Arthritis. Bone on Bone. Meniscus Tear. Patellofemoral Syndrome. Patellar Tendinitis. Gout. Knee Sprain.
These are common words or phrases we hear about knee pain on a daily basis.
Unfortunately once a patient hears this is (possibly) the source of their pain and stiffness it is extremely difficult to change that mindset. Also of concern, it is commonly thought that several of these conditions require surgical intervention to properly treat or "Fix" the "Problem".
We know when imaging is the first step in treatment abnormal findings will be discovered in the majority of those over the age of 30, whether knee pain is present or not!
Many conservative care providers (Chiropractors, Physical Therapists, Athletic trainers, etc) are well aware of the connection between knee pain and mobility issues at the hip or ankle. While less common, it is possible for the spine to refer symptoms to the knee but more on that another day.
I know. The hip and ankle are a good distance away from the knee so how is this possible?
The Hip
The hip and the knee are two of the largest weight-bearing joints in the human body. These two joints are closely connected, and dysfunction or injury in one joint can often lead to pain or dysfunction in the other.
The hip is a ball-and-socket joint connecting the thigh bone (femur) and the pelvis. The knee is a hinge joint connecting the femur to the shin bone (tibia). When the hip is healthy and functioning properly, it allows for smooth and pain-free movement of the leg below, which can help prevent knee pain.
However, when the hip is not functioning properly, it can lead to abnormal movement patterns in the leg, which can place increased stress on the knee. Some common hip conditions that can cause knee pain include:
Hip osteoarthritis: Hip osteoarthritis is a condition in which the cartilage that cushions the hip joint wears away over time, leading to bone-on-bone contact and pain. When the hip joint is painful, it can cause a limp or altered gait pattern, which can put increased stress on the knee joint and lead to knee pain.
Hip bursitis: Hip bursitis is a condition in which the bursa (a small sac of fluid that cushions and lubricates joints) in the hip joint becomes inflamed. When the hip joint is inflamed and painful, it can cause altered movement patterns in the leg, which can lead to knee pain.
Hip labral tear: The hip labrum is a ring of cartilage that lines the hip socket and helps to stabilize the hip joint. When the hip labrum is torn, it can lead to hip pain and altered movement patterns in the leg, which can put increased stress on the knee joint and lead to knee pain.
Hip impingement: Hip impingement occurs when there is abnormal contact between the bones in the hip joint, which can lead to pain and limited mobility. When the hip joint is not able to move through its full range of motion, it can cause altered movement patterns in the leg, which can lead to knee pain.
Hip muscle weakness: The muscles that surround the hip joint are responsible for stabilizing and supporting the joint during movement. When these muscles are weak or imbalanced, it can lead to abnormal movement patterns in the leg, which can put increased stress on the knee joint and lead to knee pain.
These are just a few possibilities with muscle weakness being one we see commonly and is easy to screen for. The patient often presenting with hip muscle weakness is typically younger and well conditioned. Even some of the strongest high school or college athletes you know may present with hip weakness on one side. Utilizing a combination of squat patterns (single leg squat/pistol squat in particular) can assist in diagnosis while observing for the weight bearing knee to crash into valgosity (or move inwards such as if they were "knock-kneed"). This movement or crashing can be normal so evaluation by a trained movement-based therapist is critical. Interestingly, through dry needling, percussive therapy, or other immediate stimulus into the affected musculature (typically glutes) we can provide immediate (yet short-term) improvement to further assist in diagnosis but long-term improvement requires unilateral work (depending on where the patient is at this can include single leg glute bridges, single leg deadlift variations, single leg squat variations, etc).
The Ankle
The foot/ankle complex is a complicated structure that works to support tthe rest of the day during daily movements. Changes in movement at the ankle can cause the leg above to bend inwards or outwards off and on throughout the day which is normal. However, too much of one movement can take it's toll. Let's take a look at a few reasons the foot and ankle can be a cause or contributor to knee pain
Flat feet or overpronation: This occurs when the arch of the foot decreases in height or drops toward the floor while standing or during the gait cycle. This typically involves a cascade of movement changes in the joints above as the knee can cave inwards (or into valgosity as mentioned above) increasing stress to the knee joint.
Proper alignment: This is essential to distribute force through the kinetic chain above and comes down to joint health and proper mobility. When one or a few joints of the foot/ankle are not moving properly it can change the appearance of the gait cycle and lead to pain or dysfunction of the joints above.
Plantar fasciitis: This is a fairly common condition of the foot involving a repetitive and abnormal inflammatory response in the area of the heel. This can alter a persons gait cycle and cause abnormal walking, leading to added stress in the joints above.
Ankle sprain: Ankle sprains can occur into inversion (rolled in or most common) or eversion (less common and can be more severe, often requiring surgical intervention). When sprains occur it can lead to swelling of the tissue and pain. This can again lead to abnormal walking which adds stress to the joints above with the first one to bear the brunt being the knee.
Achilles tendinitis: Tendinitis of the achilles is a painful condition at the back of the calf near the heel bone. Pain and swelling in this area will frequently change how a person is walking and cause them to favor that leg which may lead to abnormal gait and added stress to the knee above.
Gait abnormalities: It may be apparent by now that many conditions affecting the foot and ankle will change how these joints move throughout the day. Any of these changes will change the stress to the next joint up the kinetic chain and lead to knee pain
The joints of the body are complex structures that must work with those around them. The foot and ankle are no different and a mobility issue here may go unnoticed until it begins to affect the joint above (the knee) or in cases of other joint mobility issues may affect a joint above or below. Even then with knee pain you may not notice a mobility issue in the foot or ankle while a trained provider will screen adjacent regions.
The ankle and the hip are mobile areas that when an issue arises may not cause immediate pain and the first sign of one of these mobility issues can be knee pain. While seeking out treatment on day 1 of experiencing knee pain is often unnecessary, it may take a trained movement specialist to identify the cause of pain at the knee. If experiencing knee pain it is more common than not that the real issue is above or below the painful area. Dysfunction or injury to a hip or ankle are two of the most common findings when knee pain presents to our office and screening these locations is essential to uncover the involved altered movement patterns.