Keep it Simple – Knee Mechanics and TNTI (The Need to Impress)

Quadriceps - Colin Badali  I have once again crossed a bit of Paul Ingraham’s work that resonates with thoughts I’ve had for many years.  You can’t isolate the vastus medialis obliquus (the medial head of the quadriceps group – the quads being the big group of muscles at the front of your upper leg).  Hold on, there’s a greater overarching theme for my readers who might not care about such a specific topic.

Therapists of all sorts, especially physiotherapists, RMTs, fitness trainers, just love to prescribe exercises designed to isolate the vastus medialis obliquus (VMO) portion of the quadriceps group, for things like PFS or patellofemoral syndrome. The theory is that the VMO is oftentimes weaker than the vastus lateralis (the outside head of the quad group), and this causes tracking issues or issues with the position of your patella/kneecap.  For my therapist-readers, as mentioned in Ingraham’s e-book on the topic, Peeler et al. found “no significant correlation between any of VM insertion length, VM fiber angle, limb alignment, and patellofemoral joint dysfunction location and severity [of pain]”  Truth be told, these exercises (which would include squeezing a ball between your legs while you are extending/straightening your legs while sitting on the edge of a table), don’t actually isolate the VMO.  They still might help you improve, via strengthening the knee as a whole!  But the point is, you’re better off simply performing exercises designed to strengthen the knee.  No need to be fancy.

Greater themes here:

  1. Keep it simple – it is easy to impress clients by saying you’re going to strengthen the VMO in order to fix a tracking issue of the patella which should help mediate knee pain (when really, general strengthening is all that is required). Well, on second thought, I guess you can do that, and perhaps the client will be impressed.  However, one must be prepared to face the music when criticism/doubts surface (either from the client him(her)self, or from some other health professional they are seeing).
  2. Don’t be afraid to question (as a client or a therapist): I remember being taught these exercises in 2009, by physiotherapists at a clinic, while working as a kinesiologist.  I had my doubts of course, but as a recent uni-grad, you’re expected to simply do as you’re told.  You should question things, within reason though!  Don’t get yourself fired, and absolutely do not provide your client with a “nocebo” effect i.e. making them think that what they are doing is going to hurt them.  Keep such conversations between professionals only.

Full PainScience article – here

Colin Badali, RMT, CSCS

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