Starfish Therapies

June 20, 2011

Posture and Knee Hyper-extension

We have several kids who have varying degrees of knee hyper-extension when they stand.  Knee hyper-extension is when their knee bends backwards past zero degrees of extension.  This can happen for many reasons and many children and young adults do this without having any predisposing factors.  In fact it can be common in gymnasts and adolescent girls.  For kids with neuromuscular disorders such as cerebral palsy, knee hyper-extension in standing can be common in one or both legs.  One of the ways to correct for this is to use a brace called an AFO (ankle foot orthosis).  If it is set so that the child can’t point their toe, it can prevent them from going into knee hyper-extension.  Many families go back and forth on the debate of whether their child should wear AFO’s or be allowed to wear a less restrictive brace.  I myself go back and forth as well and try to help the families see the pros and cons of both choices.  As I have been observing some of our kids recently I have noticed some of the side effects of increased knee hyper-extension.

First, there is always the potential damage that is being done to the child’s joints and ligaments due to the repetitive stress of going into hyper-extension with every step.

Second, when a child’s knees are hyper-extending they need to make other postural compensations to keep their body balanced over their base of support.  To do this the tend to arch their low back more (increase their lumbar lordosis) causing their hips to flex more.  This over time (not even a very long time) can cause their hip flexors to get tight.  Specifically their ilopsoas which causes hips to flex and low backs to extend (arch).

Third, with the flexed hips and increase arch in the low back it causes their stomach and behinds to stick out further making it a challenge for them to activate their gluteal (butt) muscles or their abdominal (stomach) muscles.  These are two important sets of muscles for maintaining balance and posture.

In addition to this there are down sides to wearing the AFO’s.  If the child has decreased strength, they have trouble lifting their foot up when they are walking so they tend to turn their feet in (internally rotate their hips) more.

Also, with decreased strength they may not be able to overcome the tension on the AFO to achieve more ankle bending (dorsiflexion) so they can lose more strength in their calves.

I think the whole process is a balance that needs to take into consideration the goals of the family and child as well as the pros and cons.  I’m sure there are plenty that I have not mentioned but I wanted to start to point out some postural challenges created by knee hyper-extension.  As always, I think working towards a balance with the family and child can be effective.



  1. great article, AFO alone will not solve the problem, in my opinion we need to focus on pelvic alignment mainly hyper lordodsis and its relation with the anterior and posterior pelvis tilt,
    in the other hand using long prone standing on the frame and may be with kneeling on prone with fixation of the pelvic will be great ,
    i think using standing frame in prone for such cases will improve posture, proprioception ,
    further ideas need bio mechanics and kensiologoy deep thinking.

    Comment by Shadi Weshah — June 20, 2011 @ 10:12 pm | Reply

  2. my three year old had this, could this also cause h him to be in pain when using the toilet to open his bowls? I know strange question but wad just wondering

    Comment by anoek — May 14, 2012 @ 2:28 pm | Reply

    • I guess its possible although I don’t think that would be a cause of pain.

      Comment by Starfish Therapies — May 14, 2012 @ 5:50 pm | Reply

      • just recently he has been waking in the night because of pains in his knees and not had this before… what does tht mean? thank you

        Comment by anoek — October 17, 2012 @ 8:28 pm

      • I’d love to help but I would need more information than what you provided because knee pain can mean a lot of things.

        Comment by Starfish Therapies — October 17, 2012 @ 8:38 pm

    • He has been diagnosed with hyperextesion of the knees but never appeared to hurt him till recently…he wakes up crying in pain but nights only.the dr. tried a cast to help his knee april this year….
      He stumbles a lot when tired and…when on toilet wont put legs down as says it hurts…x

      Comment by anoek — October 17, 2012 @ 9:57 pm | Reply

      • I can’t be positive that the hyperextension is causing the pain but I can tell you that if kids are ‘popping’ back into hyperextension as they walk, they are wearing out their ligaments in their knees because they aren’t using their muscles to control the motion and this can cause pain over time. Depending on how severe the hyperextension is you may want to look at trying AFO’s to control the hyperextension as well as work on his overall muscle control around his knee, so being able to stand without going into hyperextension by strengthening his quads and hamstrings and getting them to work effectively together. I hope this helps.

        Comment by Starfish Therapies — October 17, 2012 @ 10:11 pm

  3. pls can you post more regarding this subject , my kid who is 6 has hyper extension of the right knee and elbow .. i agree with all the points you have mentioned ..w e are not using the AFO or braces for the reasons mentioned above .. can we get to know few more tips for handling the situation ..
    presently my kids ot /pt are focusing on weight bearing exercises ..

    Comment by 5hruthi — November 9, 2013 @ 7:05 am | Reply

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