If you’re suffering from chronic knee pain and seek medical attention, the typical X-ray and/or MRI that’s performed will show that you have arthritis or, worse, “bone on bone”…or maybe a meniscal tear.

As I’ve talked about in some of my other blogs, few doctors make any real attempt to understand the presentation of your symptoms—where in the knee region the pain is being experienced…what types of activities bring on your symptoms or which make them decrease. No attempt to determine if full range of motion is even present in the knee! The standard of care is pretty clear—the MRI or X-ray identified a structural variation so that must be causing your pain.

Here’s what I do to determine the cause of knee pain. First let’s think about the knee joint. It is actually made of two joints—the first, between the two ends of the thigh bone and lower leg bone (the tibia) and the second, where the knee cap meets the thigh bone, ideally with a meniscus (cartilage) between them. If a structural variation like arthritis or a meniscal tear were to occur, it would alter the ability of the joint to achieve full range of motion. So, as I talked about in an earlier blog on joint pain, the first test is to check range of motion. Quite simply if you have full range of motion or the same range of motion at the affected knee as the unaffected knee, there is no possible way that a structural variation identified on a diagnostic test is causing your pain.

So let’s assume you tested the range of motion of the knee joint and it is full or equal to the unaffected knee. We can conclude that the cause of the pain is muscular. (While it is possible that BOTH knees have a structural problem that needs aggressive intervention like surgery, it is highly unusual. Yet the diagnostic process holds true in a case like this as well—if this were causing pain, there should be a major loss of range of motion at both knees and at the end of range of motion it should feel like one bone is hitting another bone, stopping further motion from occurring.)

Now, when I say “muscular,” I don’t think most people have a good grasp of how a muscular deficit can cause joint pain. I’m going to give a lot of detail here, but it’s important to fully understand just what is going on in your knee.

The positioning of the bones in the knee joint is based on the pulls of the muscles that attach to them. The joint functions optimally when the total surfaces of the ends of the bones that make up the joint are in perfect alignment. This means that 100% of the surface area of the joint will take 100% of the force running through the joint. This is the way that all joints are designed to work.

When muscles are strong and balanced, they are able to support the joint to sustain this optimal positioning of the bones. If there is muscle weakness or imbalance, the bones will shift position and less than 100% of the bone surface will be absorbing 100% of the force going through the joint. That type of contact can lead to a breakdown of the structures of the joint, leading to arthritic changes and degenerative tearing of the meniscus and, potentially, knee replacement surgery.

Of the two joints that make up the knee, the joint between the knee cap and the thigh bone has the greater force on it, and the muscles attached to this joint are more likely to become imbalanced. An imbalance between the quads (front thigh muscle) and hamstrings (posterior thigh muscle) can cause the quad to shorten, creating excessive upward force on the knee cap. This can lead to excessive compression of the knee cap in the joint, leading to pain around the knee cap. A strain of the quads can lead to a decrease in force applied to the knee cap, causing it to move laterally and create pain on the lateral border of the joint between the kneecap and thigh bone.

One of the indicators that the cause is muscular is when the pain seems to result from performing activities—but you have no pain when sitting or lying down. Sit to stand, negotiating stairs, kneeling, walking and prolonged standing are all activities that might bring on knee pain.

What I have been seeing more frequently is knee pain occurring after a hip replacement. In this case, a muscular deficit at the hip region causes knee pain. The gluteus medius muscle sits at the side of the pelvis above the hip joint. It is responsible for creating stability and balance, especially when single-leg standing, such as with walking. This muscle is also responsible for keeping the knee joint under the hip joint when standing.

Here are the red flags that your knee pain may be from a strained hip muscle:

  • Your knee pain has occurred after getting hip surgery.
  • The thigh with the affected knee seems more angled inward than the unaffected leg.
  • When you single leg stand, your knee feels like it can’t support you and that it might cave in.
  • Negotiating stairs seems inhibited not only because of knee pain but a feeling that your leg won’t support you.
  • Tenderness when feeling the gluteus medius for knots or sensitivity.

These types of causes do not show up on diagnostic tests, and no medical specialty is educated or trained to identify or treat them. (This is why this blog is so important. You will get logic-based, symptom-based analysis to help you determine the cause of your symptoms. Without identifying the right cause, the symptoms will never be resolved and chronic pain will stay chronic.)

If it appears that the cause of the knee pain is due to a strained gluteus medius muscle, then perform hip abduction. Here’s how:

Attach a resistance-band loop to the leg of a sturdy table or chair. Stand with the affected leg’s foot in the loop farther away from the structure than the unaffected leg. The feet should be close together to start. Turn the foot of the affected leg in so you lead to the side with the heel moving first. Step out so the outside of the ankle meets the line of the hip. Put all your weight on the leg you are stepping out with and then return to the start position. Do a total of three sets of 10 repetitions with a one-minute rest between sets. As the resistance feels easier, either step farther away from the table/chair with both feet to increase the tension of the resistance band or use a more resistive band to continue to build the gluteus medius. Eventually the muscle will become so strong it will be able to support you and prevent the knee from losing alignment under the hip joint.

To determine which other muscles might need to be strengthened to fully resolve the knee pain, read this article about how to beat knee pain without surgery.

Click here to buy Mitchell Yass’s books,The Yass Method for Pain-Free Movement: A Guide to Easing through Your Day without Aches and Pains, or check out his website.

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