Knee Pain and Gait

Full technique video below!!

As therapists, we all have had clients come to us with knee pain. Unless your client has had a direct impact or injury to the knee, most of our client’s knee pain is probably coming from somewhere else. The knee is just the victim.

Let’s look at how the joint segments are incorporated through the body. (FYI--Gray Cook formed this idea.) If you start at the foot, the foot is a stable segment, ankle is mobile, knee stable, hips mobile and stable, lumbar spine stable, thoracic spine mobile, neck stable, and head mobile. So, we have alternating segments of mobile and stable. The knee is a stable segment. If we look at the joints above and below the knee, we see we have both mobile joints.

The ankle is a mobile joint. There are six common compensations that can appear when a client has a lack of dorsiflexion. One compensation is lateral rotation of the foot and ankle during gait. So, when the foot strikes the ground, the toes are facing out which in turn causes all that impact to go to the knee. You lose the kinetic drive/force to propel energy throughout the body. Imagine having this during a run. You will see this often when you are behind the person running and you see their hip and foot rotate out.

The hips are special--they are mobile and stable joints. If the hip does not have good stability or activation during stance phase, then usually the quads take over to help stabilize and support that phase into the terminal stance phase. The brain does not like that. So, it will cause the foot to rotate out because the next stable segment is the knee. Now, we are back to the ankle dorsiflexion dysfunction described earlier. Imagine having both of those dysfunctions together.

It is easy to see that with hip or ankle dysfunction, it is easy for the knee to start taking the brunt force and become irritated and abused, which causes a lot of pain for most of our clients. But the key is to assess below and above to see if something else is the true cause. Imagine working with your client and correcting those dysfunctions and you never touched the knee. Magic!!

Below is a technique guide on how to address these problems.

Hip Assessments With The Hip Flexed

External Rotation:

• The client is asked to sit on the edge of the table with the lower legs hanging off the table.
• The therapist instructs the client to put hands on the hip to help ensure the hip stays down. Be sure to tell the client to keep their thigh on the table as well.
• Therapist asks the client to externally rotate the hip. The criteria is 40 degrees of movement.
• If the client has the movement, move on to internal rotation.
• If the client does not have the movement, then the therapist takes the leg and passively moves the client’s leg to see if they can get 40 degrees.
• If the client did not have the movement passively, then there is a mobility dysfunction with external hip rotation with the hip flexed. If client has the movement, then there is a stability/motor control dysfunction with the hip in external rotation.

Internal Rotation:

• Therapist asks the client to internally rotate the hip. The criteria is 30 degrees of movement.
• If the client has the movement, move on to Hip Assessments With The Hip Extended.
• If the client does not have the movement, then the therapist takes the leg and passively moves the client’s leg to see if they can get 30 degrees.
• If the client did not have the movement passively, then there is a mobility dysfunction with internal hip rotation with the hip flexed. If client has the movement, then there is a stability/motor control dysfunction with the hip in external rotation.

Hip Assessments With the Hip Extended

External Rotation:

• The client is asked to lay in the prone position on the table.
• The therapist takes the client’s foot and bends the knee to 90 degrees.
• Therapist places one hand on the same side hip to help ensure the hips does not rise.
• The therapist asks the client to externally rotate the hip. The criteria is 40 degrees of movement.
• If the client has the movement, move on to internal rotation.
• If the client does not have the movement, then the therapist takes the leg and passively moves the client’s leg to see if they can get 40 degrees.
• If the client did not have the movement passively, then there is a mobility dysfunction with external hip rotation with the hip extended. If client has the movement, then there is a stability/motor control dysfunction with the hip in external rotation.

Internal Rotation:

• Therapist places one hand on the opposite side of the hip to help ensure the hip does not rise.
• The therapist asks the client to internally rotate the hip. The criteria is 30 degrees of movement.
• If the client has the movement, move on to the Standing Dorsiflexion Test.
• If the client does not have the movement, then the therapist takes the leg and passively moves the client’s leg to see if they can get 30 degrees.
• If the client did not have the movement passively, then there is a mobility dysfunction with internal hip rotation with the hip extended. If client has the movement, then there is a stability/motor control dysfunction with the hip in internal rotation.

Ankle Assessments

Standing Dorsiflexion Test:

• Client stands facing the wall. Client puts one foot up to the wall with toes touching the wall. The elbows are bent to 90 degrees and hands on the wall. The other foot is directly behind the front foot.
• Client is instructed to bend down at the knees and try to bring the knees towards the wall.
• The back foot is the one being tested. Client is asked to stop before the back heel comes off the floor. The criteria is 40 degrees of ankle dorsiflexion. Or, the back knee crosses over the medial malleolus on the front foot.
• If the back ankle has 40 degrees, then move onto the Standing Plantar Flexion Test.
• If the client does not have 40 degrees, then move onto the Standing Plantar Flexion Test. Keep in mind the client will need to move onto the Prone Dorsiflexion Test.

Standing Plantarflexion Test:

• Client stands facing the wall--same position as the Standing Dorsiflexion Test.
• Client is asked to raise the front foot off the ground.
• The client
• to come up onto the toes using the back foot.
• If the back ankle has 40 degrees and the dorsiflexion test was clear, then ankle dorsiflexion and plantarflexion is adequate.
• If the client does not have 40 degrees, then move onto the Prone Dorsiflexion/Plantarflexion Test.

Prone Dorsiflexion Test:

• Client lies in the prone position on the therapy table.
• Therapist takes the ankle and bends the knee to 45 degrees.
• Client puts the foot at a neutral zero-degree position. Therapist then dorsiflexes the ankle and looks for 30-35 degrees.
• If the client has 30 degrees of dorsiflexion, then the client has a stability dysfunction with dorsiflexion.
• If the client does not have 30 degrees, then there is a mobility dysfunction with dorsiflexion.

Prone Plantarflexion Test:

• Client lies in the prone position on the therapy table.
• Therapist takes the ankle and bends the knee to 45 degrees.
• Client puts the foot at a neutral zero-degree position. Therapist then plantarflexes the ankle and looks for 40 degrees.
• If the client has 40 degrees of plantarflexion, then the client has a stability dysfunction with plantarflexion.
• If the client does not have 40 degrees, then there is a mobility dysfunction with plantarflexion.