When the body is challenged with a movement it will do anything it can to find the path of least resistance and most importantly avoid pain. The site of pain is very rarely the cause of the pain, it is merely the effect of a problem created somewhere else in the body. 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. Nowhere in the body is this more accurately seen than with the knee. In this article, I will explain what the most common culprits of knee pain are so you can either prevent future injury or be able to address the source of the problem if you already have a knee problem.
What Really 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. However, with injuries that develop over a long period of time the problem was there long before you had any pain signals! Your job is to find what the under-lying source of the problem is and correct it.
The four most common causes of knee pain are:
1.Poor foot stability
2.Lack of hip mobility and poor gluteal strength
3.Poor coordination creating instability & inefficient movement
4.Inactivity – (weight gain and sitting excessively)
You could have one or several of these factors combined together to create the perfect storm that creates stiffness, swelling, weakness and eventually pain.
Inactivity is the simplest factor of all to address and I explained this in great detail in the article about tight quadriceps how sitting poorly for too long can create problems with the patella tendon.
Many people would experience a significant reduction in their knee pain by focusing on improving their nutrition habits and losing some weight. This is more to do with nutrition than any muscular or strengthening program and the benefit to the knee can be significant. Also the benefits to your overall health of your body cannot be overstated and the risk of developing a more serious health condition from being overweight is another great reason to lose weight.
Experts estimate that for every 1 pound you weigh, your knees feel the force of 3 pounds of pressure when you take a step. This is not an exact formula as there are many other variables to consider, but as a general rule this is something to keep in mind.
1 lb bodyweight = 3 lb of pressure on your knees with every step you take. Walking up and down stairs will add more pressure and any physical activity like running or cycling will be even more. This means that if you lose 10 pounds of weight there will be 30 pounds less pressure per knee, per step.
What if you are very active and not overweight?
Well, in this case you have to look at the other factors and this is it where it can be a bit tricky. There is no one absolute reason as we are all unique so this means there no templates or magic exercises that work for everyone.
One thing is for certain you cannot effectively solve these problems with anti-inflammatory tablets, using knee braces or taping, and definitely not with surgery! Even focusing all your efforts on isolating muscles with strength training in the area around the knee will be ineffective, if you have not identified why some muscles are either working too hard or not enough that is causing you to have poor alignment in the first place.
Take for example patella tracking knee pain or ITB Friction Syndrome, both of these are caused from poor alignment of the lower limb with pain felt during walking and running. Strengthening the quads will do very little to solve this problem and most likely make it worse.
You must find the answer to this question in order to really solve the problem. These muscles did not just stop doing their work from bad luck. There is a reason behind this, if you find out what it is and correct it, your problems will be gone forever!
The Knee Is A Hinge Joint & Vulnerable To Twisting & Rotation
Starting with the most common cause which is poor alignment of the lower limb.
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. This is the purpose of the ligaments surrounding the knee being the ACL, MCL, PCL to allow for some torsion but to prevent any serious twisting of the knee joint.
Unfortunately they cannot withstand repetitive movements or explosive forces very well.
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 which will inevitably lead to problems! It is a bit like being caught in a crossfire.
Take a look at the picture below to see the chain reactions of problems that can be caused by excessive foot pronation.
This same scenario can also begin at the pelvis and hips where the hip is pulled into excessive anterior tilts and as a result forces the knee inwards which is known as knee valgus. This also leads to gluteal weakness which makes the whole problem much bigger and the longer it continues the more difficult it can be to correct.
Now it would be easy to say that all you need to do is strengthen the feet and the hips but it is never that easy, especially when the problem has been there for some time.
Sometimes I find no mechanical or muscular problem with isolated tests leading me to look at coordination and how the person positions themselves during a functional movement such as a squat, lunge or single leg stance.
This is where there may be no noticeable mobility restriction and even no obvious muscular weakness, but the problem is more to do with lack of stability and a poor understanding of how to move efficiently. This is nearly always the case with highly trained athletes or people with considerable strength. There is something about how they move that is the problem that is forcing the knee into a terrible position and you have to find what this is to make any lasting changes.
This is why you must use a detailed assessment to find where the source of the problem is and put a plan in place to resolve it.
Where do you start?
Very simply you need to complete a detailed assessment of your body.
Before doing anything it is important to take a look at any previous injuries and any existing problems elsewhere in the body. This information is very important in helping you find the root cause of the problem and is often a step that is missed in many treatments and examinations. Obviously any official diagnosis from a health practitioner and imaging results like MRI and X-ray are important in determining the exact area in pain and to what extent it is damaged. The thing that this does not tell you is HOW it was injured.
To find this out you need to assess all joints for length tension imbalance, trunk stability, posture, and lastly how you move with functional movements like squat, lunge, deadlift, and single leg actions. 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 also find the article – How to strengthen a weak VMO in 5 simple steps invaluable.
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.
Improve Foot Stability
Why do I mention the foot if it is the ankle that is meant to provide mobility?
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. The ankle will tighten up when the feet are too weak in an attempt to assist with stability but as we just discussed this is a massive problem for the knee.
What can you do about 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 forward.
Watch the video below where I explain how this works.
Additional articles to read with tons of exercise video examples for foot stability are below.
•Exercise solutions for weak feet
•Why big toe mobility is so important for movement
Address Mobility Deficits At The Ankle & Hip
Okay we know that these two joints are often big players in creating the injury or the pain for they are vital in providing the multi-directional movement to prevent the knee twisting or bending sideways.
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.
As I explained earlier the ankle will often develop stiffness as a compensatory mechanism for weak feet which is why I listed foot stability as step one. The ankle can be very tricky to work with at times so you have to use various exercises to restore mobility.
You will find a stack of additional information specific to these areas in the articles below.
Improve Core Stability & Posture
Core stability is always something that must be considered and can be a much more difficult to identify, time consuming and very frustrating to correct. This step must precede strengthening and completing the integrated functional movements like squats and lunges to avoid developing “stiffness” as a protective mechanism.
This stage prepares you for the more rigorous exercises to come where you learn to engage the lower abdominal muscles and deep core muscles which are all pivotal for providing pelvic and trunk stability.
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 fail by only focusing on muscle isolation and forget to teach movement. The body does not know its little finger from its big toe, it only knows movement patterns. Strength without efficient functional movement is a waste of time but having said that it can really help if you can tie it together.
Common weak areas with knee pain are often with the Vastus Medialis Obilique (VMO) and the glutes.
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. One of the easiest ways to test this is with the single leg hip extension.
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.
As for the VMO I have never found it useful to isolate this muscle at all. I will get a much better result using reactive neuromuscular training techniques later on.
Strengthen Weak Tendons With The Decline Squat Isometric Hold
Before I progress to the more difficult functional movements I will often use a squat on a decline board to strengthen weakened tendons. This has to be treated with care as you can easily aggravate things if you use it too early or do too much too soon.
However, if you get it right it can make significant inroads to regaining knee stability and strength to handle the more difficult exercises to come.
The isometric holding is the key to making this work.
Research indicates it is as much as 80% of muscular force transfers to the connective tissue. If you lift weights with deliberate slow movements you can improve the strength of individual collagen fibres and allow your body to rebuild much stronger and resilient connective tissue structures.
You can read more about this in the article – How to use the decline squat for knee pain
Assess Functional Movement Skills
This step is by far the most important for this is how your body prefers to move during the day. If you do not change the faulty movement strategies all of the rehabilitation exercises you have used so far are pointless for the body will just go straight back to the way it was moving that caused the problem in the first place.
With enough repetition of the perfect technique 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 develop compensatory movement patterns and eventually pain.
There is much more than just learning how to squat. You will need to the deadlift, lunge, and most importantly 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.
I prefer to start with hip loaded exercises like the Romanian Deadlift first for they are the least likely to aggravate the knee with this exercise and secondly they are most likely very weak with the glutes. This exercise is a perfect way to learn how to mobilize the hips and activate the glutes which will be critical when trying to move to single leg movements.
Watch the video of the RDL below for more on this.
Once the bilateral exercises have been mastered you must progress to the next stage which is by far the most critical and the one that reveals the most weaknesses and problems.
That is the single leg stance.
You Must Master 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. This comes back to what we discussed at the beginning and teaching the body how to control alignment of the lower limb effectively.
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.
Spend the time to fully learn the movement skills in the standing position and then perfect it.
I like to use the hip airplane in the beginning to gain stability and control of the alignment. This is an awesome exercise for it demands incredible foot stability in combination with hip strength.
Once I have mastered this I move to more loaded single leg deadlifts to ensure I build the strength into the glutes correctly. The hip airplane is great for stability but will not build enough strength to finish the job.
Make sure you read the article below for more detail on this.
•How to use the single leg squat as an assessment tool
If you have made it to this stage it is fair to say your knee pain would be almost completely gone by now. This does not mean you are fixed as you still need to work on other movements like lunges, step-ups and squats on the floor that will demand strength with all of the leg muscles.
Usually the lunge is very difficult to go as it requires the body to decelerate and the quadriceps make up a big part of this. You will find the video below gives you some great ideas as to how to improve knee stability within the lunge movement.
What If You Play 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 movement patterns are no good you will get injured. If your joints are poorly aligned you will get injured. If you are weak 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.
ACL injuries are so common in sports 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.
Some of my favorite exercises for preventing knee pain in sports are shown below.
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 get a copy of this program.
Summary
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 correctly designed strength training program that takes into consideration flexibility and stability problems will remove your pain and teach you to move pain free.
About The Author
Nick Jack is owner of No Regrets Personal Training and has over 20 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
•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