Male Announcer: You’re listening to From Pain to Possibility with Susi Hately. You will hear Susi’s best ideas on how to reduce or even eradicate your pain and learn how to listen to your body when it whispers so you don’t have to hear it scream. And now here’s your host, Susi Hately.

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Welcome back, with this episode I want to dig into kneeling post total knee replacement. It's a really important discussion to have because 60 to 80% of people report difficulty kneeling 5 to seven7 to 10 years post op, depending on the literature that you read.

So it becomes really important because kneeling is such an important function because of what we do with our activities of daily living. What we do perhaps for our work, for our leisure, religion. When you fall down you have to get back up, playing around with kids and grandkids. So it's a really interesting and important conversation. And I'm looking forward to sharing what I know about this process of helping someone kneel again.

Also, if you're someone or you're working with someone who has osteoarthritis, a lot of what I'm sharing here is going to be applicable to that situation as well. I'm not going to be speaking specifically about osteoarthritis, I'll be using post-surgery, I'll be using terms like knee replacements or total knee replacements. But just know that the other language that I'm sharing can certainly be utilized in the realm for osteoarthritis.

So what's really interesting around regaining the ability to kneel is that when you're looking at the literature, we're seeing like 5 to 7 to 10 years post op. So there's this chronicity down the road of having trouble kneeling, which I think is really fascinating.

And because so many of the clients that I work with to help them recover function and get out of pain are coming to me years after surgery many of them, or years after a scenario has occurred and there's a chronicity of neuromuscular patterning. I sort of get to this place of rubbing my hands together, looking forward to working with that person.

Because what I have seen over a period of time is that we can change neuromuscular patterns, whether there has been a replacement or not, whether there's been surgery or not. There's a lot within our systems, within our bodies, within our brains that can shift. We are actually very, very plastic individuals that can shift and change if we give ourselves the correct stimulus.

So when I see this number of 60 to 80% of people reporting difficulty, like there's a ton of opportunity to help people. And it becomes really interesting to see what's actually contributing to this difficulty or how this difficulty is contributing to thought patterns that is contributing to the ongoing difficulty with kneeling. So it becomes a bit of a vicious circle.

So when we really look at it, the key arenas that make people concerned is that they are afraid of harming the actual replacement. They don't want to harm what was done. So then they're not practicing the actual act of kneeling. There's discomfort oftentimes, or even numbness, and there's comorbidities. So there's things that are not even related specifically to the replacement, or to the knee itself.

But overall the common theme within the research is that it's not due to limited knee range of motion. So anatomically and biomechanically, a lot of people have the ability to kneel. But there are these other things around fear and discomfort, which leads and kind of contributes more to fear that prevent people from actually going into the process of kneeling. Which then, as I mentioned, continues to create the issues with kneeling.

So let's sort of dig into this a little bit more. When we're thinking about kneeling, kneeling has us needing to get onto the floor. So we're moving from being in a standing or a sitting position, getting down into the floor. So think about that movement pattern of just getting down to the floor. So that's part of the process to come into kneeling.

And then there's the act of kneeling itself. So you're on your knees and there's pressure on the knees which can be challenging to feel, particularly when there's discomfort in the knee. And then depending on the form of kneeling that you take, whether it's on hands and knees as in a tabletop. Or whether you're bringing your hips or your bum down to your heels, that's another form of kneeling.

So you can see that it can actually be really troublesome for people, depending on what your activities of daily living are. Like if you have to get down to the floor to wash the floor or mop the floor with your hands. Whether you're playing with kids or grandkids.

Maybe you've got a job, like a carpet layer or other types of jobs where you are on your knees. Think about the religious services when you're in positions when you're on your knees. If you’ve fallen down and you have to get back up again.

So it impacts this ability not to kneel, or this inability to kneel or fear of kneeling. The concern for kneeling, the worry to kneel, it makes a lot of sense why it exists. And it has an incredible impact on activities of life, of living life.

So what I like to work with when I have clients who have trouble kneeling and they want to kneel, I like to first work with their mechanical patterns and what can they actually do? And in what position can we actually support them in? Because what we'll find is, early on we'll find mechanical patterns that are contributing to the way that knee moves or doesn't move, or the way that knee feels.

I like to say that the knee is the midway point between the hip and the foot. And the reason I like to say that is when you look skeletally at the knee, the only thing unique to the knee is the kneecap, the patella. The top of the knee is the bottom of the femur, which forms the hip. The bottom of the knee is the top of the tibia, which in part forms the ankle.

Then when we look more muscularly at the structures that cross the knee, a lot of them cross the hip as well. Some of them cross the ankle. There's one that specifically crosses the knee, the popliteus. So it becomes really interesting when we're looking at both the skeletal and the muscular force implications on the knee and how much actually is impacted and influenced by what's going on with the hip and the ankle.

So when we're looking at those two areas we can create a huge amount of change in the function of the knee when we're taking a look at what's going on with the hip and the foot. So the first place I like to begin with people is really there, is what's going on at the hip? What's going on with the ankle and the foot? And oftentimes, that alone can make changes.

Sometimes the mechanics between the hip and the foot are really obvious like you might see that how the knees fall inward when people do a chair position, or a warrior one, or a high lunge type of position. You can see if they go into a warrior three, how the foot might kind of turn, the heel might turn out, the toes might turn in, that knee might fall in a little bit. We can see when someone walks down the stairs or up the stairs, again, that knee might fall in.

So then that lets us know that there's something going on between that hip and the foot. Now exactly what, we can pontificate and kind of explore in our own heads about why that leg is falling inward. But the key piece that I want you to first pay attention to is that that's what's happening. And that is really interesting from the perspective of if we can help create a better coordinating pattern through that kinetic chain from the hip through the knee to the foot, then a lot can shift.

So a big piece of that part of the puzzle is I often stay away from the knee per se in terms of any cueing, or touching, or imagery. I want people to recognize when they shift what's going on with the foot, when they shift what's going on with the hip, that the knee often changes.

So I might play around with putting a strap around their legs to begin with and pushing out into the strap, so an abducting type of position. I might have them place their foot on the ground and really pay attention to the three points in the bottom of the foot, the center of the heel, the ball of the foot, the base of the pinky toe. So that when they are going into a chair position, for example, what happens as they press the legs out into that strap? What happens to their foot?

Because sometimes what happens is they press their legs out into the strap and they bring the weight over onto the outside of the foot. So then when I coach them on, okay, let's just maintain the foot position of those three points. Now press the legs out into the strap, now what do you notice?

Then they start to kind of clue in and become aware of how those mechanics are going on from their hip to their foot. And the knee might start to feel better in some cases, or they just might feel their legs, they might kind of what I like to call come into their legs, the musculature of their legs just sort of turns on a bit better.

In some cases it’s not pressing out into the strap that's the difference maker, it's actually holding a block between the legs. That can sometimes be the difference maker. Which can sometimes be confusing for people when they've been seeing someone, their legs falling inward I’m like, “But wait a second, why would putting a block in between make a difference?”

But it just depends on the neuromechanical dynamics between the hip and the foot. And one prop, like a block might just work better than the strap. Sometimes even I'll do both. When it comes to a chair position, sometimes I'll bring both the block and the strap, just to provide that extra support while I'm helping them connect to the bottom of the foot.

And then noticing how they are on the bottom of that foot. And then they can kind of play into I see, I feel this knee. I can get this idea of alignment. Although I really don't love the word alignment, I'd rather talk about the kinematics. Or I'd like to talk about the relationships and the tempo between the hip, the knee, and the foot, as opposed to specifically alignment,

I find that people tend to get that into a very factual, static, must get alignment, kind of like must get posture. Whereas when I can really help them get the dynamic nature between the hip, the knee, and the foot, something else becomes more vital and more alive.

So just really simply tuning them into the bottom of that foot. Tuning them into the hip dynamic. And simply, the foot positioning can sometimes get that hip rolling in a way that it's like, “That's the connection piece that I needed in order to feel my knee in a different way.”

So that's one area to play with. And what I find powerful when this works, then I can take it into a high lunge, or a mini warrior one, or a mini crescent lunge. Where the person then places, for example, the hand on the outside of the thigh, and they press that front leg, that outside thigh into the hand as they bring the other leg backward into that high lunge. And can they without being rigid and brace-y about it, can they maintain that as they step back?

And then if they can't then just take the stance smaller, but they're starting to gain a better sense of coordination between their parts as they move through. And that awareness, that lighting up of the awareness helps them gain clarity on what's working and not working. And it gives them a bit better of a map to work with to support themselves in moving forward.

And then you can play with this in different movements. Whether it's in tree pose with a slightly bent knee. Whether it's that warrior one, or the crescent lunge, or the high lunge. Even stepping wide into Goddess Pose and then rotating the leg bones at that hip socket. And the rotation might not be very big.

But by placing the hands to the outside of the thighs, once they're whatever the rotation position was, getting from legs wide into Goddess, and then starting to play with lowering down through that squat. Not deep, just small, bit by bit by bit. That can be a really interesting way to explore how these parts function. And the person then begins to see, you as the teacher begins to see how these parts all relate.

Now another piece to this that becomes interesting is for people who can get down to the floor really easily, but they have trouble with being on their knees. So they can get to the floor but they have trouble being on their knees.

A key area to explore is what's going on between their pelvis and their ribcage. I find that there is this real hub of congestion, I like to call it. And that might be a podcast episode for the future. But there's this hub of congestion that can land in between the ribcage and the pelvis.

You can sort of see this with people as they get older and they lose the springiness. They don't necessarily slump per se into a kyphotic posture. But there's just this springiness, this squishiness that happens. There's less of a lightness in their step. And it's almost as if their waist becomes a bit smaller.

But then when they get into some twisting, whether it's a supine twist with one leg straight and they draw that other leg over, or all the other varieties of supine types of twisting. When they free that up, it's really interesting how that changes how the pelvis sits. And then how that pelvis sits, it shifts up what's going on with how the leg bone swings in the pelvis. Which then can change up what goes on through the knee.

So it's really interesting how shifting up between the ribs and pelvis can make a real difference. And I'll put a link to a YouTube video here so that you can explore some of these movements that I'm talking about. And I'll include a few twists for you to explore and to see if that makes the difference for you around working with yourself or your clients on how that hip to knee works in relationship to then coming into kneeling.

I share all these because what you'll notice is nowhere have I actually said, “Okay, let's improve knee flexion.” And there's two reasons for that. One of them is that the research shows, generally speaking, that the problem with coming into kneeling is not about limited knee range of motion. And what I have found in my studio setting is that improving knee flexion does not come from knee flexion.

Improving knee flexion actually comes from a bunch of other stuff related to the hip, the foot, and then the relationship between that pelvis and the ribcage, as I just mentioned. So working those other areas can free up a lot of the myofascia that can contribute to that trouble with kneeling.

So, so far what I've spoken about here is thinking about the connection between your hip and the foot, and how to play with that connection. And if you can get down to the floor, thinking about the connection between the pelvis and the ribs, and working in with twists.

Now, if you can't get down to the floor, I'll also show in the YouTube link a really simple twist and sitting and in standing that can help create a better connection and kind of free up some of that congestion that can sit in between the ribs and the pelvis.

The bottom line here, which is where I really wanted to get to by talking about the anatomy and some of the mechanics, is that a big reason that people are having trouble with kneeling is this fear of harming the actual replacement, and also knee discomfort. So we can clear up a lot of that knee discomfort with some of the movements that I spoke about, or at least you can start to play with them. See if they work or they don't work for you.

But when they work, what opens up is this new belief of like, “Oh, maybe things will be okay here.” And when that belief shifts, it can have a really profound shift on what's possible for the person's knee. Because 5 years, 7 years, 10 years post-surgery, that can hone a pretty solid belief pattern that has neurological consequences.

Our belief patterns are thought patterns over time. So when we start to feel better, that can open the door to possibility, hence the name of this podcast. So if you just keep working with it and then work with that possibility, you may just surprise yourself about what's possible. Because when you dig into the research, what you'll find is that there's no evidence that there's any clinical reason why people shouldn't kneel post total knee replacement.

And yet, there's a lot of fear about doing it, there's discomfort. So there's a real need to be able to show people that it is possible. The question is, to go baby step, by baby step, by baby step. To grow the awareness of what is possible between the hip, the knee, and the foot, to recognize this relationship between the pelvis and the ribcage.

And by welcoming and coming into one's body, there's an opportunity for a change of belief, a change in thought pattern. One from fear, perhaps, to one of possibility or hope. And with that then, more change can happen, step by step, bit by bit.

Now if this is interesting to you and you want to dig into this even further, we are currently running our Optimizing Recovery Post Hip and Knee Surgery. And you can find that over at youragedoesnotmatter.com/programs. Again, that's youragedoesnot, that's does not, matter.com/programs.

I would love to support you in training others. And if you're someone who was having knee or hip issues or you yourself are recovering from knee or hip issues, I would love to support you in your own recovery. See you there.