Written by: Dr. Jonny Blue, DPT
Here’s the thing most people, including a lot of providers, get wrong about persistent knee pain: the knee is almost never the source of the problem. It’s where you feel it. That’s not the same thing.
The knee sits between two of the most important joints in your body, the ankle below and the hip above. When either one isn’t doing its job, the knee absorbs the consequences. Every step, every squat, every time you go up a flight of stairs.
The ankle connection nobody talks about
One of the most common things we find in patients with chronic knee pain is limited ankle dorsiflexion, basically the ankle can’t bend forward enough. When that happens, the tibia can’t rotate the way it’s supposed to during a squat or a stride. The kneecap ends up tracking slightly off its normal path, like a train getting nudged off its rails. Do that a few thousand times a day and you get pain, inflammation, and that familiar feeling that your knee is just always on the edge.
We test this in the clinic with something called the wall test. You stand five inches from a wall and try to touch your knee to it without your heel leaving the ground. Most people with knee pain fail this on the affected side. Most of them have never had anyone check it.
The hip is just as guilty
Weak glutes and hip abductors mean the femur drops and rotates inward with every step, which puts direct stress on the patellofemoral joint. The knee is getting loaded from above and below simultaneously, and most treatments only look at the knee itself.
When we watch a patient do a single leg squat, we can usually see this happening in real time. The knee caves in, the hip drops, the foot flattens. The knee is doing all the work it was never supposed to do alone.
Why your MRI might be misleading you
Research has shown that a significant percentage of adults with zero knee pain have findings on MRI, meniscus tears, cartilage changes, even notable degeneration. The imaging shows what exists structurally. It doesn’t tell you whether that structure is actually causing your pain. This matters because if you treat the MRI finding and not the mechanics, you’re solving the wrong problem. That’s exactly why so many people get treatment, feel better for a few weeks, and then have the same thing come back the moment they return to activity.
What we spend most of our time focusing on in our sessions is not the, “problem,” but instead the, “solution.” What manual techniques can we perform that will reduce the symptoms immediately? What activation exercises can we do, in that session, that will have you walking out of the clinic that day saying, “wow, my knee hasn’t felt this pain-free in ages?” But I’m getting ahead of myself.
What we actually look for
This is where we start. A patient comes in with knee pain. We need to start by watching them move. A double leg squat, a single leg squat, a step down. In that 60 seconds we can usually see exactly where the problem is coming from. Then we check ankle dorsiflexion side to side, tibial rotation, hip internal rotation, and glute strength.
By the time the screen is done, we almost always know what’s driving the pain. And it’s almost always upstream or downstream, rarely at the knee itself.
From there we build a three phase plan. First, manual therapy to calm down the knee and restore normal movement so it stops guarding. Second, we address the root cause directly, whatever the assessment found. Third, we progressively load the whole chain so the gains stick.
If this sounds familiar
If your knee keeps flaring up after running, squatting, hiking, or just going about your normal day, and it gets better with rest only to come back when you’re active again, that cycle is telling you something. Rest isn’t fixing it because rest isn’t addressing what’s actually loading the knee wrong.
Once you find the real driver, this kind of pain tends to respond really well. It’s not complicated. It just requires looking in the right place.
At Land and Sea Physical Therapy, every session is 1-on-1 with a Doctor of PT for a full 60 minutes. If you’ve been going in circles with knee pain, come in and let us look at the whole picture.
If you want to contact us or book an appointment, check our business profile page.
Dr. Jonny Blue is a Doctor of Physical Therapy and founder of Land and Sea Physical Therapy in Oceanside, CA. He specializes in orthopedic PT, root cause methodology, and helping active adults in North County San Diego get back to the activities they love without surgery or pain medication.