Knee pain has been a problem that has plagued me since my mid-twenties. It probably started after I got into hiking and long distance running. The pain was only in one knee – the left one. Concerned about possible damage to the joint, I went to see an orthopedic surgeon to investigate. After a few x-rays and an examination of all my leg joints – both knees, ankles, and hips – I was reassured that there was nothing sinister going on.
So what was the cause of the pain? According to the doctor, it was likely a combination of the following:
- A Prior Injury – of my right ankle.
- Muscle Imbalances – weak hamstrings and VMO (vastus medialis oblique, or inner quad muscle).
- The Female Anatomy – vertical, gravitational force from the hips applies more pressure on the outer part of the knees which are more centrally placed.
A Prior Injury
The prior injury for me was my right ankle. I have sprained it badly two or three times over the course of my “young” life but I have never bothered to rehabilitate it. Young bodies bounce back easily so I didn’t think I needed to do much aside from wait for it to get better. Unfortunately, it left me with a loose ligament and an unstable right ankle.
A “loose ligament” in the ankle, often referred to as ankle instability or laxity, occurs when ankle ligaments are stretched or torn, leading to a feeling of instability and potentially recurrent sprains. A loose ankle ligament can be seen when the doctor wobbles your foot and it moves excessively around the ankle joint. This is particularly noticeable when you compare the movement against your other ankle.
When the ligament is loose, the ankle becomes unstable. This increases the likelihood of it “giving way” or rolling inwards, leading to more sprains. Repeated sprains leads to chronic instability as the ligament fails to heal properly.
How does an unstable right ankle affect my left knee? Through compensatory movements. When there is a weak joint, we alter our gait to protect the weak joint. These compensatory movements lead to abnormal loading of the knee joint, which can lead to pain or discomfort. It isn’t only to the knee joint. It could also affect the “good” ankle or the hips. Since I was hiking and running a lot, this would have further aggravated the problem.
Since the lower extremity is a kinetic chain anything that affects the ankle is thought to affect the knee and hip as well.
To resolve this problem, we need to strengthen the muscles that support the ankle, e.g. single leg calf raises. Stronger muscles provides more stability. This stops the compensatory movements which resolves the knee pain.
Since we know that the lower extremity is a kinetic chain, improving mobility and strength in all the joints of the leg will have a positive impact on the affected joint. In a nutshell, build stronger legs.
Muscle Imbalances
Since I was hiking and running a lot (and not much else), it was likely that I had muscle imbalances between my quads and glutes/hamstrings, and between my hip flexors and glutes. These muscle imbalances could also have contributed to pain in my knee.
Another muscle imbalance that can cause knee pain is a weak VMO (inner thigh muscle). The VMO helps stabilize the patella (kneecap) and ensures it tracks smoothly within the groove at the end of the femur. When the VMO is weak, the other quadriceps muscles (like the Vastus Lateralis) can pull the patella to the outside. This leads to patellar maltracking, causing it to rub and damage the joint surface. It can also cause knee instability and subsequent knee pain.
The answer to this problem is to focus on building strength in the neglected muscles. In my case, the VMO, glutes, and hamstrings.
The Female Anatomy
Women generally have wide set hips (nature’s way of accommodating for child birth) in relation to our more centrally placed knees. This means that gravity places more pressure on the outer part of our knees. This anatomical disadvantage and its consequences has been explained from the perspective of the Q-angle.
The Q-angle is the angle between the quadriceps (thigh) tendon and the patella tendon. The average Q-angle for men is approximately 14 degrees; whereas for women it is approximately 17 degrees.
It has been ‘theorized’ that females are at a higher risk of knee injuries because their “wider” hips create a larger Q angle. As the theory goes, this larger angle leads to “unfavorable” biomechanics such as ‘knee valgus’, in movements like jumping, landing and decelerating.
Knee valgus is also referred to as valgus collapse and medial knee displacement. It is characterized by hip adduction and hip internal rotation, usually when in a hips-flexed position (the knee actually abducts and externally rotates). It can also be thought of as knee caving as you sink down into a squat or landing.
What can we do about knee pain resulting from a large Q-angle? There are three things we can do:
- Focus on strengthening the muscles around the knee and hip.
- Stretch tight areas.
- Address biomechanical issues like foot pronation with orthotics.
Which muscles do we work on strengthening?
- VMO (Vastus Medialis Oblique) – helps stabilise the patella and improve its tracking.
- Gluteus Medius – helps stabilise the hip and reduce the stress on the knee.
- Hamstrings – improves knee stability and reduces the risk of injury.
Where do we focus our stretches?
- ITB (Iliotibial Band) – improves flexibility and reduces tension that can contribute to knee pain.
- Quadriceps – improves flexibility and reduce tightness that can contribute to knee pain.
Addressing biomechanical issues:
- Foot Pronation – consider using custom-made functional orthotics to help correct excessive foot pronation.
- Footwear – choose supportive footwear that can help reduce pronation and improve stability.
The Bottom Line
Regardless of cause of pain – whether it is one or a combination of the problems mentioned above – we seem to come back to a common solution: building stronger leg muscles. More specifically, we should focus on the muscles that are often overlooked or neglected. These muscles tend to be the VMO, hamstrings, glutes, and calves. There are plenty of sites that explain how you can work these muscles. The following are some exercises I regularly use.
VMO Exercises:
- Straight Leg Raises: Lie on your back with one leg straight and the other bent. Tighten the thigh of the straight leg and lift it about 12 inches off the surface. Hold for 3 seconds, then lower slowly. Repeat 10 times for 2 sets.
- Squats: Stand near a support surface and slowly bend your hips and knees into a squat position. Ensure the quadriceps are tightened throughout the exercise, keep knees behind toes, and keep knees apart. Repeat 10 times for 2 sets.
- Ball Squeeze: Place a ball (I use the small Pilates ball) between your knees and squeeze it. Hold for 5 seconds, then relax. Repeat 10 times, gradually increasing to 5-second holds and 20 repetitions.
- Wall Squats with Ball: Rest your back against a wall and place a ball between your knees, squeezing your knees together. Go into a squat position, but only go as far as you feel comfortable. Repeat 10-12 times.
- Seated Isometric VMO and Adduction: Sit on a chair or platform where your feet hang freely and place a ball between your thighs. Squeeze the ball together, activating your VMO. Hold your contraction for 10 seconds. Repeat several times daily, gradually increasing the length of contraction.
- Glute Bridge with Ball: Place a ball between your knees and squeeze your knees together while lifting your bottom off the ground in a bridge position. Try to squeeze the ball the whole time, but if you can’t, you can relax once you come back down. Repeat 10-12 times.
Hamstring and Glute Exercises:
Many of the exercises that work the hamstrings also work the glutes and vice versa. There are lots of exercises that work both hamstrings and glutes, including but not limited to:
- Deadlift
- Kettlebell Swing
- Leg Curl
- Glute Bridge
- Single Leg Deadlift
- Squat
- Bulgarian Split Squats
- Lunge
Calf Exercises:
There are a number of exercises you can do that work on your calf muscles. The simplest and most commonly recommended is the single leg calf raise.
Start standing (next to a wall or chair for stability if needed) with your feet hip-width apart and your core engaged. Raise one foot slightly off the ground. Squeeze the calf muscle of the standing leg, lifting your heel until you are on your toes. Hold at the top, maintaining good upright posture, and then lower your heel back to the floor with control. Repeat 10 times and then switch legs.
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