A Leg-Activating Sequence to Address Common Misalignments
Could your bunions, knee pain, and hip problems be related?
by Amber Burke
Editor's note: The below recommendations are intended to be general recommendations for yoga practitioners and teachers. They are not a replacement for the personal advice of a health professional.
Q: What could the following seemingly disparate diagnoses that occur at far-flung sites in the body all have in common?
1. Bunion: an enlargement of the bone at the base of the big toe that occurs as the big toe drifts toward the other toes.
2. Plantar fasciitis: the inflammation or micro-tearing of the tissue, the plantar fascia, in the arches of the feet.
3. Patellofemoral knee syndrome: the wearing-down of the cartilage beneath the kneecap with accompanying pain or noise.
4. Hip bursitis: the inflammation of the fluid-filled sacs cushioning that ball-in-socket joint.
A: “All of these problems can derive from the same postural imbalance,” according to Bill Reif, physical therapist and author of The Back Pain Secret: The Real Cause of Women's Back Pain and How to Treat It, namely “the exaggerated anterior [forward] tilt of the pelvis, the internal rotation of the thighs, hyperextension of the knees or poor knee tracking, and overpronation of the feet—the inward drop of the ankles and the flattening of the inner arches. This pattern can cause symptoms at the hip, knee, or foot, and often, in more than one of these places.”
In common parlance, the postural pattern Reif is describing might be called a knock-kneed stance, but Reif prefers not to use this term, because an obvious migration of the knees toward each other, or genu valgum, is a clinical diagnosis, often arising from severe problems like rickets, and one that may require a treatment beyond the purview of yoga or even physical therapy. What physical therapists would call the mild knock-kneedness that is part of this pattern is more accurately identified as an increased quadriceps angle, or “Q angle,” which determines the pull on the patella (kneecap). The Q angle is measured from the ASIS (anterior superior iliac spine) to the midpoint of the patella, as shown here.
If you notice that your knees tend to “knock”—that is, track toward your big toes instead of toward your middle toes—that may indicate that you have a relatively high Q angle. In some yoga poses—especially if your knees are wide apart, as in a squat—it may be challenging for you to point your knees toward your middle toes.
The Trouble With a High Q Angle
“A higher Q angle can lead to the tightness of the adductors, which then pull on the hip, potentially causing tightness around the ilio-tibial band and hip bursitis,” Reif says. He explains that this tightness can make it more likely for the kneecap to track abnormally: “Tight adductors will pull the thighs inward at the knee, and a weak VMO [vastus medialis oblique] muscle will allow the other quad muscles to move the patella outwardly. This can cause microtrauma to the cartilage beneath the patella as it travels over the front of the knee joint, leading to what’s called patellofemoral pain syndrome (PFPS) also known as runner’s knee, chondromalacia patellae, anterior knee pain, and patellofemoral joint syndrome.”
The pain associated with this pattern is on the anterior (front) of the knee, and sometimes it comes with sound effects. “With time, a crackling noise called crepitus may accompany knee movements due to the roughening of the under surface of the patellae,” Reif explains.
"A high Q angle also makes overpronation of the feet more likely,” Reif notes. The effects of this higher-than-normal Q angle can make their way down the kinetic chain, or string of muscular engagement. A wider pelvis, especially when combined with an exaggerated anterior tilt, can lead to the internal rotation of the thighs, which then leads to the internal rotation of the shinbones, which causes the overpronation of the feet. Then, Reif explains, “as the ankles slant inward and the inner arches flatten, an excessive amount of weight can move into the bases of the big toes, contributing to bunions. The flattening of the inner arches can also overstretch and cause microtears in the plantar fascia.” (Note: Oversupination, in which weight moves toward the outer edges of the feet, and the ankles drop outward, can lead to plantar fasciitis as well.)
But the domino-like progression of misalignment can work the other way, too, according to Reif: “The problem can start anywhere in the chain. For instance, excess pronation can rotate the tibia [shinbone] internally, then the femur [thighbone], increasing Q angle from the bottom of the chain up.”
Many of the foot, knee, and hip problems mentioned above are more common among women, and so are higher Q angles, according to Reif, in part because women tend to have wider pelvises, which can cause the knees to slant toward each other.
There is some disagreement in the medical community as to what should be considered a “normal” or “abnormal” Q angle, with angles greater than 14 degrees in men being considered abnormal by some while others will allow only that an angle greater than 20 degrees is definitely abnormal. Yet another source notes that angles as low as 10 degrees and as high as 22 degrees have been deemed normal in various studies. According to Reif, “Q angle for men is around 14 degrees; for women, the angle is closer to 17 degrees. In most cases, a Q angle has to be greater than 17 degrees to cause problems, and often those problems don’t surface unless the higher Q angle is combined with a repetitive movement like running or climbing stairs. The more times your feet hit the ground, and the harder they hit, the more the consequences from this pattern may manifest.”
Each of the problems likely to manifest because of this pattern of misalignment can be addressed locally. For instance, in other articles, we offer practices and tips that target plantar fasciitis and bunions, and doctors or physical therapists will often treat knee pain at the level of the knees and hip pain at the level of the hips. This is the methodology that Reif calls “putting out the fire”—addressing the symptoms at the site where they are immediately perceptible. But once a fire is extinguished, it makes sense to look at the forces that ignited the fire in the first place, as well as the widespread effects of that fire. That would entail a comprehensive practice that addresses certain muscular imbalances that lead to or derive from a high Q angle. You can think of this as both a fire-prevention and recovery approach.
“If you have a high Q angle, you may have tightness in the calf muscles—the gastrocnemius and soleus—which is contributing to the excessive pronation of your feet and may pull your knees inward,” Reif explains. “The muscles along your inner thighs that adduct and internally rotate your thighs—the iliacus, psoas, quadriceps—are probably tight, since an increased Q angle causes these muscles to shorten. Tightness in the adductors will pull your knees inward, especially as you take your legs further apart. All four of your quadriceps may be weak, having been put at a mechanical disadvantage by a high Q angle, making it hard for you to control your knee tracking.”
That’s not all. Reif extrapolates what the relationship of a high Q angle to the glutes, hips, and core might be: “Your gluteus maximus and medius, which work to extend your hips, and the muscles at your outer thighs that abduct and externally rotate your hips—the obturator externus and internus, quadratus femoris, piriformis, gemelli, and gluteus minimus (muscles important to the stabilization of your pelvis and proper tracking of the patellae)—are probably weak, too, having been lengthened by a high Q angle. Your core muscles, whose efficiency can be compromised by an anterior pelvic tilt, may be weak as well.”
“To address these postural imbalances most comprehensively, you’ll need to stretch your calves and the inside of your thighs and strengthen the muscles around your knees, outside of your thighs, your glutes, and your core,” Reif concludes.
The vigorous practice below targets those areas. While a Q angle is a structural measurement that will probably not be permanently changed by any series of exercises (at least not for adults: the still-developing bones of children and adolescents have a greater capacity for change), faithfully practicing these or similar exercises may prevent Q angle from worsening—as it can do with time, if muscular imbalances go unchecked—and alleviate the conditions that arise from those imbalances.
Such a practice may even make it possible to temporarily alter our Q angles during movements that make our knees vulnerable—for instance, by tracking the knees toward the centerlines of the feet during a yoga pose and holding that alignment for the duration of the pose. According to Reif, it is especially important to track the knees correctly in yoga practice, since yoga often demands such a large range of motion. “The greater the movement of the kneecaps the more likely that pain and crepitus [a scraping noise] will occur. The patellae move quite a bit when one bends the knees to the degree needed in order to do poses like squats, warrior I, and warrior II,” Reif says.
According to Reif, if we can improve the patellar tracking in yoga through strength, flexibility, and mindfulness, the hope is that over time our control and awareness will carry over into the movements of our daily lives so that we will then be able to track our knees well during other activities, like walking, running, climbing stairs, and kneeling.
What You’ll Need
1. A yoga strap fashioned into a loop or a resistance band like this one.
2. A chair or wall, if you’d like something to touch for support as you balance for movements 2 and 3.
3. A yoga block or a step for movement 2.
4. If you are practicing at home, your bed could substitute for the block in pose 9.
5. A bolster or a pillow and perhaps a blanket as well for the savasana described in 14.
1. “Sumo Wrestler Walk” (with optional resistance band)
This exercise, which strengthens your abductors and external rotators, is more intense if you use a resistance band, but it can be practiced without one. If you don’t have a resistance band, simply imagine that your thighs are pressing outward as if trying to stretch a band apart. (While a yoga strap will work for most of the suggestions that follow, in this pose it won’t allow the required movement.)
Turn to face the long side of your yoga mat, and stand in the center of your mat.
1. Stand in mountain pose with your feet about shoulder distance apart, or far enough apart that, if you’re using a resistance band, it doesn’t fall. With feet parallel, root down with your feet and lift up through the crown of your head. Bend your elbows and, keeping them wide apart, clasp your hands in front of your chest. Inhale here.
2. As you exhale, take a big step to the right with your right foot—keeping your toes pointing forward—increasing tension on the band. Bend both knees, and lean forward, making sure your knees are tracking over your middle toes. Press your thighs out into the band.
3. As you inhale, step the right foot back to its starting position, straightening both legs to come to mountain pose again with your hands still clasped and your feet about shoulder distance apart.
4. Exhale and take a big step to your left with your left foot, bending your knees and pressing your thighs out into the band.
5. Inhale, and step back to mountain pose.
Repeat a total of ten times (or until fatigue) on each side.
2. Gluteus Medius Dips
This exercise strengthens the gluteus medius and the quadriceps of the leg that’s on the block. “The experience of many clinicians and runners is that increased strength of the quads, hip abductors, and extensors will significantly improve the symptoms associated with patellofemoral pain,” says Reif.
You’ll need a block placed on its lowest setting, perhaps near a wall or a chair if you want support. You could also stand on a step. (Note: This exercise will be easier on a hard block, more challenging to your balance on a foam block.)
1. Stand with your right foot on a yoga block or step, right knee slightly bent and your left foot on the floor beside the right, left leg straight. Make sure your right knee and right toes track straight ahead. Bring a hand to a chair or a wall for support if you need to; otherwise, place your hands on your hips. Inhale here. At this point, your left hip will be slightly lower than your right hip.
2. Exhale and straighten your right leg, hovering your left foot off the floor, keeping the left leg straight, ankle flexed, so the sole of the left foot is parallel to the floor. Level your pelvis, bringing your left hip in line with the right. It is this hiking up of the left hip that strengthens the right gluteus medius.
3. Slowly bend your right knee as you inhale, bringing your left foot to rest lightly on the ground.
For more of a challenge, don’t lower the left foot completely but let it hover just barely off the ground as you repeat this movement.
Exhale and repeat, “dipping” at least ten times (or until fatigue) while standing on your right leg before switching sides.
3. Heel Lifts (with strap or band)
“Heel raises are a method of exercising the gastrocnemius, tibialis posterior, and soleus muscles of the lower leg, muscles often weakened by overpronation,” according to Reif. “The movement here is plantar flexion, which plays a critical role in supporting a good arch.” Since these movements require balancing, feel free to bring your hands to the back of a chair or to a wall for added stability.
For this pose and many that follow, you’ll be placing your resistance band or your looped yoga strap just above your knees as you stand in mountain pose. If you are using a resistance band, stand with your feet far enough apart that the band is taut. If you’re using a yoga strap, stand with your feet hip distance apart and make sure your loop is taut but not so tight that it pulls your knees inward. (Your knees should track toward your middle toes.)
1. Stand at the back of your yoga mat with your resistance band or your looped yoga strap around your thighs, just above your knees, and the outside edges of your feet parallel to the long sides of your mat. (Standing at the back of your mat will make it easy to walk your hands forward to the next pose, downward facing dog.) Press your thighs out into the strap or band. Line up your ears over your shoulders, your shoulders over your hips, and your hips over your heels. Inhale here.
2. Continuing to press your thighs out into your strap or band, root down into your left foot, and as you exhale, lift your right heel, bending the right knee slightly. Instead of leaning your pelvis forward or arching your lower back as you lift, keep your ears over shoulders, shoulders over hips, and hips over heels.
3. As you inhale, slowly lower your right heel, still pressing your legs out.
4. As you exhale, lift your left heel up, still pressing your thighs out into the strap.
5. Inhale, and lower your left heel.
Repeat these single-heel lifts a total of ten times on each side.
For more intensity, lift both heels on your exhale, keeping your legs straight and pressing your thighs out into your strap, still making sure to keep ears over shoulders, shoulders over hips, and hips over heels. Inhale and slowly lower your heels.
Repeat your double-heel lifts at least ten times, or until fatigue.
4. Downward Facing Dog (with strap or band)
Downward facing dog has many benefits. Of particular interest here are the stretches for the calves—the soleus with the knees bent and the gastrocnemius and Achilles tendon with the legs straight. Pressing your legs out into the strap in this pose will continue to work your abductors as well.
From mountain pose at the back of your mat with your strap or loop around your thighs, fold forward from your hips, bending your knees if necessary so that you can bring your hands to the floor. Press your thighs out into the strap and walk your hands forward until you are in a downward facing dog that is long enough for your spine to be in its neutral position (a gentle inward curve in your lower back). Your heels, whether they touch the ground or not, should be directly behind your toes.
Bend your knees deeply and hold for several breaths even as you reach your hips up and back, not only because bending the knees might make it easier to lengthen your spine but also because bending the knees channels this stretch to the soleus muscles. (Bend your knees far enough, and reach back through your heels enough, that you do feel this as a stretch in your calves.)
Then, to target the gastrocnemius muscles, straighten your legs as much as you comfortably can without letting the spine round, pressing your thighs out into the strap, and reaching your heels toward the mat (or press them into the mat, if they comfortably touch it). Stay here for several deep breaths, aiming to hold the pose for a minute or even two.
5. Plank Pose or Tabletop (with strap or band)
Both plank and the milder tabletop can work to strengthen your core, specifically the rectus and transverse abdominals. Pressing your thighs into the strap or band in either pose will continue to strengthen your abductors.
From downward facing dog, maintain your neutral spine as you shift forward to plank, bringing your shoulders directly over your wrists. Press your legs out into the strap while reaching your heels back. Keep your heels parallel to each other as you press your thighs outward. Without losing the slight inward curve of your lower back, draw your belly toward your spine as you exhale.
Either stay here for several breaths, or, if this is too intense, lower your knees to the mat, coming to tabletop, and continue to press your thighs out into the strap or band. Draw your belly in toward the spine every time you exhale here.
6. Side Plank Variation (with strap or band)
Side plank strengthens external obliques and the abductors. The version described here, with the strap or band around the thighs and the top leg lifted, is fairly advanced; to make it more accessible, remove the strap. You could also practice with the bottom knee bent and on the ground. (Note: Reif advises that those with wrist issues or rotator cuff injuries skip this pose or modify it by practicing it on their forearms.)
From plank pose with a resistance band or strap around your thighs, root down with your left hand, especially the base of your left index finger, then roll onto the outside of your left foot. Stack your right shoulder on top of your left and lift your right arm up; stack your right hip on top of your left and lift your right leg away from your left, pressing it into the strap or band. Broaden across your collarbones: Keep your left shoulder back.
Hold here for several breaths, pressing your thighs into the strap and drawing your belly in toward the spine on each exhale.
Return to plank, then practice this pose on your right.
7. Bridge Pose (with strap or band)
This pose strengthens your hamstrings and your gluteals, which work to extend the hip joints.
Keep the resistance band around your thighs just above the knees. Lie on your back, bend your knees, and place your feet on the floor hip distance apart (or wider, if your resistance band requires) and parallel to each other, a few inches away from your sitting bones. Tip your tailbone down into the mat until your lower back curves gently away from the mat. Bring your arms alongside your body.
Press out into the strap or band (not so much that your knees go wider than your feet; keep your knees pointing straight ahead), root down through your feet, especially your heels, and slowly lift your hips up on an exhale, keeping a slight curve in your lower back.
Ideally, the quadriceps will engage to begin to lift your hips, and then your gluteal muscles will work to lift your hips higher. Reif assures us that “squeezing the buttocks,” an action some yoga teachers advise against, is alright as long you first allow the quadriceps to do their fair share of the work, and provided that you do not squeeze your buttocks to the extent that your hips externally rotate and your knees veer outward.
Walk your shoulder blades toward each other, and interlace your hands underneath you. Hold here, lifting the heart and pressing the thighs into the strap or band, for several breaths.
Lower slowly on an inhale. Repeat five to ten times.
8. Clamshells (with strap or band)
This exercise strengthens the abductors. Sit down on your mat and place your band or yoga strap around your thighs just above your knees so that you can separate your knees two feet or so.
Roll onto your left side with your knees bent to about 90 degrees, right knee stacked on top of left. Either bend your left elbow and rest the side of your head in your left hand or keep your left arm on the ground and rest your left ear on your left upper arm. Place your right hand on the floor in front of you.
Keeping your top right foot close to your left foot, as you exhale, externally rotate your right hip to lift your right knee toward the ceiling. Hold here for one or two breaths, pressing against your band or strap. On an inhale, slowly lower your knee.
Repeat this movement about ten times (or until fatigue) on your left side, then switch sides.
Take your strap off—you won’t need it for this pose, which strengthens the gluteal muscles that extend your hip joints and also strengthens the core through cross-body movements.
1. Roll onto your belly, hovering your nose a centimeter or so away from the mat, with your arms stretched out in front of you on the floor, palms facing each other, and your legs straight back behind, feet about hip distance apart and the tops of your feet on the floor.
2. On an exhale, root down through your left leg, and lift your right leg (and the right side of your pelvis) and left arm. Your head can lift slightly as well, but keep your neck long.
3. On your inhale, lower down.
4. On your next exhale, root down through your right leg, and lift your left leg (and the left side of your pelvis) and your right arm.
5. On your inhale, lower down.
Repeat ten times (or until fatigue) on each side.
10. Vastus Medialis Oblique Exercise
For this quad-strengthening exercise, roll up your yoga mat (or grab an extra mat). Though instructed from a seated position, you could certainly practice this pose lying down as well.
Come to seated and straighten your legs out in front of you for staff pose. Slide your rolled-up yoga mat under your knees. Place your hands alongside your hips, create an inward curve in your lower back, and lift up through the crown of your head. (Walk your hands slightly back behind your hips if your lower back is rounding. Creating a wider angle between your spine and your thighs may make it easier for you to curve your lower back inward slightly.)
With the feet slightly separated, align your feet and legs so that your toes and knees point directly up toward the ceiling. Root down through your heels.
Keeping your left leg steady and your spine long, lift your right heel up a few inches. Hold for a few breaths, pressing the back of your right knee against the rolled-up mat. Then slowly lower your right heel.
Repeat on the other side: keeping your right leg steady and right heel rooted, lift your left heel up and hold for a few breaths, pressing the back of your left knee against the rolled-up mat.
Move from side to side, lifting each leg ten times, or until fatigue.
11. Quadriceps Stretch from Bridge With Hips on Block—or Thomas Stretch
Have a block nearby for this pose. It’s important for both hips to be supported by the block; if your pelvis is wider, you may need to place two blocks side by side underneath your hips for the stability of the SI joint.
Roll onto your back with your knees bent and feet on the floor, hip distance apart and parallel, a few inches from your sitting bones. Press down with your feet and lift your hips up. Slide your block (on its lowest setting) underneath your buttocks. Keep rooting down through your right foot, and draw your left knee toward your chest with your hands on your shin or around your thigh, whichever is most comfortable.
Slowly extend your right leg on the floor, being careful not to overarch your lower back as you do so.
Hold for several deep breaths, grounding down through your right heel, keeping your right foot flexed, and dropping your right thigh toward the ground.
Re-bend your right leg and place your right foot a few inches away from your right sitting bone. Let go of the left leg and place the left foot on the floor parallel to the right. Repeat on the other side.
Then repeat the pose again on each side, feeling free to linger for several additional breaths on one side, if it seems to be tighter than the other. Then re-bend both knees, bringing the soles of your feet to the floor, and then press down with your feet to lift your hips. Slide the block out of your way, and release onto your back, resting for a few breaths with your spine in its neutral position.
This pose “is a milder version of the Thomas stretch for the iliopsoas, which can be done lying across your bed,” Reif says. “With your hips near the edge of the bed, hug your knees in toward your chest, then lengthen one leg, letting it dangle toward the ground.” If you’re practicing at home and have a bed nearby, consider trying the Thomas stretch variation instead.
12. Thread the Needle/Reclining Pigeon
This pose will stretch your adductors and internal rotators.
Lying on your back, with your knees bent and feet on the floor, hip distance apart, cross your right ankle above your left knee, and press it lightly against your thigh. You may feel a significant stretch here. If you need more intensity, move on to the next step.
Lift your left foot and grab the back of your left thigh with your left hand.
Bring your right hand to the inside of your right knee, and gently press your right knee away from you. (Note: Do not move the right side of your pelvis away from you, skewing the hips, as you press your knee forward. Keep your left hip heavy, and the left side of your waist long.) Hold here for several breaths.
Bring your left foot and then the right foot back to the floor. Switch sides.
Repeat the pose on each side an additional time, lingering on either side that seems tighter than the other.
13. Reclining Wide Angle Pose
This pose stretches your adductors.
Still lying on your back, draw both knees in toward your chest, then straighten your legs up toward the ceiling, flexing your feet and keeping your legs parallel to each other. (Turning your legs out would move the stretch to the hamstrings instead.)
Separate your legs and place your hands on your inner thighs to gently encourage your legs to widen away from each other. Hold for several deep breaths.
To come out of the pose, place your hands on your outer thighs and, on an inhale, bring your legs back together. On your next exhale, bend your knees and draw them in toward your chest.
14. Side-Lying Savasana with Bolster Between Shins
This version of savasana, for which you will want a bolster for your legs and either a block, a pillow, or a folded blanket for your head, gently separates the knees and allows the adductors to relax. You might even consider adopting this arrangement for sleep, varying sides from night to night.
Lie on your right side in a fetal position and place your bolster between your legs so that it provides padding between your knees as well as your ankles and feet. Place a block or pillow under your right ear. Bend your arms comfortably, perhaps stacking your left arm on top of your right arm.
Stay here for several minutes, surrendering all effort.
Connecting the dots between problems in our bodies that may have seemed disparate gives us a new approach to alleviating them. It also hints that it may be worth looking for less-obvious causal relationships in our daily lives. Just as we might need to refer to the pelvis or the knees to fully explain what is happening in the feet (or vice versa), so we might at times benefit from looking some distance away from our immediate situations to discern the real, if less proximate, roots of our moods, our energy levels, and our well-being.