4 causes of knee pain that have nothing to do with the knee

Posted: August 6, 2013 in Uncategorized
Tags: , , , , ,

Patellofemoral Pain Syndrome (PFPS) is a common condition encountered in orthopaedic practice. PFPS most commonly presents with retro- or peri-patellar pain associated with positions of the knee that result in increased or misdirected mechanical forces between the kneecap and femur. Climbing stairs, running, kneeling, squatting and long-sitting are frequent pain aggravators. Clinicians have come to understand that the cause of PFPS is not always directly at the knee, realizing the importance of surrounding dysfunctions proximal or distal to the site of pain….we must understand that knee pain is not about the knees (most of the time), a holistic approach must be utilized in both assessment and treatment to figure out why one would present with knee pain.

Here is a list of 4 common reasons for knee pain and a subsequent diagnosis of PFPS (which is a crappy diagnosis)

1) Weak Hips

You’ve probably heard it before, but it’s worth repeating: Weak hip abductor and external rotator strength is a key reason for PFPS. It is believed that weak hips cause medial rotation, adduction and valgus collapse of the tibia and femur leading to excessive joint compression and patellar mal-tracking. This is especially true in women due to the larger Q-angle they present with (wider hips), which makes it all the more important to strengthen the hips as part of a comprehensive treatment approach

“Current research reveals that poor proximal neuromuscular control and/or weakness of the hip musculature may lead to limited control of transverse and frontal plane motions of the hip (especially during single-legged stance). Other evidence suggests such dysfunction can result in dynamic malalignment including components of femoral adduction and internal rotation, valgus collapse at the knee, tibial rotation and foot pronation. Findings of deficits in hip abduction, extension and external rotation strength has also been shown with patients with PFPS. Further, multiple studies by Willson and colleagues demonstrate that there is an increased hip adduction angle in PFPS patients compared to healthy controls”

Journal of Orthopaedic & Sports Physical Therapy 2012; 42(1): 22-29.
The Effects of Isolated Hip Abductor and External Rotator Muscle Strengthening on Pain, Health Status, and Hip Strength in Females with Patellofemoral Pain: A Randomized Controlled Trial

American Journal of Sports Medicine 2011; 39(1): 154-163A Proximal Strengthening Program Improves Pain, Function and Biomechanics in Women with Patellofemoral Pain Syndrome

See what I’m talking about?

2) Restricted Ankle Dorsiflexion

I wrote an entire blog post about this a few weeks back. Long story short: If you can’t get the 10-15 degrees of dorsiflexion in your ankle that is needed for proper gait or squatting you will ultimately compensate by falling in on your arches thus pronating through your subtalor joint. Just like with weak hips, if you excessively pronate you will tend to have tibial and femoral internal rotation thus placing the knee in an awkward position when doing such tasks as descending stairs. Muscle imbalances my result along with excessive joint compression at the knee causing PFPS symptoms.

I have not come across a lot of studies that specifically look at the effects of ankle dorsiflexion on knee pain but here is what I’ve read to date:

N Am J Sports Phys Ther. 2009 February; 4(1): 21–28
Treatment of Lateral Knee Pain by Addressing Tibiofibular Hypomobility in a Recreational Runner

J Sports Rehab 2012 May;21(2):144-50.
Effect of limiting ankle-dorsiflexion range of motion on lower extremity kinematics and muscle-activation patterns during a squat.

“Altering ankle-dorsiflexion starting position during a double-leg squat resulted in increased knee valgus and medial knee displacement as well as decreased quadriceps activation and increased soleus activation. These changes are similar to those seen in people with PFPS.”

Knee to wall test: How I assess ankle doriflexion

3) Lumbar spine pathology:
Conditions like spinal stenosis, arthritis or a disc herniation from L3-4 (most likely) can refer pain down to the knee. The nerves that exit the lumbar spine at certain levels travel down to the knee to provide motor input and sensory output. Thus, irritation of a nerve root in the lumbar spine can be a chief cause of lateral (L5), anterior (L4) or medial (L3) knee pain. Anecdotally, I have treated a few clients with no back or upper leg pain, but complained of tightness and burning at the knee. Once all knee-specific subjective and objective tests are ruled out, it became apparent via dural mobility testing that the knee pain was a function of a lumbar spine pathology.

Quick tip: If a client has unexplained knee pain and you think it maybe neurologically mediated (well, all pain is neurologically mediated…you get what I’m saying though) then test dural mobility and see if that recreates their knee pain. If so, you have a great outcome measure to see if you made a difference post treatment. If a slump test causes burning lateral knee pain, treat the lumbar spine and re-test the slump. Hopefully it’s better afterwards!

4) Hallux Valgus or 1st MTP restriction:
Just like at the ankle, if the 1st toe can’t extend or dorsiflex like it should the foot  will fall into more pronation through midstance to toe off (the big toe has to find a way to get to the ground and it does so by forcing the subtalor joint into pronation). This again leads to dynamic knee valgus and the possibility of PFPS…Knee pain? Check the big toe!

Good ROM

Summary:

  • Knee pain is often multifactorial and keeping in mind regional interdependence yields a more comprehensive assessment and treatment approach
  • Knee pain can have components of articular restriction, dural irritation, tendonopathy or a combination of many things (usually the case)
  • When someone comes in with insidious onset unilateral knee pain and the prescription from their G.P says “overuse injury, treat with ROM, strengthening and stretching of the knee” (what I had last week) you MUST explain to the patient that unilateral overuse with bilateral activity (running etc) is probably impossible.
  • Treat the joints above and below and even on the contralateral side if needed
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Comments
    • Raymond says:

      Thanks for your nice blog. I have a question about reason 4:Hallux Valgus or 1st MTP restriction. I can’t find it in the articles. In which article is this written? Thanks!

  1. knee ache says:

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  5. Kirsten says:

    I am a knee pain patient, can you explain what this statement means: “unilateral overuse with bilateral activity (running etc) is probably impossible.”
    Also can you please direct me to a site that has hip strengthening excercises?
    Thank you

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  8. Amy William says:

    Thanks for the informative article. There are several conditions cause by knee pain like Tendonitis, Osteoarthritis , Illiotibial Band Syndrome.
    Get more informations from : http://painclinic.sg/category/knee-joint-pain-identifying-the-source-and-finding-an-effective-treatment.htm

  9. Foot Pain says:

    Knee pain is a common problem with many causes from acute injuries to medical conditions. Thanks for sharing insights! Really helpful! 🙂

  10. Goldie says:

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  12. C says:

    Very helpful, I am a pilates reformer instructor and I always start with feet. Thank you.

  13. joha says:

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  14. Jenni Jannu says:

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    If, like me, and most of us who… aren’t as young or as active as we used to be… you either suffer from joint pain or hope to be one of the very few people who avoids joint pain. And you probably have friends and loved ones who feel the same way… or are suffering themselves.
    Unfortunately, we’ve been taught that joint pain is a fundamental part of aging. And that dealing with joint pain is limited to treatments:
    • drugs with nasty side effects
    • painful and expensive surgery that may make your joint pain worse
    • blocking out large chunks of time (and co-pays) for courses of physical therapy
    And all of which never seem to really address the cause of the pain. Well, I’ve found part of the solution to my joint pain.
    This article by retired NBA player and joint pain relief expert, Jonathan Bender. This secret doesn’t take long, but it is kinda boring. It’s practically painless, but it is kinda boring.
    It is completely, absolutely safe, but it is kinda boring. It’s free…and you know what I’m going to say, so I won’t. And it may sound like magic, but it’s based on a great athlete’s intuitive, instinctive understanding of how your body really works.
    And every day I use this slightly boring secret, my pain levels have dropped and my comfort increased. I don’t just feel better, my life is better.
    Click here to read “Why Joint Pain Isn’t Inevitable…and How to End Yours. ”
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  15. inphrah says:

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  17. Anna says:

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  18. You are the first one I have seen to look at knee pain like this. I was born flat footed with right foot extremely flat. I am 66 years old now and I have had a hip replacement 11 years ago and a knee replacement surgery 4 weeks ago, the painful thing I ever went through, I have scoliosis with a Cobb measurement of 63 degrees so I will need back surgery and I believe it is all do to my right foot being bad. My hip and knee replacement are both on the right as my bad arch. I am now looking for a surgeon to operate on my right foot before I attempt the back. I feel if a doctor would have looked at the whole picture and operated on my foot first, I wouldn’t have had the other problems. Please tell the doctors to look at the whole body first before they start cutting. Thanks Linda

  19. You are the first one I have seen to look at knee pain like this. I was born flat footed with right foot extremely flat. I am 66 years old now and I have had a hip replacement 11 years ago and a knee replacement surgery 4 weeks ago, the painful thing I ever went through, I have scoliosis with a Cobb measurement of 63 degrees so I will need back surgery and I believe it is all do to my right foot being bad. My hip and knee replacement are both on the right as my bad arch. I am now looking for a surgeon to operate on my right foot before I attempt the back. I feel if a doctor would have looked at the whole picture and operated on my foot first, I wouldn’t have had the other problems. Please tell the doctors to look at the whole body first before they start cutting. Thanks Linda

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