Sock Doc: Knee Pain & Injuries – Natural Treatment & Prevention

Video Transcript

Dr. Gangemi: Hey this is Dr. Gangemi and welcome to the newest Sock Doc video. Today I’m going to be talking about the knee and common complaints and injuries, performance problems that people have with the knee. Who better to help out today than G. A. Long mid-fielder for UNC Soccer. They won the National Championship last year, ACC Championship and ACC Tourney.

G.A. Long: Sure.

Dr. Gangemi: Well done. The trifecta. Thanks for helping out. So, I’ve talked a little bit about the knee and one of my past video is on iliotibial band syndrome, ITBS which a lot of athletes have especially runners which is pain on the outside of the knee. We’re not going to go too much into that, but I’m going to start there. We’re going to work our way around the knee and talk about common complaints and ailments that people get which are much more common than the typical meniscus tears and cartilage debridements that people need and knee clean ups and all these things that might send someone off to surgeon. Not that those aren’t necessary, but a lot of people have knee problems and knee pain and they think they’ve torn something or injured something that needs surgery and often they don’t.

We don’t want to disregard that because obviously if you’re checking out your own knee or if you’re trying to do some of these self therapies make sure that you understand that if you’re not getting better then you can have a problem. Don’t let it go too long and be smart about it. Real quick. One point I want to make is on trigger points that I show a lot on my videos. The reason I do that is because they’re very effective, they’re easy to treat. Sometimes it’s not easy to find on yourself and you might need some assistance from another physician or therapist, but when you’re treating the trigger points it help realign the muscle . . . be aware that a lot of times those trigger points are there from the local injury in the muscle but they could also be there for another reason. From another injury somewhere else that you had. From improper footwear from training too hard. From some nervous system, health problem, nervous system imbalance or something like that.

If you’re always having to work on a trigger point make sure you don’t keep on doing it over and over again. Now, there’s a new article up on the Sock Doc site that explains that too. So, let’s quickly get right to the knee here. If you can stand up G.A. and turn a little bit this way. That’s perfect.

Real quick, on the lateral side of the knee here we talked about the iliotibial band and it’s insertion where people get a lot of pain. There’s iliotibial band syndrome here which is often from the (?) and turn this way a little bit, the glut max. Those muscles coming together and creating the tensor iliotibial band and inserting on the lateral side of the knee here. Remember almost always staying off the fatial [SP] connections and where the injury is felt, but looking for trigger points in the muscle, in the deep glut max here which extends all the way down well over half. Some say as far as two-thirds through the femur, through the upper leg and even some of the connective tissue is intertwined with the hamstrings as well as the tensor (?).

These come down and then make up your iliotibial band and cause a lot of lateral knee pain, but what I’m going to add to today is the lower part of the leg here which is the peroneus muscles and especially two muscles here, the peroneus longus and the peroneus brevis. We’re not going to talk as much about the peroneus tertius, but the peroneus longus and the brevis because of they’re actually just more commonly found than the tertius.

If you can put your knee up here, I’ll show this. The peroeus longus comes down the outside of the leg here and it’s going to insert on really the base of the toe, the first metatarsal and what’s called your medial cuneiform which is right around the arch of your foot. So, I want you to look for a trigger point right around here coming right off the big toe where a lot of it stops bending there. The flexibility of your toe. Look in here for a trigger point is a tendon of that peroneus longus comes here and the tendon of the peroneus brevis ends right here and also comes up. You can sit back down.

The reason we’re talking about these peroneus muscles which are also called the fibularis muscles is because those peroneus muscles are very much associated with proper supination which is how you walk, how you run and they help with pronation, balance of pronation supination with your gait to absorb shock. If you’re not absorbing shock properly from proper gait mechanics then you end up absorbing shock in your knee and that’s what we’re talking about. Knee problems. That can also transverse up to hip.

If you want to be a specialist of an area and really understand the area you got to look beyond it too. With the knee in this example we’re going to look towards the foot, we’re going to look towards the hip and as I’ve discussed in videos and other articles you also are going to look at gain imbalances. In this case, knee problems can sometimes come from an opposite shoulder problem, if he had an old injury or an elbow problem even and his gait mechanics are off. Going back to the peroneus real quick, here these muscles originate on the upper part of the fibula which is that little bone sticking on the outside of your leg here and then come right down. As we showed when he turned over and (?) foot wraps underneath the foot and inserts at the base of the big toe. Okay? So, you might find some trigger points up here in the belly of those peroneus muscles and then underneath the fifth (?) right here which you can see that nice anatomical landmark on his toe, on his foot as well as underneath that big toe. So, look for those and it might help your knee pain out a lot. All right.

Coming up to the top of the knee more flexion [SP] extension which is as you know that way. Right? Like you’re kicking. Like kicking a soccer ball, a short kick. A lot of people think quad problems although you can definitely have quad problems clearly or patella tendon problems when you have a knee issue and they’re not uncommon. More often than not you’re going to see anterior front of knee pain or even top of knee pain be more associated with glut max problems which are obviously related to iliotibial band problems and lateral stability of the knee which we started with and talked about in the ITB video.

If you’re having problems when you’re squatting, sitting, getting up, standing down that sort of thing, basically this motion and you have knee pain. Climbing stairs. Think not a glut max. Think more of that big powerful muscle on the back side of your body more so than your actual quads, however, the quads can be important especially in a flexion extension type movement then you should look for points in here. One little muscle I want to talk about because most people don’t talk about it too much is the little muscle in here called your articularis genu.

It sits right on top of the femur. You wanna stand up there G.A. right quick? It’s about right there. Come about an inch up from your patella. Right about in there. It’s going to be deep in there. It sits right on top of your femur deep underneath your vastus intermedias [SP] which is your quad muscle. It helps the friction of your bursa slide easily which is one of your little fat paths. You got to go deep in there and look for that trigger point. It’s probably a tender area anyway. It is in most people, but a lot of people can have a tender kneecap, interior knee pain. Their patella tendon not tracking properly because that articularis genu is injured or inflamed.

You go deep in there and hold that trigger point kind of like that with both thumbs like you’re grabbing your leg. Okay? Have a seat. Let’s move to the inside of the knee. We’re going to go right to which is a very common problem. People get pain on the inside of their knee. Even though it might be on the inside of their knee where their meniscus is here, but there’s three important muscles that stabilize and support the inside of your knee. They all come together and it’s called the pes anserine area. It stands for a goose’s foot.

So, you’ve got three muscles coming in here. One is called the sartorius. It starts from the front of the hip, comes over your quad and inserts right into that inside of your tibia, your lower right bone and does in this motion. Okay? Then you’ve got your groin muscle coming from way up in your groin, the inside of your inner thigh. It also inserts into there. That’s the second one.

Then the third muscle’s one of your hamstring muscles that starts on your (?) bone and also inserts into there and comes around and wraps underneath and inserts to the inside of your knee. Those three muscles are powerful and really the main stabilizers of the inside of your knee. Why do people think they might have a meniscus tear or a medial collateral ligament problem? In reality, they have pes anserine problem, an insertion of one of the three muscles, the sartorius, the gracilis, semi-tendonosis hamstring muscle.

You can look for trigger points right in the insertion there and see if there’s any problem with those or you can trace the muscle up. He had a knee problem actually the other day from . . . you got kneed in your quad, right?

G.A. Long: That’s right.

Dr. Gangemi: Okay. So, he had a knee problem and his gracilis wasn’t functioning properly, but the way I corrected that or one of the muscles that I had to correct was actually that gracilis muscle. I had to go way up in the groin. Check this on yourself or obviously if you’re checking it on somebody else make sure they know where you’re going because you’ve got to get way up in the groin right where that inserts in the pubic bone. It’s in an uncomfortable area anyway. It’s always tender, but it’s especially more tender if it’s an active trigger point. Feel around in there. If you feel any deep nodules especially if it’s referring pain down the aductor [SP] and especially obviously if it relieves the pain in the medial part of the knee, you know you’re on the right spot.

The sartorius could be anywhere (?) since it’s actually termed the tailor’s muscle because people will tailor a pair of pants over their leg like that. It comes over like this and it wraps on the inside of the knee. Longest muscle in your body actually. So, you can look for a trigger point anywhere along that sartorius. Honestly, I don’t think I have found maybe more than one or two of them. Very uncommon to have a trigger point in the sartorius. Usually it might be up on the front of the hip bone which you can feel right. It’s the bone sticking out of the front of your hip or on the insertion there or the gracilis could be anywhere on the inside of the leg.

Semi-tendonosis. We’re going to go to the back side of the knee here. Talk about the hamstrings. So, if you can flip around. Let’s show them the movement that we showed earlier. Let’s talk about this real quick. A lot of people think that they have hamstring problems when in reality more often they have gastroc or soleus problems. What I’m saying is more people have calf problems or even glut max problems than they do hamstring problems. Significantly more. The hamstrings might be tight, but it’s because of an imbalance between them and the calf muscles especially the gastroc which is the more meatier part of your calf rather than the soleus.

If he’s in this motion here, this range. That’s lower part of the soleus. When he comes up about midway here with his foot still pointed that’s more hamstring. Right about when you break 90 degrees here, parallel to the ground and he flexes his foot and comes all the way up, that’s more gastroc. So do a couple kicks. You can do them each way. If you’re feeling pain like that that’s probably going to be your calf. Now point and kick the same way. If you feel pain like that it’s probably going to be your hamstring. Now bring it all the way down and now kick a little bit. If you feel pain like that more like a swimming type of flutter kick probably your soleus achilles type issues like I talk about in the achilles tendonitis video. Good and then turn this way.

So, hamstring and calf muscles. Back of the knee now where we’re talking about. You do have a muscle called your popliteus muscle which helps with unlocking of the knee. It’s actually big when someone’s kicking a soccer ball and it helps to stabilize internal rotation of your lower leg, but even though that muscle can be an issue back there and people get what’s called a baker’s cyst and inflammation of the bursa back here. More times than not the gastrocs are involved, the calf muscle.

As these fibers come up and cross over the back of the knee crease here and originate at the top where the hamstring muscles come down and insert on the bottom. So, you have the calves coming up and the hamstrings going down and obviously they cross over. A lot of times if the pain appear it’s going to be more of a gastroc problem even though someone perceives it to be a hamstring problem. Really, the pain down here could be a hamstring problem, but more often than not it’s a gastroc problem. Calves are much more involved than hamstrings even if you’re feeling the hamstring pain.

Now, remember that semi-tendonosis that I talked about comes down. Starts on the (?) bone right there and then comes and wraps down and inserts to the inside of that lower leg. Let’s turn a little bit there to that pes anserine area along with the sartorius and gracilis. That’s where you can have some medial pain. So, don’t forget or don’t neglect the fact that you could have inside of the medial knee pain coming from the hamstrings back here. Okay?

Another one of your hamstrings goes on that side too. Called your semimembranosus [SP] and then your bicep femorus comes down here on the back side of your leg and inserts to the back of your fibula. A hamstring problem here could effect your fibula bone and also cause those poroneus muscles to be a problem and then effect your supination and go down and effect that poroneus longus insertion here or wrapping around the bottom across your arch or your poroneus brevis muscle. So, that’s how the foot is connected to the knee up to the groin from those pes anserine insertion muscles to your hip. A hip problem can cause a foot problem and vice versa. They can all be related to one another. Have a seat.They’re all going to influence one another to various degrees.

Remember, if you keep on having to work a trigger point, it’s keeps on coming back or if you’re not getting any relief you could be in the wrong spot. You could just not be addressing where the trigger point’s coming from. It might be a different muscle in a completely different area of the body. I’ve had to fix trigger points in his neck from playing soccer that have correct his . . . where? Everywhere. Right?

G.A. Long: Yeah.

Dr. Gangemi: Your foot? Your knee?

G.A. Long: Groin.

Dr. Gangemi: Yeah, his groin. They’re all related somehow or another. It’s hard to sometimes figure these things out on yourself and knee problems are highly related to over training, poor diet, adrenal gland type symptoms as I’ve discussed before. Too much stress. Students have that. He’s playing hard, class schedule, not the best diet in school sometimes.

G.A. Long: Right.

Dr. Gangemi: So, a lot of stress. Athletes tend to get a lot of knee problems because of the relationship of these muscles especially the internal ones, the inside ones. The medial insertions of those muscles on the pes anserine muscles. Those relationships to your adrenal glands as well as the calf muscles related to your adrenal glands and back of the knee pain and that should cover it. Thanks for listening. Thanks for coming.

G.A. Long: Yeah. No problem.

In this video I discuss common knee injuries, problems and complaints that many athletes have. Along with UNC’s 2011 Men’s National Championship soccer midfielder, G.A. Long, I describe how many athletes have knee pain due to pelvic and lower back problems, as well as foot problems. Aside from direct impact and trauma, often knee pain isn’t coming from the exact spot the discomfort may be felt. You may have to investigate an area distant from the knee joint to help resolve your knee pain. If you truly want to become a “specialist” in a joint such as the knee – you have to look at how the knee is influenced by other areas of the body, not just what is going on in the knee. This video also talks about common trigger points you can look for to treat to help improve or resolve your knee pain as well as how stress – of any type – can create or provoke knee pain. Enjoy!

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  1. says

    This was a fantastic video! You demonstrate so clearly how everything is connected. My question is, how long does it typically take for IT band pain to go away… forever? Ha! If only :) I seemed to have strained mine during a marathon on a very canted, curvy road. Never had issues with my knees before that marathon. I’ve seen an ART therapist with amazing success for other strains and pains but it hasn’t quite remedied this one. I’ve switched to a primarily paleo way of eating, I’ve cut back on training, get better sleep… the works, but I still have an issue after running over 6 miles, or during speed work. I have a few weeks before starting my next training cycle and want to go into it feeling recovered and strong. Any other suggestions? Oh, and because of you, I am giving no stretching a shot! Hard for me seeing as I have a 12 year classical ballet history! But so far I feel absolutely fine without stretching!

    • says

      Thanks there Green Girl. Not sure if you saw the ITB post and video ( How long? Depends on what is causing it. As you can see (read) from the link in the ITB post I helped the runner in one day who had it for months. That’s the Sock Doc skill :).

      Glad to hear you’re not stretching. Ballet is one of those exceptions though, but not if you’re injured.

  2. Jimmy says

    Dear Sock-doc,

    Do you mind dedicating one article or video on explaining muscle imbalances in the lower limbs, esp around the knee? Being as imperfect as we are as humans, i think all of us have varying degree of imbalances in our muscles. For some, the imbalances are minor and caused no problems. However, for others like myself where the imbalances are major, it results in injuries. Trigger point therapy does not seem to help much in this case.

    Is there any generic exercises we can do to ‘correct’ these imbalances? Or you need customised exercises for specific kind of imbalances? For me, my right knees bends slightly inward (valgus). I believe it’s likely due to my weak glutes muscles. I am just wondering if i keep working on my glutes, will i one day regain the normal shape of my knee?

    How are the exercises we can do to prevent muscle imbalances, and if these imbalances have developed, what sort of exercises can we do to correct them?

    Thanks so much for your time!

    • says

      Thanks for the suggestion, but it would be too individualized and that’s something left for the office. As I mention in the Trigger Point post and video, trigger points are there for a reason and they surely don’t fix everyone. In my practice I might spend one hour on correct muscle imbalances using trigger points. On another patient that might be spent using nutritional therapies; and on another a combination of both as well as others.

      • clay lyles says

        Dear Sock Doc,

        I have had chronic outer knee pain for years now and have been misdiagnosed all this time until just recently. I am an avid surfer and martial artist (aikido) which are both physically demanding and weight bearing and the sharp pain has become so bad I can barely do either until now. Since recently seeing another orthopedic Dr. I finally know I have IT band syndrome. Apprehensively I did receive a cortisone shot and have taken 2 weeks off from all activities. The pain in my knee has subsided quite a bit, but my entire leg mainly buttocks and hamstring area, and also the muscles on top just below the knee that run down to your foot, are always hurting. A constant dull aching pain and I am at my wits ends trying to find out the cause. Unfortunately, I have been icing the knee and stretching the it band a lot thinking that would help. Where should I go from here?

        • says

          Hi Clay – A diagnosis is good but it does nothing to fix the problem. Check out the SD ITB Video here. The reason your glutes ache is because they’re a huge part of your ITB. And of course I think stretching will only make your ITB worse and the ice will only help alleviate the pain temporarily.

  3. kelly says

    My daughter is 17 and does competition cheerleading. For almost a year now she has had pain just below her knee on the outside of her leg. Two yrs ago she had issues with under developed scapular muscles (bilateral) went through physical therapy for about 2 months and all her shoulder pain was gone. She dislikes going to physical therapy, she mainly has pain in the right lower leg usually because of the multiple jumps she must do. She tells me the pain eases when she has a few days off but that is far and few in between. She practices 5 days a week for a total of approx 15hrs. She had only some relief with cortisone shot in her knee (about 2 weeks) then the pain was back. She has had an MRI to make sure she has no damage (it was clear). What suggestion would you have us try at home to help with this.

  4. Wendy says

    Sock Doc, Thank you! Your trigger point videos rescued me from agony! When my doctor advised me to wear a really uncomfortable arch support for intense PF pain in my right foot, I got online and found your site. Working a trigger point in that calf sent an electric sensation from ankle to hip, and instantly removed the worst part of the pain. What a miracle! Thank you! I have a bit of a story and then a question about pronation for you.

    The residual pain healed steadily over the next couple of weeks and the foot now feels normal. But I’ve (re)developed patellar pain around and sometimes behind the left kneecap the past few days. It comes and goes. I had it a year or so ago, and working with a physical therapist made it go away, though that knee remains intolerant of side planks, and side lunges and single leg squats (the final exercises prescribed by the LPT) are uncomfortable on that side. Last night I found a trigger point in the outer calf just below the knee that sent a wild sensation like a 4th of July sparkler running the length of my calf and around to the bottom of the foot, just as you described the muscle path in the video. That relieved a large part of the pain. A foam roller on the front of my thighs is incredibly uncomfortable but also relieves part of the pain for awhile. But that leaves a nagging pain that alternates between the groin crease where the front of the thigh joins the trunk, and the inside edge of my kneecap. I’ve dug around in the groin as you illustrate in the video without finding anything that feels like a trigger point. The only thing that relieves it is a stretch that a chiropractor taught me, in which I lie on the edge of something elevated and let the leg dangle down and slightly turned out. This groin pain was the original pain before my knee started hurting the first time the runners knee developed, and preceded the return of the knee pain this time too, but this time I’ve only been walking, not running (when it restarted I had been working very slowly on the elliptical for 20 minutes for the first time since the PF).

    So to the question: It seems from what I’ve read that there are two polar views on the issue of pronation. One says that a certain amount of pronation is normal and serves as shock absorption. The other (which is my LPT’s position) says that pronation causes knee strain. Is there a degree of pronation that is not okay, or perhaps pronating at the wrong time, or is pronation totally a red herring? When I stand still and don’t think about it, my feet roll in, but my shoes without arch support show a balanced wear pattern, my shoes with built-in arches show a supinated wear pattern (Brooks Ravenna and Altra Instinct), and the only way I can walk without ending up in pain right now is barefoot or in five finger shoes. I want to be prepared if I go back to the LPT to find out what in my movement is causing this, because he is going to insist I need arch support, but the supported shoes I have are uncomfortable to me. Thank you!

  5. SteveL says

    I’ve recently gotten knee pain just below the knee cap which I assume after watching your videos is the Patella Tendon. This is a new pain area for me as I’ve never had this one before. I’ve been adding in more hill work for an upcoming 25K trail race that has a serious elevation profile up and down!

    I’ve been checking for trigger points and sore spots but so far I’m not finding much. I bought one of those straps that goes around the lower leg to I assume hold the patella tendon in place. I managed about 3 miles just fine and then it started hurting again and shut the run down at 3.8 miles and walked the last quarter mile back to the Y.

    Can the strap help or will that just cause more problems? Anything else I should be doing?

    I sure wish you would put a donate button on your site to help at least off set the cost of the site itself. But perhaps that’s more trouble dealing with than it’s worth. Thanks so much for sharing your knowledge and wisdom!

    By the way I just started last night in my first zero drop shoes. I’ve been running in 4mm drop for the last year and these new Merrell Bare Access 2 shoes were awesome. It felt so effortless!

    • says

      I don’t use those straps because they don’t correct the problem – but if they keep you out of pain I can see using that for a bit. But then again, if you need it to run w/o pain then that’s not healthy.

      If the pain is there (or worse) when you go up stairs or hills then think more glutes or calves. If it’s worse going down then think more quads or ITB.

      Hope that helps. Good to hear you’re zero-drop; that’s awesome.

      I have thought of the “donate” button before. I don’t know, maybe I will do it. One part of me says it’s cheesy and nobody will give a dime anyway and other sites have it. The other part says – hey I answer around 20-30 questions each week for free and no other site that I know of does that, and I’ve spent $15,000 of my own money to get this site up, managed, and supported since March 2011. :)

      I think this is a good Tip of the Week!

      • SteveL says

        Doesn’t hurt at all going up stairs coming down I notice it slightly more but still not really pain. I’m going to try running a bit tonight and I’ve got some hills I can run up and down and see it it makes a difference. Thanks again!

      • SteveL says

        Ran a route last night that had a decent hill in it. Going up hill it hurt a bit, going down hill actually felt better than even running on the flats. I’ll be checking my glutes and calves. Thanks!

  6. says

    Hi Steve, hope you as a Doc, Athlete and MCT can give me an advice how to behave with my toren inner meniscus. I’m also an MCT and as you know we need a perfect funktion of joint, muscles etc. A Year ago both knees start with crepitation behind the patella and a MRT showed a torne inner meniscus in my right knee. I tried to develop my deep squat, to keep crepitation minimal and I managed to keep it in check. My meniscus makes no problems at all. A new MRT showed the meniscus sligtly got worse but I still have no problems with it. The crepitation is still there but not worse. Since 3 weeks I have no pain on both knees but they are “talking to my” i.e. there is no pain but ther is somthing. My distal quad medials insertion aches when squeezed, that is the only hot spot, the rest is just difuse all over the knee.
    Do you have any advice for treatment, nutrition, massage, exercises, triggerpoints? Would be very important to go on ad a good MCT!
    Best Regards from Munich, Germany

  7. Jacqueline says

    Hi Doc,

    I came across your web site a few weeks ago. I love it! Thank you so much for what you do.
    I had knee (left knee) surgery for a torn meniscus in 2006. I’ve had good days and bad days but I have never been w/ pain. Last year, I developed ITB on my right knee. I’m doing the trigger point therapy and it has helped a lot. I am also making vegetable shakes on a daily basis and I switch my protein shake.
    I’ve been doing pretty good since I found your web site. But, yesterday we had a very humid and foggy day. All of sudden had a lot of pain on both knees. I had pain on the bone and sharp pain on the inside where the meniscus tear was. The pain on the right knee was dull but both where more noticeable when I walked.

    I hear people say how this can happen when their is humidity in the air. It seems silly to me that weather could have such an effect. I don’t understand what went wrong. Doc could this be happening because of the weather?

    Thanks for your help Doc!

  8. Chad says

    Sock Doc,

    My knee history is quite lengthy – numerous knee surgeries on the same right knee, including most recently cartilage allograft transplant a few years ago. After my original injury (broke small pieces of cartilage off of my femur), the pain I had then is the same I have now. It’s a very sharp pain near the patellar tendon region – any kind of loading of the joint past 30 degrees – such as going up stairs (and down – although not as bad). Medically I have full thickness cartilage again with no other structural issues – yet the pain persists. Along the way my lower back has become painful on a daily basis – of which I contribute to a lack of being able to be as active as I once was. My goal is to be as pain free as possible – and to a much higher activity level such as jogging (instead of simply the bike/elliptical).

    I’ve been doing of lot of self-research in the past months and especially after your videos and articles it appears there could very well be another source of my pain – particularly tight/weak hips/glutes.. My glutes are nowhere near as strong as they once were – in fact they (for lack of a better way to describe) have flattened out. Only recently have I learned how hip/glute issues contribute to knee pain. I’m currently using the rumble roller for quads along with a lacrosse ball for glutes which does help. The results always seem short lived – I will stretch, foam roll, use the lacrosse ball and my back/knee feel better – but hours later tighten up again. Considering going to a chiropractor as well. What recommendations can you make as far as next steps to try? I realize my situation may be unique/complex but I feel like I’m on my own here. While my knee surgeon is amazing, I don’t think there is anything further he can do to help. Thank you!

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