Piggy in the Middle

Do you remember that game where two people throw a ball to each other over the head of another player who is standing in between them? The ‘piggy in the middle’ has to run around like mad trying to intercept the pass, whilst the others play all sorts of tricks like ducking  or switching directions at the last moment. Yep, well, the piggy in the middle is a great metaphor for the knee.

When the ankle joint receives weight it is normally in contact with the ground. This restricts the movement possibilities within the ankle, providing a relatively stable base on which to stand (‘relatively’ being the operative word here). The hip joint is structurally stable being both deep inside the pelvis and reinforced by layers of strong tendons. In relative terms, the knee is in a much more precarious situation. In the downward spiral (my term, not a technical one), the knee has to accommodate the torsion created by deviations / restrictions above (in the hip) or below (in the foot) or both.

However, the knee is not designed to rotate! It’s a hinge joint. It is designed to allow us to flex in the lower limb. This decelerates the fall of the body, reducing the impact of the ground’s force when our weight is met by a hard surface. It should only move forwards (flex) or lengthen (extend – as opposed to hyper extend (that’s another story)). Restrictions around the ankle and hip force the knee into inward (knock knee) or outward (bow legs) rotation (- bow legs is not really a result of the Spiral Line collapsing, I’ll cover that on another post). Continuous torsion over time ultimately leads to injury. It’s the piggy in the middle, and all it can do is scream in pain.


It is very rare that a knee injury is directly the result of poor functioning in the knee itself! (Dislocation and hyper extension are obviously an exception.) And yet the tendency is just to treat the knee with medications, massage and exercises that directly relate to the knee alone, instead of addressing the underlying cause of the torsion which may be in the ankle, the hip or both. No, I’m not saying you shouldn’t strengthen the VMO and release the ITB (if you have dodgy knees you’ll have come across these terms already). Unfortunately, we often only know about the pattern when the knee starts to create some noise, by which time damage within the knee itself has already taken root. So we then have a situation where we do need to treat the knee to relieve the pain. But the knee pain is a symptom of a wider pattern.

So how do we identify restrictions that may be putting a torsion strain on the knee before we get to that point of injury, and what can we do to reduce them? Here are some suggestions:

  1. When you next walk up a flight of stairs, look at how your knees move over your toes. Do your knees roll inwards or outwards? Both of these are a sign of some compensation. Try sending your knee directly forwards over your toes. It may feel strange, or effortful at first, but by gradually encouraging better alignment you start to unlock the poor pattern.
  2. Listen out for noise. It’s obvious enough, but constant cracking, popping and crunching in the knee is not a good sign. If it is on one side but not on the other (unilateral) then this could be a sign of whole body torsion (again, my term not a technical one), which is particularly common for people with a scoliosis or some other asymmetry (like a leg length discrepancy). Working to reduce the impact of this structural asymmetry on the soft tissue will help to reduce the constant pulling on the knee. You need to do a well rounded class that includes release and stabilisation for the pelvis and spine. Attacking the leg alone with a foam roller may just exacerbate the situation.
  3. Decompress the knee. If you are hearing clicking sounds in the knee and starting to experience pain you need to focus on decompressing the knee joint. The typical thing to do is to strengthen the VMO (the lowest fibres of the inner most quadriceps muscle) which helps to lift the knee cap, whilst releasing the ITB (the tough tissue on the outer side of the leg). You should also look to lengthen the hamstrings. (My next post will look at functional use of the hamstrings.) But you cannot ignore the lower leg. The muscles in the lower leg also tend to tighten up, especially the ones around the outer side (the peroneals), these are particularly hard to stretch, and are often by-passed in people with dropped arches. The Feldenkrais variations of calve stretching described in the video on my previous post will massively help to relieve this tension. Try to avoid really tough stretching. Work on creating glide between the layers of muscle instead.
  4. Strengthen the muscles around the hip. This will be covered on my next post.

Warning: Listen to your body. The aim is to move without pain and no blog can really tell you how to assess and correct your movement. Speak to a professional and get them to give you some feedback on your knee tracking. Just remember, the cause is not normally in the knee.


My next post will look at the hip – foot sling.

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