One of the most controversial and confusing muscles to discuss is the vastus medialis oblique, otherwise known as the VMO. We know that this muscle plays a critical role in providing stability of the knee and prevents the onset of patella tracking problems that are so common among people of all ages. However, there is so much conflicting research and information about the best way to strengthen this muscle that many people are confused as to where to start. The problem with most of the research is that it looks at strengthening the muscle in isolation, ignoring the role of other anatomical factors contributing to the VMO weakness. Factors such as tibial torsion, valgus knee collapse due to poor hip muscle control, poor foot stability creating over-pronation, and ankle stiffness inhibiting quadriceps strength need to be addressed if you truly want to strengthen the VMO and stabilize the knee. And arguably the best way to do this is using what are referred to as “iso-integration” exercises, where you use creative methods to isolate a specific muscle within an integrated movement. It sounds complicated, but really it is very simple when you understand how the body uses compensation to avoid pain. In this article I will show you several versions of how to do this.

My Favourite "Iso-Integration" Exercises for Correcting Patella Tracking Problems with the Knee

These exercises have been around for a long time but unfortunately they are rarely taught in mainstream rehabilitation courses that still focus too heavily on the isolated muscle approach. I first started using the exercises way back in 2007 after completing a course called Rehab Trainer led by a Physiotherapist in QLD named Ulrik Larsen, who was working closely with many sports conditioning coaches for local rugby teams and many personal trainers in the area. He had a great working relationship with these other professionals and began experimenting with different methods for improving treatment of his patients. It is fair to say he was a breath of fresh air from many physios I had met before who looked down on me with disdain, and did not have an open mind to learning ideas from other professionals in the fitness industry.

Anyway, I completed the first ever and for the first time in my career I began using iso-integration" exercises. With regards to the knee we are know that in order for the knee to be protected from damage it needed to be aligned correctly, with the foot, knee, and hip all positioned in a straight line. If this was achieved it was easy to get the VMO muscle to fire and strengthen but the problem was the hip or the feet would often ruin this alignment.

Knees are exposed to tremendous pain and problems whenever they are forced into a twisting or bend sideways, (eg ACL tear) known as valgus or varus, and lastly if they hyper-extend. This joint is more or less a hinge, it cannot twist and rotate itself, and it cannot bend the other way either. The knee needs to have some mobility which many people lose through tight quadriceps and hip muscles, hence the value of all the hip mobility drills provided in our previous newsletter.

However, this is not the only thing that is essential for the health of this joint as it also requires a great deal of STABILITY to prevent the dangers of twisting and rotating that will ruin the integrity of the ligaments, tendons and cartilage.

The rotation of the leg must come from the two joints above and below the knee, being the HIPS and the ANKLES. Both of these joints have the ability to move in almost every direction but if either of these two joints lose their mobility guess what? That's right, the knee will be forced to make up for the loss of mobility and try to twist and rotate itself putting the structure at risk of serious injury! It is a bit like being caught in a crossfire.

Why Don't You Just Strengthen The VMO!

It is never a good idea to apply strengthening exercises if you have not addressed movement dysfunction or stability first. This is why so many of the isolated exercises for the VMO are a complete waste of time and do very little for preventing the reason it become weak in the first place, which is often more to do with the hip and the feet.

This is such a simplistic way of looking at the problem and is merely trying to treat a symptom and ignore the way we really move. The strength of the VMO is dependent upon the muscles and joints above and below for providing the perfect position to complete its function. It is pointless in using exercises to strengthen this if you have not addressed those factors first. 

See the article - Why the knee itself has nothing to do with knee pain

I have used the following quote in so many articles like and videos over the years for it sums up why this approach rarely works.

On the flip side of this using "big" integrated exercises like squats and lunges may not be ideal either if there is a lot of pain and dysfunction rampant that will only serve to reinforce more pain and compensation.

What about using isolated exercises for the hip and feet?

This is a much better approach as it will help to address the mobility restriction or weakness causing the knee to be poorly aligned, but it will not finish the job. The problem is still to do with isolation, for this approach fails to correct the compensatory movement pattern and motor program. To achieve the goal of changing the movement you need to find a way to combine the isolated corrections of the foot and ankle within the movement pattern that is faulty, which for knee pain is usually the squat and the single leg stance.

This is where the beauty of these unique “iso-integration” exercises comes in, and they can be real game changers in the rehabilitation process for getting back to full strength quickly. They can save you a lot of time and frustration if you get the right and combine the various other exercises and drills around it.

Before jumping into how this works it is important to know exactly what makes up the quadriceps muscle group and how the muscles differ in their function. The quads are one of the most commonly known areas of the body located on the front of the thigh and as their name suggests they are broken into four separate muscles.

1. Rectus femoris occupies the middle of the thigh, covering most of the other three quadriceps muscles. This muscle crosses two joints meaning it can act as a hip flexor and also a knee extensor. This information is very important to remember when assessing hip motion later.
2. Vastus lateralis is on the outer side of the thigh.
3. Vastus medialis is on the inner part of the thigh and is often referred to as the VMO and is commonly linked to stability problems with the knee which we discuss shortly.
4. Vastus intermedius lies between vastus lateralis and vastus medialis on the front of the femur (i.e. on the top or front of the thigh), but deep underneath the rectus femoris.

Okay, so we have a better understanding of the purpose of the iso-integration exercises and the various factors that influence the VMO to become weak where do you start? Well, you cannot just jump into the strengthening, you need to have a plan.

Developing Your Plan

I have covered the plan for correcting knee pain many times in previous articles and I will not go into great detail regarding this today so we can spend more time looking specifically at the iso-integration exercises. I will assume you have moved through the mobility and basic stability stage and you are now at the point where you are trying to improve standing up movements.

Hip mobility and ankle mobility are two areas I will often spend a lot of time with before doing these exercises, and often we will use certain drills between sets to assist the body positioning correctly during a squat or single leg exercise. Below are two videos with ideas of how to use mobility work.

If you have not completed the previous steps or would like to refresh your memory as to what is involved I suggest to read the articles below that provide you with a detailed look at each component.

This is VERY important to do this before attempting the exercises shown in this article.

• How to assess your knee and find the cause of your pain
• Addressing Weak VMO & Knee Pain In 5 Step Process

You will also find our Knee Pain program shown below which I highly recommend getting a copy of if you are struggling with knee pain right now. This includes a 60 minute video and PDF report to show you how to implement the assessment process to identify mobility & stability restrictions along with movement pattern dysfunction creating your knee pain. These programs provide over 70 exercises and teach you how to design your own program based on your test results to correct your weakness.

Click here to go straight to the online shop or on the image below to see more.

I have placed these following exercises in order of difficulty and I suggest this is the best way to try and learn these. You will need a light to medium resistance band and ideally a partner to help you, although this is not essential as you can tie your band to a pole as you will see me do in the videos and pictures shown below.

While there are many other exercises I use, these are my favourite "iso-integration" exercises I often refer to with many everyday people for correcting knee problems like patella-femoral tracking, ITB friction, and even ACL injuries. They are very simple to understand and easy to implement at home by yourself making them a perfect choice for the vast majority of people.

Hip Extension with added Resistance

This is a very simple exercise and it introduces you to the feeling of the femur being pulled inwards that places the knee in the point of "no-return". This is an exercise known for building strength into the glutes and hamstrings and is a great way to unload the knee joint. This is useful in the early stages when inflammation and pain may still be present and in combination with the mobility exercises for the hip and the quad it should allow your pain to settle.

The glutes are a real important muscle group here and they will be heavily used in the upcoming single leg exercises to come, so this is a great introduction to learning hip control. You can read more about glutes in the article – How to strengthen the glutes.

Stability is not compromised in any way with this exercise as it completely removes the feet as a factor which is fine as it allows you to focus mainly the hip. Later on we will use an exercise to focus mainly on the foot, and then eventually you can put everything back together.

Click here to see the video.

Knee Extension With Rubber Tubing Resistance

This is another very simple exercise you can use in the beginning before attempting the more difficult integrated movements. I have never liked the traditional leg extension machine and countless research has shown this to be a terrible way to improve quadriceps strength. The shearing forces placed upon the knee joint is counter-productive to what it is meant to achieve.

However, this version is much different. Instead of trying to annihilate the quadriceps with load it is more concerned with targeting the glutes by applying a lateral resistance with rubber tubing. There is still some quadriceps strength involved but it is minimal in comparison to the demands on the hip.

Once again you can see how the rubber tubing attempts to pull the tibia into external rotation forcing the glutes to pull against it to correct the alignment problem. This is known as “feeding the mistake” to make the body use the weakened muscles of the VMO and especially the glutes.

This is one of those exercises that looks really easy when you watch someone else do it, only to find out that it is pretty tough when you do it yourself. I have found this is a great way to learn how to control lower limb alignment and get used to using the glutes to control the hip without serious amounts of strength being required. A great stepping stone exercise to the much harder standing exercises like the hip airplane and single leg deadlift.

Lunge with Band Pulling Femur Inwards

The lunge is my preferred next step as it does not require a lot of ankle dorsi flexion or knee flexion as seen with the squat that can often cause pain. The lunge also shares similar body position to walking and running where we usually see the patella-tracking problems arise the most.

The concept behind the band pulling the knee inwards is to force external rotation from the hips via activation of the glutes. They are one of the keys to eliminating the problem once and for all and the band is forcing your body to adapt. The band is really trying to make you do it wrong so your body has no choice but to respond.

This is the first time we see the feet become involved and is also where you may start to see the cracks appear and what could be underlying cause of the problem. The glutes must be heavily engaged here but be careful you MUST NOT squeeze your glutes too hard and end up sucking your butt under, also known as gripping. This will lead to faulty hip mechanics and create a new set of problems, usually into the lower back and the hip itself.

Stay as neutral as possible throughout the exercise and carefully move up and down on the spot trying to maintain a perfect alignment through the foot, knee and the hip.

Click here to see the video with this exercise. Watch from the 2:25 mark to see this in action.

Foot Stability Drill - Internal Rotation of the Tibia

This is where we use an "iso-integration" exercise to activate the muscles of the feet in combination with stability of the glutes. The big toe is very important to the stability of the entire body and the maintenance of perfect alignment for the lower limb. This is why you needed to complete the assessment earlier and address any obvious mobility or stability restrictions.

This exercise helps to prevent the "cheating mechanism" we usually see with the single leg exercises we are about to show you.

If a person has significant weakness at the glutes or even simply a poor understanding of movement to keep a well aligned knee, the body is forced to find another way to maintain this alignment. What it will often do is move the foot onto the outside part of the foot, which solves the problem of faulty knee alignment, but ruins your ability to stand up well balanced as you have only half of your foot on the floor. If the foot pronates to neutral like it is supposed to, the hips roll inwards forcing the knee into the horrible position again. This is easily seen when we put someone onto one leg with exercises like the Toe Touch Drill or the single leg deadlifts and squats we are about to discuss.

Recent research has found by actively attempting to internally rotate the tibia inwards, the VMO will increase its activation potential. This may be due to the fibres of the VMO also act to internally rotate the tibia through the patella.

Click here to see the video of this drill where I use a comparison video with the single leg exercise to show you just how much influence the feet have on your alignment.

Single Leg Deadlift with Band Pulling Femur Inwards

When I finally progress to the single leg stance 95% of the time I will focus on the single leg deadlift before the single leg squat.  The reason for this is that it is often much easier for people to develop the single leg skill and strength with the deadlift than the squat. Often there will be tremendous weakness with the quadriceps near the knee joint in the squat and it can make things difficult to progress. The deadlift action removes this problem and allows the person to focus on maintaining that alignment we are looking for.

This is also the BEST exercise to strengthen the glutes bar none! The most difficult part of this exercise is trying to maintain the anterior pelvic tilt that is absolutely critical for switching the glutes on during the movement. You MUST NOT lose this anterior pelvic tilt at any point.

Read this article to see more on this - Why anterior pelvic tilt is so important to hip function

Any weakness at the foot or hip will be instantly revealed in this exercise. I would expect to make many mistakes the first few times learning this movement as the body struggles to move without its cheating mechanism in place. I prefer to use a Swiss ball to rest my foot and not a bench as this will again expose the lateral cheating movement that is the underlying cause of the problem.

If you feel you are making too many mistakes you could hang onto a stick or place your foot on a bench instead. But I would prefer to try with the Swiss ball first and make the mistakes so your body is forced to solve the puzzle.

Single Leg Partial Squat with Band Pulling Inwards

This exercise is the first time we are truly trying to strengthen the quadriceps and the VMO in a big way. This is deliberately reducing the range of motion of the squat to a partial range so that you can focus solely on the area of weakness in the quadriceps which is just above the kneecap itself.

Once again we introduce the band pulling the femur and hip inwards to force external rotation contraction from the glutes and therefor maintaining the optimal alignment of the lower limb. The stability this time is assisted by using a bench to allow for greater workload with the quadriceps.

It is important in this exercise to not lean forwards as you would normally do so with the squats and deadlifts. By removing any hip movement it forces all the work into the knee itself which is normally a bad thing to do, but in this case we are trying to create a bigger workload to the weakened quads. As long as you finish off learning good form with full range of motion these exercises are beneficial. Where they backfire is when people think this is the better way to squat.

Single Leg Stance in Motion

This last drill tries to put it all together. I could have also used a second band pulling the knee inwards at the same time that the band is pulling the hip backwards. Maybe I will do that video for you next time.

The major difference with this exercise versus all the others is that it is on the move, just like the way we move when we walk and run. This is also where the foot becomes more of a factor as it must pronate in during the transition to single leg stance. If it is unable to pronate as it wants to cheat, or if it pronates excessively you will find a loss of stability and alignment of the lower limb.

There is many moving pieces here but this is a critically exercise in restoring the pattern of movement that most likely has developed a permanent dysfunction. This drill is a great way to "unlearn" this faulty motor program and redesign the correct sequence of muscles and joints working together. Anyone who has patella-femoral pain from running this will be an exercise you will need for a long time, if not forever to ensure your compensation does not return.

Click here to watch the video. Watch from the 3:24 mark to see this video in action.

Dynamic Single Leg Drills & Plyometric for Sports

There are many more exercises I may use that are heavily integrated, these are more specific to those who play sports with learning to control lateral movement. These are essential for anyone playing sport to prevent the disastrous ACL tear! Any of the small problems we have seen with the earlier exercises are magnified with high speed lateral movement, which is often performed in single leg stance.

Approximately 70% of all ACL injuries are classified as non-contact situations where the person landed from a jump or tried to chase or evade a player only to fall to the ground in agony. ACL tears or full ruptures occur when you plant your foot on the ground and attempt to rotate your body in relation to that planted foot, placing a huge amount of weight on it. It makes perfect sense to practice these movements perfectly to avoid this season ending injury.

Below are two videos demonstrating this and we do add resistance band reactivity to this to simulate the demands of sports. Click here to watch the video of a cutting drill.

However, while there is no doubting these exercises are great to use for sporting athletes, and can make a massive difference to the stability and strength of the knee, they are not something I would often use with the majority of the population who just want to get on top of their knee pain. You will find most of

You can see more about cutting drills and ACL prevention in this article - 5 Critical Things You Need Before Returning to Sport after ACL Surgery

For more ideas and information on specific topics I may not have covered in detail be sure to check out our INDEX PAGE on the website that has over 200 of our best articles. These are all sorted into categories for quick reference so you can find what you are after more easily.

Summary

There is no doubting that exercise selection and strength programming with regards to knee injuries has evolved really quickly the past 10-15 years. The days of doing a leg extension and some crazy floor based exercise are over, as we know there are so many better ways to improve the strength and stability of the knee joint. To permanently change a movement dysfunction we must change the way muscles interact and synchronize with each other within the pattern. Training them separately may be of some use, but will have little effect if you do not change the motor program.

We also know that we have to look closely at the joints of the hip and the foot, for they are often the hidden source of the trouble and until they are resolved nothing changes. I hope this article has given you some good ideas of how to use iso-integration exercises to encourage the weak and lazy VMO muscle or gluteus medius to fire up within a movement pattern.

If you do need specific help with your exercise program please feel free to reach out to me for help and we can organise a consultation or Zoom online program if you live overseas.

And if you want to stay up to date with all our latest tips and methods you can subscribe to our FREE fortnightly newsletter by CLICKING HERE.

About The Author

Nick Jack is owner of No Regrets Personal Training and has over 15 years’ experience as a qualified Personal Trainer, Level 2 Rehabilitation trainer, CHEK practitioner, and Level 2 Sports conditioning Coach. Based in Melbourne Australia he specializes in providing solutions to injury and health problems for people of all ages using the latest methods of assessing movement and corrective exercise.

References:

• Movement - By Gray Cook
• Corrective Exercise Solutions - by Evan Osar
• Athletes Acceleration Speed Training & Game Like Speed - by Lee Taft
• Diagnosis & Treatment Of Movement Impairment Syndromes - By Shirley Sahrman
• Low Back Disorders - by Stuart McGill
• Knee Injuries In Athletes - by Sports Injury Bulletin
• The ACL Solution - by Robert G Marx
• Understanding & Preventing Non-Contact ACL Injuries - American Orthopaedic Society For Sports Medicine
• Anatomy Trains - by Thomas Meyers
• Motor Learning and Performance - By Richard A Schmidt and Timothy D Lee
• Assessment & Treatment Of Muscle Imbalance - By Vladimir Janda
• Scientific Core Conditioning Correspondence Course - By Paul Chek
• Advanced Program Design - By Paul Chek
• Twist Conditioning Sports Strength - By Peter Twist
• Twist Conditioning Sports Movement - By Peter Twist
• Twist Conditioning Sports Balance - By Peter Twist