Chronic knee pain? Perhaps Myofascial Release can help?

Knee pain is one of the most common conditions seen in clinic.

Runners knee, jumpers knee or arthritic pain, you name it and you can be sure it has been seen in clinic at some point. There are obviously many potential reasons why a client may be experiencing knee pain and the only way to truly determine the source is for a detailed assessment to take place. This, along with a well structured treatment plan is usually the best approach to try and help the client back on the road to recovery.

When a client presents with knee pain they will often explain where the pain is located. Many will mention how they feel pain just below the knee on the patella tendon whilst others will describe how the pain almost seems to be coming from underneath the knee cap. Another common site for chronic knee pain is just to the inside of the knee, where a deep throbbing pain is often reported – often described as a ’toothache’ like sensation – accompanied by a feeling the leg is about to ‘give way’.

Wherever your knee pain is located or the type of pain you are experiencing, you can be sure it will be interfering with your daily life in some way. Whether it’s stopping you from going on your morning run each day or preventing you from simply having a short walk around your local shops without having to stop every few minutes and have a sit down to try and ease the pain, knee pain will always find a way to affect your daily routine!

Often clients have tried various treatments to help with their knee pain, many of which will have included various stretching and strengthening exercises as part of their treatment plan. Although this is often helpful in the treatment of chronic knee pain, for some clients they just don’t seem to make the progress they’d hoped, despite their best efforts.

This can often lead to frustration and leave the client feeling concerned things will never really improve.

Well today I’d like to talk about something which is often over looked whilst treating knee pain but can be a key player in difficult cases….misalignment of the lower limb.

What Does This Mean?!

Misalignment of the lower limb describes how the lower leg bone (known as the tibia – often referred to as the shin bone) becomes fixated in an outwardly rotated position when compared to the upper leg bone (or the Femur as its commonly known).

When this occurs, the knee, caught in the middle of the two, will begin to twist and torsion as the tibia rotates in an outwards direction whilst the femur remains static in it’s original position.

This torsion will create pressure upon the ligaments and tendons which support the knee often creating pain and inflammation as a consequence.

As can be seen in the image above the tibia (lower leg bone commonly known as the shin bone) is in an externally rotated position in relation to the femur (the bone located above the knee). As the bones rotate in different directions, the knee is caught in the middle of the two opposing forces creating a twisting – or torsion – within the knee joint. As the knee continually rotates as we walk throughout the day, the ligaments and joint capsule are placed under increased pressure, eventually resulting in pain and inflammation.

A tell tale sign this may be a part of a knee problem is when the foot is seen to rotate outwards as we stand. The outwardly turned foot can also appear to have a lower arch, often referred to as a ‘flat’ foot.

The image above shows an outwardly rotated tibia (shin bone). As you can see the feet turn outwards and the arch of the foot appears lower. This image shows both feet turning outwards but in cases of knee pain there is normally one foot sitting in a straight line whilst the affected side rotates outwardly.

Another obvious sign of a tibial torsion is when observing a runner from behind. Often if the tibia is in an externally rotated position the runner will appear to rotate their foot and lower leg in an outwards direction as they as they push off. This can be seen in the runner on the left in the image above.

Why Does This Happen?

Whilst its difficult to say with any certainty what created the dysfunction there are some common factors including a fallen arch in the foot (or flat foot) or stiffness and restriction within the ankle joint.

Fallen Arch in Foot

When a client presents with a fallen arch the foot can be seen to rotate in an inwards direction as they take each step. Whilst initially the lower leg will follow the foot and rotate in an inwards direction, over time, as the foot arch begins to lower further, the lower leg will begin to rotate in an outwards direction. This will then, in turn, create the twisting within the knee joint and resulting pain.

Fallen arch on right foot resulting in foot turning inwards. Often, the tibia (shin bone) will rotate in an outwards direction.

Stiffness in The Ankle Joint or Tightness Within The Calf Muscles

When the ankle joint becomes stiff and lacks range of motion ( possible from a previous break or ankle sprain) the foot is unable to got through what is known as Dorsi flexion. Dorsi flexion basically describes the action of bringing the foot up towards you further towards the tibia. Dorsi flexion is required in order for us to go through the gait cycle as we walk and run.

Image above shows example of Dorsi flexion.

If the foot is unable to Dorsi flex as we walk, the foot will compensate by twisting inwards to allow the leg to progress through the gait cycle. This twisting in of the foot will result in the lowering of the foot arch. As the arch continues to lower the result will be the tibia (lower leg) begins to rotate outwards, eventually becoming fixated in this position. Thus will then begin to create the torque and torsion in the knee joint as discussed previously.

How Can Myofascial Release Help?

When a client presents with knee pain and a misalignment is present within the lower limb, a rehab program consisting mainly of body weight exercises such as squats and lunges is unlikely to have a positive affect on the clients presenting knee pain.

In this instance, rather than trying to strengthen the area the key is to remove the torsion within the knee and then begin to mobilise the foot and ankle in order to create a stable base from which to begin strengthening the muscles around the joint. Following this, strengthening to the foot and even the hip can be applied successfully into any rehab program.

I often initially use myofascial release techniques to realign the tibia and femur in order to release tension within the knee joint. The client is then given exercises to do at home in order to maintain the new position and ensure the lower leg and foot is aligned correctly before any strengthening program can be put in place.


Removing torsion from the lower leg can often be key to resolving ongoing knee pain. Even when clients have confirmed cases of arthritis within the knee, having the lower leg and foot aligned correctly and then having an appropriate strengthening program in place can have a big impact on recovery, pain reduction and prevention of worsening of the condition.

If you are having difficulties with knee pain and are not progressing as you would like, then it may be worth just checking that foot and lower leg position as it may be having more of an effect on your knee pain than you would ever have thought!



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