I first heard this quote by Tim Hewitt at a Sports Section meeting of the American Physical Therapy Association (APTA) in 2015. He meant the knee just gets stuck in the middle of the hip and knee mechanically. The core should probably be included in this, but it is in between 2 long levers and goes along for the ride. This doesn’t mean the tissues at the knee don’t break down, get overused, and hurt. Actually, it is quite the opposite. To try to fix any mechanical issues at the knee causing pain, however, you must treat the hip and the foot.

Research is mixed on orthotics (shoe inserts, arch supports) and other footwear interventions as to decreasing pains at the knee. However, clinically it must be evaluated. Major mal-alignments should be addressed even if only with inexpensive OTC orthotics. There are many more quality options than ever before for these devises. Certain foot/ankle exercises can help as well.

Maybe more importantly and certainly more substantiated in the literature, is correcting hip weakness to improve knee alignment, position, and movement function. Lateral hip muscles, hip rotators, and gluteus maximus must be activated (can shut down if pain) and strengthened. This is a must. Dynamic valgus is the knee going inward in relation to the hip and knee on jumping, landing, running, and cutting. This is excessive femur internal rotation and adduction (see picture). This is slowed or stopped by hip muscles especially eccentrically. Since we care more about dynamic positions than standing, static positions, hip muscle strengthening becomes critical.

I never expect a knee condition with dynamic valgus positioning to improve without hip strengthening. This also means we should use hip strengthening to prevent pain and to improve performance, which is what we do every day, especially in female athletes.

Take home point: See a sports physical therapist (call me). Evaluate the specific cause of knee pain. Support the foot and strengthen the hip if there are movement impairments. We usually do some modalities to the knee, but basically, if we can improve mechanics above and below the knee, the athlete will decrease pain, improve performance, and limit the potential for pain to return.

That is smart!!!!

Kash Eagleton, DPT, SCS
Doctor of Physical Therapy
Board Certified Sports Physical Therapy Specialist
keagleto@hotmail.com
Fredericksburg, VA

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