Suzie Says...Look After Your Knees!

Disclaimer: This article is intended to be for educational purposes only, and does not constitute medical advice or replace professional assessment. Please seek a professional assessment before undertaking a new exercise program especially if you have any medical conditions, any previous or current injuries or other health / physical concerns. If you undertake any of the exercises within this article you do so at your own risk.

Any website pages/links added are also for education purposes only and are not under my control and may change or be removed at any time.

Knees, knees, knees...we often forget about them and don't give them much thought, but we rely on them so much. Every time you walk, sit down, stand up, stop your bike, stand up on your pegs and so on, you need your knees, and you need them to work well.

Ok, so there are soooooo many knee injuries you can get from motorcycling and this is not a blog about all the different things that can happen or else I will be here for days! This is about the most common injuries sustained in motorcycling, mainly when off-road, and some good exercises that you can do on a regular basis in preparation for riding and to keep your knees strong (however it is not a specific rehab protocol for any one injury, more a preventative measure). If you have had a knee injury, especially if it's recent, you should really see a trained professional like a physiotherapist for a thorough assessment prior to taking on any new exercises.

Some Basic Knee Anatomy

So, first of all, what is the knee and what is it made up of? Well it's known as a modified hinge joint, and the most complicated and largest joint in our body. I will not go into crazy detail because there's a lot, but the main things to know are the 4 bones, 4 key ligaments and cartilage. The bones are the Femur (thigh bone), Tibia (shin bone) and Fibula (on the outside of the tibia) and your Patella (knee cap). The main ligaments are the anterior cruciate ligament (ACL), posterior cruciate ligament (PCL), medial collateral ligament (MCL) and the lateral collateral ligament (LCL). The cartilage rings in the knee are called meniscus and you have two in each knee; the lateral meniscus and the medial meniscus. The ends of the bones are also covered in another type of cartilage called the hyaline cartilage, which gives the bones a smooth surface, so is better for movement. When this cartilage gets worn over time, you can get what's called osteoarthritis.

The most common injuries in motorcycling, particularly off-road motorcycling, are injuries to the ACL, MCL and menisci. In fact, I have two friends and my partner who all have had these injuries from motorcycling or extreme sport, that are also currently travelling, and have all had some sort of surgery related to their injuries. All of these bits of anatomy are shown in the picture above. Remember, when you look at the picture above, the picture on the left is the back of the knee.

So why are the knees so vulnerable? It's often a combination of things including the angle of the leg and knee and force going through it when the foot plants on the floor, the surface you land on, poor knee strength and control, bad luck and no knee support, among other things. Most of the injuries my friends and partner sustained were from very low speed accidents, with no other vehicles involved, just coming off the bike. As they say....Shit Happens!

Common Knee injuries in Motorcycling

ACL injury or tear

So, as you can see from the picture, your ACL is slap bang in the middle of your knee joint. It is crucial for the stability of your knee and is the most debilitating knee ligament injury you can have as your ACL is the main thing stopping your tibia (shin bone) from sliding too far forwards. Often people say they hear a 'pop' when it goes. Quite often, but not always, people will say their knee feels very unstable after an ACL injury and is more prone to giving way. If your knee gives way regularly and it feels very unstable, please seek urgent assessment by a qualified health professional.

MCL injury or tear

Your MCL is a thick ligament on the inside of your knee (see picture above). This is often injured in motorcycle accidents, especially when you plant your foot and your knee is forced inwards so that there is a lot of strain on the ligament. You can strain it, partially tear it or in the worst case fully tear it as with the ACL. It's also common to injure it if you twist.

Meniscus injury

This is common in knee injury and the menisci also often get degenerative changes over time as we age. In the case of an MCL injury for example like when the knee is forced inwards, the lateral and medial meniscus' may both be injured...the lateral because the force of the end of the femur (lateral condyle) on the top of the tibia laterally is increased and can therefore damage the lateral meniscus which sits on top of the lateral part of the tibia (tibial plateau). The medial one can be damaged as it is attached to the capsule which is being stretched, and therefore may also be injured. If your knee locks (and I don't just mean it feels a bit stiff), and you have to physically unlock it to allow it to move, you must seek urgent medical attention; you will possibly need urgent surgery to remove whatever it is preventing your knee from moving e.g. a piece of meniscus.

Muscles around your knee - the stuff you can work on!

There are many muscles which are found around your knee, with many different functions. The groups of muscles e.g. quadriceps, hamstrings, calves etc are all made up of separate muscles, however I will not go into that much detail here. The key things to know are that your quads are the big bulk of muscles (four in total) on the front of your thigh and are primarily responsible for straightening your knee. The hamstrings are three muscles situated on the back of your thigh and primarily responsible for bending your knee. Your calf muscles at the back of your lower leg are quite bulky and strong because they help bend your foot down and therefore help push you forwards when walking, running etc, whereas the much smaller muscles on the front of the lower leg (like the tibialis anterior) just lift your foot up (very important as you would trip over your feet otherwise).

Obviously this is a very brief introduction to the anatomy of the knee and there's a lot more going on, so if your're interested in more info check out the Physiopedia website.

Right, so now you know a bit about the knee, what can you do to keep it strong, flexible and well controlled without having to find a gym when you're on the road? I have written down some straightforward exercises below which can be done almost anywhere, however they should not be painful. If you've had a knee injury already and it's causing you pain or other issues, I would recommend you get a physiotherapist assessment (or see your Doctor) before starting a new exercise programme.

Exercises

Squat (double or single)

So there's lots of information about squatting and the different ways of doing then. Here I am going to focus on a basic squat where your feet are hip with apart, you concentrate on not letting the knees drift over the toes and you only go to the horizontal position i.e. not a full/deep squat.

Stand with your feet hip width apart and make sure your feet are pointing forwards. Have your arms relaxed down by your side. Slowly move your bottom backwards (as if to sit down). You can bring your arms forwards if needed for balance. As you do this, make sure your knees do not travel forwards over your toes. Keep your back straight and head up, looking forwards. Go as far as you feel comfortable, but no further than your thighs being level with your knees as it is not nececcary for the purposes of this exercise programme to go into a deep squat. Then return slowly to the start position. When you first do this exercise, you can use a sturdy object to place your hands on to steady yourself if needed and to aid working on technique. Also, sometimes it can help to use a full-length mirror for reference (if you have this luxury). Repeat 8-12 squats as able, with good form. Rest and then repeat another 2-3 sets depending on your fatigue levels.

Alternitavely you can do a squat on one leg, which is basically standing upright on one leg without leaning over to one side, really focusing on alignment of your knee during the exercise (do not let it drift in or out), however you probably will not be able to go as far as a normal squat. I often advise to practice this initially with support to get your technique right, and just do small squats to start with. Obviously you need to do this on both legs, so do 8-12 reps on one leg, then 8-12 reps on the other leg, then rest. Repeat upto 3 sets depending on how you feel.

Lunge & walking lunge

Stand straight. Place one foot forwards at about one large step length away (you can adjust if needed). Then drop your back knee down towards the floor and then lift back up again, making sure that your front knee also stays strong and stable during the exercise and does not drift inwards. You can stay in this position and do 8-12 lunges, or you can return to an upright position between each lunge. Make sure you do one set on the right then one set on the left. Rest and repeat another 8-12 lunges on each side. Depending on fatigue, you can repeat this exercises for about 3 sets on each side.

The other thing you can do to make the exercise a little more dynamic is a walking lunge. Basically, you go into a lunge position (as above) then straight into a lunge on the opposite side, i.e. when you are coming back up from the lunge you transfer your weight onto your front leg, lift your back foot off the floor and place it in front of you to go into the next lunge. It's key here that you have good control over the exercise and you are not wobbling from side to side or leaning over. If this is too difficult, stick to the lunging in place and then move on to a walking lunge at a later date.

Bulgarian split squat

This is a good alternative to the reverse squat and personally I prefer this exercise, although my reasoning is purely personal-preference and not for any evidence-based reason, although there is some good evidence-based information about this type of squat in the references if you are interested (see number 2).

Stand in front of a chair/raised surface about the height of a standard chair. Place the foot of one leg back onto the chair/surface. You may want to put a rolled up towel or t-shirt etc under the front of your ankle to avoid forcing it into extreme plantarflexion (hurty ankle). Now, in a controlled manner let yourself dip down, the front knee bending and controlling the movement. Make sure you do not drift forwards during the movement, it is rather a controlled up and down movement. Then push yourself back up to the starting position. Repeat 8-12 reps. Rest. Repeat upto 3 sets of this.

Step down

Stand on a step that is about 6 inches high (if it's less or more it doesn't matter). Stand facing down the step. Let one leg come forwards over the edge of the step and then slowly lower the foot down towards the floor as if stepping down, however stop before the foot touches the floor and come back up again. Make sure you keep your hips in line during this exercise and do not rotate your body. Use your leg on the top step to control your lowering without letting the other hip drop. Repeat 8-12 reps. Rest. Repeat upto 3 sets.

Heel raises (double or single)

Stand upright. With your feet hip width apart push up onto your toes and lower back down. If this is far too easy, do the same but on one leg at a time. You can use support if needed.

Repeat 12 repetitions on each leg. Rest, then do upto 4 sets. This can be done anywhere, and is good to do when brushing your teeth, waiting for the kettle to boil etc.

Hamstring curls

Stand up straight. Keeping your knees in line, bend one knee up so you bring the heel towards your bottom and then lower. Repeat for 12 reps on each side and repeat upto 4 sets of this. If you're feeling a little lazy you can also do this exercise lying on your front while you read a book etc.

Bridge

Lay on your back with your knees bent up and feet flat on the floor. Gently engage your core. Slowly lift your bottom off the floor and your back, vertebrae by vertebrae, until your body is in a straight line from your knees to your shoulders. Slowly reverse and lower. Repeat 8-12 times, upto 3 sets.

To make this harder, when you do the bridge do it on one leg (with the other one out straight) without letting your hips dip, and return to the start position. Repeat 4-6 times each side, up to 3 sets.

To make things even harder, place your feet on a wobbly surface e.g. a pillow, BOSU ball etc whilst doing this exercise, but always start with both legs if doing this before going to the single leg version.

Finally, do a bridge and hold it for 30-60 seconds. Lower and repeat once more if you are not fatigued. If you are doing this on one leg, just hold it for about 15-30 seconds only.

Single leg stand (+/- activity)

Again, this is nice and simple and can be done whilst brushing teeth, waiting for the kettle to boil etc. Stand on one leg. Keep your balance. That is it! Make sure you have something sturdy close by to hold if needed.

If you're getting good at this then try closing your eyes when you do it. Practice on both legs for as long as able. 1-2 minutes maybe.

If you need more challenge then try passing an object around your middle while trying to keep your balance, or use 1 foot (the one you're not standing on) to touch the floor all around as if you were stood in the middle of a cloack face. You can use a few stones or objects on the floor as markers. Again, keep your hips level throughout this exercise.

The other thing that will make it a lot harder is reaching down to touch the floor or pick up an object whilst stood on one leg. Again, you can place a few stones or objects about a foot away from you in a semi-circle and you can try to pick one up at a time. Only do this if you feel confident to do so and do not have acute back pain.

Quad stretch (Rec. Fem. Stretch)

Stand up or lay on a firm surface, flat on your stomach. Bring your heel towards your bottom and use the hand of the same side of the leg you are stretching to grab your foot/ankle and hold it as close to your bottom as possible until you feel a stretch in the front of your hip/thigh. If you can't reach your ankle then you can use a towel or belt to place anound your ankle to help bring it towards your bottom. While doing this exercise, do not let your knee drift forwards and keep it in line with your other knee. This is mainly applicable in standing as when you lie on your front, the ground should stop your knee drifting forwards, however make sure your hip does not lift off the floor. Hold this position for 20-30 seconds, then release and repeat 3-4 times. Do this on each side.

Hip flexor stretch (Iliopsoas stretch)

Kneel on the floor. Place one foot in front of you, flat on the floor so your knee is at a right angle. Keeping your back upright and hips straight, push your hips forward until you get a stretch in the front of your hip of the leg which is back. You can put something under the knee of your back leg to make it more comfortable if needed and as you do the exercise and push your hips forwards, the front knee will bend more. Hold this position for 20-30 seconds, release and repeat upto 3-4 times in total.

Hamstring stretch

Option 1. Sit on the edge of a chair. Keep one leg bent at 90 degrees and have the other one out straight with the heel resting on the floor. Lean forwards from the hips using your hands on your leg to support you, until you get a stretch in the back of your thigh. Hold 20-30 seconds. Release slowly. Repeat 3-4 times each side.

Option 2. Lay on your back. Using your hands to help (or use a belt etc), bring one leg up and straighten it until you get a stretch in the back of your thigh/knee. Hold 20-30 seconds. Release slowly. Repeat 3-4 times each side.

Calf stretches (gastroc & Soleus)

Gastroc stretch - Stand facing a wall, worktop or solid object that you can place your hands on. Place one leg straight back behind you with your heel firmly on the floor and lean on your hands. Now let the front knee bend until you feel a stretch in your calf. Hold this for 20-30 seconds and repeat upto 3-4 times each side.

Soleus stretch - Stand facing a wall, worktop or solid object that you can place your hands on. Place one foot in front of the other. Now let your knees bend and make sure the back foot stays on the floor. You should feel a stretch in the calf of your leg which is at the back. Hold this for 20-30 seconds and repeat upto 3-4 times each side.

Link to YouTube video of the for knees - https://youtu.be/KLyZPo8ghyE

Other things you can do to help avoid a knee injury:

Knee braces - yes, these are a good consideration, although they can take a little bit of getting used to. Sadly I do not have any myself at present, however when I get home and have more available options it will be my next investment. There's a really good write up about knee braces by my friend Michnus available HERE. There's nothing that will ever completely prevent a knee injury from happening, and if you have a bad accident with a lot of force, something has to give, however it can help prevent a lot of other lower-force injuries. For example, my partner Kelvin injured his knee when he put his foot down at almost a standstill, it slipped to the side putting pressure on his knee (valgus force) and he tore his ACL, MCL and damaged his meniscus. Had he worn a brace the injury would have likely been a lot less debilitating and could have avoided several weeks on crutches, surgery and HUGELY increased travel insurance premiums! So, the most common injuries are ACL, MCL and menisci, and prophylactic bracing appears to have a beneficial effect in prevention of these injuries, however to date there is no sound conclusion.

Knee pads - decent knee pads are also consideration to protect your knees against direct trauma, e.g. hitting your knee on a rock or the floor. There are plenty of options on the market and these often fit very snugly to your knee. I have Knox knee pads for when I am trail riding at home and I barely notice them, plus they are small enough to not cause discomfort by hitting the tops of my boots...very important when you have short legs! They stay in place much better than a lot of armour which slots into your trousers as well. My Rukka trousers have D30 armour in the knee area and have large coverage, which is also very comfortable.

Good boots - wear good boots, suitable for the terrain you will be riding. If you're riding off-road, wear boots with good support and a sole which doesn't flex too easily. If you've had previous ankle injuries a boot with good ankle support (especially laterally) is very important. I will soon be writing a blog on ankle sprains...watch this space!

Regular exercise - keep yourself fit. Your body reacts much better if you look after it, and if you are fit your body can tolerate that little bit more. If you sit on your arse all day and then take your bike on a one day jolly every couple of weeks, your risk of injury will be higher.

References

1. Clinical Edge Podcast 052. ACL acute injury management and return to play with Enda King. 29/10/2016. Available online: https://www.clinicaledge.co/podcast/physio-edge-podcast/physio-edge-052-conservative-or-surgical-management-for-acl-injuries-with-enda-king

2. [P]REHAB Guys, (2017). Bulgarian Split Squat is an Effective Alternative to the Back Squat. Access [online]: https://theprehabguys.com/bulgarian-split-squat/

3. Sanders, M., Cates, R., Baker, M., Barber-Westin, S., Gladin, W. and Levy, M. (2011). Knee injuries and the use of prophylactic knee bracing in off-road motorcycling. America Journal of Sports Medicine, 39 (7): 1395-1400.

4. Leatt, C., Jongh, C. and Keevy, P. (2014). White Paper: Research and Development Efforts towards the Production of the Leatt® C-Frame Carbon Knee Brace. Online [https://www.leatt.com/product_uploads/white.../C-FRAME_WHITE_PAPER_A1.pdf].

5. Olivier, M. (2018). Why are so few adventure riders wearing knee braces? Online [https://www.pikipikioverland.com/why-are-so-few-adventure-riders-using-knee-braces/].

6. InfoFit, Knee Rehab - Stabilize the Knee to Prevent Injury. Access [Online]: http://www.infofit.ca/knee-rehab-prevent-injury/

Please e-mail me at cyril@avvida.co.uk for any constructive comments/feedback or questions.

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