The Dumbest Joint in the Body

by Mitch Hauschildt, MA, ATC, CSCS

I have always loved what Gary Gray says about the knee…”It is the dumbest joint in the body”.  At first glance, it sounds like to harsh to say that a joint is “dumb”, but when you stop at think about it, it really is a dumb joint.  If there is such a thing as a joint that can think for itself, the knee is not it.  It has no original thoughts and can’t do much of anything on its own.  It is stuck following along with its friends above and below it.

If the foot pronates and flattens out, causing a chain reaction of internal rotation up the chain, then the knee will follow along.  If the ankle is stuck and isn’t mobile enough to allow for proper function, the knee will usually end up compromising quality of motion to make up for the ankle’s lack of motion.  When the hip rotators and abductors aren’t turning on and off at the right time and in the right sequence, the knee will fall into a poor position.  And many times these patterns coincide with each other, adding fuel to each other’s fire.

What frustrates me about treating the knee is that so many clinicians still look only at the knee when treating it.  I end up treating a lot of patients who have failed therapy with other clinicians and it amazes me how many of those patients have knee pain and have never had their feet or hips looked at.  The knee is the victim, not the criminal.  Stop accusing it of doing things that it just isn’t going to do on its own.

Recently, I had a college freshman with a history of 7 years of knee pain who had seen multiple physicians, therapists and athletic trainers to try to cure her of her pain.  She tried multiple braces, knee taping and quad exercises to no avail.  On her first day with me I simply taped her hips and feet to put her in a more neutral position and sent her out to practice.  Later in the day, she returned from practice stating that she was pain free for the first time that
she could recall.  Is it because I did anything magic?  No way.  I’m not a magician or that smart.  I treated her hip and her foot.  It’s that simple.

I think about the knee as the flag in the middle of a tug of war rope.  It will go wherever each team takes it.  In an ideal world, each team is strong, stable and works together.  When that happens, the rope remains taught, centered and in a straight line.  But, when one team is weaker or more unstable than the other, crazy things begin to happen.  The rope starts moving sideways, at an angle, or simply drops to the ground.  That’s what happens when either the lower leg or the hip don’t hold up their end of the bargain for the knee.  

If I break things down a little bit, here’s what we need to keep in mind:

• In order to squat or lunge efficiently, you must have decent ankle dorsiflexion.  If you don’t, you will shift abnormal loads to your knee when you load up the lower extremity.  Poor ankle dorsiflexion usually leads anterior knee pain long term and can also lead to acute ligament tears in certain situations.
• If you pronate or have poor mid foot and forefoot control, this will cause tibial rotation which then leads to valgus at the knee, resulting in chronic knee pain or acute knee injuries.
• When you have a great toe extension restriction, you will typically compensate by pronating at the mid foot to gain extra motion which then leads the chain of events that I just described.
• Looking from the top down, the external rotators and abductors of the hip are what controls the amount of valgus that occurs at the knee.  Clearly by everything that I’ve written, valgus is an issue with knee pain.  I don’t like to get into specifically which muscles control valgus, because honestly, I don’t care.  I train my patients to externally rotate, abduct and extend the hip with closed chain movements and as long as the movement is clean, I let the brain decide which muscles should be turned on and off.  If the hip isn’t controlling the femur, valgus will occur and knee pain will follow.

When you evaluate someone for knee pain, you need to look at the hips ability to control the femur.  You also need to go below the knee in order to assess the ankle, mid foot, forefoot and great toe.  All of them have a large impact on the knee joint.

I do apologize a bit for being on a little bit of a soapbox on this post, but I am passionate about improving the lives of others.  Simply put, the knee is dumb.  Don’t look at it.  Look at the things above and below it that actually affect it’s function.