Got Knee Pain?

The knee is one of the most commonly injured regions in the body:

  • An estimated 80, 000 to 100, 000 anterior cruciate injuries (ACL) occur annually in the US
  • Approximately 70% of these are non-contact (i.e. related to poor biomechanics)
  • There is a strong correlation with ACL injuries and future arthritis in that knee

Functional Anatomy

The anatomical location of the knee joint it such, that it is greatly influenced by the neighboring joints above (lumbo-pelvic-hip complex) and below (foot and ankle complex).
I have heard it said that the knee goes where the foot directs it and the hip permits it, i.e. It is greatly influenced by the mobility of these joints.

Bone and Joints

The primary bones making up the knee joint include:

  • Femur (thigh bone)
  • Tibia  (inner leg bone)
  • Fibula (outer leg bone)
  • Patella (knee cap)


Proximally (above the knee joint) the femur joins with the pelvis to make up the iliofemoral joint. The pelvis and sacrum join to make the sacroiliac joint.

Distally (below the knee joint), the tibia and fibula help form the ankle (talocrural) joint.


There are a number of muscles in the lower leg and lumbo-pelvic-hip complex that can influence the knee.

  • Gastrocnemius/Soleus (posterior lower leg)
  • Adductors (Inner thigh)
  • Hamstrings (Posterior thigh)
  • Tensor fascia latae/IT- Band (Anterior and Lateral hip and thigh)
  • Quadriceps (anterior thigh and hip)
  • Gluteal muscles (Posterior and lateral hip)


It is essential that these muscles have optimum length, tension and strength to ensure optimum flexibility, range of motion and neuromuscular control.

Common knee Injuries Associated With Movement Deficiencies

Patellar Tendinopathy (Jumper’s Knee)

  • Repeated stress from overuse on the patellar tendon results in inflammation and degeneration
  • Increase risk from knee valgus (knock-knee) or knee varus (Bow-leg)
  • Poor quadricep and hamstring flexibility can  lead to increased risk
  • Women more susceptible (8x) due to an increase in the Q angle (a measurement of the angle between the quadriceps muscles and the patella tendon that provides  information about the alignment of the knee joint)

Iliotibial Band Syndrome (Runner’s knee)

  • Inflammation of the distal part of the iliotibial tendon as it inserts into the outer part of the femur at the knee joint or less commonly proximally at the hip, where it can cause bursitis
  • Common in runners, cyclists and tennis players, as an overuse injury
  • Factors such as an over active Tensor fascia latae pulling on the IT- Band, as well as weakness in the hip abductors,  greatly influence proper mechanics, resulting in friction and eventually inflammation

Patellofemoral Syndrome

  • Abnormal tracking of the patella due to altered activation of the muscle surrounding the knee as well as weakness in the hip musculature (Gluteus medius and maximus)
  • Patella tracking can also be affected by an abnormal Q-angle

Anterior Cruciate Ligament (ACL) Injury

  • Commonly due to altered or insufficient  lower extremity neuromusculoskeletal control from muscle imbalances and joint misalignments (Pelvis, knee and ankle)
  • Valgus torque (knees tending more towards adduction, which is more common in women), affects frontal plane stability (side to side movements) and greatly increases the risk of injury during side-to-side movement and landing from a jump

A Systematic Approach to Identifying and Correcting Knee Impairments

An integrated assessment of the knee should involve:

Static Posture- Look for pronation at the ankle resulting in knee adduction stress

Movement Assessment (e.g. Overhead Squat)- Knee´s move in (valgus); Knee´s move out (Varus)

Jump Assessment- Look at landing mechanics, e.g. knee valgus and poor foot placement

Range of motion- Of the  Hip, Knee and Ankle

Manual Muscle Testing – Muscles around the Hip, Knee and Ankle

Joint Palpation- Ankle, knee, Lumbo-Pelvic-Hip


Sample of A Corrective Approach to Knee Injuries


Phase Modality Muscles Acute Variables
Inhibit Dry needling

Manual therapy

Foam roller




Piriformis (Knees move out in squat)

Hold tender area 30-60 seconds
Lengthen Stretching Gastrocnemius/Soleus



Piriformis (Knees move out in squat)

30-60 seconds
Joint Mobilization Manual therapy Ankle




Mobilization with pain-free movement
Activate Isolated  strengthening exercises


Tibialis muscles

Gluteal muscles

Adductors and medial hamstrings (knees move in on squat)

10-15 repetitions

4/2/1 Tempo


4 reps

Increasing intensity

Integrate Functional dynamic exercises Ball squats



Single-leg squats

10-15 repetitions

4/2/1 Tempo


Key Points

  • The majority of injuries in both college and high school athletes involve the lower extremity, with the knee being the most common area
  • The knee is linked to and impacted by proximal (lumbo-pelvic-hip complex) and distal (foot and ankle) joints via relationships in the kinetic chain
  • Most knee injuries involve neuromuscular deficits such as joint misalignment, muscle imbalances and poor neuromuscular control, often perpetuated by overuse
  • An integrative assessment should consist of:

Static Posture Assessment

Movement Assessment

Jump Assessment

Range of motion

Manual Muscle Testing

Joint Palpation

  • A comprehensive treatment plan should involve:

Inhibiting and Lengthening overactive muscles

Activating underactive muscles

Joint mobilisation

Integrating full body functional dynamic movements


Got knee pain?


Other References

Clark, M., & Lucett, S. (Eds.). (2010). NASM essentials of corrective exercise training. Lippincott Williams & Wilkins.




I am teaching 5/15 in Bellevue at Fitness Forward. Details below:


About the Author

Dr. Geoff LecovinNaturopathic Physician/Chiropractor/Acupuncturist/Certified Strength and Conditioning Specialist/Corrective Exercise Specialist/Performance Enhancement Specialist/Certified Sports Nutritionist/View all posts by Dr. Geoff Lecovin