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Sock Doc WorkshopsKnee pain is a common complaint for many runners, cyclists, and triathletes leading them to succumb to pain medication, anti-inflammatories, knee braces and other contraptions just so they can continue pushing through the miles. From elite athletes to fitness walkers, an individual may be told they have bursitis, tendonitis, arthritis, chondromalacia patellae, iliotibial band frictional syndrome, a meniscus problem or some other ailment as their diagnosis gives a name to the problem but does absolutely nothing to treat the condition or tell them how it even occurred in the first place.
The balance of the muscles surrounding the entire knee joint is essential for the knee to function normally, as well as to provide maximum power and strength. Starting in the front of the leg, the quadriceps make up the majority of the musculature as well as the patellar tendon. Often athletes are told they have tendonitis if there is pain below the kneecap or bursitis if there is pain above the kneecap. The integrity of the quadriceps and their balance with the hamstrings and gluteus maximus muscles is of utmost importance. With respect to gait, fatigued (“weak”) quads will cause an athlete to run with an exaggerated kick back with each push-off. Another symptom of fatigued quads is a feeling of weak knees or thigh muscles when climbing stairs, or being unable to stay in a squatted/kneeling position for a while without pain and/or discomfort in the thigh or knee itself. Often this is because the quads are working too hard because the powerful gluteus maximus muscles are not functioning correctly, perhaps from injury, overtraining, or some disturbance in the gait.
Deep inside the very lower front part of the thigh muscles, just on top of the femur (thigh bone) lies a very small, but sometimes very troublesome muscle called the articularis genu. It is many times overlooked in knee problems, especially those chronic in nature, and can be a major culprit with what may appear to be bursitis-like problems. Deep trigger-point work on this muscle can sometimes be of great benefit, allowing the muscle to heal. But sometimes that fluid-filled sac between the tendon and the bone can be inflamed, which is called bursitis. If it’s on back of the knee, it’s known as a Baker’s Cyst. Bursitis must be treated differently than tendonitis, though often a person is given a pain drug and/or anti-inflammatory drug for any problem, hoping for the best. To heal the bursa, one needs optimal calcium metabolism; this is the key point for bursitis. This does not just mean that calcium needs to be available in the body, but the proper balance of fats is also needed to drive the calcium into the soft tissue to heal the bursa. It is the fatty acid balance that most people don’t have in their favor.
Optimum fatty acid balance means two basic things – no harmful fats and plenty of the healthy ones. Harmful fats are the partially hydrogenated fats, commonly referred to as “trans” fats as well as excess vegetable oils. Trans fats are listed as shortening, margarine, and as partially hydrogenated corn, vegetable, soy, cottonseed or some other oil on a package. These fats cause a lot of inflammation and block essential enzyme reactions from occurring while also preventing the good, anti-inflammatory fats from doing their jobs. Even eating them a little bit is a problem because the half-life is a whopping 51 days. That means after 102 days there is still 25% of the stuff causing problems and over a year before some people can metabolize all of it entirely. This pretty much ends the debate whether to eat margarine or butter. Those still eating margarine because they were told it is better for cholesterol and body weight can see why it’s beneficial to change to butter and get the laboratory-made trans fat out of the diet 100%.
Healthy fats are the essential omega-3 and omega-6 fats. Most people are deficient in the omega-3s because they are primarily from fish and flax seeds, and to some extent walnuts – foods often not consumed in high amounts. Most eat too many omega-6s fats found in processed, packaged, and fast food. Healthy omega-6 fats are plentiful in most vegetables, nuts and seeds, and legumes but the ones found in soy, corn, safflower, and peanut oils can quickly inflame the body, especially when consumed with too many carbohydrates. So a good amount of both omega-3, (perhaps supplementing with flax or fish oil), and omega-6 fats from raw nuts, seeds and vegetables, and a diet absent of trans fats will allow the body to fight inflammation and recover faster, as well as lower cholesterol and heart disease risk. And, for the purpose of this topic, it will allow calcium to be pushed into the tissues to heal inflamed bursa. As a side note, two other symptoms of inadequate calcium metabolism due to poor fatty acid metabolism are calf cramps, especially ones at night that resemble “Charley horses”, and cold sores/fever blisters, including herpes simplex infections. (Yes, these are viral infections, but their eruption is often provoked by a calcium problem.) Also, although olive oil is a great fat to eat and should be included in every diet, it is not considered an essential fat because it is an omega-9.
Tendonitis of knee is perhaps the most common diagnosis given to many runners when there is pain around the knee that isn’t in the meniscus or the actual muscles. One such tendon pain is along the iliotibial band, or ITB, and a major complaint that forces many runners to stop their activity all together, sometimes for many months. The pain, known as ITB Frictional Syndrome, (ITBS), is a stabbing pain over the outside of the knee, and sometimes on the outside of the mid-thigh region. Athletes are told to ice it and take some anti-inflammatory medication (NSAIDs). However, this rarely helps with healing as many know after the fact if they’ve dealt with this miserable injury. The use of these NSAID drugs causes a major amount of sulfur depletion in the body, and this is the same stuff needed to repair the cartilage (such as knee cartilage!) and detoxify hormones in the liver. Instead of using NSAIDs, this problem can usually be treated quickly and without the use of medication by evaluating the balance of the muscles contributing to the pain as well as addressing fatty acid imbalances. Check out the SockDoc video on ITBS here.
Pain on the inside of the knee is just as common, especially at the area called the pes anserinus which is just to the inside of the lower part of the knee. This is where three muscles come together to make up a significant amount of support for the inside of knee. When these muscles are not working as well as they should, they leave the medial meniscus open for problems due to the improper biomechanics of the joint. The imbalance of these muscles, and often pain and/or weakness around the inside of the knee is usually associated with adrenal gland problems. An athlete will often have this discomfort along with other adrenal gland related symptoms – dizzy when standing up, a craving for salt and/or sugar, irritability and blood sugar handling problems, and perhaps a history of shin splints or plantar fasciitis. Sleep problems as I discuss here, and poor performance while training and racing are signs that the adrenals are taxed too. Evaluation of overall stress – training, diet, and lifestyle is of utmost importance.
The muscles of the back of the knee cannot be forgotten as they often are. The hamstrings as well as the calf muscles are two of the major players here – with such a great distance these muscles span on the back of the leg, they are very important not only for the knee, but the foot and low back as well. These muscles functioning abnormally will cause the athlete to have a foot problem, or a knee problem, or a lower back or hip problem, or maybe one after the other – or simultaneously. These also tend to occur from taxed adrenal glands due to too many of life stresses at once, or excess anaerobic activity, or a poor diet.
And let’s not forget how important footwear is and the mechanics of the feet when dealing with knee pain too…
Proper pronation of the foot, a major source of shock absorption, and the muscles of the foot are extremely important for the health of the knee. If the foot is not functioning optimally then the knee takes a lot more stress than it is able to handle leading to various aches and pains as described above. A strong foot is necessary for a strong knee, and that means considering minimalist-type footwear and staying barefoot as much as possible so the muscles, ligaments, and tendons of the feet become strong and supportive to provide proper proprioception, balance ,and power to not just the knee, but the entire body.
Dr. Stephen Gangemi "Sock Doc"
I'm a board-certified chiropractic physician and clinical nutritionist with a passion for true natural health care. I implement dietary & nutritional therapies, exercise & movement practices, and lifestyle changes along with manual therapy techniques to help the body heal and prevent illness and injuries.
Sarah says
Great post – thank you for the information! I recently have been suffering from knee pain (about 5 months now) and saw a physical therapist who said it was chondromalacia patella as you mention. I had been running / doing step classes in more minimalist shoes (Nike frees) when the pain started occurring. I agree it must be an imbalance of these muscles, but do you have any particular exercises you recommend for solving the imbalance? At the time when the knee pain occurred I was under a lot of family stress but am not anymore and it is still occurring. I do try to eat healthy and do not have any sleep problems or issues craving sugar/salt (although I do have seasonal allergies). The main thing that hurts the most now is simple squats, my knee hurts doing just one full squat. Would this be weak calves? I was given exercises consisting of leg raises with ankle weights (not sure how you feel about those). It’s just weird to me if that’s the case because I try to do a lot of leg workouts. Thank you!
Sock Doc says
Hi Sarah, thanks. You can’t exercise a weak muscle and turn it on. Such muscle weakness is neurological, meaning the muscles are inhibited due to some nervous system stress – diet, overtraining, injury, etc. So exercises just don’t work unless the muscles is properly firing again. You can do weights all day long; if it gets better over time it was because of the time, and not the exercise.
If your knee hurts on the way down think more quads and if it hurts more on the way up think more glutes (max). Those muscles have a huge impact on the knee and the proper tracking on the kneecap. Check out the ITB video where I talk about how to work out the glut max.
Sarah says
That is really helpful – thank you so much!
Patrick says
Very interesting article, which I read because I have occasional knee pain. My pain is on the inside, lower part of the knee. You mention that this can be an adrenal gland symptom. Then I noticed that I have ALL of the adrenal gland symptoms that you list. I need to know more about this and what I can do. Can you point me toward some good info??
Thanks!!
Sock Doc says
I’ll have a new Sock Doc Video up on the knee the week of April 16th.
Dealing with adrenal gland problems means dealing with stress – as I discuss throughout this site and drgangemi.com. Lifestyle, training, diet, sleep, etc…
Irena says
Hi I´m I Irena and Im 24 years old an Im really desperate. It is 4 weeks and I have a big pain in my knee during walking it hurts me sooo much.. I was on magnetic resonance on x ray and they wrote me just this: There is a small trace of oedema deep to the iliotibial band, lateral to the lateral femoral condyle and proximal attachment of the fibular collateral ligament suggesting possible mild iliotibial band friction syndrome. They told me ice it but you re saying no.. Pleaase help me Im so desperate im in Australia now far away from my home. Thank you Irena 🙂
Sock Doc says
Check out the ITB Video as well as the Knee Video. If you feel temporary relief with ice then use it but it won’t “cure” ITBS.
Jafar says
Hi Sock Doc…
Great vid & explanation. I’ve been experiencing a lot of discomfort in the top interior of my patella. (inside the knee) The pain is apparent mainly when I bend or go up & down stairs. It’s a sore achy feeling. It really feels as though I have non strength in there as well. I’ve been an athlete my entire life(33) & I’ve noticed that my knee would sort of give way once in a blue moon when I would go for a layup after I got a steal or something. But I’ve never paid much attention to it. I always figured I stepped incorrectly or something. My bod has always been strong & I’ve never been injured until last year(10 months ago) when I had a complete tear in my Achilles tendon in that same leg.
Since then I’ve had surgery & rehab. However, it wasn’t until after my cast & boot came off that I began to notice a lil discomfort when doing step ups on that side. I’ve since completed therapy but my knee pain has gotten significantly worse as my Achilles pain has subsided dramatically. I’m very concerned as I’m trying to recover to full function & feeling. (I do have poor arches in my feet. lil to no arch. As well I’ve noticed significant atrophy in my entire left leg as it compares to my right). What can you tell me? I have my own thoughts based on this vid. But I thought I’d ask a lil more in detail.
Sock Doc says
A complete tear in the AT usually means that you were under a significant amount of stress (physically, nutritionally, and/or emotionally) or your foot/lower leg was under too much stress from past injuries/gait imbalance/footwear problem. Now you need someone to look at your entire body and address the compensations you’ve made before (leading up to the injury) and after – wearing a cast & boot creates a lot of muscle imbalances.
Jafar says
hmm…I appreciate that response. I admit that I did not consider emotional and nutritional stress. I suppose I’ve been working to find my overall balance over the last couple of years. I was a real estate developer right in the middle of the meltdown in 08 & beyond. I have been health conscious my entire life. However my diet has been altered as of late by comparison to earlier years. Also, the injury occurred the day after my beloved 3yr old dog died suddenly in ICU w/ out any explanation. I was playing ball to move past some of my shock & grief. I’ve been so used to the mindset to press through adversity I did not consider these things. I have simply expected to do the work…for my body to heal & to move fwd. I suppose I have to do a bit more total system work…(meditation…pusing throughout the day…listening to my body… alkalizing my system…proper hydration…rest etc…along with physically restrengthening & conditioning my body). I will definitely take up your advice & work to correct these issues. I’ll also dig through your material to examine ways to help myself.
Thanks again…
jafar
Sock Doc says
You bet. Lots of stress there with work and the death of your dog and add in that some dietary stress – there goes the Achilles. These things are NEVER genetic, and NEVER a coincidence.
Justin says
This is a great article but I’m having some trouble figuring where my issue fits. I’ve been running fairly consistent for a couple years, primarily a route that takes me up and over a bridge twice. I use this 5 mile route for the elevation since I live in Florida. In addition to running, I’ve wanted to get back into cycling, specifically cycling to work. I’ve done so for three weeks now and absolutely love it, however a dull pain throughout both knees started about a week ago and has slowly grown worse. I’ve learned to use a gear with a higher RPM potential to ease the transition into a cycling lifestyle. For the first two weeks I did not use this method and was pushing fairly hard in a gear with a good amount of resistance. I only run on the weekends taking that time to give my legs a break from the bike. Is this a simple case of take a week off from everything till the pain subsides? I really didn’t want to do that, afraid that I’ll loose the momentum and motivation and the bike will end up in the garage unused for however long again. Thanks very much in advance.
Sock Doc says
If it’s both knees and primarily related to the bike then I’d be looking at a bike fit from someone who knows what they’re doing. It could be seat position (height or fore/aft) or shoe cleat position too. If that’s been done (and correctly). A RPM (cadence) of <80 could do it too if you're not conditioned well on the bike.
DeOliver Davis says
Hey Doc,
I have been having trouble with my knee since January. My trainers at school said it was my IT bands and I did a lot of foam roams to heal the pain. At first the foam rolling worked but after a month the pain came back on the inside of my knee. I thought it was some ligament damage but my MRI was good. Then I assumed it was my medial Plica but even that was fine. I feel pain and awkwardness when I run and when I squat. I think it is a muscle. When i run I usually put on a brace, it makes it feel better but does not completely take away the pain and the feeling that my knee will give out on me. Do you think you know what it is
Sock Doc says
Muscle imbalance between the inside and outside of the knee. Watch both the ITB Video and the KNEE Video.
Darren says
Hi Doc, great article and great site. I apologise in advance if you answered this question in your video. I am starting to feel patella tendinitis in my left knee. I also am managing plantar fasciitis on the
left foot as well. I am training for an uphill half marathon in November and have just starting hill training. I am planning on supplementing with fish oil and foam rolling my legs. Is this correct and is there anything else to do?
Sock Doc says
Fish oil is okay – I discuss this and other fats in Part III and IV of the Injury Series: https://sock-doc.com/2012/08/first-aid-for-injuries-inflammation-part3/.
Foam rolling okay too – but of course there could be more to trigger points and maybe a lot more to do if these don’t help but hard to say exactly what that is w/o seeing you.
Read this too if you haven’t: https://sock-doc.com/2012/04/trigger-point-therapy/
Sam says
Hello Dr.Gangemi,
I believe I have over-done my walking in barefoot shoes today, and my right knee now has a low, dull pain. The pain is present when I’m not moving. If I had to say where it is in my knee – I would say inside or/and the front – though it is quite dull so it is hard to place.
I have been wearing custom orthotics for pronation since I was 12, and it has been 12 years since I got them. I started barefoot a week ago and the longest I walked was 1.5hrs. Today I walked 4hrs and had pain for half it. I went for a hike, apparently a bad idea, I didn’t realize barefoot shoes required a disciplined training program.
If you could let me know how to treat my knee to prevent furthur injury that would be greatly appreciated!! I haven’t been able to find this knee injury on your website. I will continue to read up on transitioning to barefoot carefully.
Thank you,
Sam
Sock Doc says
I have a whole video on the knee and if your knee pain is on the front, back, or either side (it has to be) then hopefully something I show will help. Read this too to learn how to properly transition out of your shoes. https://sock-doc.com/2012/03/healthy-people-barefoot-people/
Megan says
I primarily run on asphalt and concrete and begin to feel a bit of pain in my knees after mile 7 or 8. I haven’t gone above 11 out of fear of overuse. Not sure if my shoes need to be replaced from inadequate cushioning or if I’m simply over-training and/or need to do more work on my quads.
I’m interested in moving to minimalist shoes to improve my form overall, but am concerned about the shock from my feet pounding on said surfaces. I know NB designed a minimalist shoe for road running, but am curious about your opinion on this (not the brand, per se, but minimalist shoes in general). Should I stick with a more stable, cushioned shoe for the road or give the minimalist shoes and natural form a go?
Many thanks for this informative article!
Sock Doc says
Check out the articles in the START HERE box as they will answer your questions.
Jacqueline says
Hi Doc,
I had arthroscopic knee surgery in my left knee for a torn meniscus (outer part) in 2006.
I have good days and bad days..better in the spring and summer. I get stiff in the winter. I swim and cycle when my knee is not painful. I was wondering if you could help me understand why I still have sharp pain on the area that I was operated on. It doesn’t always happen but it doesn’t if I do more that I normally do.
Doc, do you have any suggestions for me?
Thank you!
Sock Doc says
Please read this; thanks!
https://sock-doc.com/sock-doc-questions-comments/
Mikael says
Hi Doc,
Thanks for a great video. I’m having a problem with “jumpers knee”, mostly pain on my way down doing squats or when jumping to much.
After watching the video and reading the comments, is it correct that I should think more quads than glutes in my case?
I’m a heavey coffee drinker and I’ve noticed that my knee gets way better if I avoid drinking coffee and other caffeine products. Perhaps I should give it up once and for all if caffiene is one of the causes to my pain.
Thanks in advance for your feedback
Best regards
Sock Doc says
Correct – that’s more the eccentric motion so more quads. Yup – give up the coffee!
frankie rodriguez says
Hi Doc,
I’m trying to figure out what type of knee pain I have.I’m flat footed,have heel spurs,have been walking on hard surfaces for years while at work.My knees crack,I have pain when I go up stairs,bend down,walk.I recently purchased a pair of Lems shoes.They have helped.I know this will take time.Just want to know if this sounds like Itb pain or something else.Thanks
Sock Doc says
Please read this; thanks!
https://sock-doc.com/sock-doc-questions-comments/
Sonja says
Hi, Doc, I also am trying to figure out what my knee pain is…I was running regularly with my dog, she is about 60lbs , and she ran into my right knee it seemed about 90 mph..it seemed, I have been to my doctor three times and no answers yet…From what I have read and watched it could just be runners knee, or pes anserine. mr knee has pain most with flex extensions, a lot of pain when I go to stand both lateral, and medial, and directly in back of my knee the bursa sack? from what I watched. My right knee on both sides of my knee…on the lateral more to the top, on the medial directly across from the knee and directly behind the knee. Xrays have shown no damage to bones and I have not had a MRI yet..still waiting..OH and it has been at least 2 months or longer…If my muscles are the culprit can you give me the exact work out to recover and get me back on the road PLEASE…
Sock Doc says
Please read this; thanks!
https://sock-doc.com/sock-doc-questions-comments/
Rene says
Hi. I’ve a fairly new consistent runner (starting in Jan including a half marathon in May). During the past two weeks I’ve had pain on the inside of my left knee and on Friday it became excruciating. I’m icing it and taking ibuprofen. I totally fit into the pain described above wherein you speak of adrenal glands problems (I crave sugar like you wouldn’t believe and it’s gotten particularly worse the past couple of weeks) My question is what do I do to get a grip on the pain and on the sugar intake. Please help.
Sock Doc says
Please read this; thanks!
https://sock-doc.com/sock-doc-questions-comments/
Josh says
Doctor,
Would you say Pes Anserine is more of a calf or a hamstring related?
Sock Doc says
I’d say it’s more of an adrenal gland issue actually that affects the thigh muscles, one being one of the hamstring muscles.
Bernard Bulaitis says
Dear Soc Doc. In an attempt to strengthen my achilles, after a niggle there, I started doing a lot of flat footed squats. I think I overdid these, moving too quickly to 15 minutes at a time. My hips felt really stiff coming out of these squats. However, characteristically, I stupidly did not listen to my body and carried on. My left knee seized up with a ‘bakers cyst’ bursitis. Trigger point massage in the thigh helped this, but both hip joints now really ache. I thought I was over it on Sunday and went running but had to pull up due to what felt like a tear in my left hip flexor. It’s feeling better now, and I’ve been for some long swims. Do you agree with my ‘self diagnosis’ that I’ve damaged my hip ligaments by over-stretching them in the squats? Any suggestions as to how I might proceed, or is it just a case of rest? I have a marathon booked for April and am getting worried I may miss too much training. Any advice most welcome. Bernard – London UK
Sock Doc says
It’s rather difficult to over-stretch your ligaments in your squats unless you were getting a pinching-type of pain in the hip joints when you were doing them and you just pushed through it. Of course, it’s impossible for me to tell you what you did, especially if you tore something. Best for you to see a doc/therapist to help you out. Don’t push yourself for April – that’s a recipe for disaster if you’re not ready.
Jean Rouvelin says
Hi Doc,
My name is Jean and i am 36. I find you with the trail nation podcast, and I am looking for a solution for my knee problem.
I am in the uk and I run a fair bit, not at the moment, and been injured for the last two months now.
I have seen a physio, a GP and a chiropractor to get answers and solutions but not brilliant I have to be honest.
I apparently have a patellar tendinitis on my left knee. I had the same last year with an inflamed bursa, they decided to inject the bursa with cortisone and that sort out the problem for the time being and I had a tendinitis a few years ago on my other knee which took 18 months to make better. The pain is getting worse and i am desperate to find a solution to my multi knee problems. I am riding my bike a bit, because that is the only things who help me to deal with my day to day issues.
If you have any input or exercises to help I am a taker. A bit desperate to be again on the side line.
Thank you and carry on the good work.
Dr. Stephen Gangemi "Sock Doc" says
Hi Jean – check out the articles on this site about bursitis and inflammation (search button works well). This is most likely an inflammatory/overtraining issue. Hope that helps! Good luck.