Popular Causes of Knee Pain

Knee pain is a very popular issue for Personal Trainers and Physical Therapists.  Although the pain is localized to your client/patient's knee, you must observe the peripheral joints as possible causes.  One of the first joints you need to assess is the ankle/foot.  Many times, your client may be flat-footed on one or both sides.  Pronation or "flat-footed" many times creates a "down and in" movement of that entire lower extremity.  "Down and In" refers to an internal rotation motion of that leg.  This internal rotation leads to a shortening/tightening of the Ilio-Tibial Band/Tensor Fascia Latae (ITB/TFL).  This then leads to more internal rotation and "down and in" and it becomes a viscious cycle. 

Tightness of the ITB/TFL may create an increase in lateral pull of the patella or knee cap.  Instead of the patella tracking superiorly upon knee extensor contraction (quadriceps), it tracks supero-laterally.  In time, this may cause knee pain.  Most of my "knee clients" are taught how to perform proper calf (gastrocnemius/soleus) stretches to help minimize the "down and in."  They are also educated on ITB/TFL stretches if I observe the patella tracking laterally.  Unfortunately, these stretches alone will not correct the "down and in" motion.  You must ensure proper carry over by immediately practicing the activity in which the "comparable sign" (your client's chief complaint) was observed.  During the practice, make sure that the "down and in" motion is minimized.  For example, many times this motion will be obvious during step downs.  Instead of the knee tracking over mid to lateral foot, the foot arch drops (pronates) and the knee track medially over or past the big toe.  This step-down (using the affected leg to lower the body) may create your client's symptoms of knee pain.  Teach the stretches, and have your client perform the step down during that same session, making sure the knee tracks properly over the foot.  Many times, if you correct the movement pattern, the involved muscles will begin to work properly and efficiently.  Oh yeah, and don't forget to check the VMO contraction which assists with medial pull of the patella during contraction.  The VMO is the tear drop shaped muscle on the inside aspect of your thigh just medial and superior to the knee cap.  This muscle helps minimize lateral patella migration.  So, stretch the calves and ITB/TFL and strengthen the VMO.  Then perform the required activity and make corrections.  Remember "Perfect practice makes perfect!"

On a side note, for those trainers with clients who want to train barefoot, keep the above information in mind.  Training barefoot may have its benefits.  However, if your client demonstrates any of the pronation and "down and in" movement patterns with shoes on, their form will very likely worsen without foot/ankle support (training barefoot).  If they are unable to correct this inefficient pattern when barefoot, you may want to scrap barefoot training for now.  This is especially true if they already require orthotics in their footwear to reduce pronation.  Make sure the benefits outweigh the risks of barefoot training.