Kinetic Chain Patterns Causing Complicated Knee Conditions Including Ascending Syndromes
Kinetic Chain Patterns Causing Complicated Knee Conditions Including Ascending Syndromes

Kinetic Chain Patterns Causing Complicated Knee Conditions Including Ascending Syndromes

By James Waslaski , Author & International Lecturer

Kinetic Chain Patterns Causing Complicated Knee Conditions Including Ascending Syndromes

By James Waslaski , Author & International Lecturer

Stated so brilliantly at a number of past seminars I have taken with my friend and colleague, Erik Dalton, “the knee is the slave to the foot and hip”. So I have learned that the stirrup spring system in the ankle is responsible for “Ascending Syndromes” that work their way up into the knee, hip, back, spine, and neck.

If the client has bilateral pronation that can contribute to “knock knees”, or bilateral supination that can contribute to “bow legged conditions,” that should be addressed prior to assessing and treating the pain in the knee. After many years of studying and co-teaching with Erik, I have come to realize that one of the most challenging and complicated ascending syndromes is when one ankle over-pronates and the other ankle supinates.

Manual therapists can swipe the arch of the pronated foot (pronation includes eversion, abduction and dorsiflexion.

Figure 1

(Fig. 1). With 2 fingers the therapist can try to lift the navicular bone. If the assessment reveals the navicular and cuneiforms have no spring and the foot appears to be flat, the arch is pronated.

(Fig. 2) For the supinated foot (plantar flexion, inversion and adduction) the arch will be high (Pes cavus). The therapist can palpate a high arch that feels stuck in a supinated position

(Fig 3 -middle photo). In a supinated foot the subtalar joint is usually fixated in a varus position accompanied by a collapsed cuboid. The combination of foot pronation and foot supination not only affects leg length, but begins an ascending syndrome pattern that travels up the kinetic chain distorting knee, hip, and low back structures”.    

Figure 2

The pronated foot (Fig.4) results in a valgus subtalar joint accompanied by a dropped navicular bone. This causes internal tibial torsion patterns in the knee

(Fig. 5) along with sacral torsions

(Fig. 6) and pelvic obliquities. Pelvic Obliquities can be caused by anatomical or functional leg length differences. Corrections of proper arch support and foot strike to address functional leg length patterns will be covered in a future articles. 

This ascending pattern can continue into roto-scoliosis of the lumbar spine which can lead to ascending kyphosis of the thoracic spine. This sometimes locks down the OA joint, and can often be the cause of migraine headaches. The first thing therapists should do is look at the ankles, and the stirrup spring system, which is the foundation of the entire body. Once the lower body kinetic chain is addressed, by restoring proper foot strike and resolving the ascending tibial torsion and sacral torsion patterns, the manual therapist can do good orthopedic assessment for anatomical structures causing knee pain.

Figure 3

Most of the time chronic knee pain will go away just from restoring prober foot strike, releasing hip capsular patterns (Fig. 7) and sacral torsion patterns (Figs. 8-10) of the hip, and correcting tibial torsion patterns of the knee. This simplifies the ability to restore proper fibular glide for the normal stirrup spring system. All of these techniques are done through positional release of articular ligaments and muscle balancing protocols, to mobilize or stabilize proper joint function of the hip, knee and ankle. 

In other words 90 percent of knee pain is not due to the structures of the knee. In fact various articles, and clinical studies, have shown that rarely ever will the knee pain be coming from conditions like Patellar Femoral Syndrome (damage to cartilage under the kneecap) or Iliotibial Band Friction Syndrome. Chasing The Pain Blog from Erik Dalton, and an article published by Whitney Lowe, elaborate on “New Perspectives on ITB Friction Syndrome”. So therapists that abide by “conventional wisdom,” who often seek out sore spots around the epicondyle of the knee and friction that area along with fascia mashing with forearms and foam rollers, might want to look into the benefits of massage cupping as a replacement for forearm work and foam rolling for the Iliotibial Band Problems . Even in 4th grade degeneration of the patella, the pain is rarely from that cartilage.

Due to tracking of the patella, pain is usually coming from the irritated bursa and fatty sacs or irritated nerves in the knee area. In the classroom settings for knee pain, manual therapists will spend time just analyzing gait patterns, and the function of the bones of the foot, for open and closed kinetic chain foot biomechanics.

Figure 4

So for structures that are actually injured in the knee, manual therapists can quickly assess and treat the actual structures damaged in the knee. But that should only be done after assessing and correcting kinetic chain patterns coming from the foot and hip, along with balancing all the actual muscle groups around the knee.

Once the muscles around the knee are balanced, therapists can start by addressing ligament sprains of the knee to see if stability or mobility is the proper route to pursue. Perform the Posterior Drawer Test (Fig. 11) to assess a ruptured or injured PCL. Then the Anterior Drawer Test to assess for an injured or ruptured ACL (Fig.12) Refer out clients with Ruptured ACL and PCL injuries for additional evaluation by a good orthopedic physician. Then do the Valgus Stress Test (Fig. 13) to identify an injured medial collateral ligament (MCL) and the Varus Stress Test (Fig. 14) to evaluate for an injured lateral collateral ligament (LCL). These can often be treated quickly and effectively if the kinetic chain patterns have been addressed. 

Once the therapist knows the knee has proper stability from the major ligaments, we can assess and treat the other structures of the knee. From many years of manual therapy experience, I suggest you evaluate and correct any non -weight bearing tibial torsion patterns to align the tibia with the fibula. This brings all the structure of the knee back into their normal resting positions for more effective therapeutic outcomes. Start by bending the knee to 90 degrees, put the ankle in a neutral position, and assessing the position of the foot. Often times, especially in the right leg because of the way we drive our car, the foot will be externally rotated out 30-45 degrees from the biceps femoris pulling on the proximal fibular head (Fig.15).

Figure 5

That can compromise fibular glide and stress the fibular nerve. This should be corrected before treating conditions like patellar tendinosis, ligament sprains, muscle tendon strains, nerve adhesions, bursitis, or meniscus injuries. Simply lengthen the biceps femoris (Fig. 16) and rotate the tibia and fibula back in alignment with the femur (Fig.17/ Fig. 18).  In most cases, after correcting tibial torsion patterns of the knee, most knee pain will go away. That assures that the ligaments are back where they belong, the muscles around the knee are balanced, the patella is tracking normally, and the nerves glides are not compromised.

Once the kinetic chain patterns are addressed in the ankles knees and hips, therapists will have so much more success in assessing and treating what would have seemed like complicated knee conditions. Correcting tibial torsion patterns of the knee will often allow the MCL and LCL injuries to heal properly, the patella to track normally and the nerves to properly glide without joint fixations or scar tissue lesions. Our next article in this series and our newest seminar and newest DVD on Kinetic Chain Patterns for Complicated Knee Conditions, will include additional assessments such as the McMurray’s Test and Apley‘s Compression test for Meniscus Injuries, along with therapeutic treatment and rehabilitation for Meniscus tears. It will also include treating muscle-tendon strain patterns for hamstring injuries, Pes Anserinus Tendinitis/ Bursitis, and treating popliteal and plantaris strains. It will also include looking at myofascial cupping (vacu-therapies) for nerve adhesion release, iliotibial band pain, and retinaculum release for the structures of the knee.

We will also elaborate on the studies in regards to patella femoral syndrome and IT band pain not being properly treated in most situations. Future articles, kinetic chain knee seminars, and our recently produced new DVD will include, assessment, treatment and home care retaining for about 12 different contributions for complicated knee pain. State of the art anatomical inserts will aid all therapist with understating the cause, treatment and rehabilitation of most complicated knee conditions. Our most recent DVD produced in March of 2019 takes therapist through Kinetic Chain Patterns and total body lesion assessments for complicated knee conditions prior to doing orthopedic evaluations of the knee. For details on seminars or DVDs go to

References; Dr. Erik Dalton-Dynamic Body: Exploring Form/ Expanding Function; Whitney Lowe-Functional Assessment in Massage Therapy; James Waslaski-Clinical Massage Therapy-A Structural Approach to Pain Management. Articles: Erik Dalton-IT-Band Friction Fallacy; Whitney Lowe-New Perspectives on ITB Friction Syndrome Article. Erik Dalton-Don’t Get Married Article. Blogs-Erik Dalton. Artwork from Clinical Massage Therapy: A Structural Approach to Pain Management (Illustrator: Marcelo Oliver-Body Scientific International, LLC)