When dealing with any knee injury, your practitioner should consider all the anatomical structures both above and below the knee. New patterns of dysfunction will develop whenever any segment of the knee's kinetic chain is not functioning properly.
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It is important to understand that our body is one very large Kinetic Web, in which tension within one area directly affects the soft tissue structures in adjacent areas.
The Kinetic Web can be thought of as a linked series of kinetic chains. Each kinetic chain is made up of individual links (your joints, bones, and soft tissues) which are connected to each other to form a Kinetic Web.Any weak link in this chain not only generates its own set of problems, but also creates problems and compensations within its entire Kinetic Web.
Common Musculoskeletal Connections
Common muscular structures above and below the knee that must be considered for any knee injury include:
- Hip extensors.
- Hip flexors.
- Internal and external hip rotators.
- Calf muscles.
- Structures below the knee in lateral, medial, anterior, and posterior directions.
- Structures involved in normal ankle and foot motion.
- Core imbalances that effect lower extremity function.
For an example of the importance of the knee's kinetic chain, let us take a look at a person whose foot is excessively pronated (rolled inwards). This pronation causes the person's foot to flatten out during normal walking. This flattening then causes the tibia to rotate inwards (medially) and the femur to rotate outward (laterally). These actions place a considerable amount of stress on the knee, eventually leading to friction, inflammation, and injury of the soft-tissues of the knee. Thus, a problem that started at the foot ends up causing abnormal hip and femur rotation, which in turn leads to knee problems.
It is possible to achieve moderate success by treating just the immediate structures of the knee. However, in order to truly resolve the problem, we should also treat those structures that were the original cause of the excessive pronation that is, the structures in the knee's kinetic chain. For example, restriction in any of the following structures may be the cause of the excessive pronation:
Peroneus longus and peroneus brevis muscles are responsible for allowing you to point your feet and for eversion (rolling inward) of the foot when walking or running.
Abductor hallucis is responsible for flexing the big toe and allows your big toe to move laterally (sideways). This is important since the normal walking/running stride requires us to push-off with our big toe.
Flexor hallucis brevis is responsible for flexing the big toe and for supporting the medial arch of the foot.
Tibialis anterior lets you bend your foot upwards (dorsiflexion) and also helps to invert the foot (roll outwards) when you walk. The inversion of the foot is an important part of the normal gait pattern.
Flexor hallucis longus is responsible for flexing the big toe, supinating the ankle (turning inwards), and in pointing your foot (plantar flexion).
Restrictions in any of these structures can cause excessive pronation, which in turn leads to hip restrictions, and subsequent knee problems. Obviously, in such situations, treating just the structures of the knee will not resolve the knee problem. Instead, the practitioner must treat the knee, and then, based on the biomechanical and hands on analysis, treat all other affected structures in the knee's kinetic chain. The knee problem will only be resolved when restrictions in all these affected structures are removed and any abnormal muscle firing patterns are addressed with exercise.
Abnormal Muscle Firing Patterns
A key point here is that for every restriction that is created an altered muscle firing pattern will also be created. These dysfunctional movement patterns will still remain after the restriction (adhesion/scar tissue) has been removed. Only a corrective program of exercises will re-establish a normal motion pattern. That is why it is essential to combine both the removal of the adhesion with the exercise protocols, both are key components.
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