Common Dysfunctions Leading to Knee Pain | Modern Manual Therapy Blog

Common Dysfunctions Leading to Knee Pain

I've blogged about this in several cases, but it can never be reiterated enough. You should look to the hip and the ankle for patients with "knee" pain.

This has been backed up by recent research showing hip OA referring to the knee. Manual and exercise approaches to the hip have also recently been shown to help patients with knee pain.

Common "issues in the tissues"

  • TFL facilitation leading to glut med inhibition
  • ITB restrictions doing the same
    • may cause lateral femoral cutaneous entrapment that also causes knee pain
  • hamstring lateral gluteal junctional area restrictions
    • often restricts hip IR, SLR (tissue lengthening), hip extension (tissue folding)
  • psoas
    • often restricted, but also weak, release with caution and strengthen appropriately
    • may entrap the femoral nerve
  • QL
  • lateral superior gastroc
    • often restricted, leading to dorsiflexion restrictions, eversion, and subsequent genu valgus
    • bony contours of anterior talus
    • bony contours of medial and lateral superior calcaneus
    • medial bony contours of posterior tibia
Common joint dysfunction
  • hip capsular pattern
    • improve hip IR, flexion after working on tissues
  • hip extension
    • after release of psoas, iliacus, QL
    • use prone knee bend with anterior glide for MWM and femoral nerve stretch
  • talocrural posterior glide
    • often glides posterior lateral, causing eversion, and genu valgus
  • subtalar tilts
    • restore whichever planes are restricted, commonly subtalar eversion
  • tibia often responds to tibial IR MWM per Mulligan
    • my rationale behind this is many of the above dysfunctions causing genu valgus in closed chain, thus causing relative tibial ER
Notice how the knee was listed last. Unless a patient has severe arthrosis, is post operative and/or just release from an immobilizer, you will not need to work on the tibiofemoral joint directly. I have not use patellar mobilization in years. Your mileage may vary, but this is what I find useful!


  1. Definitely agree on all f these parts. I was going to(and still might) write about addressing the hip before the ankle. I am not a huge fan of orthotics and I hear about individuals getting them if they have knee pain before addressing the more proximal chain. I think the research is really coming out now to put the science behind what we see on a daily basis, treating the hip and ankle to get positive knee symptom results.


  2. Dear Dr E .I respect yours blog & technique a lot.I believe if you add references below urs each article it makes it more authenticated as well as valuable for reader .

    Dr B M Jha

  3. Dr B,

    Agreed, however, I blog so much, I've often said that I don't have time to cite each reference I allude to. That's when there are references to support claims I make about patterns I see like in the post above. There is research out there that shows that a lack of tibial IR is found in knee pain as well as several recent references directing us toward the hip when looking at knee dysfunction. I more have them in my head after reading them, but do not keep a running list to copy and paste, perhaps I will do this in the future if I ever stop blogging so often! I know that sounds like a cop out, and thanks for calling me out on it. I do reference in my courses however, just so you know.

  4. As a young Therapist (Graduated 1 and 1/2 ago) I truly appreciate this blog because I feel it has helped me as a therapist starting out. Just wanted to say thanks for starting a great blog and helping us young guys become better at what we do. Truly appreciated!!

  5. You're welcome Mike! Every clinician needs a mentor to excel and that's my goal one blog post at a time!