The Knee is controlled by the muscles at the Hip. To properly treat and Rehab knee pain, you must look at what’s going on at the Hip!
When a person presents to a doctor’s office with knee pain, the most common diagnostic procedure is some form of imaging study, x-ray or MRI. The doctor want to look at the knee itself, but doesn’t ask why the knee is injured. The knee is most often an innocent bystander, while the hip is the major problem. You can do all the right things to help someone with knee pain, but if you don’t correct the problem at the hip, you won’t fully correct their problem and it will come right back.
The hip joint controls what happens at the knee because the Gluteal muscles control how the femur or thigh bones moves. You don’t want excessive hip adduction or internal rotation (see picture below), or the knee with get overused and begin to hurt eventually.
So, the big picture is you have to look at the whole patient and how their whole body is functioning, regardless of what injury they have. Each body part contributes to the whole when it comes to stabilization, and the hip plays a major part in why a knee will begin to hurt. My rules are treat the local tissue that are causing the pain while you are correcting the cause of the problem which is normally NOT at the sight of pain. Then you but a corrective exercise plan in place to help correct the true cause of the patient’s problem that they can continue to work on once I have released the patient from my treatment.
Do X-Rays and MRIs really help doctors make accurate diagnosis of spine and joint pain? That surprising answer is NO!
There has been a lot of research done on the guidelines for treating spine and joint pain and this research has concluded that for the most part, diagnostic imaging (x-rays, MRIs, etc.) should NOT be used as a screening tool for pain. The reasons is there are too many false positives. What this means is that if we took 100 people off the street, took a MRI of there low back, 50 of them would have some sort of positive finding (degenerative changes, bulging disc, herniated disc, etc.). But, those 50 people would not be the same people who reported having pain!
What the above study tells us is there are functional reasons for spine and joint pain, and that it isn’t that important what a joint looks like on diagnostic imaging. The function of a joint is to move, and to move based on how it is designed. Some joints aren’t supposed to move very much in certain directions, like the lumbar spine and rotation. Some joints are designed to move a lot in all directions, like the shoulder joint. A joint can look bad on an x-ray or MRI and still function okay and therefore not be painful.
And no, even if you have a joint that looks bad on imaging it doesn’t mean you are going to have lots of pain in that joint. I have seen some pretty bad looking joints in the spine and extremities, but have been able to change their pain quickly and have it last. What I do is change the function of the joint, I don’t need to change the structure of it. The model of healthcare has to change when it pertains to spine and joint pain. We have to get away from the structural model and lots of diagnosing based on imaging and start to use a functional model where we diagnose based on how a joint moves and treat based on those findings.
There is one muscle in particular that causes the most problems at the knee. It’s name is the Rectus Femoris, but it is often called the “Wreck”us Femoris, because it causes so many problems.
The rectus femoris muscles begins at the front of the pelvis and attaches to the patellar tendon at the front of the knee, so just above the knee cap. The reason why the RF causes so many problems is because of its attachment to the pelvis and crossing in front of the hip, so it acts like a hip flexor. Because of its attachment points, the RF tends to become very tight on people, and this causes a lot of compressive forces at the knee cap as it slides on the femur (thigh bone).
Because we sit so much and the hips are therefore flexed, the hip flexor muscles will tend to shorten and causes extra tension at their attachment points. Also, if we do not stabilize our pelvis in the correct alignment with our lower rib cage, which is parallel to each other (see picture below), then the RF will act as a stabilizer for our pelvis, which is a task that it is not designed to perform, so it performs it poorly and creates too many tightness or tension at the knee.
There is an easy test to see if your RF is too tight. You lay on your belly on the floor or on a bed and try to take your heel to your butt. It is normal to get your heel pretty close or all the way to your butt. You can use a towel wrapped around your ankle to pull the lower leg if you have a hard time doing this test. If you cannot come close to bringing your heel to your butt, then you have a tight RF and it needs to be treated, especially if you have knee pain.
The good news is that a lot of knee pain is causes by this mechanical problem and getting the tension to reduce in the RF isn’t that hard. When you do get the tension or tightness reduced in the RF, your knees will feel a lot better!
When a patient first presents to my office with shoulder pain, the first thing I want to know is if this patient has a condition I can treat. There are good orthopedic tests to determine that. However, the next most important thing to figure out is the pattern the patient’s shoulder pain is exhibiting. The usual pattern is pain on forward or lateral movement as the arm is raised upwards. The next question is does the pain occur during the movement or only at the end of the movement.
The typical pattern for shoulder pain is that the pain occurs during movement, reaching up for something or reaching into the backseat of a car, etc. Once this pattern is established, then I want to see if movements in the opposite direction will improve the painful movement direction. We spend a lot of time with our shoulder joints forward and almost never move them backwards, so I test extension first. I will do 1 set of 10 reps of shoulder extension and then see if that improves the ability of the patient to move in their painful direction. For the vast majority this will improve their symptoms right away!!
We will then continue doing shoulder extension mobilizations for a few more sets in the office and then I teach the patient how to do it at home. We will also begin to work on the other issues the patient may have doing on in their neck, mid back, scapula, etc. What is super cool about this method of diagnosing and treating is that it improves symptoms fast!! And it tells us that most of the joint pain we deal with is mechanical in nature, which means it is a movement problem not a structural problem (like arthritis, which doesn’t usually cause pain).
Here is a video of me performing the at home version of the shoulder extension mobilization:
Dr. Peter Attia is a medical doctor who focuses on longevity and natural health solutions. He has a great podcast and the podcast he released on March 8th is about Dynamic Neuromuscular Stabilization! This is the philosophy that I use in my practice everyday!!
It is great that Dynamic Neuromuscular Stabilization, DNS for short, is starting to hit the mainstream. Dr. Peter Attia is a very well known medical doctor who has a great podcast and a subscription website that focuses on longevity and living healthy. I don’t agree with him on everything, but he is one of the best out there breaking away from the mainstream healthcare narrative which has lots of faults. He is a big proponent for DNS and has been promoting it from quite some time. I wish he would have done this podcast with Dr. Brett Winchester, who is my mentor because Dr. Winchester was one of the first to bring DNS over from the Czech Republic.
DNS was created by Dr. Pavel Kolar out of the Czech Republic. I have had the pleasure of training multiple times with Dr. Kolar on DNS. DNS is centered on the principle that when we are born our muscles and joints are immature, and in the first year of life we develop the shape and structure of our joints/posture, which culminates once we are upright and walking. When we are adults we can use the developmental positions which are used by the baby to activate the proper muscle coordination that we may have lost due to injuries, repetitive movements, or constant postures (like sitting). These are the exercises that I use for rehab purposes.
I have not had the chance to listen to the whole podcast just yet, but here is a link to the podcast page on Dr. Attia’s website. While you are there, look around and read some of the other posts about diet and health, they are really good!
Here is a link to the DNS website, there is a lot of great information there that I use all the time!
The most overlooked muscle in the shoulder is the Serratus Anterior. This is because it doesn’t actually attach to the shoulder, but the shoulder blade.
The Serratus Anterior begins at the inferior rib cage and attaches to the shoulder blade on the anterior surface of the medial border (see picture below). What this muscle does it is guides the shoulder blade around the rib cage and upwardly rotates the shoulder blade. As you learned from my last email, upward rotation of the shoulder blade is crucial to avoid injuries in the shoulder, especially the rotator cuff muscles.
Why is the Serratus Anterior so commonly weak? This is because it is super common for us to have poor control over our lower rib cage, and if we don’t stabilize our lower rib cage via our abdominal muscles, then the serratus anterior doesn’t have a stable base to pull off of, and we will use a different method to control and upwardly rotate our shoulder blade which won’t be as good and cause overload injuries.
Getting the serratus anterior to function properly takes a very specific approach, but fortunately it can be done. Here is a video of the exercise I use when I need to get the serratus anterior working. And when the correct treatment protocol and corrective exercise are used we can not only get you out of pain quickly but correct the underlying cause of your problem at the same time! This is how you get results that have staying power.
Referred pain is when you feel pain somewhere but the pain is coming from somewhere else. Pain that is under the shoulder blade that you can’t reach or touch is a classic example of the referred pain phenomenon. This pain is actually being referred from a disc in the lower neck! And, to top it all off, you typically don’t feel any pain in your neck at all, even while moving your neck. Crazy right!
As you can see, the nerves leaving your neck go right in front of your shoulder blade, which is why you can feel pain here from a disc injury in your lower neck.
How do you know that this deep, shoulder blade pain is coming from the neck? Its actually quite simple, performing a traction test to the lower neck determines if the lower neck is involved. If the test relieves the pain or you feel the pain move out of your shoulder blade towards you mid back or neck, then the pain is coming from the neck and NOT the shoulder.
Also, you will most likely NOT see anything on MRI or x-ray imaging studies. Fortunately, proper history, physical exam, and orthopedic testing can figure out more spine and joint injuries without imaging being necessary.
I hope this information helps! This is a very common presentation I see in my office because most doctors and PT’s miss diagnose this patient and treat it as a shoulder problem instead of a neck problem. If this email describes you or someone you know, don’t hesitate to call my office so I can help!
To finish this series on why pain and phases of healing are different, I am going to give you a very common example.
The best way to know that pain and healing times are different is how quickly you can sometimes get someone out of pain but then their pain can come right back. How is this possible if pain and healing times are the same? Simply put, once you are out of pain your body still has to finish the stages of healing for whatever tissue was injured, which can be weeks to months.
This is why it is so important to get someone out of pain quickly, so they can start working their way through the healing process as fast as possible. This is also why it is so important to continue your rehab exercises and lifestyle modifications once you are not seeing a doctor like me anymore. You have to make sure you heal your tissue heals so it isn’t so easy to exacerbate or reinjure.
I hope this email series has helped you understand the difference between pain and the phases of healing. I think it is an important topic to discuss because it is confusing for patients. A lot of my patients will feel a lot better even after just 1 or 2 treatments, but then their symptoms will be really up and down based on what they are doing in their lives and how it effects their injury. Knowing that the patient still has to get through the healing process and that is most likely why they are feeling some mild symptoms helps me know NOT to treat them too much and that time is what they need while not irritating their injury. It also gives peace of mind to the patient that just because they still have some pain, their is not something we are missing or something bigger wrong with them. They have to get through the phases of healing and pain doesn’t tell us exactly where they are at in that process, pain just tells us what the body is tolerating at that time and what to avoid.