Why Knee Pain Happens and How To Fix It (spoiler: it isn't likely coming from your knees)

Knee pain is probably the most common complaint I hear about, second perhaps only to back pain. This makes sense, when we look at what the knees do for us. 

The knee’s job, in a perfect world, is to transfer force from bottom to top, acting as a bridge from our feet to our hips. When we are riding they should function as a channel that connects our feet and our hips, assisting in appropriate absorption of force from our seat. Knee pain or stiffness when riding is a signal that something has gone awry with the process of appropriate force absorption. 

If you think about how many bridges are built, the key is having stability on either side of the pathway. If the connections to either side aren’t solid, there’s a good chance there won’t be much integrity in the middle of the bridge either. 

Our knees work the same. If our feet aren’t solid or our hips are busy compensating for lack of stability- our knees are left vulnerable to collapse. Collapse for us usually looks like pain during or after rides and long term potential for degenerative changes (arthritis). 

When the knees hurt I always look above and below. What is the base of support like into the foot? How is the rider supporting themselves in the stirrup and even on the ground while walking or carrying on with life? How are the hips managing stability laterally and is the knee having to pick up the slack by collapsing inwards (causing the foot to have to rotate externally)? Does the person’s ankle move well and can it absorb force like a spring, or does it divert upwards into the knee and hip? Does the rider tend to collapse forwards at the hip to absorb force (a common consequence of the ankle and knee not able to do their job well) or can they open efficiently through their seat and utilize their core? 

In an efficient posture, every joint and connection is utilized. Pain and stiffness at any joint, especially the knee, is more often than not a clear signal that something above and below is not working as well as it could. 

A few common functional tests I’ll use to begin unraveling what might be contributing: 

The Squat Test: This will test the knees, hips, and ankles as to how they are working with force. Standing with feet about hips distance apart, cross the arms over the chest and sit into a squat. Repeat 3-5x. 

To pass this test, the body in question should be able to sit down and back while keeping their feet flat on the ground, knees stacked over ankles (and not crossing the toes), and not arching the back or closing the hip angle excessively. 

Common fails:

  • The heel lift: this tells me that the ankle mobility is lacking. Because flexion at the ankle is limited, the heels must lift in order to allow the knees to bend and the squat to occur. Now imagine the impact of absorbing the force of your horse’s movement (and yours) on that limited range of motion. No wonder things are hurting. 

  • The knee collapse: the knees fall in, often combined with the heel lift, due to poor stability management, lack of range of motion in the ankle and decrease balance. The knee collapse is usually a sign that the hip stabilizers aren’t working, allowing the femur to collapse inwards. Often this also tells me that the person’s feet are inactive and a collapsed arch is usually also visible. Sometimes this will happen only on one side, sometimes on both sides. 

  • The knees too far forward fail: looking from the side, the knees cross the line of the toes. This tells me again that ankles are lacking mobility and the hips aren’t hinging well. To make space, the body is forced to push the knees ahead of the feet. Joint stacking is thrown to the wayside and this means waaaaaayyy more force for the knees to handle, and in a vulnerable position to boot!

  • The closed hip angle: the human believes they are squatting but in reality they are just folding their torso towards the ground with very minimal ankle, knee, or hip action involved. See above reasons why this may happen. 

  • The weight shift: As the human squats they shift their weight onto one side or the other. This is a sign of hip stability imbalances as is usually accompanied by any of the above other fails. 

The Hip Stability Test: This will tell us if your hips are stabilizing well. Raise one knee up and hold a single leg stance. Can’t do this? Well we already have an answer! 

To pass this test we need to be able to stand on one leg without the hip falling out, the knee collapsing in, or the foot having to shift around (rotating out or letting the arch fall in or both). 

Common Fails: 

  • The hip falls out: this means that your pelvic stabilizers are deactivated (not weak, necessarily, just forgotten about). You likely have existing tightness in your hips, stiffness or pain in your back, and of course the knee issue.