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Knees: A User's Manual



There are only a few certainties in life: death, taxes, and knee pain. If you choose to walk around there is a high probability that you will experience knee pain at some point in your life. The duration and intensity of this pain will vary widely based on a number of influencing factors. This manual will walk you through the anatomical nuances of the knee joint, different patterns of dysfunction, and viable treatment options:


Anatomy of the Knee Joint

The knee joint is the articulation of three bones: the thigh bone (femur), the shin bone (tibia) and the knee cap (patella). In an ideal world these three bones glide smoothly in a typical hinging motion. The two cruciate ligaments (ACL and PCL) and two collateral ligaments (MCL and LCL), form a protective halter around the knee joint that keeps everything tight and in its place. While some rotation is acceptable, massive amounts twisting is not healthy for the joint and can lead to tears in these ligaments. Between the femoral head and the tibial plane, there are two dense pieces of fibrocartilage called the meniscus (medial and lateral) that help absorb some of the forces between the bones.


In addition to the ligaments holding the knee together, there are also numerous muscles and tendons that cross the knee joint. The primary extensors of the knee are the quadriceps. These four muscles share a common tendon (the patellar tendon) which encompasses the patella bone itself. The patella is largely responsible for gliding along the femoral groove at the bottom of the femur, thus keeping the patellar tendon from falling out of alignment and allowing for mechanical advantage for knee extension. On the posterior of the knee the muscles of the hamstrings and gastrocnemius cross the knee joint and work to flex the knee. The iliotibial (IT) band crosses the lateral portion of knee joint and attaches to the head of the fibula and aids with stabilization of the joint.


Pathologies

The knee is the largest joint in the body and contends with a large amount of force on a daily basis. Despite the knee being quite resilient to these demands, it still can break down. Here is a short list of all of the ways it can become hurt:


  1. General Muscle Soreness

  2. Knee Bursitis

  3. Patellar Tendonitis

  4. Iliotibial Band Syndrome

  5. Patellofemoral Syndrome

  6. Chondromalacia Patella

  7. Baker's Cyst

  8. Torn Meniscus

  9. Torn/Sprained Ligaments

  10. Degenerative Osteoarthritis


Differential diagnosis and treatment of these various conditions is best handled with the assistance of a licensed healthcare professional. Catastrophic injury to the knee joint (which usually causes excessive swelling) should be addressed with urgency to limit damage to the articular cartilage. For minor injuries, if pain or limitations to range of motion persist more than two weeks, you should probably pursue medical intervention.


Knees and Traditional Chinese Medicine

Knees lie firmly in the domain of the Water Element in Traditional Chinese Medicine. The Water Element, synonymous with the Kidney Organ System, becomes weaker as we age...unless we do preventative maintenance. This is why, in general, knee pain is far more prevalent in older populations. The Kidney Channel (and its paired channel, the Bladder) is also associated with the low back, the hips, the heel, and the inner arch of the foot. This points to the connection between the muscles of the posterior chain and the biomechanics of the knee (which we will discuss further in the next section). The Kidney System is injured by long periods of standing, excessive fear, unhealthy amounts of sex or work, and external pathogenic cold. These are important factors to consider when figuring out what exactly is causing knee pain. It might not just be related to one's body, but might also be tied to one's lifestyle.


Biomechanics of the Knee

Again, diagnosing specific biomechanical issues with the knee joint is best left in the hands of a knowledgeable health professional, but here are some of the basic concepts to consider:


Feet: Knee pain can be related to weakness in the muscles and structures of the feet. If a person is not regularly working to develop their foot strength, then the forces that enter the feet upon walking are more easily translated upward. Feet form the foundation (to use the metaphor of a house) and if they are weak the forces of gravity affect the knees (walls) instead.


Ankles: Limited strength and mobility in the ankle joint is also a common cause of knee pain. If the ankle has limited range of motion or strength, then load will be unevenly distributed to the knee and hip joint.


Hips: Often times knee pain is caused by either lack of mobility in the hip joint and/or a lack of strength. The gluteus maximus and medius are involved in abduction and extension of the femur bone. If these two muscles are not coordinating the hips properly when bending the knee and hinging at the hips, pain can result.


Quadriceps/Psoas: Numerous issues can arise when the quadriceps and psoas become too tight or are used too much in movement. Most often the excess pull on the patellar tendon or the IT band will result in improper tracking of the patella. This will cause pain around or under the kneecap. Countless cases of knee pain can be corrected by properly stretching the quads and psoas.


Hamstrings: The hamstrings can also become overly tight and (in most cases) weak when the quadriceps are tight or overused. This resulting imbalance can cause pain to occur in the back of the knee joint. Correcting this deficit is crucial to eliminating the pain.


Treatment

Restoring normal biomechanics to an intact knee involves 1) addressing tight muscles with stretching, ROM exercises, massage, and acupuncture, 2) strengthening weak muscles with exercises and changes in motor patterns, 3) addressing other lifestyle related issues. A complete guide to this process will be unique to each person, but the above areas are goods places to start looking. Often times the "affected" side will exhibit an asymmetry when compared to the the "good" side. If problems occur on both sides, then usually weakness and/or tightness is occurring bilaterally as well.


There are several interventions in Western medicine for knee pain. The typical recommendation is rest, application of ice, and non-steroidal anti-inflammatory drugs (NSAIDs). Physical therapy is usually prescribed before surgical intervention, unless a torn meniscus, tendon, or ligament is suspected. Injection of corticosteroids into painful areas is very common. Less common treatments include the injection of platelet rich plasma (PRP) and stem cells. When pain becomes too intense, usually a partial or complete knee replacement is the only thing that can relieve it and restore normal functioning.


In Chinese medicine, the knees are benefited by improving the Kidney System. Aiding digestion, reducing overall stress, limiting work load, and boosting Kidney qi with acupuncture, moxa, and herbs are all indicated. TCM takes a different approach to caring for knees than what is typical in Western medicine. Instead of using ice, heat is recommended to increase circulation of lymph and blood. Likewise, the use of NSAIDs is not recommended due to their deleterious effects on the liver and kidneys. The use of corticosteroids tends to make things better for a few weeks, but symptoms often return. A long term strategy for strengthening the knee joint and appropriately modifying lifestyle is a must to maintain a healthy knee joint into old age. Again, each person presents with a unique set of variables, so there is no one-size-fits-all formula.




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