What Causes knee Pain without Injury?

This huge page packed full of information is about knee pain and arthritis. Pain in your knee seems to be different because patients of all types are getting it- with seemingly 2 causes.

Most people state that without a doubt that the main factors causing knee pain are age and weight.

Our bones and joints get older so they wear out more- that’s the age angle

Our bones and joints can only take so much, so if you put on extra weight then those joints get squashed, and the “jelly” and soft tissue that makes up the knee cant handle it, and then we get “bone on bone” irritation. That’s the weight angle.

When you go to a Doctor, you are given tablets or even a steroid injection to ease the knee pain short term (steroid injection) or over a long period of time (tablets, usually pain relievers or anti-inflammatory).

I don’t have an issue with these (yes, one of the first websites to actively advocate these treatments).


Because I have actually seen them work, and they work very well. It is painful to get a steroid injection, but the pain reduction within the knee joint is awesome. Also you reduce weight and knee pain reduces.

The Knee Pain Problem
knee inflammation
But these 2 different types of treatments really only solve the one main issue:


In other words, not the actual issue, but the inflammation from something happening within the joint itself.

So, in other words. If you kept on scratching your arm every day, making it bleed every day and the Doctor advised you to put a Band-Aid on the wound- it might heal the wound and make it better for that day, but once you start with that scratching…the issues continue. The wound is not really the issue- the scratching was- or the cause of the scratching.

I agree that at some point in the future age and weight do play a part. But there is one simple little issue that stops that from being the main answer:

Teens have knee pain and so do people who have a very active lifestyle.

Then people state:

“Well those runners had it coming to them, they over used their joints and wore them out”.

Now our joints have a Pedometer. If we go over a few steps or do a bit too much of something we are done for.

Again, this is not right.

Age is sometimes a “go to” factor with diseases if we can not understand what causes them. The only problem with age is that everyone at that age doesn’t get the same issue.

If I reach 60 years old and my right knee gets “arthritis pain” then Doctors state that it is down to age. Am I right?

Well, how does that necessarily explain the left knee pain? They are, I assume, the same age as each other. So why does one leg get the issue compared to the other leg?

Its true isn’t it, especially when you take a little step back and think about it.

But when people have knee replacement surgery on one knee you tend to find that the other knee goes a few years later. This doesn’t necessarily mean that the other knee was a problem, but what you do find are a couple of issues:

Surgery sometimes shortens the treated leg, off balance and mechanics then kick in causing more pressure and aggravation to the other leg
Whilst the patient has had pain attached to the problem arthritic knee they usually shift their mechanics over to the other, non-problematic knee
Once their new knee heals and all is well, patients sometimes do a little more than they should- mechanics then increase on the non-problematic knee
So what we find is the following.

Maybe age and weight are not the main factors in knee pain?

Sure, I believe they play an important part, but I do not believe that they play the main part in causing knee arthritis.

When we start to look at all the factors there is one thing that appears to have been “missed” or at least scanned over.

Mechanics is how we walk and how everything works together for a useful result.

There are lots and lots of ligaments (bands of tissue that go from bone to bone), tendons (tissue that comes from muscles), muscles, cartilage and actual bone which makes up the knee:

knee pain
Image from https://en.wikipedia.org/wiki/File:Blausen_0597_KneeAnatomy_Side.png

But…your knee is not in isolation.

Your knee is attached and works with your lower leg. Many of those muscles work around the knee and go straight into the foot.
Your thigh muscles (hamstrings and Quads) go straight around your knee
The inevitable question
So a reasonable question would be:

Would any of those structures, if poorly working, cause knee pain?

The answer would probably be yes.

Unfortunately there has actually been research upon other factors affecting the knee which causes arthritis but that information has not been repressed or anything “conspiracy”. It is just the information has been pushed aside to make “age and weight” the main factors.

But here is why they are used as factors, all the time:

When we are young our bones within the foot do not stop growing until we are 18. Now we inherit a lot of our walking and alignment issues. When kids run too much and don’t have a break their muscles are usually over-worked.

Kids have flat feet which aren’t diagnosed, sometimes they have foot issues that are not diagnosed (kids get bunions which are not shoe related). Sometimes we have thigh muscle issues which have not been treated.

Now as we get older, those non-treated issues are still there but what happens is that our body tends to adapt to them. We walk a little “off”. Sometimes if we walk very far our muscles ache (over working again).

This can easily be seen with people who wear high heels over a long period of time. Their calf muscle shortens, so when they go to a flatter shoe and walk a distance they get bad calf muscle pain.

We Adapt
Our body is great at adapting.

But with adaption means doing something that isn’t right, but fits our needs.

So when we play certain sports as an adult those underlying issues accelerate. If we don’t play spots or are as active as we should, those issues reveal themselves later on in life.

Many people find that bunions come on as they get older. It is not bad shoewear that is causing those issues (they don’t help at all but they are not the cause). The mechanics that were present- handed down by your parents, have accumulated into a bunion. It has been going on for years.

Ballet dancers feet: (http://www.blisstree.com/2012/06/13/fitness/ballet-dancers-feet-graceful-but-really-gross-898/gallery-page/6/)

ballet dancers feet
The above picture is from a ballet dancer. Notice how the feet are- and this dancer is under 40 years old.

So when you have a prolonged underlying (minimal) issues over time your body adjusts. Now when the feet adjust the ankle adjusts, then the knee and then the hip- if required.

This can also happen in reverse. If you have a hip or knee issue it can be spotted within the feet- because they are all interlinked. “The toe bone is attached to the ankle bone” is a fitting song, because it is true.

The problem with adaption
What happens is that joints lock or unlock because the body requires movement to…move 🙂

The foot needs a certain amount of movement in all of its joints to move and if it doesn’t get it then it will adapt by making you walk differently or unlock other joints to get that movement.

So to move your foot up, it is about 45 degrees.
Your big toe needs about 67 degrees of movement to push you off when you walk
So when people have bunions they do not have 67 degrees of movement, they have much less. Bone presses into bone and more bone is formed reducing the movement of that joint. Damage is occurring because the alignment is unequal.

Sounds familiar?

In this instance the bone is not the cause but the after affects of poor alignment that has been going on for years.

So what happens is that the body unlocks joints within the foot to get movement- or it will make you roll off the side of your big toe (hence why hard skin builds up around that area). In many instances it will work its way up to the ankle, then knee or hip.

So when we have patients coming into us with foot pain/ foot issues then we usually ask about their knee pain. In most cases they have an issue and are going through a treatment regime with the Doctor.

“This unequal damage can cause or worsen a malalignment that may make your stance look knock-kneed or bowlegged.” Mayo Clinic: http://www.mayoclinic.org/tests-procedures/knee-braces/basics/why-its-done/prc-20019007
I went to a conference recently and I found a Podiatrist Dr Lou Pack (RIP) talk about this issue which I have found in my clinic for a long time.

However Dr Pack did much more research about the relationship between the feet and the arthritis within the knee. He visited well known clinics, discussed with heads of hospital departments, treated well known sports players in his own clinic and recorded everything.

Here is a great photo of a patient with knee pain from Dr Lou Pack’s archives:

If you can’t exactly see the issue, here are my drawings:

The left knee (looking at the picture, it is the one on the right :)) is moved around slightly. The feet have also moved outward.

One other thing to note is that the left leg is slightly shorter than the right leg (more of the knee cap is showing in the left leg with the line drawn across). When this occurs the body tries to realign the legs. It makes the longer leg shorter and the shorter leg longer. So the knee on the left leg rotates outwards and the right leg rotates inwards.

And now we can see on this patient where the knee pain could lie (red marks):

It is interesting to mention that the foot is also included- not because of arthritis, which it does frequently get, but also Plantar Fascia pain due to excessive pressure being put upon that area.

Excessive weight can also press the knees inward (causing pain) and squash the arch of the foot. You can easily see how this works by sitting down and then lifting the outside of your foot up. Without you realising it your knees go inward.

So if you have reduced arches anyway and you are not over-weight? What happens? Your feet flatten and your knees come in- regardless of weight.

As we get older, what happens to muscle? Gets slightly shorter, gently messing up the mechanics of the feet and legs.

The foot and knee pain?
Really- the foot?

Ok, here is another reason why knee arthritis might be about mal-alignment rather than age.

The Knee Brace.

This is a great idea because it works in many different people who have knee pain. It works for many and not for some (it can only do so much). Ultimately a properly fitted (and assessed usually with an XRay) knee brace removes pressure from one side of the knee that is affected. This gives relief.

“The less knee misalignment the patient had, the less disability they experienced, and they saw an improvement in pain, stiffness, and function,” said study researcher J. Richard Steadman, MD,.
That was a quote from WebMD: http://www.webmd.com/osteoarthritis/news/20100413/knee-braces-ease-osteoarthritis-pain?page=2

Another quote?

“In some people, arthritis may affect mostly the inside of the knee. This may be because the inside of the knee often bears more of a person’s weight than the outside of the knee. A special brace called an “unloading brace” may help take some of the pressure off the inside of your knee when you are standing.”
That was from the US National Library of Medicine: https://www.nlm.nih.gov/medlineplus/ency/patientinstructions/000372.htm

See, when you check out the various studies, most state that they do not know why braces help patients, in many cases they do. But there is a point where the brace can not shift the muscle, tendons and bone enough to make a big difference with some patients. Also if you are overweight that actually is a factor for the brace to have limited effectiveness.


More research
Here are a list of medical studies and their conclusions (with terms explained :)) when arthritis of the knee and orthotics are studied together:

The effect of a subject-specific amount of lateral wedge on knee mechanics in patients with medial knee osteoarthritis. http://onlinelibrary.wiley.com/doi/10.1002/jor.20423/full. “Similarly, the wedged orthotic device significantly reduced the knee adduction excursion”- an orthotics reduced a knee going in.
Are foot orthotics efficacious for treating painful medial compartment knee osteoarthritis? A review of the literature. http://onlinelibrary.wiley.com/doi/10.1111/j.1368-5031.2004.0084.x/full. “These data indicate a strong scientific basis for applying wedged insoles in attempts to reduce osteoarthritic pain of biomechanical origin.”
Effectiveness of a lateral-wedge insole on knee varus torque in patients with knee osteoarthritis. https://www.ncbi.nlm.nih.gov/pubmed/12098144?dopt=Abstract. “These data imply that wedged insoles are biomechanically effective and should reduce loading of the medial compartment in persons with medial knee osteoarthritis”
The effect of a subject-specific amount of lateral wedge on knee mechanics in patients with medial knee osteoarthritis. https://www.ncbi.nlm.nih.gov/pubmed/17469197?dopt=Abstract.”A subject-specific laterally wedged orthotic device was able to reduce the peak knee adduction moment during early stance, which is thought to be associated with the progression of knee osteoarthritis”. An orthotic was able to reduce the knees from going in
More “real world” evidence?
What happens when we put a simple device under the foot that helps with the foot alignment, an orthotic. What does that do to the patient that we have seen?

So before is the left picture, and after is the right picture.

If you notice the following things:

I have tried to use a computer line at the same spots on both pictures. The right picture shows level knees
Both feet are now somewhat pointing forward
The patients left leg is standing on 2 rectangle pieces of material to wipe out the limb length difference by adding to the shorter leg (some clinicians add to the heel only which makes it worse)
The white bits of material sort out the alignment.
Big difference isn’t there?

Many people who have had orthotics find that they haven’t helped other types of foot issues, so why should it work now?

Well orthotics are not the golden bullet that many people make them out to be.

But…it’s not the orthotics fault.

But with orthotics, here are the:

5 main reasons orthotics dont always work
Orthotics are a little like eye glasses. They help but will not cure or reverse the issue
Orthotics sometimes are made by people who do not know what they are doing (that is a very big book within itself)
Orthotics are not for everybody
Orthotics only work if everything else is sorted out. If you have a limb length issue then that needs to be taken into consideration and applied to the sole of the shoe (not the heel)
If you have shortened muscles then the orthotics wont work as well unless those muscles are stretched.
I have seen great things with orthotics being applied to the right type of patient. Just like any prescribed device or medication, they really need the appropriate patient.

Knee arthritis is not a sentence to be in pain for ever. Like with everything, check with your Doctor first and then start to ask questions.

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