Knee Pain From the Kinetic Chain
Adjustment strategies to address the potential causes.
By Kevin Curtin, DC and Terry Elder, DC
As practitioners of manual medicine, chiropractors often treat patients suffering from knee pain. In fact, according to the 2006 National Health Interview Survey, approximately 30 percent of adults reported experiencing some form of joint pain during the previous 30 days and knee pain was a leading cause of that discomfort.
When evaluating a patient with knee pain, it is often a challenge to sort out which structure or structures are the pain generator(s), especially when an injury has occurred. The clinical exam may not be sufficient and advanced imaging may be necessary for definitive diagnosis. As with any other joint in the body, pain may be a result of osteoarthritis, injury, prolonged abnormal posture, or repetitive motion / overuse. However, having ruled out pain due to injury, OA, etc., the focus should be on pain due to dysfunction.
We are often reminded of the phrase, the knee tries to do what the ankle wants it to do, but does what the hip allows it to. Simply stated, the knee is just one more link in the kinetic chain that is subject to the function or dysfunction occurring at the joints both above and below it. Therefore, it wouldn't be fruitful to focus our treatment just to the knee. This is not to say that pain-relieving modalities shouldn't be employed – they just shouldn't comprise the entire treatment plan.
Kinetic Chain Involvement
A thorough examination of the foot / ankle is key to unlocking pain syndromes further up the kinetic chain. For this discussion, let's focus our attention on subtalar joint hyperpronation. Subtalar joint hyperpronation is often the result of diminished dorsiflexion. This may be the result of soft-tissue dysfunction, joint dysfunction or a combination of the two.
For example, postural muscles, including the gastrocsoleus, often become facilitated as a result of our societal propensity toward sedentary postures. As a result, the necessary amount of talocrural dorsiflexion needed for ambulation is reduced and compensatory movement strategies result – subtalar joint pronation.
Although necessary for shock absorption and adapting to discrepancies in terrain, excessive subtalar joint pronation can wreak havoc throughout the kinetic chain. Hyperpronation leads to internal rotation of the tibia; leading to internal rotation of the femur; leading to unleveling of the pelvis and anterior tilt; leading to increased lumbosacral extension.
Let's rewind for a second and focus our attention on the effects subtalar joint pronation has on the tibiofemoral joint. As stated previously, excessive subtalar joint pronation results in tibial internal rotation. This rotary motion forces the medial tibial plateau into a posterior glide underneath the medial femoral condyle, placing the medial meniscus and joint capsule under significant strain. Excessive tibial internal rotation has also been implicated in the development of chronic pes anserine bursitis.
Excessive subtalar pronation and the resultant tibial internal rotation may also have deleterious effects on the lateral side of the knee as the iliotibial band is dragged over the lateral femoral epicondyle with each step. The result is a painful case of ITB friction syndrome.
What can be done in terms of treatment from a manipulative therapy standpoint? This is not always an easy question to answer. The key to successful manipulative therapy is sound palpatory skills. Any dysfunctional region along the kinetic chain deserves a thorough motion palpation examination to uncover any joint restrictions.
Remember, our bodies are excellent at compensating for movement deficiencies. In general, we recommend assessing the common offenders when it comes to joint dysfunction in the lower extremity: talocrural and subtalar joints, which are commonly restricted; and let's not forget about the gastrocsoleus, which is easily treated with a quick stretch technique.
It is important to understand that dysfunction often leads to pathology and not the other way around. If we search for and fix the biomechanical issues, the pathologies will cease to exist.
1. Anterior Glide of the Distal Tibiofibular Joint (Posterior Glide of the Talus)
2. Subtalar Joint Distraction
3. Subtalar Joint Eversion
4. Quick Stretch of the Gastrocsoleus
Editor's note: This is the second article in a series on
chiropractic techniques to treat challenging patient presentations.
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