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I t p a y s t o b e A B M P C e r t i f i e d : w w w. a b m p . c o m / g o / c e r t i f i e d c e n t r a l 107 Knees are complex structures with a near-endless list of possible disorders. This can make it tough to identify the main culprit when there's knee pain. Designed primarily for stability, some say the knee has little control of its fate. Functionally, the knee is a slave to the hips and ankles and could therefore be described as a "dumb" joint. It may be tempting for manual therapists to see the soft tissue and bony components between the femur and tibia as the sole source of knee pain. However, researchers have found this is not always the case. 1 The tibiofemoral and patellofemoral joints serve as pain centers for functional problems that may begin as far south as the feet and as far north as the thorax. For example, Image 1 depicts a common right-motor dominant (RMD) compensatory pattern frequently seen in clients presenting with chronic runner's knee and iliotibial (IT) band friction syndrome. A person with this RMD postural pattern would present with excessive right-sided foot pronation, internal tibial rotation, and external femoral rotation. COMPENSATORY PATTERNS In the presence of prolonged foot pronation, the arch and calf antigravity muscles forget how to turn on and off in proper sequence. This can lead to altered neural drive, muscle amnesia, and faulty ingrained movement technique MYOSKELETAL ALIGNMENT TECHNIQUES Is the Knee a Dumb Joint? Contributing Factors to Knee Pain By Erik Dalton patterns. During gait evaluation, the trained eye observes how the weakened medial arch permits excessive internal tibial rotation as weight transfers from heel-strike to toe-off. With the average American taking more than 5,000 steps per day, repetitive strain accumulates in supporting ligaments, cartilage, and the joint capsule. To make matters worse, the moment the hyperpronated foot bears weight and internally torsions the tibia, the motion is met with resistance from tight external hip rotators, particularly the piriformis, in conjunction with the vastus lateralis and tensor fascia latae (via the IT band). These tug on the lateral side of the knee's retinaculum, forcing the femur into external rotation and causing an abrasive shearing of joint surfaces. Many joint problems, including runner's knee and IT-band friction syndrome, are born from this common compensatory pattern. Luckily, it's pretty easy to prevent and is often correctable, provided the trauma hasn't dug its tentacles too deep into joint structures. In Images 2–4, I demonstrate a few myoskeletal alignment techniques you may find helpful in unwinding femur, tibia, and ankle torsional patterns. DEALING WITH WEAK HIPS Only in recent years have scientists studied the hips as possible contributors to knee pain. Tracy Dierks, director of the Motion Analysis Research Laboratory at Indiana University, was among the first to focus on hip strength, gait changes, and knee pain during prolonged running. 2 During stance phase, the arch overpronates, causing excessive internal tibial rotation. Meanwhile, the tight hip external rotators pull the femur in the opposite direction, causing shear forces through the knee. ©erikdalton.com. External femoral rotation Internal tibial rotation Hyperpronation Patella 1