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)
- often restricted, but also weak, release with caution and strengthen appropriately
- may entrap the femoral nerve
- 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!