For those of you who have ever suffered knee pain, you will know how debilitating it can be. As we have to be on our feet all day, any knee or ankle/foot pain can be very frustrating and can take a long time to recover. Unlike shoulder pain where the shoulder can be rested, the legs get very little rest if we have to get about. So if you have knee pain, it can be treated but expect a longer recovery than, say, a shoulder or arm.

 

Generally there will be 2 kinds of knee pain, that which results from trauma (sport), and that which 'just comes on' (insidious). It is difficult to say which is more common, but the pain that results from trauma has an advantage over the insidious pain in that you know what caused it. In the insidious form, there is usually no obvious cause, and can be from an accumulation of many little things over a lengthy period of time. In these instances, by the time pain shows, the body may have been through many adaptive changes, so the problem did not start when the pain started! This is something as a patient you need to be aware of as you might become impatient expecting the pain to go as "it only started yesterday...". The longer the body has adapted to try and protect itself, the longer the recovery.

 

Let's talk more about the insidious type of pain in the knee. Commonly someone will report pain starting when they woke up and got out of bed, or after exercise, or after a walk with the dog, but very seldom describing a one-off incident. The pain can start small and get worse with time or stay constant, it can be sharp, dull, 'inside the joint', all around the joint, front or back, and on occasions can be accompanied by 'giving way' or 'locking' of the knee. No one injury or pain pattern is the same. We are all individuals and everyone's circumstances are different. Pain can also be accompanied by stiffness, which can spread to the thigh or calf.

 

The general rule with knee pain that was not caused by trauma, is that the knee is a victim of hip muscle imbalance. It is very unusual for the knee to be the starting point of this type of pain, so any therapist who goes straight to the knee will be missing out on the possible cause, and will only be treating the result/symptom. It is vital to test hip muscle strength and range of movement, as without correct support from the hip, the knee will suffer under excess load. What the hip cannot do the thigh will compensate for, and this affects the knee function. Overuse there causes stiffness around the knee and thus dysfunction and pain.

 

So what causes hip weakness? Well again this could vary from person to person. I have found the most common cause to be some form of overuse. Now this could be something such as exercise overuse, or even overuse from sitting in one position for a long time. Either way the soft tissues of the hip are affected in such a way that they will stiffen. Soft tissue of the body (fascia) is an adaptable tissue. If you stress it too much or if you leave it in one position for too long it will shorten. The problem is this, though. The shortening not only affects the movement of the hip, but it has a direct effect on the strength of the hip muscles. This results in weakness as the muscles do not have the space required in which they can contract fully. So the rule here is stiffness causes weakness. So for the body to function well, it requires flexibility, which in turn will allow muscles to work at their best.

 

Now, if the hip was weak, that means every time you stand on that leg, the muscles do not support you and more weight goes into that leg, which means you then have to push off more weight with that leg, causing overuse of the thigh muscles and calf muscles. This overuse results in tightness in these areas, which in turn can cause weakness and thus dysfunction and pain. At the same time, with weak hip muscles your body naturally compensates, thus using other muscles to balance the pelvis, such as thigh muscles (knee pain) and back muscles (back pain). So the soft tissues of the thigh will tighten, thus restricting mobility of the knee and this can stress ligaments of the knee, causing pain. This process could take weeks or even months to develop before pain becomes part of the problem, so by the time you get pain, there might be a lot of adaptive changes your body has been through, thus a lot more treatment than you might think.

 

The majority of knee pain is treatable through restoring flexibility and thus strength, but exercise could be detrimental, especially if weakness has not been tested for or analysed, and not just that, but the CAUSE of the weakness is often not assessed. If exercise is prescribed to treat this type of problem it will overload an already dysfunctional system, which is not weak due to lack of exercise but due to tightness. So the exercise will cause further stress, and most likely force the body to compensate again, thus putting stress on more areas, making the condition worse, even though there may be an initial ease in the symptoms. So be aware of exercise when you have pain. Just think of what your pet dog or cat would do if injured, they will not run around until they are better, so why should we?

 

I have mentioned the knee collapsing or locking earlier, and this often indicates some damage inside a joint. This damage if not caused by trauma, is often an end result of months of constant strain on the joint due to tight soft tissues and weak muscles. Wear and tear eventually results, and the pain from this is quite deep. This will often require further investigation, however, it will be worthwhile receiving treatment anyway, as the causes of the joint damage still need to be reversed, even if surgery is required. Then all you will be recovering from will be the surgery, which makes any post-op recovery a lot quicker.

 

Occasionally, knee pain could be caused by something lower down in the bio-mechanical chain, that is the foot. This is less frequent, but one of the common causes I have found is the inserts you find in most trainers/joggers/running shoes. By this I mean the extra little piece on the inside of the shoe insert, under the arch of your foot. If you have a pair of trainers, look inside on the side of your big toe and you will see the insert rises up in the shoe under the inside arch. This little piece of material could be a major irritant of the foot. When your foot lands on the ground in the shoe, the arch drops, which is a natural action which normally allows the toes to splay and builds up a spring-like tension under the foot, ready for pushing off. However, if your arch senses this insert in the way, the foot will lift off this piece of the insert and force you to walk on the outside of your foot, then roll around and back onto the big toe. This lifting action causes tightness to develop in the muscles that lift the foot and these are found on the inside of your shin bone deep in the calf muscle group. This tightness can then affect knee function and thus knee pain. So beware of inserts, give your foot as much freedom in your shoes as possible.

 

So what about traumatic knee pain. Well this is a bit more obvious as to the cause, but different trauma will result in different types of knee injury. Commonly knee trauma from the sides will affect the ligaments, such as the Anterior Cruciate Ligament seen in many sports injuries. But, generally any trauma of the knee from being kicked to falling on it will have an effect not only on the knee but also the hip and calf as there are soft tissue links throughout. So just because your knee hurts from being traumatised does not mean that the knee is the only area requiring treatment. An assessment must be done of the hip and calf/ankle on the same side to ensure all supporting structures are working well, otherwise the knee may never recover fully.

 

In conclusion, knee pain is common, but just as common is the cause, which is not always the knee but the hip, so ensure any treatment you get includes the hip and not to forget the calf/ankle.