With a diagnosis of knee pain there are many things to consider. I?m going to go over some of the more basic things first and expand from there to a more detailed and whole-body assessment in looking at the knee.
One of the basic ideas in physical therapy in general and Integrative Manual Therapy in particular is that the knee is usually the ?victim.? It is not usually the actual cause of the problem, but merely the area that took the big hit or injury. Even in a traumatic injury, the knee is rarely the primary problem, but instead is the location of the patient?s pain. The reason the knee expresses the pain is that it takes so much of the stress, being at the end of two long levers, the thigh bone and the lower leg bone. Forces are accentuated where they meet, and in this case they meet at the knee.
How does this translate clinically? Say someone comes in with a recent onset of knee pain. Maybe they have started a new exercise routine, or they have been doing some extra walking or standing. Maybe they actually ?blew out? the knee with a traumatic sporting injury. Maybe they have no idea how it started, but they have a few-month history of knee pain that is not clearing up on its own. When I see this type of patient, I may find tenderness to touch in a tendon or a ligament or along the joint line of the knee. As I have found that knee pain is usually caused by a hip problem and/or a foot problem, I will usually also see one or more of the following: an asymmetry in the pelvis, a lack of motion in the back and hip more on one side than the other, a foot that lacks motion in the ankle, or a foot that has too much motion in subtalar joint pronation (a rolling-in causing a flat foot).
The problems at the hip, back, and foot are placing undue stress at the knee and making it more vulnerable to injury. The imbalances are also not allowing healing to occur in the knee. These are common findings when looking at a knee patient from an orthopedic physical therapy model. The forces need to be balanced above and below the knee to allow good mobility and stability at the knee. Specifically, treatment to correct the imbalances at the knee and allow healing of the tendon, ligament, or joint of the knee would involve balancing the pelvis, hip, and foot through manual therapy, exercises, and orthotics.
From a more whole-body, Integrative Manual Therapy approach, we can take this idea of balanced forces a step further and find ways to help even the more chronic problems at the knee. Say someone comes in with a knee pain that has been problematic for 10 years or more. We have seen patients with long standing problems, who have findings on an MRI of degenerative problems, patients who have been un-helped with standard good quality physical therapy, orthotics, and anti-inflammatory medications. We?ve been able to help these people by looking further into the cause of the problem, the ?why? of the injury. Why would a person?s body keep a pain or problem for 10 or more years, despite resting it and despite good treatment?
What I?ve found is that, especially in difficult or chronic cases, the body is protecting something very important, and this is why the knee is not healing. Let me give a brief explanation. In standard physical therapy treatments, we look at muscles, connective tissue like ligaments and tendons, joints, and even nerves. We look at strength and flexibility. But there is so much more in the body. There are organs, lymph vessels, veins, and arteries. There are also toxins affecting the body. The body will use ?less important? structures like muscles, ligaments, tendons, and even joints to protect ?more important? structures like organs or vessels. It will also do the same to protect itself from toxins.
There are common patterns when you look at the body from this more whole-body approach. If the body has toxins from a leaky gut syndrome, which is very common, the pelvic organs can be affected. The body will then lock down the joints of the pelvis and hip, which in turn affects the way the leg works. If the body has infection and inflammation in arteries, also very common, the body can lock down the spine, pelvis, and legs. If the body has infection and inflammation in the urogenital areas (uterus for women, prostate for men, or bladder for both), the pelvis can lock down, causing more compression in the knee and leg. In all of these cases, the knee will have a hard time healing because of all of these protective restrictions in the spine, pelvis, and legs. The body is more protected from infection and inflammation, but the spine, pelvis, and legs are tight and causing stress on the vulnerable knee.
In this approach correcting the actual cause of the locked-down pelvis or leg would bring faster and longer-lasting changes. Specific Integrative Manual Therapy techniques to help the body fix up the restrictions in the pelvic organs or vessels can be used to balance the pelvis and legs to allow better mobility and balance. Specific Pilates and pelvic floor exercises can help strengthen and balance the pelvic floor muscles. This is important to retrain the pelvis and allow better function in all activities. A detox diet could be useful to turn things around if toxicity is causing the problem. A gluten-free diet is especially useful for correcting a leaky gut problem affecting the pelvis and knee. Additionally, the gluten molecule is very similar to hyaline cartilage in the knee, and research has shown a direct correlation between eliminating gluten and eliminating the inflammation and pain of both rheumatoid arthritis and osteoarthritis.
As you can see, there is much to consider when looking at why someone with knee pain, especially chronic knee pain; but there is also so much we can do to help someone with this problem and help them return to walking, running, and living life they?ve been missing.
Ralph Havens, PT, OCS, IMTC
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