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. 

  • The knee collapses in: a consequence of the above- the body feeds one imbalance with another to keep things upright. This is a counterweight. 

  • The arch collapsing and or the foot rotating out: see above! 

Now everything I’ve explained so far is possible without a history of trauma to the knee (or ankle or hip) but also common after a injury (new or old) to any of the joints around the knee, including the knee itself. The body is a master of getting things done and keeping us perceivably “safe” while doing so. So when we rehab injuries we have to keep in mind that some compensations have happened for good reason, it’s just that that good reason is no longer valid. 

Here’s where I would start for *most riders dealing with the above issues: 

Ankle Mobility: 

  • Knee to wall taps: two goals!

  • First, facing the wall with your toes right against the wall, bend your knee *while keeping your heel rooted) and work to tap the knee to the wall. Move back and forth. This is a mobility test and exercise for your ankle. As you are able to tap the knee easily to the wall with the toes at the wall, scoot them back a few inches and try again. Work with this new range.

  • Second, turn sideways and find a lunge-ish position with your front leg closest to the wall. Root through the whole foot, feeling specifically the heel and the ball of the big and pinky toes. From here, attempt to bring your knee out towards the wall, tapping if possible. You will likely feel your hip turn on too to help accomplish this range of motion. Do not let your big toe lift (the arch of the foot can move, but not the root points of the heel, big toe and pinky toe). Repeat x10 on each side a few times a day until you achieve a rooted foot and mobile/stable hip. 

Hip Stability: 

  • Reverse Lunge to a High Knee:  Root down through your feet and with control step back with one leg while bending into the front leg and ankle. Moving with control step back forwards without letting the knee collapse in or the hip fall out. Maintain balance. Repeat 5-10x/side a few times a day.

Another thing to consider after you've worked on correcting any blatant biomechanics issues and stability issues (see above) is adding a general strength program to improve muscle tone through the lower body and core. When it comes to force absorption, the more muscle we have access to, the less our joints will have to deal with impact. The key here? Just getting stronger will not fix poor biomechanics. Understand and become aware of how to move first, and then build tolerance to load. If you're doing big force potential movements (jumping higher than 3ft, higher level dressage work, endurance, eventing) in your riding, you will do well to maintain a higher level of fitness. You body needs to know and tolerate weight. Weight based exercises I think all riders should do? Loaded squats (barbell squat, goblet squat, thruster squats) and deadlifts. Seek professional guidance from a movement professional you trust and like to ensure you're building a program that is suited to you.

Some external contributing factors may be:

  • Stirrup Type: for English riders at least there is so many variations of stirrups available to us, we are no longer to have to put up with one limiting option. That being said, there are so many options available it can take some trial and error to find what works. If you’ve fixed all the above and are still having pain/stiffness into the knees and or ankles then the next assumption would be to try out a different style of stirrup. My personal favorite stirrup style has always been a stirrup with a joint in the bar. These will help to absorb force and take some of the strain off your joints. Stirrups with a wider foot base can be helpful, as long as you know how to use your foot in them (review above). 

  • Stirrup Length: I meet too many riders with weird stirrup lengths that they’ve chosen because it “keeps their leg secure”. Sorry, but if you’re relying on two thin strips of leather and a piece of metal to put your foot in to keep your leg stable, you don’t have appropriate postural stability. If you’re shortening your stirrups to feel secure, I can almost guarantee the above tests will be tough for you to pass. I’m not saying you need to go crazy and have a crazy long leg either. Generally, your stirrups should be at a length where when your legs are hanging, relaxed, out of the stirrups the stirrup lands not too far above the ankle joint. As you correct any of the above compensations, you’ll probably notice that you have more leg length to work with- and will eventually feel a bit more secure with a longer stirrup length anyway. 

  • Saddle Fit: some saddles put us more into our knees than others. I am not an expert at fitting saddles (yet), so for now- IF all of the above has been tested and worked through, and your knees still hurt, it’s a good idea to have someone who is an expert at saddle fit take a look at see if it’s not putting you in a great position to absorb force through the leg. 

Long story short, when it comes to majority of knee pain we have to look elsewhere to truly begin correcting the issue. In cases of trauma directly to the knee, of course there is a vulnerability for pain related to the knee itself, but long term majority of continued complications will stem from stability or mobility issues above and below. Wondering where to start? RideWell offers a complimentary introductory consult for riders in pain. Send me an email at ridewellperformance@gmail.com and I'd be happy to answer your knee (or other) pain related questions!

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