It Looks Like a Knee Problem, But It's Probably Not

Why your knee pain most likely has nothing to do with your knee

Jul 06, 2024

I’ve been an acupuncturist for over 20 years, and a yoga instructor for almost 30. I have seen a lot of “problematic” knees over the years. My experience with treating hundreds (or more) of orthopedic patients is that 80% of knee pain has nothing to do with the knee.

Of course some people have osteoarthritis of the knee, ACL or MCL tears, or meniscus problems, etc. I would consider these true knee problems. But most of the time, the knees are simply the “hapless bystander” between the hip and the ankle. Poor little knees, it’s not their fault!

Whenever someone comes in with knee pain, and they’ve had scans that tell them there is “nothing wrong” with their knee, that’s my cue to look at the hip, foot, and ankle.

Many times the patella (kneecap) is getting pulled in the wrong direction by overly tight quads, adductors and/or hip flexors. Tight calves can cause the foot to move incorrectly which will also send pain into the knee. Sometimes the problem is weak Glutes, which can be the cause or result of tight hip flexors and adductors. The knees often bear the brunt of dysfunction above and/or below.

Case Study

A patient in her 50s came to see me for knee pain. She’d been to physical therapy for months and it did nothing for her pain, so she wanted to try acupuncture. She’d had an MRI which showed “nothing wrong” with her knees, yet she had chronic, constant, achy knee pain.

I “listened” to her knee with my hand (a Craniosacral technique) and found the patella was pulling toward her outer (lateral) hip. I started poking around her hip which felt tight to me, and tight and sore to her. I treated her hip and when she came in the next week, she reported no knee pain for the first time in months.

Intrigued? What is a next step?*

Step one is to get a professional consultation to rule out actual knee problems. If an x-ray or MRI show “nothing wrong,” yet you still have knee pain, that’s when it’s time to do some investigation.

As a general rule, there are 2 types of tight muscles: gnarled, and shortened. Gnarled is when the muscle fibers ball up or “knot” rather than run parallel to each other. This can happen with injury or overuse. This type of tightness responds better to massage or foam rolling.

Shortened muscles are tight from being chronically contracted. This can happen with repetitive movements like running or biking, or from sitting at a desk all day not moving. This type of tightness responds better to stretching.

I recommend first rolling then stretching whenever you have tight muscles. Rolling warms them and stretching loosens them.

Tight Quads

Rectus Femoris, is one of the Quadriceps muscles that affects both the hip and the knee. It’s job is both to extend the knee (straighten), and flex the hip (bring the thigh toward the chest).

If you start poking with your thumb just above your patella and work your way up the front of the thigh, you might feel the tightness, either under your thumb, in the quad itself, or both.

Use a foam roller or Tiger Tail (or a rolling pin can also work) to massage the muscle, moving up and down between your hip bone (Anterior Superior Iliac Spine, or ASIS) to just above the knee.

Once that has loosened up, do a quad stretch to extend the muscle and improve range of motion. Be gentle while pulling your heel toward your buttock. If you can’t reach your foot, take a strap or a towel and hook it around your foot as a way to “lengthen” your reach. Make sure your thighs are parallel to prevent your knee from going out to the side.

Hold the stretch for 5-7 breaths, breathing smoothly and evenly through your nose. Even if you only have pain on one side, I recommend stretching both sides so as not to create further imbalance.

Tight Hip Flexors

The hip flexors are a group of muscles that include the Iliacus, the Psoas, and the Tensor Fascia Latae (TFL). These muscles bring your thigh toward your chest.

Take your thumb again, and start poking from your front hip bone (ASIS) down toward your thigh, then from the hip bone outward toward the side of your body (laterally). Again, you might feel a soreness or tightness under your thumb, in your hip, or both.

Use a foam roller or tennis ball (or lacrosse ball if you need more pressure) and start to dig into this area. Be gentle with yourself; being aggressive will only leave you bruised and sore. Roll up and down as well as side to side, staying below your hip bone. Focus on a 3-4” area.

You can also lie on the ball and let your body weight create the release. Once the sensation lessens, find another spot. The soreness will tell you you’re in the right place. I find a ball is the better option in this area, because it’s more point specific. It’s a smaller area, so sometimes the foam roller is just too big to be effective.

After you’ve rolled and released, do a Low Lunge to stretch out the area. Activate the glutes on the back leg and adjust the pelvis to be as vertical as possible for your body. Hold 5-7 breaths, breathing smoothly and evenly through your nose. If you need padding under your back knee, a folded towel or blanket will help.

Don’t force the stretch, try to relax into it. More is not always better, and forcing often causes the body to fight back. All that gets you is injured. Find the path of more ease and less effort.

Practice on both sides.

Tight Adductors

The Adductor group makes up your inner thighs. Often when the Gluteal muscles are weak, you get tight adductors. Gluteal muscles (The Glutes) move the leg away from your midline (abduction) and the adductors move the leg toward your midline (adduction). If the Glutes are weak and not doing their job of abduction, chances are, the adductors will over work.

Adductor Magnus and the Gracilis muscles attach above and below the knee, and can be a culprit with knee pain as well. Poke around your inner thigh toward your knee and you might find the guilty party.

These muscles can be challenging to foam roll. Come down onto your elbows and place your inner thigh on the foam roller, knee bent, kind of like a Plank pose. Roll side to side from your inner hip to your inner knee (stabilizing with your obliques). The other option is to use your Tiger Tail (or rolling pin) up and down the inner thigh.

There are a number of ways to stretch the inner thighs, once you’ve rolled. See my favorite options below. Keep the quads engaged to support the knees while you stretch. Pick the pose you like best and hold it for 5-7 breaths, relaxing into the pose. Practice on both sides, remembering to be easy and gentle with yourself.

Tight Calves

There are a number of muscles in the lower legs that can cause problems for the knees, including (but not limited to): Soleus, Gastrocnemius, Flexor Digitorum Longus, and Peroneus Longus and Brevis. These are found on either side and in back of your calves.

Any of these muscles could cause you to walk more toward the inner or outer foot, as well as impair full range of motion through the ankle. Since the body is a “Master Compensator,” as I like to call it, your body will adjust and this may cause pain at the knee joint.

Poking around at the different muscles in the calves can help you identify what needs work. Or you can just roll and stretch them all.

Rolling the calves can be done on the foam roller with lots of upper body effort, or you can use your Tiger Tail/Rolling Pin while seated on the floor with your knees bent. I find rolling the calves very unpleasant, so be gentle with yourself. Calves work every time you walk, go up and down stairs, or drive, so be kind to them.

My favorite calf stretches are with one leg extended in Table pose reaching backward through the heel, or Downward Dog with the feet parallel, turned inward, and turned outward. Downward Dog with these variations gets all the calf muscles, if you want to cover your bases.

Hold each of these stretches for 3-5 breaths, that’s usually plenty for the calves. The calves don’t need much stretching all at one time, but repetition is good (3-5 times per week).

In conclusion

Generally speaking, foam rolling and yoga are helpful tools for tight, aging bodies. Using these modalities with mindfulness can help you feel less achy and tight, generally speaking. They can often resolve nagging problems related to overuse, inefficient posture, or having a human body that fights gravity every day.

If you have any questions about any of the above stretches, please ask in the comments, and I will do my best to answer them. If you’d like to see a part 2 on how to modify your yoga practice when you have actual knee problems, like osteoarthritis, knee replacement, meniscus tears, etc, please let me know in the comments!

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