If you’re a knee-locker and you’ve ever tried to stop, you probably appreciate how difficult it is to change. Maybe you’ve observed this tendency in clients and wondered if it was related to some of their aches and pains. Perhaps you’ve tried to use manual techniques to address the pattern in your clients, only to see them lock their knees when they get up from the table. Are hyperextended knees actually a problem? And if they are, is there anything manual therapy can do about this stubborn habit?
In this column, we’ll discuss factors involved in knee hyperextension, knee-locking’s consequences for the rest of the body, and a multipronged approach to help clients shift this pattern.
Referred to in medical literature as “genu recurvatum,” locked knees appear to bend backward in standing. A common pattern among ballet dancers (Image 1), gymnasts, and runway models, knee hyperextension creates a straighter profile for the back of the leg. Dancers and gymnasts are often selected for this quality, and many go to great lengths to increase their knee hyperextension, to the point of having trainers sit on their extended legs to further elongate the back line of the leg.
Unfortunately, what may be beautiful to the eye can also be difficult to live with. Knees, like the lower back and neck, are designed to have a slight lordotic (or backward-facing) curve (Image 2). Individuals who habitually stand with knee hyperextension that is greater than 5 degrees have more frequent knee pain, as well as poor proprioceptive control of knee extension.1 Additionally, genu recurvatum is a predictor of ACL injury.2
Although knee hyperextension may sometimes be a symptom of a serious medical condition such as Osgood-Schlatter disease,3 it is more often a feature of a genetic predisposition to general joint laxity. Hypermobile joints (e.g., fingers, elbows, and wrists) move beyond the normal range with little effort. Generalized joint laxity occurs in up to one-third of the population, and is at least twice as common in women as men.4
In a neutrally positioned knee, the head of the tibia supports the femur. In a locked knee, the tibia is slightly posterior to the femur (Image 3), making it impossible to transmit forces efficiently. Instead, there is constant strain on the knee’s soft tissues, making them vulnerable to injury. What is more, when the femur and tibia are not stacked, the rest of the body must compensate—often resulting in problems at the ankles, hips, and low back, or even issues in the shoulder girdle and neck. Addressing locked knees is often crucial to creating long-term relief to problems elsewhere in the body.

Hyperextension Assessment
View your client from the side. If her knees are locked, you will notice a reversed or flattened knee curve (Image 2). In this pattern, the head of the fibula is posterior to the lateral malleolus (Image 3). Touch the back of the knee—you’ll likely feel tissue tension in this area. If you try to gently push the knee more posteriorly, you will sense immediate resistance.
Keep in mind that locked knees don’t occur in isolation. They undermine support of structures above, and increase load on areas below. As mentioned, in a neutral leg position, the head of the trochanter, the head of the fibula, and the lateral malleolus are vertically aligned. In a locked knee posture, we often see a tendency toward anterior pelvic tilt, internally rotated femurs, knee hyperextension, and sometimes, limited ankle dorsiflexion.
Working with chronically hyperextended knees is a multidimensional task, since it means addressing short and tight structures, overstretched structures, and habitual postural patterns. We find we are most effective when we use a four-pronged approach:
1. Client awareness
2. Myofascial techniques
3. Homework
4. Strength and stability training

1. Client Awareness
Clients can’t change what they don’t understand. Once you observe knee hyperextension, have your client observe her stance side-view in a mirror. Draw her attention to the reduced curve of one or both knees. To help her feel the difference between a locked and neutral knee, ask her to intentionally lock out her knees and notice the tension on the back of the knee. Then ask her to just barely unlock her knees. Other effective cues might be, “Back off just enough to reduce the tightness in the back of your knees,” or, “Let your knees breathe.” Ask your client to describe the difference between the locked and balanced positions. Clients often describe changes in knee tension, hip placement, or weight shift in the feet. Have your client hyperextend and soften her knees a few times to compare the difference and appreciate its effects throughout her body.
Take care that your client doesn’t overcorrect and stand with bent (flexed) knees. Over-flexed knee patterns also place unnecessary strain on the body. Our goal is to help the client learn to find balance in standing by aligning the bones and recruiting only the appropriate postural muscles. Once your client has had a glimpse of this, it’s time to take her new awareness to the table, where you will address the fascial patterns related to knee hyperextension.

2. Quadriceps: Knee Flexion Technique
This technique is an excellent approach for releasing any fascial inelasticity and shortness in front of the leg that can contribute to knee locking. To perform this technique, have the client lie supine and slightly diagonally on the table, so the working leg hangs off the edge and bends at the knee (Image 5) without abducting the hip.
Once in position, support her leg with your bottom hand under the femur. With the client’s leg extended (straight), use a soft, open fist or sensing forearm to sink into the outer fascial layers just above the knee (Image 4). Angle your pressure superiorly, with the intention of freeing the fascia lata (the outer wrapping of the thigh) above the kneecap. As the tissue begins to soften, ask your client to slowly bend (flex) her knee, which encourages the tissue to lengthen. Keep sensing with your bottom hand and cue the client to move at a smooth, deliberate speed. Repeat a couple times at this layer, moving your position to address the tightest areas.
On your next pass, gently sink deeper into the quadriceps femoris tendon (Image 6). In knee hyperextension, rectus femoris and vastus intermedius fascia are often shortened and undifferentiated. You can customize this technique to work wherever there is denser, inelastic tissue around the superior aspect of the knee. In people with a tendency toward anterior pelvic tilt, we commonly see internal rotation of the femurs. This may result in hard, tight tissue at the superior medial aspect of the patella. If needed, repeat the technique, focusing on vastus medius fascia at the knee.
Although visually assessed hyperextended knees will most commonly show the tissue tension patterns described here, always retest the tissue itself by palpating it before working, and pay attention to your observations as you proceed. You might find denser or shorter tissue where you least expect it—this is the nature of compensatory myofascial patterns. Keep your awareness on the whole body, not just what you’d expect based on visual assessment.
In addition to shortness in quadriceps, check for hypertonicity in the iliopsoas and gastrocnemius. Addressing any dorsiflexion restrictions in the ankles can help make repositioning the tibia easier as well (see “Working with Ankle Mobility,” Massage & Bodywork, March/April 2011, page 110).

3. Homework
As clients experience more ease in areas that are habitually tight, introduce movement reeducation homework, so they can practice on their own.
Movement Reeducation Exercise A: Weight Shift
Before your client leaves the session, return to the awareness exercise you began with, comparing locked and unlocked knees.
• Have your client lock her knees again. Ask, “Where is the weight in your feet? Is it more toward your toes? Your heels? Or somewhere in between?” Knee hyperextension typically shifts weight either more forward or more back.
• Then, suggest she unlock her knees. Ask, “Where is the weight now?” Usually it becomes more centered front to back.
Movement Reeducation Exercise B: Kneecap Lifting
• Teach the client to lift her kneecap by tightening her quadriceps. If the knee is hyperextended, she typically won’t be able to lift the patella when standing, because the quadriceps will be already contracted. If this is the case, have the client soften her knee, and practice lifting the kneecap and releasing it.
• Draw her attention to the proprioceptive sensations of this kind of movement, and of the details of standing in a way that makes it possible to lift and lower the kneecaps. Clients can do this throughout the day to retrain the tone in their quadriceps.
Encourage clients to practice these techniques whenever they find themselves standing and waiting somewhere. Since the main purpose of these exercises is reeducation, rather than strengthening or stretching, even a little bit of practice can yield results.

4. Strength and Stability Training
Now that we’ve addressed chronically short, tight areas with both myofascial work and movement reeducation, encourage clients to strengthen and stabilize any overstretched, weak areas. Knee-lockers generally need to improve their use of gluteal and transversus abdominis muscles. Additionally, strengthening thigh and leg muscles often provides needed support to hypermobile knees. Whole-body exercises like single-leg bridge pose, planks, and stability exercises are ideal. Don’t hesitate to refer clients to a qualified physical therapist or sports and conditioning trainer to help them strengthen appropriately, especially if there are any complications or special considerations relevant to exercise, such as additional musculoskeletal concerns or medical issues.

Summary
Although hyperextended knee patterns often change slowly, addressing them in the ways described here will typically improve issues throughout the body. At first, clients may be surprised to find that standing with neutral knees actually takes a bit more effort than their old approach—certainly, it takes more awareness. But as we engage the whole person through a variety of sensory and motor activities in every step of this approach, clients can often find a softer, more supported posture that feels natural to them, and when they do, they’ll appreciate the increase in available energy and comfort that comes from being able to rest into a balanced knee position.

Notes
1. Katsuhiro Kawahara et al., “Effect of Genu Recurvatum on the Anterior Cruciate Ligament-Deficient Knee During Gait,” Knee Surgery, Sports Traumatology, Arthroscopy 20, no. 8 (August 2012): 1,479–87.
2. Janice K. Loudon et al., “The Relationship Between Static Posture and ACL Injury in Female Athletes,” Journal of Orthopaedic and Sports Physical Therapy 24, no. 2 (1996): 91–7.
3. Christopher Bellicini and Joseph G. Khoury, “Correction of Genu Recurvatum Secondary to Osgood-Schlatter Disease: A Case Report,” The Iowa Orthopaedic Journal 26 (2006): 130–3.
4. M. Acasuso Díaz, E. Collantes Estévez, and P. Sánchez Guijo, “Joint Hyperlaxity and Musculoligamentous Lesions: Study of a Population of Homogeneous Age, Sex and Physical Exertion,” Rheumatology 32, no. 2 (1993): 120–22; Lars-Goran Larsson, J. Baum, and G. S. Mudholkar, “Hypermobility: Features and Differential Incidence Between the Sexes,” Arthritis & Rheumatism 30, no. 12 (1987): 1,426–30.

Bethany Ward is a member of the Advanced-Trainings.com faculty, which offers distance learning and in-person seminars throughout the United States and abroad. She is also a Certified Advanced Rolfer, a faculty member at the Rolf Institute of Structural Integration, and past president of the Ida P. Rolf Research Foundation. Contact her via bethany@advanced-trainings.com or www.rolfusa.com.

Til Luchau is a member of the Advanced-Trainings.com faculty. He is a Certified Advanced Rolfer and originator of the Advanced Myofascial Techniques approach. Contact him via info@advanced-trainings.com and Advanced-Trainings.com’s Facebook page. His book Advanced Myofascial Techniques, Volume 1 has just been released, with Volume 2 slated for publication by the end of 2015.