Knee pain is a common complaint that hinders basketball, volleyball, and many other athletes from training consistently and competing at their full capacity. As a response, there have been generational methodologies regarding the “best way to get rid of knee pain”: strengthening your glutes, squatting with your knees over your toes, and others. Each phase of these knee pain rehab trends have garnered praise of physical therapists and healthcare providers and been popularized through social media. However, each trend has also experienced shortcomings, whether it be failing to provide long-term relief or resulting in patient setbacks.

This is not intended to dissuade you from strengthening your glutes, squatting with knees over toes, or whatever else it may be that has been popularized. All of these methods have a time and place, but each must be based on individualized clinical assessment and reasoning for their respective applications. A thorough examination must be performed to ensure that the exercise or treatment prescribed can be explained through sound understanding of functional anatomy and biomechanics.

Clinical exams investigating causes and sources of knee pain generally focus on the knee joint itself, but more often than not, chronic knee pain or nagging knee injuries are simply local symptoms resulting from underlying root causes away from the knee. Three body regions that may contribute to your local knee pain are: the foot and ankle, hip, and ribcage and pelvis. 

1. Foot and Ankle

The foot and ankle joints are the structural foundation for our body’s movement. Moreover, they provide important sensory information for our brain to organize our body’s resting posture and significantly influence movement patterns when we are in upright, weight bearing positions.

Our feet and ankles are composed of 26 joints interconnecting 33 bones; therefore, our feet and ankles need to move accordingly. Specific to the mid foot region, the arch should be able to pronate (flatten) and supinate (raise up). These mid foot movements are paired with the ankle’s ability to dorsiflex and plantar flex respectively. We need our ankles to dorsiflex, or having our shin bones move forward, when squatting, lunging, cutting, and changing directions. Equally, we need our ankles to plantarflex, or having our shin bones move backwards, when jumping and running.

When our feet are stuck in a flattened arch or high-arch position, this will affect how well your ankle can plantar flex or dorsiflex, which inevitably can influence knee stability and alignment, force distribution throughout the lower extremity and improper weight and load distribution that can cause additional stress to the knee joint.

2. Hip

The hip joint and its surrounding muscles play a crucial role in maintaining proper knee alignment and stability. Weakness or tightness in the hip muscles can lead to altered movement patterns, causing the knees to overcompensate during activities. Often, strengthening or stretching exercises are given to these hip muscles in hopes of improving movement patterns. Unfortunately, this short-sighted treatment strategy does not take into consideration the position of the hips and how position can lead to muscle length tension inefficiency that can present itself as “muscle weakness or tightness”. Hips must be able to internally and externally rotate. This is evident in common movement patterns we do every single day: walking, running, and squatting. 

For example, when we squat, we must have hip external rotation during the initial lowering phase to start the movement. At around 70-90˚ of hip flexion, our hips must internally rotation to allow for us to continue lowering down. At the bottom of the squat, we need to have more external rotation as we prepare to ascend. The same undulation between external and internal rotation is needed as we elevate out of the bottom position. 

When walking, initial contact is paired with hip external rotation as the outer portion of our heel hits the ground. As our body progresses over our leg, our hip must internally rotate to support our center of mass. Once our leg is behind us, we need external rotation combined with hip extension for the glutes to be able to propel us forward into our next step. 

When rotational capacity is lost at the hips, the force that cannot be attenuated is directed towards the knees. Although our knees have rotational properties associated with knee bending and straightening, this is an aspect of knee mobility training that most athletes have not addressed before. These significant rotational forces directed from the hip exceed the knees ability to absorb those loads, thus resulting in knee pain.

3. Pelvis (and Ribcage)

The relationship between the pelvis and ribcage is crucial for overall body stability and postural control. Asymmetries or rotations in these regions can create compensations throughout the entire body, including the knees. An imbalanced pelvis or ribcage can disrupt the body's natural alignment, leading to abnormal forces acting on the knees during weight-bearing activities.

Specifically, if we have a pelvis that is in excessive anterior pelvic tilt (tipped forward), we will usually be limited in hip internal rotation. Moreover, this anterior pelvic tilt will place the anterior chain muscles (quadriceps) at a mechanical advantage in comparison to the over-lengthened hamstrings and gluteals. On the other hand, if we have a pelvis that is excessively posteriorly tilted (tipped backwards), we will usually be limited in hip external rotation, which when paired with hip extension will optimally train the glutes in multiple planes.

Pelvis position, on the right and left side, is dictated by ribcage position, which is governed by internal thoracic and abdominal pressure management on each respective side. Pressure management is controlled by 2 components: abdominal trunk control and breathing mechanics. Both must be assessed and addressed to provide meaningful change to pelvic position and will influence stability and control and the foot, ankle, and hip. 

Conclusion:

Knee pain is not solely a localized issue but often a result of imbalances and compensations in other areas of the body. Addressing foot and ankle mechanics, hip imbalances, and restoring pelvic and ribcage relationship can lead to significant improvements in knee pain and overall functional performance.

For individuals experiencing knee pain, seeking guidance from a physical therapist who is trained to recognize these imbalances and compensations can be highly beneficial. A comprehensive evaluation and personalized treatment plan can help restore postural imbalances, alleviate knee pain, and foster a healthier and more functional body. 

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