the Kneeling Lunge Stretch as described above.

As a side note, many patients will ask if they can simply reach around and hold the foot up with their arm. I advise against this as it complicates the stretch and usually causes the spine to rotate and extend.

 

Standing Quad Stretch

This is probably the most common quadriceps stretch. When patients are questioned about their current stretching routines this stretch is often on the list. While this can be an effective stretch (one of the biggest benefits is it can easily be done throughout the day), it is also one of the most poorly performed stretches.

Most people will arch the back and twist the spine as they perform this stretch. Usually this occurs as an attempt to reach the foot with their arm.

The better way to perform this stretch is to begin with the knee bent and the thigh positioned in front of the body. This places the foot under the hip making it easier to reach. From this position the key is to gently pull up on the foot to take the slack out of the quad. Then while maintaining this tension the patient can bring the thigh into extension until they feel a comfortable stretch.

With the quad pre-tensioned the thigh will rarely get all the way behind the body. And it doesn’t need to. The goal is only to feel a stretch. This is an important point that needs to be explained to the patient.

 

Side Lying Quad Stretch

The Side Lying Quad Stretch is similar to the Standing Quad Stretch, but is performed in a non-weight bearing posture. This is a better option for patients who have difficulty standing on a single leg. It can also be helpful for people who have trouble keeping their spine in the correct alignment.

Other than the side lying position the stretch is performed in the same manner. Start with the thigh in front, pre-tension the quad by pulling the foot towards the hip, then bring the thigh back.

Performing a posterior pelvic tilt and/or an abdominal brace can be a helpful addition for those patients with a tendency to hyper-extend the lower back.

 

Prone Quad AIS Stretch

Active Isolated Stretching (AIS) utilizes the contraction of opposing muscles groups in combination with passive assistance to achieve a deeper stretch. I often used these stretches with muscle imbalances where there is a tight agonist along with a weak antagonist.

To perform an AIS stretch for the quad begin in a prone position with a stiff strap around one foot. The other end of the strap is held in the hand. Now actively pull the foot towards the hip. At the top of the motion gently pull the foot further towards the hip. This does not need to be a hard pull. It should be just enough to increase the stretch in the quad.

Hold for 2 seconds then straighten the knee. Perform 10-15 repetitions.

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