Knee Pain: Looking Beyond the Knee

A patient who had undergone knee surgery approximately 10 years earlier came to our office because of persistent knee pain.

At the time of the original surgery, the patient had been diagnosed with a meniscus injury, arthritis, and abnormal patellar movement. However, when we reviewed the patient's history, one important detail stood out: there had been no significant direct trauma to the knee.

Instead, the patient reported experiencing significant low back pain for many years before the knee problems developed.

After the knee surgery, the patient underwent physical therapy. However, knee exercises repeatedly caused severe pain, eventually leading the patient to stop physical therapy.

Ten years later, the patient continued to experience chronic knee pain. Walking for more than approximately 15 minutes would cause a sharp, stabbing pain that became severe enough that the patient had to stop and rest before continuing.

Looking Beyond the Knee

Our examination began with the knee itself.

Interestingly, the knee did not demonstrate an obvious structural abnormality on our physical examination. However, the quadriceps muscles were chronically tight, significantly limiting the patient's ability to bend the knee.

We then carefully observed the movement of the patella while the patient's leg was moved through its range of motion.

The patella did not track straight. Instead, it tended to move toward the inside of the knee.

The quadriceps is a group of four muscles that work together to extend and control the movement of the knee. Proper coordination of these muscles is important for normal knee function.

When muscles surrounding the knee become excessively tight or do not function in a balanced manner, they may influence patellar movement and tracking.

In this patient, the chronic quadriceps tension appeared to be associated with altered patellar tracking, which may have contributed to increased stress and irritation around the knee during walking and bending.

But the examination did not stop at the knee.

Examining the Spine and Pelvis

Because the patient also had a long history of low back pain, we examined the lumbar spine and pelvis.

Our examination identified findings involving the lower lumbar spine and pelvis, including restricted movement around L5 and the right pelvic region, along with substantial muscular tension in the right lower back and hip.

X-rays provided additional information regarding the patient's spinal and pelvic positioning.

The L5 vertebra appeared to be positioned posteriorly, with an associated change in the lumbar curvature. The right side of the pelvis also appeared to be positioned approximately 6 mm anteriorly compared with the left, and an apparent leg-length difference of approximately 7 mm was observed on the radiographic analysis.

These findings were considered together with the patient's history, physical examination, muscle tension, and movement patterns.

Rather than assuming that the knee was an isolated problem, we considered whether the patient's lumbar spine, pelvis, hip, and lower-extremity mechanics could be contributing to the way the knee was functioning.

How Can a Back Problem Be Related to Knee Pain?

This raises an important question:

How could a problem in the lower back be related to chronic knee pain?

The body does not function as a collection of completely independent joints. The spine, pelvis, hips, knees, ankles, and feet work together during standing, walking, bending, and other movements.

Changes in one region can influence movement and muscular demands elsewhere.

For example, when a person experiences low back or pelvic discomfort, they may unconsciously change the way they stand, walk, or distribute their weight. These changes may place different demands on the muscles surrounding the hip, thigh, and knee.

Likewise, restricted movement in one area may lead other joints or muscles to compensate.

Over time, these altered movement patterns may contribute to muscle tension, fatigue, changes in joint loading, and altered movement of the knee.

The quadriceps and other muscles surrounding the knee play an important role in controlling patellar movement and stabilizing the knee during activities such as walking, climbing stairs, and squatting.

When these muscles are excessively tight or fatigued, knee mechanics may be affected.

This does not mean that every case of knee pain originates in the lower back. Knee pain has many possible causes, including injuries and degenerative changes within the knee itself.

However, in some patients, what appears to be an isolated knee problem may also involve a larger spine–pelvis–hip–knee mechanical relationship.

Why Knee Treatment Alone May Not Always Be Enough

When someone visits an orthopedic office for knee pain, the evaluation naturally focuses on the knee.

Imaging may identify findings such as arthritis, meniscus damage, cartilage changes, or other structural abnormalities. Depending on the condition, treatment may include medication, injections, physical therapy, or surgery.

These treatments can be appropriate when indicated by the patient's condition.

However, treating the painful area alone may not always address other mechanical factors that could be contributing to the patient's symptoms.

This can be particularly relevant when knee pain occurs together with:

• Chronic low back pain
• Hip tightness
• Pelvic movement restrictions
• Altered walking mechanics
• Muscle tension or weakness
• Previous injuries
• Recurrent symptoms after knee-focused treatment

For example, if a person has altered movement through the lumbar spine, pelvis, or hip, simply increasing activity or strengthening the leg may not address every factor affecting how the knee is loaded.

This does not mean that physical therapy or exercise is inherently harmful.

Rather, exercise and rehabilitation should be appropriate for the individual's condition, examination findings, symptoms, and ability to tolerate the activity.

The Importance of Looking at the Whole Body

The human body functions as an interconnected musculoskeletal system.

The spine, pelvis, hips, knees, ankles, and feet work together with muscles, nerves, and other tissues to produce coordinated movement.

Because of these relationships, a problem in one region may influence movement or mechanical demands in another.

That is why, when a patient has chronic knee pain—especially when symptoms persist despite previous knee-focused treatment—it can be useful to examine more than just the knee.

The question is not only:

"What is wrong with my knee?"

It can also be:

"What factors may be contributing to the way my knee is being loaded and used?"

In the patient described above, the knee was one part of a larger mechanical pattern involving the lumbar spine, pelvis, hip, and leg muscles.

A Gonstead Approach to Knee Problems

The Gonstead System emphasizes a detailed examination of the spine and related structures rather than assuming that every patient has the same underlying problem.

Depending on the individual case, an examination may include:

• Postural evaluation
• Static palpation
• Motion palpation
• Instrumentation
• Range-of-motion testing
• Orthopedic testing
• Neurological examination
• Evaluation of the lumbar spine
• Evaluation of the pelvis and sacroiliac region
• Assessment of related joints and movement patterns
• X-rays when clinically indicated

The findings are considered together with the patient's history and symptoms.

This can help determine whether chiropractic care may be appropriate or whether additional medical or orthopedic evaluation is necessary.

How Can Nova Gonstead Chiropractic Help?

At Nova Gonstead Chiropractic in Fairfax, Virginia, we do not look at knee pain in isolation.

When appropriate, we evaluate the spine, pelvis, hips, and lower-extremity mechanics to determine whether findings in these areas may be relevant to the patient's symptoms and movement patterns.

Using a Gonstead-based examination, we assess spinal and pelvic motion, posture, muscle tension, and other clinical findings to develop an individualized approach to care.

If you have chronic knee pain, recurring knee problems, abnormal patellar tracking, or knee pain accompanied by low back or hip discomfort, a comprehensive examination may help identify factors that could be contributing to your symptoms.

Your knee may be where you feel the pain, but understanding the factors affecting the knee may require looking at the entire kinetic chain.

If you have persistent or worsening knee pain, particularly following an injury or surgery, an evaluation by an appropriate healthcare professional can help determine the possible causes and the most appropriate treatment.

NoVA Gonstead Chiropractic Clinic
9514 Lee Hwy (Route 29), Suite B
Fairfax, VA 22031
(703) 359-6262