TREAT THE CAUSE AND NOT JUST THE SYMPTOMS
Knee pain is annoying, can really limit activity options, and can cause real pain and difficulty in people’s lives. Many people have been dealing with it for years and think that they are just going to have to get used to it forever. We don’t agree with that. Knee pain is the most common musculoskeletal pain complaint after low back pain. Almost everyone has had a knee problem at some point. Our collective understanding of the causes of knee pain has made staggering strides and progress just in the last 10-15 years. Even though we now have a much clearer understanding of what causes knee pain and how to fix it, lots of people are still stuck with very old and incorrect information about why it’s happening and what to do about it. Many corners of the fitness and rehab professions are still stuck using the wrong information when it comes to how to treat knee pain. Let’s talk more about the actual causes as well as the most typical incorrect diagnoses and treatment plans.
The most important thing to understand is that in almost every case, even though the pain is in the knee, the problem is not in the knee. Sure, if you tear your ACL or meniscus the problem is in your knee, but even then, unless it was a contact injury, the cause of the tears were problems at the other end of the femur. Almost every case of knee pain is caused by poor hip and trunk stability and function. Most of the time the knee is a totally healthy joint that is an innocent victim of faulty mechanics elsewhere and is getting beaten up. The femur, which is the bone in your thigh, is the longest bone in the body. It inserts into your pelvis on the top end and the bottom connects to your lower leg at the knee. It is impossible to talk about hip stability without including control and stability of the femur. Essentially, hip stability is femur stability.
Many well-intentioned treatment plans look solely at the knee joint itself to fix the problem. It used to be widely accepted in clinical and orthopedic circles that the best plan to fix knee pain was to strengthen the quadricep muscles near the knee, mainly the VMO which is the teardrop shaped quad muscle on the diagonal inside of the thigh. It was thought that improper tracking of the patella (kneecap) was causing knee pain and strengthening this VMO muscle would pull the kneecap back into the center. So over the last 20-25 years, hundreds of thousands if not millions of surgeries were performed to correct “lateral patellar tracking”. Basically all of these surgeries were unnecessary given what we know now. Isn’t that crazy?? It turns out that while MRIs in fact did show that the patella was tracking laterally from the groove where it should sit, instead of the patella actually moving out of the groove, the femur was simply internally rotating underneath the patella. It’s as if the patella was staying in the same place and its foundation was moving underneath – which looks the same on an MRI. I had this issue back in college where I couldn’t sit with my leg bent for very long – I had to straighten it out to relieve the discomfort. This is a classic symptom of the type of knee pain that is caused by poor trunk, pelvic, and femur control but is not a structural issue.
Dr. Chris Powers is a savant orthopedic specialist and the arguably the top expert on the planet on the biomechanical causes of lower body injury. He is also a renowned expert in knee injuries specifically. He has published over 150 research articles and received many awards for his work. In case you are looking for some clinical commentary on the biomechanical causes of knee injury, Dr. Power’s research here is enlightening.
The most common problem involved in most knee pain cases involves internal rotation and adduction of the femur. Internal rotation is exactly that – the femur rotates inward – and adduction just means that the knee end of the femur moves towards the centerline of the body. Another term for this combination of internal rotation and adduction is “valgus collapse”. In the center picture below you see a picture of a female landing from jumping down off a box. As she lands you can see her femurs internally rotate – this is easy to see because the knee is inside of the foot. You technically never want your knee to be inside of the foot. If you draw a line straight down from your knee cap it should always be above your middle or outside toe.
A discouraging trend in the treatment of knee issues are injections. While cortisone, PRP and other substances may cause some sort of temporary relief, they never really fix why the inflammation and discomfort happened in the first place. Treating the knee joint only is like mopping the floor instead of fixing the leak in the pipe. You are not addressing the cause so it’s not going to work long term. At Human Movement Lab we consider injections to be “mops”, instead of a wrench that will actually fix the cause. Other mops that may provide temporary relief but do not address the cause are ice, soothing creams, knee braces, pain medication and rest. All of these have their place, but they aren’t going to fix the problem. It’s not bad to use a mop, as long as you don’t think it’s a wrench. A lot of advice, commercials, and other advertisements describe mops as if they are wrenches, which is misleading.
Even with very painful knees, there is usually nothing wrong with the knee itself – it is just getting beaten up by the forces placed on it. The analogy we like to use is as follows: a face that gets swollen and inflamed from getting punched is responding normally. There is nothing wrong with the face other than the fact that it is getting punched. The solution to a swollen and painful face from face punches is not to use ice or injections or pain pills so the face doesn’t hurt or get swollen as the face punching continues, the solution would be to stop getting punched in the face. These “mops” just try to stop the results of the punching. We want to help your knees stop getting punched in the face instead of waiting for it to happen and then handing them an ice pack
Stabilizing the trunk and hips, correcting the mechanics of a symmetrical hip hinge, elimination asymmetries as well as checking other basic movement patterns and mobility is a sure way to fix knee pain even if it has been going on for years. We see people all the time that have had issues for a long time and have been through multiple unsuccessful attempts of fixing them, and we are able to fix these problems completely.