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When You Have Knee Pain Rarely Is The Knee The Problem

Written by: Nick Jack
Category: 2014
on 08 November 2014
Hits: 26264

It seems like such a strange statement to make. But in the case of knee pain, hardly ever is the problem to do with the knee itself! In fact with nearly every case of chronic pain this is also true. Take for example the cases of special diagnostic tests of a specific areas that come back with normal results, although the patient complains of pain. The site of pain is often not the cause of the pain, it is merely the effect of a cause somewhere else. Vladimir Janda a pioneer in the development of postural correction and movement assessment states, that "these two anatomical systems cannot be separated functionally". Therefore, the term “sensorimotor” system is used to define the functional system of human movement. In addition, changes within one part of the system will be reflected by compensations or adaptations elsewhere within the system because of the body’s attempt at trying to maintain optimal homeostasis. In nearly all cases of injury that has developed over time and not from trauma, you can trace the cause of the problem to somewhere else and in the case of knee pain we find the main culprits are the joints above and below the knee being the hip and the ankle. Add on top of this a poor understanding of movement and you have the perfect recipe for knee pain.

What Causes Knee Pain?

If your knee pain is not from a collision injury or a traumatic event like a car accident and evolved over time then you can guarantee you have muscle imbalance and a movement dysfunction.  

The big question that needs to be answered is, are you moving poorly because you are in pain? Or, are you in pain because you are moving poorly? 

Trying to remove the pain and not addressing this question will only lead to more problems and a lifetime of treating symptoms. But this is exactly the current model of the modern health approach to knee pain. We are trained to think that pain is bad and it must be removed and once it is gone everything is okay. But with these injuries that develop over time the problem was there long before you had any pain signals! Take for example patella tracking knee pain or ITB Friction Syndrome, both of these are caused from poor alignment of the leg and muscles working either too hard, vastus lateralis and ITB, or too little VMO (vastus medialis) you end up having a problem with your knee.

You cannot treat these problems with anti inflammatory tablets, using knee braces or taping and definitely not with surgery! Even focusing all your efforts on strength training on the area around the knee is a waste of time! Why? Because you have not established why these muscles are either working too hard or not enough and causing you to have poor alignment in the first place. You must find the answer to this question in order to really solve the problem. These muscles did not just stop doing their work for the fun of it. There is a reason behind this, if you find out what it is and correct it, your problems will be gone forever!

As mentioned in the beginning there is often two big causes of knee pain and they are - the HIPS and the ANKLE. I could also throw in a third one labelled MOVEMENT SKILL. Let me explain why they where you need to look for getting rid of your pain.

The Knee Is A Hinge Joint And Cannot Twist Or Rotate

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, but it needs a great deal of STABILITY to prevent the dangers of twisting and rotating that will ruin the knee.

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 is right the knee will be forced to make up for the loss of mobility and try to twist and rotate! It is a bit like being caught in a crossfire.

Read our articles on hip and ankle mobility below for more information on this.

Take a look at the picture below to see the chain reactions of problems that can be caused by either or both of these joints.

This is where we find the cause of the problem most of the time. But not always. You might also need to address a weakness in the core and lastly ensure that your movement patterns like squats, lunges and bending are correct. For sometimes there is no loss of mobility at all, but the problem is more to do with lack of stability and a poor understanding of how to move. Before we look at movement let's take a close look at stability.

You Must Have Optimal Stability Of The Feet & Pelvis

Stability is again one area that is rarely looked at and often missed in a treatment plan for someone in pain. It is easy to see why, for the weak stabilizers are very rarely in pain, many do not even know how to activate them anyway. It is also a very misunderstood concept as many people think of planks and abdominal exercises as stability training. Unfortunately these exercises will have very little influence on changing anything to do with your knee pain. You need to understand how stabilizer muscles work and what ones will influence perfect alignment of joints for movement. When you understand this the corrective exercise choices become much easier to select.

The pelvis need to stabilized with multiple muscles and joints all firing at exactly the right time, and in the perfect order to produce movements that prevent the dangers of twisting and rotating that will ruin the integrity of the ligaments, tendons and cartilage. However, sometimes the pelvis and hips could be perfectly fine but the problem begins at the feet and forces the hips into a compensatory movement pattern, exposing the knee to a horrible alignment that poses serious injury. 

Many people have been educated to treat the core stabiliser muscles in the same we would use a bicep curl to make our arm stronger. Unfortunately, the stabiliser muscles do not respond to this type of training and are not programmed to functions in this manner. 

Stabilizers rely more on TIMING and SEQUENCING and are highly dependent on the MOTOR PROGRAM used by the brain for each movement we make. 

"Core control is reflex driven, not conscious driven"

Not only are people wasting their time with exercises that will do little to enhance the way their core actually functions, but they are gradually destroying joint stability and creating postural dysfunctions. It is ironic for the intention of using these exercises is to prevent these very things.

What people fail to understand is that your abs are unable to move you, other than making you wiggle or flop around like a fish out of water. You need your arms and legs to move you for your abdominal muscles are not capable of doing much. Basically the abdominal muscles have very little influence over how you move, for this is not their true purpose.

True core stability is all about being able to react with perfect reflexes to be able to maintain joint alignment ready for efficient and smooth movement.

You can read more about this in the article shown below.

You Must Assess Your Movement Patterns

Now let's say we have addressed mobility with the ankle and hip, and we have also corrected any stability problems with the feet and pelvis. We should be good to go right? Wrong!

I have seen many cases where a person came to see me in pain and during our assessment we found not one area that had a length tension imbalance, they passed our core stability tests yet when they moved they were very stiff and used poor technique. Especially with squats, single leg squats, lunges and bending. The problem is with the brain the nervous system using an ineffective movement pattern.

Stiffness could also be a result of poor stability in this movement pattern. You might not see it in the lunge but it comes up in the squat. This person knows only one way to move, and until the brain is shown a better way it will continue to use the motor program it knows the most. This is why you MUST ALWAYS LEARN HOW TO MOVE.

If you stay in the stages of just fixing muscles you will never truly rehabilitate the problem. This is why surgery is just a band-aid approach and does nothing to address the cause, being how you move. This is why we see some many sports people suffer multiple ACL injuries after surgery that was supposed to "fix them".

You can read more about this in our article What To Do If You Tear Your ACL.

Okay So How Do You Correct This? Where Do You Start?

Very simply you need to do a complete assessment of your body. You need to assess all joints for length tension imbalance, trunk stability, posture and lastly how you move. I will give you some great ideas on how to do this but I suggest if you are someone with a chronic knee problem right now your best bet is to get my full online report shown at the bottom of the page.

You will find this article invaluable to read as it takes you through my assessment process.

Okay let's take a look at each factor and give you some ideas on how to go about correcting your problem starting with the feet.

Assessing Foot Stability

The very first thing I look at is foot stability and in particular the big toe function.

It makes sense to start at the feet as they are the first part of the body to touch the ground when we move. Our feet and ankles are meant to withstand incredibly high forces and should provide more in terms of shock absorption than perhaps any other body part. Unfortunately, we begin to gradually lose this ability once we start wearing shoes. Over time, the feet, ankles, and toes become inhibited. And as we expose our feet to some trendy shoes with all types of padding and support, this only make matters worse and exacerbates the lazy and weak feet muscles.

Besides minimizing the ability to withstand intense ground reactive forces, the body gradually begins sending fewer and fewer signals to the feet, leading to distortions in pro-prioception and loss of innervation all the way up the kinetic chain. This is where poor stability evolves and injuries are born!

I have seen countless ACL injuries that began with poor foot stability. But how do you assess this? Firstly I start with the BIG TOE! Since power during propulsion is dependent upon the foot’s ability to become a rigid lever, making sure you can flex your big toe is the key to achieving full foot supination. When you walk, the entire body is advancing past this single joint, the ability to dorsiflex, and then be able to raise the heel as you move through the various stages.

If this mechanism fails, compensation will be forced to occur at ALL joints from this point onwards.

Watch the videos below where I explain how this works.

 

Additional articles to read with tons of exercise video examples for foot stability are below.

Correcting Ankle & Hip Mobility

Okay we know that these two joints are often big players in creating the injury or the pain. What are some good exercises to improve the mobility?

What you will find is that there is no one magical exercise that improves this for you. You will need to experiment with a combination of foam rolling, stretching and mobility drills. Each person will respond differently so you need to find what works for you. Some of my favourite exercises for the ankle and hip are shown in the videos below.

  

Reflex Stability & Posture

Stability also must be addressed and this can be a much more difficult to identify, time consuming and very frustrating to correct. But it must come before strengthening and completing the standing up movements like squats and lunges etc. Otherwise you will develop "stiffness" in order to create stability for the body and continue to move poorly. Remember it is not the knee that is the problem. It is just copping the effect of the cause of instability coming from somewhere else. This stage addresses this instability and prepares you for the more rigorous exercises to come. Lower abdominal strength, breathing and TVA activation are all basic fundamental exercises for improving trunk stability. 

Below we show you 2 of my favourite reflex stability exercises.

  

Strengthen Weak Muscles

Before jumping into integrated movement it is wise to assess the strength of known weak muscles. This helps activate muscles that may have been dormant for a long time. But don't fall into the trap of where most rehab programs fall over as they focus so much on muscles and forget to teach movement. The body does not know it's little finger from it's big toe, it only knows movement patterns. Strength without this is a waste of time but it does have relevance if you can tie it together.

Common weak areas is often the glutes, VMO and glutes. I don't like to stay here for too long and prefer to use a method of combining the isolated exercise with the more integrated movement based exercise. More or less trying to take the information from the isolated exercise and transfer it to the standing up integrated version. I like to use some strange looking exercises called iso-integration to do this.

See the video on the left below for an example of this. The video to the right uses a simple hip extension exercise to activate the glutes. This is a great test to use to see if they are firing as they are supposed to.

  

The glutes get a great deal of attention when it comes to knee injuries as they are so important to maintaining optimal alignment at the hip by providing external rotation of the femur. This is where I may suspect weakness here if I found knock knees on the posture assessment.

It is important to perform this exercise as a holding position because this mimics the stabilising role of the gluteal muscles more closely. Building up the length of time you can position will improve strength-endurance of the gluteals in the inner range position.

What I am looking for here is where the person feels the contraction. If they feel it strongly in the hamstrings or lower back, the gluteals are not doing their share of the work. If they start to feel the exercise moving out of the gluteals into the hamstrings, and maybe even cramping the hamstrings, I know they have weak glutes as they have fatigued. I also observe if they try to push their hips up too far and arch the lower back too much indicating poor abdominal control. I also assess how they position their knees and feet which may give me more clues as to how they are going to move.

I suggest getting a copy of our Glutes Checklist below that takes you through everything you need to know about this stage.

 

Good articles to read on this with even more examples are shown in these articles.

Assess Movement Skills

Again this is an area rarely assessed, and even when it is it is done very poorly.

This step is by far the most important for this is how you can change all of the things above in one go. Learning to squat correctly with great stability of the knee and pelvis combined with great mobility of the ankle and hips all at the same time, produces efficient movement that strengthens and lengthens muscles as they were designed. With enough repetition of perfect form you can rewire the motor program and teach the body a much more effective way to move that does not crush cartilage, tear tendons, and ligaments that create faulty compensatory patterns and pain.

There is much more than just learning how to squat. You will need to the deadlift, lunge, and even the single leg squat to guarantee your body understands how to control the knee. The strength from one pattern does not transfer to the others, as the body develops strength specific to these patterns. Which is why you must learn them all.

Obviously this is a complex topic to explain here without making this article too long but I have provided you with two videos to watch below about the squat and the deadlift that set the foundation for good integrated movement. The squat is a knee dominant movement, whereas the deadlift is a hip dominant movement. 

  

Good articles to read with additional information are shown below.

Master The Single Leg Movements

I cannot say this enough but the single leg squat, single leg deadlift, and just about any exercise or movement on single leg stance is critical for you to master.

Hip extensions are okay to start but you must learn how to do single leg exercises and perfect them. Leg press, leg curl, leg extension and every machine does not count and in fact I encourage you to stay away from these as they teach your body to not need stability. And as we have seen already this is a disaster. Learn the movement skills in the standing position and perfect it.

The two videos below show you all the things I look for in a single leg squat, and the second video to the right provides you with an example of how to encourage more activation of the glutes and VMO to control perfect alignment of the knee.

  

Make sure you read the articles below for more detail on this.

 

What About Sports?

Training for sports is a lot more involved as you really are putting your body through much more risky movements and using high speeds often with sudden braking forces. If your brakes are no good you will get injured. If your movement is poorly aligned you will get injured. Strength training is not a luxury it is a necessity when it comes to sports and you must have a very intelligent and specific way of choosing exercises and methods to prepare you for what the sport is demanding from your body.

Using body building exercises like the bench press and bicep curls is not going to teach you how to move with skills that require agility, balance, power and high levels of coordination. ACL injuries are so common these days and most can easily be avoided if all the things we have spoken about in this article were adopted in their training as a preventative program. Most injuries occur from landing after jumping or twisting and turning during evasion or chasing. These injuries are not from bad luck but poor alignment and movement patterns performed repetitively. 

For more detail on this area if you play sports I suggest to read the article - 5 things you need before returning to sport after ACL surgery

 

Do You Need More Help?

I suggest if you are someone with a chronic knee problem right now your best bet is to get my full KNEE PAIN program shown below. I created this program a few years ago to provide a program in a simple step by step process to effectively change all of the things we have just spoken about in this article. We have been able to successfully help hundreds of all types of knee injuries, (if not thousands over the internet) using this exact program. Click here to see a preview trailer of what is in the video.

Click here to get a copy of this program.

  

Conclusion

Now you can start to see that the Knee Pain is just an end result of compensation from other joints, lack of stability, poor posture and dysfunctional movement patterns being imposed on your body. The poor old knee has very little influence over any of these problems which is why you must look elsewhere to solve your problem! Surgery and relying on medical treatment to "fix you" will be futile if you do not address the real cause of your problems.

Only a well designed strength training program that takes into consideration flexibility and stability problems will remove your pain and teach you to move pain free.  

If you would like to know more about any of our programs or you would like to arrange a Free Postural & Movement Assessment click the image below and I will be in touch with your within 24 hours.

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