Hip,Thigh and Knee Pain? Perhaps Your Foot is the Problem?!
Knee and hip pain are one of the most common conditions seen in clinic. Pain located on the outside of the hip travelling down the outside of the leg, often accompanied by pain within the knee joint are a regular occurrence.
Often, strengthening of the quad muscles at the front of the thigh or the muscles around the hip joint are common strategies employed to try and increase stability within the joint and reduce the clients pain. Although this approach can be successful, what do you do when the pain persists despite your best efforts? The answer is usually to find where the pain is actually originating from. Pain and discomfort in one part of the body can be as a result of weakness, instability or dysfunction in another, seemingly distant part of the body. With proper assessment the area can normally be identified and successfully treated.
This is what i’ll attempt to give an example of here by discussing where the source of the hip, thigh and knee pain can often be found…..the foot!
There are many bio mechanical factors within the foot complex which could potentially be responsible for knee and hip pain but I’d like to talk about a pattern I personally see often in clinic – the over pronated foot (or flat foot as it is commonly known).
What is a Pronated Foot?
Over pronation refers to a lowering or flattening of the medial arch of the foot. Often this can be seen when the arch is lower on one foot then it is on the other.
Example above of a low foot arch (on far right) or flat foot as it is often termed.
The foot is a complex series of movable joints which adapt to the ground forces as we take each step. It’s normal for the arch of the foot to flatten (pronate) and then rise again (supinate) during gait as we walk and run throughout the day.
What we are discussing here is when the foot arch is lower than the other foot as we stand in a static position and how this can potentially affect the knee, outer thigh and hip as a consequence.
A Side Note
Often on examination a foot arch may appear to be ‘normal’ and a good arch appears to be present. If it’s suspected the clients symptoms may be originating from the foot then I will usually ask the client to stand on one leg to. The client will attempt this on both sides. Often the client will find it’s more difficult to balance on one side and the foot can be seen to fall inwards towards the mid line as the arch collapses; this is an indication the foot, and it’s arch, are weak. Although the foot arch appears normal from a static stance, when the foot is weight bearing (such as when we place our weight on one leg as we walk) it is simply not strong enough to control the arch position and results in the over pronation, or flattening of the medial arch during gait.
This is something you can test for yourself at home; stand in front of a full length mirror and simply try to balance on one leg. Do you find that your balance is not as steady on one side? Perhaps you can see in the mirror that your foot arch is collapsing inwards and then moving to the outside to counter balance? Also be aware of your upper body as often a way to counter balance is to lean your upper body to the opposite side; try to keep your upper body straight – no cheating!
How does The Lower Foot Arch Create Knee and Hip Pain?
I’ll attempt to explain a common pattern I often see in clinic which can lead to the pain and discomfort in the knee, outer thigh and hip we’ve been discussing….here goes!
Often when a client presents with a fallen (or weak) arch, the foot will begin to rotate inwards during mid stance (when your weight is placed upon the standing leg as you walk). This is known as over pronation.
An example of foot rotating inwards during mid stance.
As a result of the foot rotating inwards the lower leg (known as the tibia and fibula bones) will often follow and begin to rotate in the same inwards direction. This inwards rotation of the foot and lower leg will then often cause the knee to follow in the same direction resulting in the whole lower limb and knee internally rotating during single leg stance.
As you can see in the image on the right, when the foot and lower limb begin to rotate inwards, the knee will follow, collapsing inwards during single leg stance as we run and walk throughout the day.
This pattern, in it’s self, can create pain and inflammation within the knee joint as the lower limb rotates inwards placing increased strain upon the knee joint.….but the situation can get even worse as the hip gets involved!
How Can this Affect the Hip?
As the foot, lower leg and knee internally rotate, the body, sensing the increased strain being placed upon the knee, will try to prevent the internal rotation by recruiting the muscles at the hip – known as the gluteus medius and gluteus maximus .
The glute maximus and medius are located at the side and back of the hip (basically, you will know them as your hip and butt muscles!). The main role of these muscles is to help keep the hip stable during walking. They do this by abducting and extending the hip, which means to move the leg in an outwards and backwards motion. As this motion is the opposite direction to the one the lower limb and knee is travelling in, the body will ask the glute muscles to work even harder in an attempt to counter balance the inward rotation of the lower leg and knee.
As the client takes thousands of steps each day, the gluteal muscles will continually be trying to prevent the lower leg and knee from collapsing inwards by pulling the hip in an outwards direction. This will usually result in the muscles becoming overworked. When muscles are forced to overwork for a prolonged period the result is usually the development of muscle tightness, restriction and the development of tender muscle knots. In this example the client will often begin to feel pain along the outside of the hip and along the outside of the thigh. This then results in the glute muscles becoming weak and unable to perform the original role they were designed to do which is to help stabilise the hip as we walk. There is then the potential for the muscles of the lower back to get involved in attempt to help out the weakened hip muscles in stabilising the hip.
Image shows how weakness within the foot can potentially have an effect higher up the chain causing hip and back pain.
How do we Fix the Problem?
As I mentioned at the beginning of this blog, there are numerous bio mechanical factors which could be contributing to knee and hip pain. The pattern I’ve described here is just one but one I see most often in clinic. If a client is presenting with knee and hip pain and previous treatment has focused solely at the sight of complaint then the likelihood is the pain will return at some point as the underlying bio mechanical factor has not been addressed. Similarly, a progressive strengthening program may not have the desired outcome as the muscles of lower leg and hip have had to endure months, and possibly years, of compensation and overwork, resulting in muscle tightness, tenderness and usually pain. Muscles are generally difficult to strengthen when there is pain and restriction present and therefore clients will often mention how they feel the prescribed exercises are actually causing the pain to worsen or they feel a stiffening or tightening immediately after exercise.
This usually indicates the muscles and/ or the surrounding fascia is restricted and preventing range of movement.
Initially improving foot, hip and ankle mobility by using soft tissue therapy and myofascial release to release the muscles, joints and surrounding fascia should be enough to reduce the clients pain and discomfort whilst also improving range of motion.This should leave the client in a good position to commence any strengthening program which should focus on improving strength and stability in both the hip and foot, with considerations also given to strengthening of the core.
So there we have it! Hopefully this wasn’t too difficult to follow (I did try!) and you have a better understanding of how weakness in the foot can potentially create problems further up the chain including the knee, hip, lower back and beyond (I’ll leave that for another time!).
Although we’ve concentrated on the foot in this instance, there is usually more than one factor involved and the whole chain – from foot to hip and potentially beyond – and should by investigated if the goal of long lasting pain relief is to be achieved.