Knee pain…a real pain in the butt

Knee pain…a real pain in the butt

Knee pain…a real pain in the butt”  

“Pain is a lier”, have you ever heard that phrase?  What most people mean by this phrase is that pain does not truly tell you where the cause of your problem may be located it only tells you where it ended up.  This isn’t more true than when you are talking about knee pain in runners, especially female runners.  Knee pain is very common in female runners and can be due to all sorts of inadequacies throughout the knee, hip, foot, or ankle.  We will discuss one common cause of knee pain seen in female runners…weak hips and buttocks.  Yep that’s right the buttocks are not just for show they have a very important function, and a deficit here can lead to pain in the knee.

It is a very well known fact that the male and female body is not architecturally made the same.  The female pelvis for example is wider than her male counterpart (this is in preparation for potential child birth).  This widening of the hips leads to an increase in the “Q angle” of the leg. The “Q angle” is the angle formed at the knee by the femur and the tibia when looking at the front of the body.  This increased angle has been purported to be a cause of knee pain.  While this architectural difference between males and females is something one can not change there are muscular influences throughout the hips and legs that can be changed with proper training and exercise.  Through proper training the female (and male) hip and pelvis can function better with less chance of injury to the knees.

Lets look at some of the muscles in this area that influence the knee.  One of the largest and most powerful muscles in the human body is the gluteus maximus, which is the biggest of the three gluteal muscles that make up your buttocks.  The Gluteus maximus functions chiefly to extend (move back), abduct(move out to the side), externally rotate(turn out) the leg and also helps stabilize the pelvis and lower spine.  The gluteus medius and minimus function to abduct and internally rotate (turn in) the leg as well as helping to stabilize the pelvis also.  This means that these muscles not only help control the movement of the leg they help control the pelvis which is the foundation to where many leg muscles are attached.  Two of the three gluteal muscles have a direct connection into the infamous Iliotibial tract (also known as the IT band), while all three of them functionally influence the IT Band.

The gluteals now a days act as a cushion for sitting rather than an explosive lower body muscle used for walking and running as they were designed.  This lack of use leads to atrophy and weakening of this muscle group.  A weakened gluteal area can lead to a pelvis that moves around too much during running which in turn puts more strain onto hip and thigh muscles that cross the knee.  It can also lead to an unstable knee that will drift inward causing increased tension onto the patella and IT Band which causes pain to the knee cap and outside of the knee.


There is another group of hip muscles that are extremely important to the function of the leg.  The six external rotators of the hip (they turn the leg outward).  These tiny muscles are deep in the hip, extremely difficult to touch,  and are rarely talked about in comparison to the bigger, more popular gluteal muscles.  For all intensive purposes these are grouped in with the gluteal muscles. This external rotation is needed to counteract the influence of such things as the Q Angle and over-pronation of the feet which both lead to the drifting of the knee inwards.   As with the gluteal muscles weakness in these external rotators can lead to increased pain at the knee.  Some of us in the sports medicine field feel that these muscles are as important to the hip as the rotator cuff muscles are to the shoulder.  And as the rotator cuff in the shoulder needs to be strong for the shoulder to function properly, these hip rotators need to be strong in order for the rest of the leg to function better.

Several recent studies found that female runners with IT Band syndrome showed significant weakness in the abduction of their involved leg as compared to their healthy leg and as compared to other non-injured runners.  A study done at the University of Delaware showed that in a group of 18 female distance runners with IT Band syndrome all demonstrated an increase in the adduction (inward drift) and internal rotation (turning in) of the involved knee  which can be counter acted by strengthening the muscles that abduct and externally rotate the leg….gluts and external rotators. Most patients in this category report full pain relief did not occur until strength was improved in there injured leg.

This information should encourage to re-look at your current “nagging knee pain” (if you are unlucky enough to have it) or the knee pain of your clients, and reconsider if you are doing all you can for it.  These IT Band tendonitises, patella tendonitises, patellafemoral syndromes, and chondromalasia problems are not just tightness issues that need stretching, massage, and ice.  You need to ensure you have adequate strength in the muscles of the hip or the tightness and pain will just keep coming back.

Also keep in mind when you are running there is no rest period for your legs you are always leaping from one foot to the other and you have a force several times that of your body weight at the knee when your foot hits the ground.  These two factors will lead to a magnification of any deficit you may have in your legs.  Running is a stressful activity for your legs so, yes distance runners need to strength train and get “Buns of Steel” it could be the answer you are looking for to get rid of chronic knee pain.

Stay tuned for future posts to learn great ways to strengthen hip muscles to help support the rest of the leg.


Michael Silva, MS, PT, CSCS