Kienbaum Presentation
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Martin Koban, personal trainer
Spent the last 3 years researching knee health & how to prevent knee pain
Published my findings in a book, which your colleague Alessandro found useful
Share my thoughts about knee health in a presentation
Structure of presentation
o About me: What I am and what I’m not
o The framework
o Parts of the Framework
o Connections to Patellar Tendonitis
o Simple Screening Exercises
o Limitations and How You Can Overcome them
About Me
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Not a Doctor / Physical Therapist
By accident
Volleyball/Basketball
After 15 years, some knee pain, not enough to warrant action
2009, brother meniscus volleyball warm-up
“Easy” injury could happen to me … needed to know how to prevent that
Started reading about knee health and experimenting
Went to seminars on a variety of topics, absorbed what was useful for knee health
2011, started website to make scientific findings useful for the layperson
2012, compiled everything I had discovered into a book
2013, work on a second book, patellar tendonitis
Exercise selection based on what people can do at home
o Nothing too complicated
o No expensive equipment
o Never looked into pharmaceutical or invasive approaches
 Not useful to my readers or me
 Not qualified to give advice on these topics
The Framework
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My finding: barring traumatic injury, knee pain caused by movement dysfunction
To prevent pain: optimal movement (end
Need joints/muscles to work optimally
o The means to create movement
o hardware
Motor Control System
o Stores movement patterns,
o muscle activation sequences,
o extensibility
o software
MCC
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Joints/Muscles
Movement
3 areas we can directly improve through exercise:
o Joints
o Muscles
o Movement
Joint Restrictions: Joint Mobility
o Maintenance Work
o Rehab Exercises
o Strengthening
o Discussed in next part
Muscles: Problems are soft-tissue restrictions, lack of extensibility, and lack of “strength”
o Massage
o Stretching/Mobilization
o Strengthening
o Each can be applied by various means and techniques
o More on that later
Work on joints/muscles: fixing the hardware
Lastly, Movement
o Alignment Problems
o Timing Issues
o Improving the software
Joint Mobility
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Effects/Goals:
o Remove joint restrictions
o Provide cartilage with nutrients
o Flush waste products out
o Remove tension and relax muscles, with breath
o Improve motor control
o Strengthen joints (ligaments, capsule)
o Reduce risk of injury
o Warm-up before activity
 Improve circulation, more nutrients and oxygen
o Retain movement capability in old age
 Maxwell: fountain of youth
 Muscle tension, body adapts, always tense
Types:
o Daily Maintenance Work
o Rehab Exercises
o Strengthening Drills
Daily Maintenance
o 20 – 30 minute Routine
o Gently move every joint through full range of motion
o Relaxed breathing
o From simple to complicated
o In the morning, after a long flight, after a hectic day, active recovery for rest days
o Example
Rehab Exercises
o Joint with problems, maybe impingement, maybe otherwise limited ROM
 Address a certain problem
 Until it’s fixed
o Traction
o Compression
o Gapping
o Example: Knee, Ankle, Voodoo band
Strengthening Drills
o Incrementally put higher loads on the joint in unusual ways
o Stimulate Collagen Synthesis in ligaments, Strengthening of the Joint Capsule
o Martial Arts
o Example: Pushups, Ankle Drill
o Two to three times per week, depending on a number of factors
For Knee Health:
o Ankle Mobility, specifically dorsiflexion
o Hip Mobility, specifically hip extension ROM
o Knee through full ROM
Massage
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Effects/Goals:
o Remove soft-tissue restrictions
 Adhesions between muscle
 Scar tissue
o Improve Extensibility
o Help remove tension
o Restore ability to glide freely
Several Options:
o Self-Massage
o Partner Massage
o Professional Soft-Tissue Treatment
Self-Massage
o Became more popular in the last 10 years
o Using variety of implements
 Foam-roller
 Tennis, lacrosse, golf, medicine balls
 Bars, sticks, doorframes
o Cheap, high compliance, easy to do
o Great results
o Limitation: can’t reach deep tissue
Partner Massage
o No massage experience necessary
o Either using implements or hands/feet
o Exposed to this three times:
 Seminar in 2011
 Thai Massage
 Russian Martial Art Seminar 2013
o Very intense, penetrates the tissue deep, potentially really painful
o Combine with breathing and relaxation
Professional Soft-Tissue Treatment
o Active Release Technique, uses hands and movement
o Graston Technique, uses specialized metal tools
 Often criticized for doing too much damage to tissue
o Couldn’t visit seminars: Soft-tissue malpractice insurance
o Safest and most effective way to resolve soft-tissue restrictions
o Potentially costly
Problem with massage:
o Doesn’t permanently solve soft-tissue restrictions caused by
 Motor control issues
 Bad habits
For Knee Health:
o All muscles of the leg, including
 Front of shin
 Underside of foot
o Hip Muscles
Stretching/Mobilization
Stretching
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Goal/Effect:
o Restore extensibility by retraining the central nervous system
o Allow better alignment
 Anterior pelvic tilt
 Knee alignment over toes
o Allow better muscle recruitment
 Reciprocal inhibition of glutes and hamstrings due to tight hip flexors
o Various Stretching methods like PNF, AIS
Problem: Symptom treatment
o There’s an underlying cause for tightness
 Unbalanced exercise choices
 Only train quads, never glutes
 Wrong movement habits
 Sitting all day
 Compensations after injuries
o Without fixing that real cause, you’ll have to keep stretching
 Need to combine it with strengthening
o If you don’t know what you’re doing, it can be dangerous
 Only few exercises in my books
 Example: weak and tight psoas
 Test if it’s weak, only then stretch
o Ideally we don’t need to stretch
 Comparison to nature: mobilize yes, stretch no
Common Target Muscles:
o Hip Flexors (Iliopsoas, Quadriceps)
o TFL
o Adductors
o Calves
o Hamstrings
Mobilization
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Popularized by Dr. Kelly Starrett of San Francisco Crossfit
Combination of joint mobility and stretching
Done in or close to position you want to improve
Great for improving alignment
Example:
o Ankle dorsiflexion mobilization with band and compression
o Done standing or in squat position
o Quad mobilization with compression in squat position
Muscle Strengthening
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Goal/Effect:
o Strengthen muscles needed for good movement
 Through improved neural activation
 Through hypertrophy
o Improve load distribution (anterior shift)
o Better posture and alignment
Methods:
o Isolating exercises
 Side-lying hip abductions, clamshells, glute bridge
o Compound Exercises
 Squat, Hip Hinge patterns (deadlift, kettlebell swing, Good Morning)
o Single Leg Exercises
 Greater Stability Demand
 High carry over to athletic movements (all single leg)
 Example: 1RDL, Bulgarian split squat, Single-leg Squat
o Incremental Resistance
 Bodyweight, Isometric Holds
 Bands
 Weights
Target Muscles for Knee Health:
o Gluteals
 Abduction, External Rotation, Extension
o Hamstrings
o Tibialis Anterior (ankle dorsiflexion)
o Quadriceps, particularly vastus medialis
Movement
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Integrated into strengthening exercises and regular training
Goal:
o Reduce load on passive stabilizing structures
o Improve Load distribution (anterior weight shift: overload of patellar tendon)
Methods:
o Slow training
o Disassembling movements into individual parts
o Education of the athlete, Self-Monitoring
Alignment
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Common mistakes:
o Feet turned out when walking
o Knees caving inward / not tracking over toes
o Too much knee forward translation
Methods:
o Ankle Mobility, Calf Muscle Mobilization
o Hip External Rotation Training (Clamshells /w band)
o Hip Hinge training
Timing
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Common Mistakes:
o Knee flexion before hip flexion
o No hip flexion at all
o No force absorption
Methods:
o Slow training progressing to faster training
o Hip Hinge Patterning
o Barefoot Training
Framework Recap
MCC
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Joints/Muscles
Lots of things we can do for
o Joints
o Muscles
o Movement
If we know where the problem lies
Difficult to identify problems during the sport itself
Need for screening tools
Simple Screening Exercises
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There are highly sophisticated screens:
o Functional Movement Screen
o Selective Functional Movement Assessment
o Others I’m not aware of
o Great for physical therapists, sport’s orthopedists etc.
Difficulty to apply for recreational athletes at home
o Complex movements
o Special equipment needed
o Need a partner
o Too much effort
Simpler Screens needed
o Easy-to-teach movements
o No equipment
o No partner
o Little time investment
My Favorites:
o Regular bodyweight squat
o Glute Bridge
o Slow Single-leg Squat (onto box)
o Box Jump
o Drop Jump
Regular Bodyweight Squat
o Feet underneath hips
o Foot rotation => Ankle Mobility
o Knee Position => Gluteal Exercises
o Depth reached => Ankle Mobility/Motor Control
Glute Bridge (alignment reached)
Movement
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o Gluteal Activation
o Gluteal Strength
o Hip Mobility
Slow single-leg squat
o Same as regular squat, higher stability demands, reveals more problems
Box Jump / Drop Jump
o Does movement quality break down under ballistic load?
Progressions:
o Perform exercises with moderate to high exhaustion
o Does technique degrade?
Movement practice, not work out
Connections to Patellar Tendonitis
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Patellar Tendonitis
o Overuse of patellar tendon
o Tendon cannot recover fast enough between stimuli
o Tenocytes become reactive, increase protein synthesis for more collagen production
o If overuse continues:
 ECM will begin to degrade
 More Tenocytes in the area
 Collagen alignment degrades
 Tenocyte death
 Tendon Rupture
 Very enlightening research paper on tendinopathy
At a certain workload, only some athletes become symptomatic
o Certain factors that influence tendon load during movement
o Unchangeable factors such as
 Sex, body type
o Changeable factors such as (all backed by research)
 Low Ankle Dorsiflexion
 Tight Calves
 Tight Quads
 Tight Hamstrings
 Weak Gluteal Muscles (abduction, external rotation)
 Low Hip Mobility (extension)
 Wrong foot alignment (turned out)
 Wrong jumping technique (hip hinge)
 Overtraining
 Nutritional deficiencies (vitamin C, omega-3 fatty acids)
Exactly identical to knee health requirements identified earlier
Same methods to address them
o Plus supplementation with
 Vitamin C (1-2 g per day)
 Omega-3 fatty acids (liquid fish oil, 2 or 3 teaspoons per day)
To rebuild the tendon
o Slow eccentric exercises on a decline
o Slow weight training
 3 to 5 second eccentric, 3 to 5 second concentric
 Prevents energy storage in tendon
o Done with pain or discomfort in tendon
o Systema: Extremely slow weight training
 30 to 60 seconds or more per repetition!
 Goals:
 Tendon Strengthening
 Removing tensions
 Improving muscle recruitment efficiency
o 8 weeks minimum
o Best results when avoiding ballistic exercises
Limitations of This Model
MCC
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Joints/Muscles
Movement
Body programmed for survival
Extremely good at compensation
Injury: hardware issue
o Body wants to create the same output
o Compensational movement patterns are developed
o End result is the same
Deeply ingrained movement and muscle dysfunctions
o Stored in the motor control centrum in the cerebellum
o Still used, even after injury has healed
o Difficult or impossible to fix with conventional means
 Stretching/Mobilization
 Strengthening
 Movement Practice
 All fail
o Compensation overworks certain parts of the body (muscles/joints/ligaments)
 Continued overuse: pain
 Continue pain: injury
 Injury: Additional compensational patterns, more difficult to solve
Required: Treatment modality that allows changing stuff store in the MCC
The only modality I know:
o Neurokinetic Therapy
o Works through
 Muscle testing
 Identifying weak or facilitated
 Trigger learning response in the MCC by releasing muscle tension in involved
muscles
 Short window of opportunity: retraining proper muscle activation
o Changing muscle activation patterns directly in the MCC
o Reinforcement through specific exercises/taping to retain proper muscle activation
o Potential to solve cases of chronic pain
o Awesome to increase athletic potential
o Excellent for preventing injuries
Great to use in conjunction with other modalities
o Active Release Technique soft-tissue treatment
o Deep Tissue Laser Therapy
o Selective Functional Movement Assessment
Conclusion
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Even within the limitations, achieved great results
o Regularly get unsolicited emails from people about how the exercises have helped
them tremendously
Limitations of my model stem from:
o Me “just” being a personal trainer
o No thorough medical education
o No face-to-face interaction and no hands-on assessments
o Tradeoff:
 either you collect lots of knowledge and experience to perfect your craft
 or you put considerable work into making information available to lots of
people
 With my background, the latter choice allowed me to help more people in
shorter time
For a Doctor or physical therapist, overcoming the limitations I have is simple
o Huge payoff, particularly in regard to professional sports