When the knee starts to grumble it can be hard to get on top of patient symptoms and sometimes even harder to stop these symptoms coming back.

Lateral knee pain is a common issue and injuries like patella-femoral joint pain, illio-tibial band (ITB) pain or lateral meniscal problem can cause major distribution to a patient or athletes function, particularly the more active they are.

So what might you be missing?

What could you do better to get on top of lateral knee pain and stop this problem coming back no sooner than you have got rid of it.

Here are 3 tips to help you better manage lateral knee pain cases…

#1 Forget About Treating The ITB  

The ITB is extremely strong and in terms of tensile strength is stronger than steel!

Also many people think the ITB is a muscle…

But it is not!

The ITB is a thick band of fascia that runs on the lateral side of the thigh from the iliac crest and inserts at the knee and largely has the properties of a tendon, not a muscle.

Given it is not a muscle and given how strong the ITB is, it makes sense that many ‘muscle’ techniques like stretching, foam rolling or massage are ineffective to help ITB injuries.

That’s not to say you should not treat the ITB, you should if it is a problem (see #3), but just that many treatment techniques and rehab exercises will be a waste of your time and efforts.

 #2 The Knee Is Like A Washer Between Two Bolts

A top physio I know once said this to me and it is a simple but great description for the knee joint.  

He’d picked it up on a talk from a top knee surgeon who described the knee this way, the washer being the knee, the bolts being the ankle joint below and the hip joint above.

The point he was making was that whatever the hip and ankle do, the knee has to adapt to what is happening above and below the knee joint and ultimately if there is a problem, it is the knee (like the washer) that is usually the first thing to break!

You see this all the time with your patients as often when the knee starts to hurt, its because it is working too hard…

A result of a problem somewhere else, like the joint above (the hip) or below (the ankle).

Making sure you identify any issues at the joints above and below the knee is key and must be included as part of any knee joint objective assessment.

If you miss any issues here it does not matter how good your knee assessment, treatments and rehab exercises are…

If the issue driving that lateral knee pain is not the knee, but an issue up or down the chain, then there is an almost 100% chance that that issue is going to come back…

Because that issue is still left unresolved. 

#3 Not Just Glutes, Glutes, Glutes

The most common reason therapists tell patients they have knee pain is that they have a ‘glute’ problem.

Something like…

‘Your glutes are not firing…

Or working well…

You need some glute strengthening to help your knee.’ 

I won’t lie, I told many patients this as a new grad.

At the time I thought it was true and whilst this might be true for some patients, often it is not, and this is why so many patients struggle to overcome their lateral knee pain.

If your patient does not have a glute problem you can do as many glute bridges or hip clam exercises to strengthen the hip as you want…

But it will not take away your patient’s knee pain if you don’t have a problem with the glutes in the first place!

So what do you need to do instead?

Back to the washer…

If the ankle and hip are big contributors to how much load the knee has to absorb, then does strengthening the muscles are the ankle (calves) or the hips (glutes) change this?

For sure, if you identify a lack of strength in the hip or ankle muscles.

But often, it is not about getting stronger.

Think about a runner you see in your clinic, who runs ten-twenty miles a week.

When running there is approximately 4-6 times your bodyweight going through their knee.

If they weren’t strong enough, they physically would not be able to run!

What is often more important is how all the muscles in your legs work together.

When running if your quad muscles are doing too much work and your hamstring, glute and calf muscles are not doing enough work, more load will go through the knee.

Like any joint, muscle, or tendon, if it is working too hard, it will become tired and at some point will have taken too much strain.

This is when you break…

And lateral knee pain starts.

There are several reasons why the knee might start to overwork.

The most common reason is an old injury that your patient has had in the past.

This might be an old ankle injury, or lower back pain or something else.

It could be on the same side as the knee problem or even the other side of the body.

For most people it is an old problem that is causing their new problem, even if that old injury has not caused any issues for some time.

The body is clever and whenever it gets injured it will adapt the way it moves to compensate.

Like what happens when you roll your ankle and limp around for a few days. 

But even when the pain goes away, unfortunately the body does not always return to how it moved before your injury.

So whilst the pain might have gone and that ankle is no longer causing your patient a problem, you might still be moving and loading other muscles and joints differently as you did when that ankle injury first happened.

Often this is not something you will notice and it is not a problem…

…until another injury happens!

If you’ve worked with a patient or athlete that has had a bad run of injuries, when it seemed like it’s just one injury after another, this is probably what was happening.

The body was just compensating and shifting load to other joints and muscles, which caused them to overload and then break!

So, it is important not only how the knee functions but how the hip, knee and ankle work together during movement. 

If the muscles in the leg work well together, this allows the knee to perform well, with an even distribution of load and force…

…meaning it won’t be overworking and as a result, you are much less likely to see reoccurrences of lateral knee pain once you give your patient or athlete the green light to return to higher level activities like running or even sport.
If you have failed in the past to get rid of your patients lateral knee pain, then the problem might not be the the lateral knee.

Unless you fix the knee AND the other problems, it is likely once you let your patient get moving again, allow them to start running or get back in the gym, that pain might quickly return and as quick as it went away.

Just to recap, here are 3 tips to help you better manage patients or athletes with lateral knee pain…

#1 Forget About Treating The ITB  – The ITB is NOT often the issue with patients presenting with lateral knee pain and because of how this structure functions it needs to be treated differently to other ‘muscle’ injuries

#2 The Knee Is Like A Washer Between Two Bolts – The joint above (hip) and joint below (ankle) play a vital role in how the knee joint functions between them.

#3 Not Just Glutes, Glutes, Glutes – There is much more to knee pain rehab than just strengthening the glutes.

Hope this helps.

Andy

The New Grad Physio Mentor

PS. Special mention to top sports and private practice physio Gareth Robinson for teaching me the knee ‘washer’ concept. 

I caught up with Gareth, who is currently working on the golf circuit as the personal physio to a top golfer on the New Grad Physio podcast. You can catch this episode here. [https://newgradphysio.com/success-series-gareth-robinson-a-day-in-the-life-of-a-top-sports-physio/]