Knees. If there’s one part of the body that I get questions about it’s knees. Specifically the kneecap and often from those who are getting a bit older. They hurt in the morning. Creak and pop when we climb stairs. Sometimes the kneecap slides in and out of position, which just really feels unpleasant.
The allopathic medical community has treated these cases of patellofemoral pain pretty much the same for years. Rest and stop the irritating activity. Brace and tape. Strengthen the outer muscles of the thigh, and then get the knee scoped to “clean it up”. Sometimes a lateral release is performed to help free the restricted kneecap and allow better movement. The problem with these approaches is that they rarely bring lasting relief because none of the address the root cause of the pain and dysfunction.
So what is going on that causes all of this pain and dysfunction is the small area where our kneecaps reside. The quick answer is improper alignment and muscle recruitment, but to really understand we need to go a bit deeper.
The Patellofemoral Joint
The Patellofemoral Joint (PFJ) consists of the thigh bone, the shin bone, and the kneecap, as well as a ton of supporting muscles. We all know that the thigh bone is connected to the shin bone, but most people don’t really understand how the kneecap fits in. It doesn’t just float around in our knees on top of the joint. Instead, the kneecap is enclosed in the tendon that connects the thigh muscles to the shin. It’s called the patellar tendon and many athletes have issues with pain there are well. And yes, it's related. The cool thing about our bodies is that the end of the thigh bone has the little valley in it that is perfectly shaped for the underside of the kneecap to fit. It’s like pieces of a puzzle.
Then the end of the thigh and shin bones and the underside of the kneecap are all coated with slick cartilage that allows them to move against one another without building up friction and irritation. But here’s the catch - the bones have to be positioned in perfect alignment in order for the puzzle to fit. If not, we can kind of jam the pieces in the fit, but we get a lot of friction that leads to fraying of the slick cartridge and irritation. The more we try to fit the pieces together, the more fraying occurs. So really what we need to do in treating and resolving patellofemoral pain is to figure out why our particular puzzle is fitting like it’s supposed to, and then correcting the alignment to make it worked effortlessly again.
There’s a really good chance that the root cause of your knee pain can be traced back to how you stand, sit, and move throughout the day. Look down at your feet. Which way do they point - straight ahead, out like a “v”, or in like a peak? Most of us have a bit of turnout when we stand, but unless your feet are aligned perfectly in front of you, that slight turn out or turn in can affect how that kneecap tracks in its groove. Think of it like the alignment of a car. Imagine what would happen to your car if you tried to drive it with the tires pointing outward instead of straight ahead. If you were able to control it, there would definitely be damage to other parts of the steering mechanics in your car. You might be able to get away with it for a bit, but eventually, those other parts are going to wear out and you’re going to have to fix a lot more than your tires. The same goes with your feet. When we turn them in or out, it can reposition the shin bone where it attaches to the thigh bone, and also how the thigh bone sits in the hip joint. Remember that the kneecap lives inside the tendon that connects our quads to our shin bone. When the groove of the thigh bone shifts, the patella doesn’t necessarily change with it. It’s still trying to move straight up and down, but it’s nice slick groove isn’t there anymore. It now slips between the slick cartilage groove and the rough bone on the outside of the groove. This causes friction and breakdown of the cartilage that’s underneath the kneecap, and this breakdown leads to pain and irritation
Another contributing factor is the forces of our muscles.
When our feet and leg bones are aligned, the muscles of the inner and outer hip work together in balance to help us walk a and pull the kneecap up and down in a straight line. However, with that shift in how the bones fit in their joints is altered, the muscle forces can become imbalanced. For example, when our feet are turned out and the thigh bones are slightly turned in, the inner thigh muscles tend to work a bit more than the outer thigh and hip muscles. This means that the knee cap may sit and track more on the outside of that patellar groove (known as “lateral tracking). In addition, if the shin bone is slightly rotated outward, following the turned out position of the foot, that can also cause the kneecap to sit on the outside of that groove. This is why we get knee pain or kneecap subluxation sometimes with running, lunging, squatting, and standing from the floor. Our body is literally trying to pull the kneecap out of the groove, and this does not feel good!
So what can we do about it?
Most of the braces and taping that are popular aim to try to keep the kneecap in its groove, and while these modalities can help for a time, they really aren’t helping to correct the issue. There are surgical techniques that can “clean up” the kneecap and joint from all of the breakdown of cartilage, but again it’s not really addressing this alignment issue. Another popular surgery is called a lateral release when a tight band of tissue is cut with the goal of allowing the kneecap to get back to its groove and not have a muscle pulling on it, but many people don’t find relief after this surgery, because again it’s really not addressing the problem.
The best thing you can do is to start fixing your alignment and restoring your core stability. Go ahead and brace and tape if that helps you move better right now, but in order to wean yourself off these techniques and prevent further degeneration, you have to start putting in some work.
Fix the Feet - Start working on foot alignment. This won’t happen overnight and it’s going to feel weird at first, but baby steps in the key. Align your feet so that the outer edges are in a line and your feet are about hip-width apart. You may feel like you’re turned in now, but that’s OK. Eventually, this will become more comfortable. Stand like this when you can - brushing teeth, filling up your car, etc.
Strengthen the Hips & Core. I mentioned the imbalance that occurs when our alignment it off, so after we’ve found our good neutral alignment, then we need to start telling those outside hip and glute muscles to start working again to bring stability back to the pelvis. Unfortunately, this can take some work, but spending just a few minutes a day to on corrective exercises can really help these muscles learn their role in supporting our knees.
Try these exercises. Aim for 3 per day:
- External Rotation of the Hips (hold 30-60 seconds)
- Pelvic List (5-10 reps ea side)
- Monster Walks (5-10 steps ea way)
- Patella Centering Exercise (5 reps ea side)
- Supine Block Squeeze (hold 30-60 sec) -
- Strap Stretch (hold 30-60 sec ea side)
- Calf Stretch (hold 30-60 sec ea side)
- Bolstered Spinal Release (Hold 3-5 min per side)
- Bolstered Psoas Release (Hold 5+ minutes)
Move More. I know this sounds a bit simple, and it is. Start moving more during your day. I don’t mean adding extra minutes onto your fitness routine, but rather moving your body in a greater variety of ways throughout the day. If you spend most of your day sitting in a chair, start spending more time either standing or sitting closer to the floor. I personally love floor sitting because it forces you to engage in several different positions while you’re done there. We really live in a mobile world, which means that we aren’t chained to a desk. Find different workspaces for you to cycle through during the day. Not working? If you’re shuttling your kids around to playdates, you can also get out of the chair. Stand, sit on the floor (who cares about the looks). Sit on the curb at the park, or better yet, start climbing and swinging with your kid. Fold laundry while sitting on the floor or standing. Place frequently used kitchen items either up high or down low so that you must move through a greater range of motion to get to them. Get creative - how can you add variety to moving your body each day (hint - don’t forget rotation. If you’re always turning one way to get something, start turning the other way).
These are just some basic ideas that should get you feeling better and relieving some of that knee pain that plagues so many of us. However, sometimes a more specific approach is really needed to get to the source of what’s causing the pain and to develop a plan that matches your needs because you are not like everyone else and a “one-size-fits-all” protocol rarely works in the long run. If that’s you, then let’s chat more. Click here to schedule a FREE 20-minute coaching call to discuss your specific needs.
Want some exercises that you can do on the go? Be sure to download the Knee Pain Audio QuickFix. This is a 10-minute guided practice where I take you through 5 exercises to help you improve knee alignment and strengthen your core.