Knees are complex structures with a near-endless list of possible disorders. This can make it tough to identify the main culprit when there’s knee pain. Designed primarily for stability, some say the knee has little control of its fate. Functionally, the knee is a slave to the hips and ankles and could therefore be described as a “dumb” joint.
It may be tempting for manual therapists to see the soft tissue and bony components between the femur and tibia as the sole source of knee pain. However, researchers have found this is not always the case.1 The tibiofemoral and patellofemoral joints serve as pain centers for functional problems that may begin as far south as the feet and as far north as the thorax.
For example, Image 1 depicts a common right-motor dominant (RMD) compensatory pattern frequently seen in clients presenting with chronic runner’s knee and iliotibial (IT) band friction syndrome. A person with this RMD postural pattern would present with excessive right-sided foot pronation, internal tibial rotation, and external femoral rotation.  

Compensatory Patterns
In the presence of prolonged foot pronation, the arch and calf antigravity muscles forget how to turn on and off in proper sequence. This can lead to altered neural drive, muscle amnesia, and faulty ingrained movement patterns. During gait evaluation, the trained eye observes how the weakened medial arch permits excessive internal tibial rotation as weight transfers from heel-strike to toe-off.
With the average American taking more than 5,000 steps per day, repetitive strain accumulates in supporting ligaments, cartilage, and the joint capsule. To make matters worse, the moment the hyperpronated foot bears weight and internally torsions the tibia, the motion is met with resistance from tight external hip rotators, particularly the piriformis, in conjunction with the vastus lateralis and tensor fascia latae (via the IT band). These tug on the lateral side of the knee’s retinaculum, forcing the femur into external rotation and causing an abrasive shearing of joint surfaces.
Many joint problems, including runner’s knee and IT-band friction syndrome, are born from this common compensatory pattern. Luckily, it’s pretty easy to prevent and is often correctable, provided the trauma hasn’t dug its tentacles too deep into joint structures. In Images 2–4, I demonstrate a few myoskeletal alignment techniques you may find helpful in unwinding femur, tibia, and ankle torsional patterns.  

Dealing with Weak Hips
Only in recent years have scientists studied the hips as possible contributors to knee pain. Tracy Dierks, director of the Motion Analysis Research Laboratory at Indiana University, was among the first to focus on hip strength, gait changes, and knee pain during prolonged running.2

Dierks’s research team confirmed that the application of specific hip strengthening exercises improved joint and muscle biomechanics and effectively reduced pain. As the legs were trained to move through a greater range of motion, the (pain) guarding mechanism was reduced, allowing greater coordination and control.
According to Michael Fredericson, MD, orthopedic professor and team physician for the Stanford University track program, patellofemoral pain often originates in the hips. “Runners who have patellofemoral pain and IT-band problems are often weak in the hip abductors,” Fredericson says. “Systematic strengthening of the hips can help alleviate and prevent pain.”3

Global Assessment is Key
Whether the knee is a dumb joint, unable to determine its destiny, is debatable. However, we can say with certainty that it is a vital part of the kinetic chain and must be globally assessed to ensure a positive outcome. Take time to look above and below the pain site, examining the system as a whole. As author and physical therapist Gray Cook often says, “Treat the pattern, not the parts.”
Manual therapy, alongside a well-designed and executed corrective exercise program, will help keep your clients in the game. Ultimately, this treatment combo will improve movement pattern dysfunction and permit optimal functioning of the body’s natural healing processes.

Notes
1. Tracy Dierks et al., “Hip Strength and Hip Kinematics During Prolonged Running in Runners with Patellofemoral Joint Pain,” Medical Science in Sports and Exercise 37, no. 5 (2005): 157–8; M. L. Ireland et al., “Hip Strength in Females with and without Patellofemoral Pain,” Journal of Orthopaedic & Sports Physical Therapy 33, no. 11 (2003): 671–6; M. R. Prins and P. van der Wurff, “Females with Patellofemoral Pain Syndrome Have Weak Hip Muscles: A Systematic Review,” Australian Journal of Physiotherapy 55, no. 1 (2009): 9–15; Frances Long-Rossi and Gretchen B. Salsich, “Pain and Hip Lateral Rotator Muscle Strength Contribute to Functional Status in Females with Patellofemoral Pain,” Physiotherapy Research International 15, no. 1 (2010): 57–64.
2. Dierks et al., “Hip Strength and Hip Kinematics During Prolonged Running in Runners with Patellofemoral Joint Pain.”
3. Michael Fredericson and Tammara Moore, “Muscular Balance, Core Stability and Injury Prevention for Middle- and Long-Distance Runners,” Physical Medicine and Rehabilitation Clinics of North America 16, no. 3 (2005): 669–89.

Erik Dalton is the executive director of the Freedom from Pain Institute. Educated in massage, osteopathy, and Rolfing, Dalton has maintained a practice in Oklahoma City, Oklahoma, for more than three decades. For more information, visit www.erikdalton.com.

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