Root Cause of Knee Pain: It's a Consequence of Something Else | Your Wellness Nerd
If you're reading this, you've probably been told to "rest your knee," "strengthen your quads," or "ice it." But, if that worked, you probably wouldn't be here, right?
What if I told you that in almost all of the knee pain cases I see, the knee itself isn't the real problem?
The knee is the victim. It's stuck between two powerful movers: your hips and your ankles, and governed by the lower back. When these aren't doing their job, your knee can pay the price. In this ultimate guide, we're going to explore the true root cause of your knee pain and give you a clear plan to address it for good.
Table of Contents
The #1 Myth About Knee Pain We Need to Debunk
The Myth: Knee pain means your knee is damaged, weak, or "worn out."
The Truth: Your knee is a stable hinge joint. Its primary job isn't to generate power, but to smoothly transfer force from your powerful hips to your mobile feet and ankles.
When your hip is restricted or weak, your ankle is stiff, or your lower back is dysfunctional, that force gets distorted. Instead of flowing through the knee cleanly, it creates shearing and compressive forces where they don't belong. This can lead to pain under the kneecap (patellofemoral pain), on the outside (IT Band Syndrome), under the knee cap (patellar tendonitis), or set us up for any number of tissue issues in and around the knee.
Think of it like this: Despite all the individual labels, the body is a closed system. If something above or below the knee isn't functioning normally, everything closely associated to it has the potential to become unhappy. And if it does, we can't just treat that unhappy consequence - we need to look at the bigger picture in it's entirety.
Root Cause #1: Hip Dysfunction (Weak or Restricted)
This is such a common issue to treat clinically. Your gluteal muscles are important drivers of movement and stability for the rest of the leg. Not only that, but restrictions through the front, back or sides of the hip can ask your entire leg to work around this - ultimately changing the way the knee is loaded.
- What It Does: Its main job is to prevent your thigh bone (femur) from collapsing inward (into what we call a valgus position) during walking, squatting, or running.
- What Happens When It's Weak or Restricted: When your glutes aren't optimal, or your hip tissues are restricted, your thigh bone may drift inward every time you take a step. This can allow the knee to "dump" inwards, altering how you load your kneecap and the structures within the knee. This can be the primary driver of Patellofemoral Pain Syndrome (PFPS) and IT Band Syndrome, and even be a precursor to an ACL injury.
The Hidden Link: A sedentary lifestyle is the likely #1 cause of tight and weak hips. Sitting all day with our hips bent to 90 degrees may have a lot to answer for.
How to permanently loosen tight or stiff hips
Root Cause #2: The Stiff Ankle (Poor Mobility)
If you can't move your ankle freely, your body will find a way around it to complete the task.
- What It Does: Your ankle needs sufficient dorsiflexion (the ability to bring your shin forward over your foot) to perform basic movements like squatting, lunging, or even walking downstairs.
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What Happens When It's Stiff: When your ankle is stiff and can't dorsiflex properly, your body's workaround is to either:
- Lift your heel (limiting depth).
- Force your foot to flatten (over-pronate).
- Make your knee cave inward to accommodate the missing range.
All of these compensations directly load the knee joint differently. This is a huge factor in Achilles tendinopathy and issues like meniscal tears and knee osteoarthritis.
Root Cause #3: Hidden Lower Back Dysfunction
Your spine is the foundation of all movement in your lower half. If the foundation is stiff, restricted, or less stable, everything it governs - including your knees - may suffer.
- What It Does: Mechanically, the trunk is the stable platform that all lower limb movement relies on. Similarly, the neural tissue that drives knee function originates from the lower third of the spine.
- What Happens When It Becomes Dysfunctional (Stiff, Tight, Weak): When the function of your lower back suffers, it can inhibit the muscular strength and flexibility of your hips and thighs. Glutes can "weaken", quadricep muscles can tighten, the femoral and sciatic nerves that supply and pass through the knee can lose their mechanical slack - altering how everything feels and functions at the knee.
This dysfunctional chain reaction places continuous strain on the tendons, ligaments and cartilage of the knee - either increasing the chances of developing an issue like a patellar tendinopathy, fat pad impingement, or just robbing us of the ability to buffer accidental trauma.
The 3-Minute Self-Assessment: Find Your Root Cause
Try these simple tests at home. (Note: Be respectful in case they're symptomatic.)
1. The Squat Test
- How: Stand on two legs (or one if able), with your feet straight, and slowly lower into the deepest squat you can. Watch what your body does.
- What to Look For: Does your knee cave inward? Does your back round at the bottom? Do your heels lift or feet turn out? Do you have to lean forward because you'd otherwise fall backward? If any of these are a yes, then your hips or ankles may not be doing their job properly.
How to Do a Squat Assessment
2. The Back Ball Test
- How: Using a lacrosse ball or tennis ball, stand with your back to a wall. Starting toward the bottom of your ribcage, gently let the ball press into the joints of your spine (just either side of the main bumps down the middle)
- What to Look For: Anything that feels thicker, tighter, more dense, stiffer, harder, or more restricted than the other side. It may not be tender, but if it is, we care more about the side that feels the most restricted.
How to Do a Squat Assessment
The Solution Framework: How to Fix the Real Problem
Fixing knee pain isn't about endlessly strengthening the knee, although this is still an important feature for many. It's more often about finding those hidden handbrakes to optimal function within the entire lower half of the body and filling in those gaps.
Step 1: Improve Mobility
As you work to settle down any acute knee pain or adjacent symptoms, it's a great time to work on those hidden mobility restrictions. Not only can this help feed much-needed slack to your current knee complaint, but we are also beginning to address those hidden underlying causes.
- Ankle Mobility: Banded ankle stretches, calf muscle stretches, and even mobilising the skin around your heel can help improve how your knee feels and functions from underneath.
13 ways to improve your ankle mobility
- Hip Mobility: Improving hip extension and hip rotation can again improve how your knee feels and functions from above.
5 simple hip stretches for those who don't want to get down to the ground
- Back Mobility: Improving back joint and soft tissue mobility can have a profound impact on the function of the knee.
Learn how to use a lacrosse ball to mobilise hidden back restrictions
Step 2: Improve Strength.
- Gluteal Muscle Strength: Hip abductors and hip external rotators help support the function of the knee from above. Traditional clams and side-lying leg lifts (to which a booty band can be added as needed) are a great, simple place to start.
Step 3: Integrate and Strengthen.
Now, use your newly loosened and strengthened tissue in a way that reflects actual life.
- Squats: As shown above, pay attention to driving those knees out while going down to a depth that maintains good foot, arch, knee, hip and back positioning.
- Step-Ups: Fantastic for single-leg strength and control.
- Deadlifts: Fantastic for core, hip and hamstring strength, as well as optimising how we bend and move.
Frequently Asked Questions
Q: Can I still exercise with knee pain?
A: It depends. Pain is there for a reason and deserves our respect. Your pain limits are often nuanced and require constant attention to ensure you aren't doing too much or too little. Focus on pain-free range of motion and correcting your form, often by reducing depth, speed, intensity or weight.
Q: How long does it take to see improvement?
A: If you consistently address the root causes, you can often feel a significant difference immediately. However, some knee issues can take time to fully recover. True, lasting change and strength building typically takes 8-12 weeks of dedicated work.
Q: Is it really possible to fix knee pain without surgery?
A: In the vast majority of cases, yes. Surgery is typically only a last resort for specific traumatic injuries or advanced arthritis that hasn't responded to a high-quality conservative care program.
Q: I've been told I have arthritis. Does this still apply?
A: Absolutely. Arthritis is often a "wear and tear" diagnosis. By correcting the faulty loading patterns over time, you can unload the arthritic part of the joint, reduce irritation, and optimise your chances of living pain-free despite the arthritis diagnosis.
Q: What about IT Band Syndrome?
A: IT Band Syndrome is a classic example of a hip-related knee issue. A tight IT band is often a symptom of sub-optimal hip mobility and strength. This changes the way we load the IT band over time. The solution isn't just stretching the IT band (which you as it turns out); it's more about strengthening and mobilising the hip.
Ready to Fix Your Knee Pain For Good?
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