A SIMPLE PROGRAM FOR

STRENGTHENING &
STABILISING THE KNEES
& RELIEVING KNEE PAIN

By Simon Borg-Olivier
MSc BAppSc (Physiotherapy) APAM c-IAYT
STABILISING THE KNEE JOINT COMPLEX WITH
VARIOUS TYPES OF KNEE MUSCLE CO-ACTIVATION
Stabilisation and strengthening of the knee joint complex can be achieved by
co-activating (simultaneously tensing) the antagonistic (opposing) muscle
groups around the knee joint complex. I will simply refer to this as Knee Muscle
Co-activation.

There are five sets of muscles around the knee that are important to strengthen.
These muscle groups, and how to activate them individually in many simple
postures are as follows:

• Front thigh muscles (quadriceps / knee extensors), which may be activated

by ‘pulling up the kneecap’ when the leg is straight.

• Inner thigh muscles (hip adductors), which may be activated by squeezing

the thighs together from the heels.

• Rear thigh muscles (hamstrings / knee flexors/ hip extensors), which can
often be activated by trying to pull the heel towards the buttocks, or by
'pulling up the kneecap and simultaneously trying to bend the knee.

• Rear calf muscles (knee flexors / ankle plantarflexors) can be activated by

raising the heels off the floor or simply pressing onto the front of the foot

• Outer calf muscles (ankle evertors) can be activated by lifting the outer foot
towards the ankle.

In this short video, I show a very simple but effective exercise, which almost
anyone can do to strengthen and stabilise their knee and to help to relieve knee
pain. In this video, I teach you the simplest and most effective way to create a
knee muscle co-activation. I share more about knee muscle co-activation below,
but it is a great preparation for many sports and other activities, where there is a
load on the knee, or it can potentially be under strain.

Knee muscle co-activation is also a very good exercise to do as therapy for many
musculoskeletal conditions of the knee, such as ligament strains, patella
maltracking, and even meniscal tears.

I developed this simple exercise about 35 years ago to successfully treat myself
after I had badly dislocated my knee in a skiing accident, in which I ruptured my
anterior cruciate ligament (ACL), strained my medial collateral ligament (MCL),

2 © Simon Borg-Olivier MSc, BAppSc (Physiotherapy) APAM C-IAYT simonborgolivier.com

and damaged my medial meniscus. I also used it to successfully treat my knee
when my patella (kneecap) was shattered after a major fall about 30 years ago.
This exercise has meant that I have never needed a knee operation.

In my practice, as an exercise-based physiotherapist over the last 30 years, I

have used this exercise to help many people with the most common knee pain
and knee joint problems.

Basic instructions for the exercise shown in my video:

To create knee muscle activation around your left knee, simply stand on your
right leg and take your left leg behind you into hip extension.

Keep the top of your hips level and raise your left leg a few centimetres off the
floor. Round your lower back slightly outwards by pushing your pubic bone
toward the floor and the top of your hips away from the floor.

Keep the top of your hips level and roll your left thigh inwards. Then feel how this
can relax and release the muscles around your buttocks and activate your rear
thigh muscles (your hamstrings) and your inner thigh muscles.

For many people, it is enough to simply come into this initial position and allow
the inner thigh muscles and the hamstrings to become active. This is especially
useful for relieving non-specific pain at the front of the knee, as well as relieving
lower back.

For people who have issues with knee stability, it is also useful to activate the
muscles at the front of the thigh by pulling up the kneecap, tighten the calf muscles
by pressing away with the base of your big toe and to tighten the outer calf muscles
by trying to pull the outer foot towards your knee.

A B
Figure 1:

While balancing on your

left leg, turn your right
thigh inwards to
activate and strengthen
your rear thigh muscles
(hamstrings) and your
inner thigh muscles.

Here is a video showing

me teaching this exercise
to one of my clients, the
lovely Mariana.

3 © Simon Borg-Olivier MSc, BAppSc (Physiotherapy) APAM C-IAYT simonborgolivier.com

Knee Joint Opposing Muscle Co-activation (Knee muscle co-activation):

Knee joint muscle opposing muscle co-activation (which I will now simply refer
to as knee muscle co-activation) involves activating (tensing) muscles on the
opposing side of the knee joint complex. Knee muscle co-activation can be used
as an effective therapy for many musculoskeletal problems of the knee. Knee
muscle co-activation can also help improve circulation in the body, and
essentially help to move energy and information through all the channels of the
body, including nerves, blood vessels, lymph vessels and acupuncture
meridians.

Knee muscle co-activation can be made in many different ways. All knee
muscle co-activations can give stability to the knee joint complex but
depending on what position the knee joint is in, the knee muscle co-activation
will also have a significant effect on blood flow.

Two Main Types of Knee Muscle Co-activation:

• A compressive (high-pressure) knee muscle co-activation restricts blood

flow through the knee.

• An expansive or (low-pressure) knee muscle co-activation enhances blood

flow through the knee.

Compressive or expansive knee muscle co-activations can be created in different

situations in the following ways:

Use compressive (high-pressure) knee muscle co-activation when the knee is

flexed (bent):

• Weight-bearing:
Push the foot forward as if you are trying to straighten the knee
(to tense in front of the knee).
Press into the front of the foot as if you are trying to raise the heel
(to tense the back of the knee)

• Non-weight-bearing
Tighten the back of the knee (this is like trying to the make a
‘bulging biceps’ at the elbow, but doing the same thing at your knee)
If the foot or shin is touching something then try and straighten the
knee against resistance

4 © Simon Borg-Olivier MSc, BAppSc (Physiotherapy) APAM C-IAYT simonborgolivier.com

Use expansive (low-pressure) knee muscle co-activation when the knee is
extended (straight):

• Weight-bearing:
‘Pull up’ the kneecaps (to activate knee extensors)
Try to bend the knee with kneecaps still ‘pulled up’ and/or press
into the front of the foot (activate knee flexors)

• Non-weight-bearing
‘Pull up’ the kneecaps (to activate knee extensors)
Turn the thigh inwards (to activate inner thigh muscles as hip internal
rotators and hamstrings as hip extensors and knee flexors)

FURTHER INFORMATION ABOUT THE KNEE AND HOW TO

HELP IMPROVE ITS FUNCTION
Stabilisation and strengthening of the knee joint complex can be achieved by
co-activating (simultaneously tensing) the antagonistic (opposing) muscle
groups around the knee joint complex. I will simply refer to this as Knee Muscle
Co-activation.

There are five sets of muscles around the knee that are important to strengthen.
These muscle groups, and how to activate them individually in many simple
postures are as follows:

• The knee joint complex is usually very mobile but requires good muscular
control to maintain its stability.

• When the muscles of the knee can be controlled and used to stabilise the
knee in the way that I show in this short video, the hip can be me more
safely manipulated. Then it is much easier to walk effectively, run, do active
sports, do the active movements of the spine that I highly recommend and
do useful postures such as comfortable sitting on the floor. All of these
things become more accessible with less risk of knee or lower back pain.

• My clinical experience as an exercise-based physiotherapist is that many

physiotherapy studies have shown that co-activation (simultaneous tensing)
of antagonistic (opposing) muscle groups around the knee joint complex can
help to stabilise and strengthen the knee and make it much easier to move
your hips, spine and engage in the activities of daily life and more extreme
sporting activities such as skiing.

5 © Simon Borg-Olivier MSc, BAppSc (Physiotherapy) APAM C-IAYT simonborgolivier.com

Figure 2: Structure of the knee (Courtesy Borg-Olivier & Machliss, 2014)

Glossary of important anatomical terms used here:

Flexion bending a joint
Extension straightening a joint
Flexors muscles that cause flexion when shortened
Extensors muscles that cause extension when shortened
Femur thigh bone
Tibia shin bone

The knee joint complex

The knee joint complex [Figure 2] is not considered in anatomical terms to have
a very good bony fit – it is simply the thigh bone (femur) sitting on top of the shin
bone (tibia) held together with ligaments (anterior and posterior cruciate, medial
and lateral collateral ligaments) and the surrounding muscles. The cartilage (meniscus)
between the two bones helps increase the bony fit of the thigh bone (femur) and
the shin bone (tibia). The kneecap (patella) functions to protect the knee joint and
increase the power of the front thigh muscles (quadriceps) by increasing the leverage
of these muscles. As a result of the knee joint not being intrinsically stable, it is
important for the muscles surrounding the knee to be strong throughout the full
range of functional positions.

Main problems of the knee

There are many types of knee problems – the most common injuries are likely to be:
1. Torn knee ligaments
2. Damaged knee cartilage (meniscus)
3. Patella maltracking
4. Hyperextended knees

6 © Simon Borg-Olivier MSc, BAppSc (Physiotherapy) APAM C-IAYT simonborgolivier.com

Intelligently applied posture, movement, breathing and mental control can be of
assistance in most cases in managing and improving problems with the knee.

Three basic principles should generally be adhered to when treating knee

problems with posture, movement, breathing and mental control:
a) Do not do any exercise that causes or exacerbates any pain or problem.
b) Train strength and flexibility simultaneously throughout the full
available range of motion of a joint.
c) To treat the knee, it is good to work with the hip and ankles as well.

General Principles for Addressing Problems of the Knee:

1. Increase flexibility in the muscles and joints of the hips and ankles
2. Increase strength and control of muscles around the knee
3. Take a holistic approach to knee problems – treat the whole body
4. Correct knee alignment
5. Move actively into knee postures
6. Modify postures to reduce knee pain

(1) Increase the flexibility of the hips and ankles

Most knee problems are best addressed through strengthening, not stretching
the muscles around the knee. Being able to control the muscles around the knee
is as important as developing strength in these muscles, i.e. being able to tense
and relax the muscles in various knee, hip and ankle positions at will. In terms of
flexibility, knee health is generally maintained and enhanced if the hip joint, and
to some extent, the ankle joints are kept mobile and are made more flexible.

(2) Increase strength, and control of muscles around the knee

A healthy knee needs to be stable and has to have adequate blood flow. To keep
the knee stable, and to enhance the flow of blood, it is important to be able to
co-activate (simultaneously tense) the muscles around the knee. Co-activation
of knee muscles has been shown to be of assistance in the recovery of many
knee problems [Aagaard et al., 2000].

Most exercise programs for the knee should incorporate some form of knee joint
muscle co-activation. If appropriately applied, knee muscle co-activation can
help to reduce pain and swelling around the knee, increase knee stability, and
help to improve the knee’s ability to move freely through a full range of joint
motion.

7 © Simon Borg-Olivier MSc, BAppSc (Physiotherapy) APAM C-IAYT simonborgolivier.com

(3) Take a holistic approach to knee problems – treat the whole body

As with the treatment of any physical problem, the whole person must be
considered. Knee problems are often associated with other problems throughout
the body, which includes hip joint stiffness, ankle joint stiffness, weak lower limb
muscles and loss of natural spinal curvature. Thus, an overall body flexibility and
strengthening program is recommended to address all the associated problems
of an unhealthy knee. In the beginning, the main aim while taking a person
through the program is not to aggravate the existing condition. Then slowly, as
their whole body responds to the exercise, the main problem itself can be
addressed. The main problem can be made worse by an exercise program, which
is not well-thought-out or not well-applied. An incorrect exercise program or
incorrect treatment can exacerbate all the problems mentioned above. Simple
general rules to adhere to when practising posture and movement with knee
problems are:

• Do not do anything that causes knee pain, or increases it

• If your knee hurts in any posture when it is fully straight, then bend it slightly
• If your knee hurts in any posture when it is bent, then straighten it slightly

Generally, it is not sensible to adopt the ‘no pain –no gain’ mentality with knee
problems, but sensible to modify postures by either bending or straightening
your knee, and/or activating (tensing), or relaxing the muscles around the knee to
reduce knee pain. If there is pain during a movement, try to remove, or at least
reduce the pain by moving less, or at a different speed, or in a different manner.

(4) Correct knee alignment

Correct alignment is an important issue for the correct flow of energy, and also
for the safety of the knee joint complex. The thigh bone (femur) and the shin bone
(tibia) must generally be kept in line without too much knee rotation of the shin
bone (tibia) on the thigh bone (femur). For example, in postures such as the half
squat posture, if your feet are hip-width apart, then your thighs will be turning out
slightly. Therefore, your feet should also be turning out slightly. It would be not a
good idea to have your thighs turning out while your feet are turning inwards.
This could potentially strain your knee.

Vertical alignment is also important for most people, especially if there is a knee
problem in lunge-like standing poses. Most people should not let the knee bend
more than 90o, and not beyond the heel to minimise stress around the kneecap
(patellofemoral joint). It has been shown that bending the knee greater than 90
degrees while weight-bearing puts up to seven times more stress on the knee.
However, once you can do this safely, it can potentially make your knee stronger.

8 © Simon Borg-Olivier MSc, BAppSc (Physiotherapy) APAM C-IAYT simonborgolivier.com

(5) Move actively into knee postures

The safest way to take a knee into a posture is using the muscles of the hip, knee
and ankle, and only using the arms as little as possible, or preferably not at all.
This active movement approach gives an added strength to the knee where it is
needed to support ligaments and also causes reciprocal relaxation of muscles
that do not help the movement. Even in relatively simple postures such as sitting
cross-legged, it is prudent to actively draw the bent knee into your final position
using the muscles of that limb, and if possible, not assisting with the hands at
all.

(6) Modify postures to reduce knee pain

If the ability to straighten (extend) or bend (flex) the knee is limited due to pain,
or an immobilising injury, then one should perform postures only in the range of
motion of the knee joint which is pain-free and modify poses accordingly. For
example, postures such as the ‘Cross-legged posture’ [Figure 6] can be practised
with one, or both the bent (flexed) knees straightened. Alternatively, it may be
possible to kneel rather than sit cross-legged. Note that it is best for symmetry
of the hips and spine to practice both sides of a modified posture in the same way.

Addressing Common Knee Problems

Torn Knee Ligaments

Knee ligaments join bone to bone and give stability to the knee joint. Knee ligaments
are often damaged when the knee is suddenly twisted and/or bent in the wrong
direction, which can happen while doing ordinary movements, or during sporting
activities. It is common for knee ligaments and cartilages (see below) to be damaged
by people who try to manipulate their knees into some of the elaborate positions
taught in modern yoga classes without having sufficient hip flexibility or knee
muscle control to support the knee joint. Torn knee ligaments can lead to pain,
instability, swelling and loss of joint movement in the knee.

The most commonly ruptured knee ligaments are the anterior cruciate ligament
(ACL), which joins the back of the thigh bone with the front of the shin bone, and
the medial collateral ligament (MCL), which joins the inside of the thigh bone
with the inside of the shin bone [Figure 2]. Rupture of the ACL and/or MCL usually
results in a very unstable knee. The hamstring muscles act synergistically to the
ACL (i.e. both the hamstrings and the ACL can perform the same function of stabilising the
knee joint by preventing the shin bone moving in front of the thigh bone). Therefore, in
cases of ACL tear/rupture/over-stretching, strength and control of the hamstrings
are very important for aiding recovery and preventing further damage. Hip
adductors (inner thigh muscles) are synergistic to the MCL.

9 © Simon Borg-Olivier MSc, BAppSc (Physiotherapy) APAM C-IAYT simonborgolivier.com

Therefore, the strength and control of the inner thigh muscles are very important
in cases of MCL damage. Tears of the MCL can heal depending on the severity of
the tear, while ACL tears usually do not heal, and require surgical reconstruction.
All postures that assist in the generation of knee muscle co-activation, such as
the half squat with the heels raised, will help stabilise the knee when knee ligaments
have been damaged.

Damaged cartilage (meniscus):

Knee cartilages (menisci) act as stabilisers, lubricators, and shock absorbers inside
the knee [Figure 2]. Damaged cartilage (meniscus) may result in instability, swelling,
and often pain, and/or locking of the knee joint in certain positions. Damage to the
medial meniscus (inner knee cartilage) often happens at the same time as tears of
the ACL and MCL but can also occur independently to ligament tears. Damage to the
medial meniscus is more common than damage to the lateral meniscus (outer knee
cartilage), which often happens at the same time as of the posterior cruciate ligament
(PCL) and lateral collateral ligament (LCL). If left untreated, meniscal tears may lead
to degenerative changes and arthritis of the knee in later life. The menisci have a
good blood supply in children, but only have a blood supply on their periphery from
age 10. If torn, the periphery may heal, but the central portion is unlikely to heal in
adults. If locking, pain or instability persists, surgical intervention is often recommended
via arthroscopy to clean the tear up, so that it is no longer catching or causing pain and
long-term inflammation in the knee. Only the outer third of each meniscus has a nerve
supply, therefore any pain felt from a meniscal tear must be from a peripheral portion
of that meniscus. It is important that in your daily life, and when doing your conscious
practice of posture, movement, and breathing with a meniscal tear, do not repeatedly
do movements that cause the knee to increase pain, or make a clicking sound, as this
will usually cause the problem to worsen. A general principle is to simultaneously tense
(co-activate) all of the muscles around the knee, in the ways described here, before
moving into or out of any posture, and eventually learn to maintain a gentle grip of
these muscles throughout your physical practice, and in everyday life.

Patellar maltracking:

When the kneecap (patella) does not track correctly (i.e. slide over its correct path of
movement) over the thigh bone (femur), this is referred to as patella maltracking.
This painful problem, which can lead to instability and pain, can be due to imbalances
in strength between a muscle on the inner knee called vastus medialis obliquus
(VMO), which is usually weak, and a muscle on the outer knee called vastus lateralis.
The VMO originates on the inner thigh muscle called adductor magnus. This is the
anatomical basis for recommending inner thigh muscle (hip adductor) strengthening
in cases of patella maltracking. Strength and flexibility training for the outer thigh
muscles (hip abductors) such as the gluteus medius is also recommended as this
helps to stabilise the hips and increase their range of joint motion.

10 © Simon Borg-Olivier MSc, BAppSc (Physiotherapy) APAM C-IAYT simonborgolivier.com

Hyperextended knees:

Hyperextended knees, where the back of the knee curves outwards like a banana,
maybe due to hereditary ligament laxity, or because of over-stretching. Hyperex-
tended knees may be painful and have a deleterious effect on the entire posture
of the person. They may often result in lower back pain. Do not hyperextend
(over-straighten) the knee, especially in weight-bearing postures. In cases of
knee hyperextension, all postures that are weight-bearing on straight legs such
as the ‘one-sided standing hamstring stretch’ [Figure 8] are best practised with
the knee of a weight-bearing leg kept slightly bent (flexed), so the knee locking
mechanism cannot operate and force the knees into hyperextension.

How to address these problems while doing postures and movements

These exercises and recommendations should nevertheless be used with caution,

and should be suitably modified for each individual, so as not to exacerbate their
problems. Pain is a relatively good indicator of how an exercise program is progressing.
Although some pain may not be a problem, beginners and untrained practitioners of
the various types of posture and movement exercises should avoid moving so
deeply into a posture that is causes pain, or an increase in their resting pain.
Also, pain should not be increased directly after the practice. It is okay for a small
amount of muscle tenderness to be present on the day following a strong exercise
session, but when beginning an exercise program for knee pain, it is prudent to
make the program quite gentle, and then see how the body responds to that first.
Over time and with consistent practice, the intensity of the program can be gradually
increased.

Muscles that need to be lengthened (stretched) to improve the health of the knees

Assuming that the knee is flexible enough to fully bend (flex) and straighten (extend), the
main flexibility exercises should focus on lengthening and relaxing stiff structures of
the hips, knees and ankles, especially:

• the outer thigh muscles (hip abductors)

• the inner thigh muscles (hip adductors)
• the hip rotator muscles
• the rear thigh muscles (hamstrings / knee flexors/ hip extensors)
• the rear calf muscles (knee flexors / ankle plantarflexors)

Muscles that need to be strengthened to improve the health of the knees

There are five sets of muscles around the knee that are important to strengthen to
improve the general health of the knee.

11 © Simon Borg-Olivier MSc, BAppSc (Physiotherapy) APAM C-IAYT simonborgolivier.com

 See page 2 for the ways to activate (turn on) these main muscles around the knee

However, in terms of knee health, it is generally more effective to simultaneously

tense (co-activate) these opposing muscles groups to generate a knee joint muscle
co-activation. For example, it is possible to activate the quadriceps by first ‘pulling
the kneecap up’ to activate the front thigh muscles, then — keeping the kneecap
pulled up — trying to bend the knee slightly using the rear thigh muscles (hamstrings)
into the half squat posture [Figure 3]. This knee joint muscle co-activation is usually
easier to activate if you squeeze your thighs inwards to activate the inner thigh
muscles at the same time.

Figure 3:

Extended half-squat posture’:

To generate a knee joint muscle co-activation

i.e. the simultaneous tensing of front thigh muscles
(quadriceps) and rear thigh muscles (hamstrings)
start with the legs straight and ‘pull up the
knee-caps’ then — without losing the sensation
of pulling up the kneecaps – bend the knee
slightly into the half squat posture using your
hamstrings.

Further knee joint muscle co-activation can be

achieved in this posture if you squeeze your
upper thighs inwards, press your knees slightly
outwards, and lift the outside of your feet.

Figure 4:

‘Standing hug knee to chest posture’:

This posture should be started with the standing

leg slightly bent (flexed) at the knee so the front
thigh muscles (quadriceps) are active. Lean the
trunk forward and pull the leg that’s in the air as
close to the trunk as possible. Keep the leg and
the trunk as close together as possible then lean
backwards with trunk and try to straighten the
standing leg. This exercise usually causes the
rear thigh muscles (hamstrings) to become
active at the same time as the front thigh muscles
(quadriceps) and hence generates a knee joint
muscle co-activation

12 © Simon Borg-Olivier MSc, BAppSc (Physiotherapy) APAM C-IAYT simonborgolivier.com

Two simple, yet powerful one-legged exercises that can simultaneously tense the
muscles around the knee and generate a knee joint muscle co-activation are the
‘Standing hug knee to chest posture’ [Figure 4] and the ‘Rear leg turned in standing
balance posture’ [Figure 1]. Both of these poses generate a knee joint muscle co-
activation and give strength and stability, specifically to the knee of the standing leg in
‘Standing hug knee to chest posture’ [Figure 4], and in the knee of the leg that’s in the
air for the ‘Rear leg turned in standing balance posture’ [Figure 1].

Please note, although it is possible to treat torn ligaments and damaged meniscus with
posture, movement and breath-control if the injury is recent, it is advisable to consult
an orthopaedic surgeon and physiotherapist regarding the possible reconstruction of
ligaments, or trimming of meniscus surgically, as this can both increase stability,
and restore a person to normal activities of daily living. Posture, movement, and
breathing can also help to restore a knee to full health post-operatively, provided it
is done with care, using the principles outlined above, and in conjunction with post-
operative physiotherapy outlined by the surgeon. Most importantly, during daily life,
or during your conscious practice of posture, movement and breathing, it is your
responsibility to be sensitive to the capabilities of your body in any given moment,
and not allow your ego to take over, which may result in an unnecessary knee
injury.

You can also watch my demonstration of

Knee Therapy Exercise with Mariana

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References:
Borg-Olivier, SA & Machliss, BE (2014) Applied Anatomy and Physiology of Yoga available at
https://yogasynergy.com/product-category/books/

Borg-Olivier, SA & Machliss, BE (2007) https://yogasynergy.com/yoga-therapy-for-knee-problems/

Photo Credits: Cover Photo Donatella Parisini. All other photos Alejandro Rolandi

13 © Simon Borg-Olivier MSc, BAppSc (Physiotherapy) APAM C-IAYT simonborgolivier.com