Knee Pain From the Kinetic Chain

Adjustment strategies to address the potential causes.

By Kevin Curtin, DC and Terry Elder, DC

As practitioners of manual medicine, chiropractors often treat patients suffering from knee pain. In fact, according to the 2006 National Health Interview Survey, approximately 30 percent of adults reported experiencing some form of joint pain during the previous 30 days and knee pain was a leading cause of that discomfort.

When evaluating a patient with knee pain, it is often a challenge to sort out which structure or structures are the pain generator(s), especially when an injury has occurred. The clinical exam may not be sufficient and advanced imaging may be necessary for definitive diagnosis. As with any other joint in the body, pain may be a result of osteoarthritis, injury, prolonged abnormal posture, or repetitive motion / overuse. However, having ruled out pain due to injury, OA, etc., the focus should be on pain due to dysfunction.

We are often reminded of the phrase,the knee tries to do what the ankle wants it to do, but does what the hip allows it to. Simply stated, the knee is just one more link in the kinetic chain that is subject to the function or dysfunction occurring at the joints both above and below it. Therefore, it wouldn't be fruitful to focus our treatment just to the knee. This is not to say that pain-relieving modalities shouldn't be employed ? they just shouldn't comprise the entire treatment plan.

Kinetic Chain Involvement

A thorough examination of the foot / ankle is key to unlocking pain syndromes further up the kinetic chain. For this discussion, let's focus our attention on subtalar joint hyperpronation. Subtalar joint hyperpronation is often the result of diminished dorsiflexion. This may be the result of soft-tissue dysfunction, joint dysfunction or a combination of the two.

For example, postural muscles, including the gastrocsoleus, often become facilitated as a result of our societal propensity toward sedentary postures. As a result, the necessary amount of talocrural dorsiflexion needed for ambulation is reduced and compensatory movement strategies result ? subtalar joint pronation.

Although necessary for shock absorption and adapting to discrepancies in terrain, excessive subtalar joint pronation can wreak havoc throughout the kinetic chain. Hyperpronation leads to internal rotation of the tibia; leading to internal rotation of the femur; leading to unleveling of the pelvis and anterior tilt; leading to increased lumbosacral extension.

Let's rewind for a second and focus our attention on the effects subtalar joint pronation has on the tibiofemoral joint. As stated previously, excessive subtalar joint pronation results in tibial internal rotation. This rotary motion forces the medial tibial plateau into a posterior glide underneath the medial femoral condyle, placing the medial meniscus and joint capsule under significant strain. Excessive tibial internal rotation has also been implicated in the development of chronic pes anserine bursitis.

Excessive subtalar pronation and the resultant tibial internal rotation may also have deleterious effects on the lateral side of the knee as the iliotibial band is dragged over the lateral femoral epicondyle with each step. The result is a painful case of ITB friction syndrome.

Chiropractic Techniques

What can be done in terms of treatment from a manipulative therapy standpoint? This is not always an easy question to answer. The key to successful manipulative therapy is sound palpatory skills. Any dysfunctional region along the kinetic chain deserves a thorough motion palpation examination to uncover any joint restrictions.

Remember, our bodies are excellent at compensating for movement deficiencies. In general, we recommend assessing the common offenders when it comes to joint dysfunction in the lower extremity: talocrural and subtalar joints, which are commonly restricted; and let's not forget about the gastrocsoleus, which is easily treated with a quick stretch technique.

It is important to understand that dysfunction often leads to pathology and not the other way around. If we search for and fix the biomechanical issues, the pathologies will cease to exist.

1. Anterior Glide of the Distal Tibiofibular Joint (Posterior Glide of the Talus)

Palpation:

With the patient supine, dorsiflex your distal leg into the table, pressing your knee into the table edge for stability.
Dorsiflex and evert the patient's foot and stabilize their tibia against your knee, as close to the distal tibia and fibula as possible.
Allow the patient's leg to abduct against your thigh and brace your forearm against their tibia.
Take a web contact with your caudal hand over the talus; palpation is performed by pushing the talus A-P, creating a relative P to A of the distal tibia and fibula.

Manipulation

The patient is supine on the table with the knee of their affected foot / ankle flexed to 90 degrees and resting on a loaded toggle board.
Stand perpendicular to the table, dorsiflex into the table for stability, and stabilize the patient's distal tibiofibular joint with your cephalad knee and forearm.
With your caudal hand, establish a web contact over the dome of the talus, grasping the foot with your thumb and fingers. Dorsiflex the ankle to neutral position and evert the foot.
With caudal hand, thrust in a A-P direction to engage the toggle board.

2. Subtalar Joint Distraction

Palpation

With the patient in a "frog-leg"-type position, sit at the foot of the table.
With your cephalad hand, take a firm web contact over the talus, being sure that the thumb and index finger are just distal to the malleoli and the tibia is stabilized against your thigh.
With your caudal hand, firmly grasp the calcaneus and move it away from the talus in pure distraction.

Manipulation

With the patient supine on the table, assume a catcher's stance at the foot end of the table, facing cephalad.
With your outside hand, establish a palmar contact over the posterior aspect of the calcaneus with your fingers wrapping firmly and contacting the medial aspect of the calcaneus.
Place your inside hand at any level along the dorsum of the foot to maintain neutral positioning.
Evert the calcaneus and deliver a caudal thrust, drawing the calcaneus away from the talus.

3. Subtalar Joint Eversion

Palpation

The patient is supine on the table in a frog-leg position with their hip and knee flexed to 90 degrees.
With your caudal hand, establish a thenar contact over the medial aspect of the calcaneus, wrapping your fingers around to the plantar surface of the foot.
With cephalad hand, establish a web contact over the dome of the talus.
Tilt calcaneus downward to evert.

Manipulation

The patient is supine on the table in a frog-leg position and their hip and knee flexed to 90 degrees. Place a loaded toggle board under the ankle of their affected foot, parallel to their tibia.
Stand facing the foot end of the table and use your knees to stabilize the patient's knee.
With your cephalad hand, establish a thenar contact over the medial aspect of the calcaneus, with your fingers wrapping around to the plantar surface of the foot.
With caudal hand, establish a web contact over the dome of the talus.
Evert the calcaneus and push down into the toggle board.

4. Quick Stretch of the Gastrocsoleus

Patient should be supine with loaded toggle board under knee, open cephalad.
Contact above and below the knee as you use your thigh to passively dorsiflex the ankle.
Patient actively dorsiflexes as you thrust posteriorly.
Repeat 3-4 times.

Resources

CDC Feature: Adults Reporting Joint Pain or Stiffness in the Past 30 Days, 2006. Centers for Disease Control and Prevention, National Health Interview Survey, 2006.
Michaud T. Foot Orthoses and Other Forms of Conservative Foot Care. Williams & Wilkins, 1993.

Editor's note: This is the second article in a series on chiropractic techniques to treat challenging patient presentations. "The Struggle to Heal the Cervical Syndrome" kicked off the series in the June 1, 2014 issue.

Dr. Kevin Curtin graduated from National University of Health Sciences in 2007. He is an assistant professor of clinical sciences at NUHS and practices at The Hart Wellness Center in Flossmoor, Ill.

Dr. Terry Elder graduated from Cleveland Chiropractic College in 1987, and maintained a private practice in Kansas prior to coming to National University where he has been an instructor in chiropractic medicine for more than 17 years. Dr. Elder serves on the postgraduate faculty of NUHS and Canadian Memorial Chiropractic College, and has been an instructor with the Motion Palpation Institute for over 25 years.