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Knee Pain

Recently as I was walking into the YMCA for my daily workout I noticed the group of mature (ranging 30’s - 60’s) male basketball players having at it on the indoor court.  What struck me that day was the number of men wearing a knee brace on their left knee.  There had to be 7 of them.  First, I wondered why the left knee is the one most affected and if that was true in general when it comes to basketball players.  Secondly, I wondered what the knee issues were that caused them to wear braces.  As I went in to the cardio room to start my workout I took notice of several more wrapped up knees.  Some were left leg and some were right, but again there were several on the treadmills and cross-trainers - men and women.  


Of course, as a professional massage therapist, I wondered if any of these people had an idea as to how they could do some routine self-maintenance massage to keep their knees healthier.  As a jogger and exerciser I’ve had my share of knee discomfort over the years and know the value of doing some preliminary soft tissue massage prior to my runs.  


The knee joint is one of the most injured joints in the body.   It was recently reported at the annual convention of the American Academy of Orthopaedic Surgeons that 4.5 million American citizens are sporting at least one knee replacement, they are occurring in progressively younger individuals and osteoarthritis is the prevalent reason for the surgery.  


Given the heightened health craze of the boomer generation, pounding their legs into the concrete and asphalt pavement in search of prolonged health, that number is likely to rise.


Alignment is key to the knee


Proper bone alignment is critical to the function of any joint and is important for the knee due to the amount of body weight it supports and its role in everyday activities.  We tend to abuse the knees a lot by kneeling on hard floors and using them to nudge heavy objects we are trying to move or prevent from moving.  Sports activities are often unfriendly to the knees, too.  The connective tissue that wraps the knee joint is subject to the strains and twisting forces associated with the abuse we give it.  Unfortunately, these tissues do not respond like the “memory foam” on our mattresses.  Rather, the tissue becomes distorted and results in mis-alignment of the bones and un-natural pulling forces to the knee.  We often respond to the resulting pain by taking a few aspirin before and after activity and putting a neoprene bandage around the joint for support.  If we knew enough to do some soft tissue maintenance to the tissues once in a while perhaps these countermeasures could be avoided.


The main movement at the knee is bending (flexion) and straightening (extension) with some twisting (rotation) when the knee is bent.  The movement provided by the knee allows us to walk, run, sit, and kneel.  The knee is formed by the junction of three bones - the thigh bone (femur), leg bone (tibia) and knee cap (patella).  The surface between the femur (thigh) and leg (tibia) bones is the the largest single joint surface in the body.  The end of the thigh bone is round (condylar) while the top of the leg bone is relatively flat.  It is this structure that allows the knee to provide a fair amount of movement and the ability to adapt to a variety of surfaces - uphill, downhill, sidehill - it is quite a feat of engineering, and we all know that nature is pretty good at designing things that humans have tried to copy.


To provide more depth, stability and cushion, there are pads (called the meniscus) of cartilage positioned between the two bones; one on the inside (medial) and one on the outside (lateral). These pads may tear when sudden side bending of the knee or twisting of the joint occurs.  The joint is held together by strong ligaments inside the joint (cruciate) and outside the joint (collateral).  These ligaments are subject to injury from sudden forceful movements as well.  The whole knee joint is wrapped in layers of connective tissue to provide stability and integrity.  To provide additional stability there are a number of muscle tendons that cross the joint.


The muscles that move the knee attach the pelvis and thigh bone (femur) to the leg (tibia and fibula) bones.  They are amongst the largest and strongest muscle groups in the body.  They are also prone to tightness and gluing.  Excessive tension and overuse of these muscles can result in restricted knee movement and pain in the knee, thigh, lower leg and foot due to trigger points and waste product build-up in the tissue.  

The main muscle group responsible for straightening the knee is the quadricep femoris.  One of the 4 muscle bellies, the rectus femoris, attaches to the front of the pelvis and just above the hip socket.  The other 3 connect to the front and sides of the thigh (femur) bone.  They converge to engulf the knee cap (patella) in tendon and then continue on to the tibia through a strong ligament called the patellar ligament.  The quadriceps is a major anti-gravity muscle which contracts powerfully to allow for a controlled  movement as when sitting down in a chair.  They are the main force in powering the effort to rise out of a chair.  In the first case, they contract while lengthening to allow for a soft landing in the chair.  In the second case, they contract while shortening to lift you out of the chair.  Maintaining their strength and flexibility is key to maintaining your quality of life.


If the strength and flexibility of the muscles that act on the knee joint are unbalanced the knee may be pulled out of alignment.  This can cause uneven weight bearing on the joint surface ultimately leading to a breakdown of the cartilage that lines the ends of the bones.  This is how the osteoarthritis develops which leads to the need for joint replacement.  The kneecap can also be pulled off to the side when bending the knee if the quadriceps muscles are out of balance.  This can cause the cartilage on the back of the kneecap to deteriorate and cause pain when walking or running.  The kneecap may end up rubbing against the condyle of the femur in some cases or the muscle tendons may rub against bony structure causing pain and inflammation.


Excess body weight being supported by the knees also contributes to their early breakdown.  If you overload an automobile with cargo or tow a trailer with it chances are it will need new shock absorbers and springs much sooner than a similar automobile that is not overloaded.  The knees are subject to overload much more than most other joints.


Trigger points that can develop in the quadriceps muscles may refer pain sensations to the inside, outside and front of the knee joint.  They also can cause pain sensations on the inner and outer thigh.


The hamstring group is located on the back of the thigh.  Three of the hamstring muscle bellies attach to the back of the pelvis on a feature called the ischial tuberosity (sit bone).  The fourth muscle belly arises from the back of the thigh bone.  These muscles cross behind the knee joint, two attach to the tibia and two attach to the fibula.  They are responsible for bending (flexing) the knee and for extending (straightening) the hip joint.  The quadricep group and hamstring group oppose each other in terms of actions yet must work in harmony and balance for smooth knee and hip movements.  If one is tighter than the other they both end up suffering.


Trigger points in the hamstring group can refer pain to the back of the thigh near the buttocks and to the area behind the knee.


The muscles affecting knee movement that get little press are the adductors and the popliteus.  The adductor that crosses the knee joint is the gracilis.  It attaches the middle of the pubic bone to the inside of the tibia.  This is one of the muscles often strained in the “groin pull” situation.  The gracilis combines with the sartorius and semitendinosus (one of the hamstrings) to form a tendinous web just below the inner knee called the pes anserinus area (translated as goose’s foot) due to the appearance.  The tendons of these three muscles often get adhered to one another and the connective tissue wrapping the knee joint.  This can limit mobility and cause pain in the knee.


The popliteus and plantaris muscles are found in the back of the knee.  Most people are unaware of their existence.  The popliteus performs a small yet critical function in rotating the knee when it bends.  The tendon of this muscle wraps around the outside of the knee in close quarters with the lateral collateral ligament.  It attaches to the back of the tibia bone just below the knee joint.  It has been known to get very tight.  It has a trigger point pattern that can cause pain in the back of the knee and into the calf area.


The Emotional Knee


There are several authors who have written about the emotional baggage that can be attributed to knees.  Two agree that in general the knees have to do with ego, pride and inflexibility.  One suggests that problems with the left knee indicates a need to be more receptive to events; feelings of insecurity; or experiencing unresolved stress.  The right knee has to do with a need to assert authority or not wanting to give in to authority.  As always, the emotional charge you may be storing in your knee is unique to you.  Perhaps a healthy dose of introspection can shed some light on chronic knee issues in your life.




Massaging the muscles that act on the knee is a great way to maintain their health and flexibility.  It can also serve as an outlet for some of the stuff you store there.  Pay particular attention to the quadriceps and hamstrings to work out any adhesions in the muscle itself or that may be sticking the muscle bellies of the muscle groups to one another.  Notice if there is a difference in the strength of the quadricep muscle on the outside of the thigh (vastus lateralis) as compared to the one on the inside of the thigh (vastus medialis).  If the inside one is weak the knee cap may be pulled off line to the outside causing knee pain.




The reflex area for the knee is located on the outside of the foot near the bump created by the base of the 5th metatarsal bone as shown in the illustration.


Spiral Synergy


The Spiral Synergy approach to the knee aims to restore balance in movement of the bones that form the knee joint.  By gently checking for the directions of ease and comfort the bones are currently experiencing and exaggerating those positions, the tension levels in the muscles that move the joint are balanced and pain-free movement can be restored.


There are a couple of instructional DVDs available on this website that show great techniques to perform on yourself or on a loved one.  Check them out.