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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: 24138

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 there is two main culprits, the hips and the ankles!

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.  

Just removing the pain and not addressing this problem 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 article on ankle mobility for more information.

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 Stability Of The Trunk & 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 not in pain, many do not even know how to activate them anyway. And even the exercises that people think are stability exercises like planks, make matters worse not better. (Make sure you read our full article on Stability Training for more detail on this). The pelvis need to stabilized with multiple muscles such as abdominals, gluteul muscles, hamstrings, hip flexors etc all at the exact right time and in the perfect order to produce movement that does not stress either the spine or the lower limbs. The most common postural fault we see is a lordosis type posture that has an anterior tilted pelvis. This is often the problem for hyper-extended knee pain but it will cause the hips to rotate inwards (valgus) causing the knee being forced into a position that will create a shearing effect that ultimately leads to pain! This postural dysfunction is commonly known as Lower Cross Syndrome. 

This means that the hip flexors and back extensors become short and tight and the opposing muscles of abdominals and glutes, hamstrings become long and weak! See picture below and alongside it a picture of a Lunge where the hip flexor is needed to be stretched out in order to complete the movement correctly. It is this postural fault that is the reason why so many people struggle with the lunge movement and why it creates so much pain. The tight hips, quads pull the person forward putting the entire body weight into the knee, and at the same time the gluteul muscles and hamstrings instead of taking the majority of the workload take a backseat and let the quads take over. This creates a further imbalance and on and on it goes until the day you end in pain. The longer it stays uncorrected the greater the imbalance and the longer it will take to resolve. 

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 trunk, knee and even the feet flexors! 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 bandaid 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 KNEE PAIN video and ebook program on how to do this 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. 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.


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

Correcting Ankle & Hip Mobility

Okay we know that these two joints are often big players in creating the injury or the pain. So it makes sense to take a close look at these two joints.

Start with flexibility imbalances first. A simple stretch assessment will do. Common areas that require stretching are the Hip Flexors and Quads, plus the calves. It is important to stretch these muscles first as they will inhibit the weak muscles. Meaning they will rob the message from the brain to do the movement. After you have completed a thorough assessment and identified areas of imbalance and using stretches to correct it, I then like to use a series of mobility exercises. These are different to stretching in that they move more than one joint and begin to look more like a real movement.

For ideas on this topic read our article Stretching vs Mobility which comes first.

I also have given you some good videos to watch below with some great exercises to use.

Trunk 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. 

Good articles to help you out here are Breathing & Exercise plus Posture Is Everything When Trying To Get Out Of Pain

Below is some videos of simple core stability exercises.

Strengthen Weak Muscles

Before jumping into 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 hamstrings. 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.

See below for an example of this, where we use the clam which is an isolated glute exercise then straight away apply the same resistance to the leg in a lunge stance where multiple joints and multiple muscles are involved.

Good articles to read on this with even more examples are How To Strengthen The Glutes and also Weak VMO How To Strengthen In 5 Simple Steps

Whatever you do, make sure you do not use the exercise squatting against a swissball on a wall with a ball between your legs! This exercise will ruin your knees and is not even a vmo exercise anyway. Watch the video below to see why and better choices of exercise than this to target the vmo.

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 & 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 and create faulty compensatory patterns that lead to pain. There is much more than just the squat to learn, the deadlift, lunge and even the single leg squat are all patterns you must learn. 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, which is why I suggest getting our Knee Pain Program where I go through each pattern in detail and give you little tools and tricks to help you.

Good articles to read with great detail are Single Leg Squat Is The Best Exercise For Knee Pain and How Functional Movement Can Save Your Life

Below is two good videos to watch about learning movement skills. The squat pattern is an excellent video to watch that explains how to make this easier to learn great form.

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. Below is a great exercise called the Toe Touch Drill that we use with many clients to improve overall stability on single leg.

Integrated Strength Training Completes The Process

Now that you have improved mobility at the ankle and hip, improved stability at the trunk and knee, learned how to move correctly with squat, single leg squat lunging and bending the last thing to do is strengthen the system so it can withstand any force or load. You have to upgrade your skills to a level that is higher than you require in life. Everyone needs to work on their balance and I regard single leg movements a non negotiable skill every person must have, in particular the elderly. If the hardest thing you ever do is walk up stairs then in the gym you must be able to do a box step up with weights in order to have an ability higher than you require. If you play sports you will need much more than this and you will need to develop many more skills in order to remain injury free.

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 get injured. If your movement is poorly aligned you 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. You will see two videos just below and the ACL video gives you great examples of poor movement patterns versus optimal movement.

A great to read about sports training are is The 8 Must Haves For Strength Training In Sports

Below is a great video to watch about how to do a complete Sports Assessment where you can test braking skills and lateral movements similar to those used in sports.


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. For more information you can download a Free Copy of our Secrets To Rehabilitation and Injury Prevention or Functional Training reports below by clicking the image.

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.