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Knee Pain? Maybe It's Your Feet


There are several painful conditions of the knee that may be caused by problems with your feet. The knee joint is one of the most complex joints in the body.  It is a hinge joint, a sliding joint and a rotating joint all at the same time.  The proper and pain-free functioning of the knee requires near perfect alignment of the bones, ligaments and tendons that make up the knee joint. Pain in the knee is usually an early warning sign that something is wrong with the alignment.  It is important to address these problems early to avoid serious, long term problems such as severe arthritis.  

The improper alignment that causes knee pain is often the result of improper alignment of the joints of the foot and ankle.  Let me give some examples.

Pain on the inside part of the knee may be caused by bursitis at the location where three of the tendons from the thigh muscles (sartorius, gracilis and semitendinosus) come together and insert into the upper/inner part of the tibia (bone of the lower leg).  This condition is known as Pes Anserine bursitis.  Pes Anserine is Latin for “goose foot”.  I suppose it is called goose foot because these three tendons coming together look somewhat like a goose’s foot.  The pain is caused by inflammation of the bursa beneath these three tendons.  A bursa is a fluid-filled sac that is found where tendons and ligaments rub against bone.  The bursa is designed to prevent the bone from irritating and damaging these tendons and ligaments as the rub back and forth over the bone.  When these bursa become inflamed this is known as bursitis.  Pes anserine bursitis is inflammation of the bursa beneath the three tendons that form the goose foot.  Pes Anserine bursitis can be caused by excessive pronation of the foot.  The excessive pronation (see article on normal foot motion) causes excessive stretching of these tendons which over time results in inflammation.  The treatment and prevention of this condition involves an arch support to prevent excessive foot pronation.

Pain on the outside of the knee is sometimes caused by a condition known as iliotibial band syndrome.  The iliotibial band runs from the pelvis down the outside of the leg and attaches to the outside part of the knee.  Problems with the foot together with overuse (such as running or bicycling) can lead to inflammation where the iliotibial band inserts into the outer knee.  There are several different foot problems that can cause this inflammation.  If the person is flat-footed (over-pronatnor) this causes the tibia (lower leg bone) to excessively internally rotate.  This increases the stretch on the iliotibial band and causes inflammation.  On the other hand if someone has a high-arched foot, the foot is in a supinated position (see normal foot motion) and this too can cause excessive stretch on the iliotibial band and inflammation.  These two very different types of foot problems result in the same painful condition (iliotibial band syndrome).  However the two problems require very different treatments.  In order to correct the problem it is essential to determine what exactly is causing the problem.

Knee arthritis can be caused or exacerbated by problems with the foot.  Someone that has arthritis pain on the part of knee closest to the midline (medial compartment) may have a supinated foot that contributes to a bow-legged type of stance.  Someone with pain in the lateral compartment (the outer part of the knee furthest from the midline) may be flat-footed, a hyper-pronator, which leads to a knock-kneed type of stance.  Through the proper use of a foot orthotic I believe that we can, over time, reduce the load on the painful knee compartment, reduce the pain and at least slow down the degeneration of the cartilage.

Pain in the center of the knee is often cause by chondromalacia patella, also known as retropatellar (behind the kneecap) pain syndrome.  This is often seen in someone with excessive pronation (flat-feet).  As the knee straightens and bends the kneecap is supposed to ride smoothly in a cartilage-lined groove on the lower end of the femur (thigh bone). Someone that is a hyper-pronator has excessive internal rotation of the tibia. This excessive internal rotation changes the angle that the kneecap rides up and down in this groove (known as the Q angle or Quadriceps angle).  Over time this leads to irritation behind the kneecap and the retropatellar pain syndrome.  An arch support or orthotic can be very helpful in treating this condition.

In conclusion I have discussed a few of the common causes of knee pain that can be relieved or at least improved through the use of a simple foot orthotic.  The key to treatment however is knowing what is causing the problem in the first place.  The techniques we use for diagnosing the problem will be discussed in an upcoming article.


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