You have bad knees right?? No matter what you do you end up with knee pain. You’ve foam rolled your ITB till you're black and blue, you’ve strengthened your VMO (inside quad muscle - can’t really be independently strengthened, but that’s another story), you’ve had x-rays, M.R.I’s and consulted very expensive specialists who surely should know best as to what’s going on with your knees. But alas, you still have knee pain. Have you ever considered that it may not be you knees that are the problem?
Whilst a lot of knee issues can be the knee joint itself, especially traumatic injuries to the knee, more often than not it is the knee that is screaming out in pain because you have an issue upstream or downstream of the knee, ie: the hip or the ankle. There is also the case where it is a knee pathology that is being aggravated by an instability in the hip or ankle so it is alway important with the knee to check the hips and ankles.
In regard to the body regional interdependence basically means that each part is mutually or equally dependent on each other ie: the hips rely on the knees as much as the knees rely on the hips for proper biomechanics.
Joints take turns from the foot all the way up to the head, alternating between stable and mobile joints. A mobile joint is considered a joint that can move in many directions. A stable joint doesn’t like to move in many directions and usually only moves fin a couple of directions and prefers stability.
Here is a list:
Foot - Stable
Ankle - Mobile
Knee - Stable
Hip - Mobile
Lower back (lumbar spine) - stable
Middle back (thoracic spine) - mobile
Lower neck (cervical spine) - stable
Upper neck (cervical spine) - mobile
Scapula - stable
Shoulder - mobile
Elbow - stable
Wrist - mobile
Hand - stable
The ankle is a mobile joint. This means that it can move in many planes of motion. Ankles can flex up or down (dorsi flexion= pulling foot up towards body and plantar flexion: pointing foot down)., they can go in and out (invert and evert), pronation and supination as well as a bit of rotation.
The hip is even more mobile than the ankle. It can rotate, move forwards and back (flex and extend) as well as go out the side and back across the body (abduct and adduct).
The knee however really only likes to move forwards and back (Extend and flex) as it is a hinge joint. Think of the movement a hinge in a door will do. The knee can rotate slightly but many issues can arise when we ask our knee to rotate too much or in repetitive tasks for the knee such as running. Anyone who has torn their ACL in the knee will agree with this as the ACL is most commonly injured when the knee is asked to rotate more than it can.
So you can imagine that if the hip is unstable then the knee can move all over the place. The most common issue is that the hip stabilisers aka the Gluteus Medius and Minimis are weak or not doing their job properly so instead of holding the knee in proper alignment the knee can drift inwards over the big toe side of the foot. The knee will likely also rotate inwards too.
Also if the foot is pronating, which usually means the ankle is dropping inwards, then the knee will also follow it and drop inwards.
So there you have it. If the ankle and hip are unstable or weak then the knee will be asked to move in ways that it isn’t capable of doing and over time can damage the knee joints the ligaments or the meniscus inside the knee joint. One of the most common knee injuries is called patellofemoral pain syndrome. One of the most common causes of this injury is that the patella (knee cap) isn’t sitting well in its joint on the femur, often called a patella tracking issue. This can often be caused by the femur and or the tibia rotating inwards caused by the hip or the ankle weakness or tightness.
So what can you do?
What??, I hear you ask, you mean I have to do something?? Yes, unfortunately, if you want to fix these kinds of issues you need to put some good time into exercises to help strengthen muscles and establish motor patterns that can allow for stability in these important joints.
Obviously having an assessment to see where your issues lie is the first step. But a general rule of thumb is to check if your feet are dropping inwards or you have flat feet. You can also stand in front of a mirror with your knees exposed and see if your knee caps rotate inwards. This is a sign that the femur (upper leg bone) and/or tibia (lower leg bone) are rotating internally.
To fix the hip
The first thing to do if your hip is dropping inwards we need to find out if it is a weakness in the abductors/external rotators of the hip or if it is a tightness in the adductors or internal rotators that are keeping the femur locked into an internal, dropped position.
To help the femur rotate externally or outwards and to also stop the femur from dropping inwards you need to strengthen the gluteus medius. The Glute medius, most commonly called Glute Med (pronounced mead) is an overachieving muscle as it wants to do pretty much all of the hip ranges of motion. This includes hip abduction (lifting leg out to the side), external rotation of the femur, extension of the femur (taking the leg back), the front fibres of the muscle also perform internal rotation and flexion of the hip as well. So the only hip action the glute med doesn't do is adduction. Often left out of anatomy books as to what glute med’s action is, is hip stability, which is basically the hip flicking out to the side. If you think of an olympic walker flicking their hips all over the place, or a catwalk model, then this is what Glutei med is trying to prevent. A strong glute med is seen when you stand on one leg and the pelvis stays level and the hip doesn’t push out to the straight leg side.
To self assess your hips you can stand of a mirror and place your fingers on the bones that stick out at the front of your pelvis (A.S.I.S). Stand on one leg and then lift the other leg bending it at the knee. You should lift the knee up to hip height. The pelvis should stay level, so you shouldn’t see one of your fingers drop down as the pelvis drops. If the pelvis drops on the side where your leg is straight then it is showing that the glute medius can't hold the hip in position.
Glute Medius/minimus strengthening / stabilisation exercises.
Easy isolated exercises: banded clams, Jane Fondas,
More functional exercises: banded crab walks and all the variations - side walking, forward/diagonal walking, backwards diagonal walking, 90/90.
Stability exercises: single leg exercises are the key to hip stability and therefore knee stability. Single leg deadlifts, lunges, single leg hip thrusts,
You can also incorporate glute med strengthening and stability into your everyday life. When walking try to make sure that your knee doesn't drift inwards. The rule of thumb is that your knee- cap should track over the 2nd and 3rd toes.
To fix the ankle
If the foot is dropping in or flat the this will also let the knee drop in which then means the knee joint isn’t aligned properly and also the knee cap can be rubbing at the patello-femoral joint.
Try this!! If your feet are flat or you think/have been told you have flat feet then you can do this quick assessment to see what is causing the flatness. Flat feet or over pronated feet can be caused by a variety of issues. The 2 main ones are weakness in the muscle that holds the arch or the way your bones are aligned. If you can lift the arch in you foot then it is likely that it is just weakness in the Tibialis Posterior muscle which lies deep to your calf muscles and attaches to the Navicular bone in your foot. If this muscle is weak then it will just drop the navicular bone and it will appear you have flat feet. Most commonly flat feet is just weak feet. Most people have flat feet because most of us have weak feet. When was the last time you did isolated foot exercises at the gym?? But you’ll do biceps or glutes right?? Same thing, we need strong feet and ankles.
Isolated: banded foot inversions (strengthens tibialis posterior), toe curls, arch raising, toe spreading, toe raising.
More functional: calf raises, single leg calf raises (can easily do calf raises at the traffic lights or waiting for the bus), toe walking (walking around on the toes. Being more mindful of keeping the arch up when walking and not letting your foot drop inwards, this also helps to reprogram the motor control of foot mechanics or the way you walk. You can also apply this to any gym training. If you are doing squats, deadlifts or lunges make sure to keep your arch raised and not let your ankle drop in.
If the ankle or foot is tight then the ankle won't be able dorsi flex enough, this then means that the foot will roll in when you walk. The foot will compensate by using the pronation of the foot which will also make the knee drop in. To increase your dorsi flexion you need to stretch your calf muscles. If you have tight calves then you may find you pronate and then get knee pain.
Stretching the peroneals (outside of lower leg). If the peroneals are tight then they can be pulling the ankle and foot into pronation.
A good combination of Mobility (flexibility and strength), Stability and Strength is important to fix injuries and also prevent them from happening in the first place.
So there you have it. Hopefully now you realise that those pesky knees aren’t so pesky after all and it may have been the ankle or hip all along. Whilst knee pain can be caused by the hips and knees it is always important to still check the knees themselves as there may be an injury there that is being aggravated by the instability or tightness in the hip or ankle. At Muscle Therapy Australia we endeavor to perform a thorough assessment so we are not just making assumptions and guessing about what the issue is. A good assessment will look at the whole body and not just isolate to one joint, this way we are less likely to miss things.
As always we are here to help if you would like to have a professional assessment and find out if your knee pain is actually coming from the hip and/or ankle. Also if you need more direction on any of the exercises then feel free to get in touch.