The Real Reason You Have Knee Pain

Credit: Odilon Dimier / Getty Images

The U.S. has more than 700,000 total knee replacement surgeries every year, and that number is growing precipitously. We are getting to the point in society where we just expect to wear through key structures in our bodies — our knees, hips, and ligaments. It's a disturbing trend and a reason why I think it is so important to educate people on how to get their bodies moving correctly. Unless there is a traumatic incident to the knee, most people should be able to decrease their knee pain by looking at and correcting one thing: their Q angle.

Whenever people come into one of my clinics with pain in their lower extremities, after I check their pelvic alignment, I check their Q angle. In the physical therapy world, the Q angle is often overlooked and underestimated. But in my work, when I see a Q angle that is off, I also see an excessive amount of rotational force absorbed by the knee. Furthermore, the meniscus and other internal structures of the knee are compromised more when the Q angle is increased.  

The result is a tight knee, which is a precursor for all types of issues — ACL tears, meniscus tears, MCL tears, osteoarthritis, and even knee replacement.


Think of your knee as wet sponge. If it is in proper alignment and working mainly in flexion and extension, it is like compressing the sponge on a flat surface. The water comes out with compression but soaks back in after released. However, if you add the rotation force, or wring the sponge, the water comes about and stays out. The excessive rotational force that occurs because the Q angle is off means serious trouble for the knee. 

The most scientific way to check the Q angle is to draw a line from the ASIS of the pelvis, or the upper most bony prominence in the front of your waist, to the midline of the patella, and then draw another line from the mid line of the patella to the tibial tuberosity, the bony notch right below your patella. If you had a goniometer at your house — which you probably don't — you would find that a healthy Q angle might be 10 degree angle formed by those two lines. For the purpose of this article, I want you to check the midline of the patella and draw a line straight down to the tibial tuberosity. Does it seem mainly centered? Great. But if is seems way off, we have a problem.

Why Your Q Angle Is Off
The Q angle comes out of position because of imbalances in the pelvis or the foot and ankle. Look at the pelvis: If this is out of alignment, meaning one side is higher than the other or it is tilted forward, the hip flexor gets tight. This in turn will cause the femur to internally rotate, increasing the Q angle.  Internally rotated femurs are not your friend. It can lead to overuse of the lateral thigh structures (TFL, IT Band, and/or the outer quad) and poor motor control of the VMO, the inner most quad.  The poor congruency of the knee will lead to increased rotational stress of the knee soft tissue including the patella and quad tendons as well as the retinaculum, fibrous tissue that helps to keep the patella in place.  

It could also come from the foot and/or ankle due to improper body mechanics. Next time you walk in the down the street, watch people's feet. You will see them walking on the outsides of their feet, their feet may seem stiff. I see it all the time. Both walking on the outside of your feet and poor foot/ankle joint mobility can limit tibial rotation. If the tibia is not able to internally rotate due to limited foot/ankle pronation (especially the midfoot) the femur will internally rotate at a faster rate. Long story short, your Q angle is off, and you need to get to some serious prehab to get it back in line.

Here's what you need to do to fix it:

Hip Flexor Release
For this release, use two lacrosse balls taped together.

  • Lay on your stomach and place the double lacrosse ball just below your hip bone.
  • Lean a tolerable amount of weight onto the lacrosse balls.
  • Bend the knee on the side of the release back to a 90 degree angle.
  • Swing your leg side to side in a tolerable range of motion.Repeat this in 30 second to two minutes intervals.

Vastus Lateralis Release

  • Lay on the side you wish to release.
  • Place the foam roller under your bottom leg halfway between your hip and knee.
  • Slide your leg up and down along the foam roller, moving it from the top of the knee to the base of the hip.
  • Try to work over the more tender areas as you can tolerate.
  • Repeat in 30 second intervals for two minutes.
  • To focus on a specific area of the IT band, locate the most tender area with the foam roller and stop. Bend your knee at a 90 degree angle, and then straighten. Repeat motion of bending and straightening knee for 10-15 seconds. You may repeat this with other areas along thevastus lateralis.

Soleus Release

  • Sit with your lower calf on top of a lacrosse ball or foam roller.
  • Place your other leg over the one you are releasing and roll yourself up and down over the ball.
  • Once you find a spot that is tender, stop and point your foot up and downfor 30 seconds

Mobilization to Correct Q-Angle

  • Stand with the leg you wan to mobilize in front of the other.  
  • With the front leg, make a circle outward over the pinky toe, bending and straightening the knee during the process.  
  • Perform  this  motion  for  three  sets  of  ten,  taking a break  after  each set.  The  joint  that's  being  mobilize  is  the  knee  joint.

Inner Thigh Squats

  • Place feet shoulder width apart with your toes pointed out at a 45-degree angle.
  • Weight should be placed through your heels.As you begin to squat, bring your hips back like you are sitting in a chair that is too far behind you.
  • While squatting, try to move your knees out. Go as low as you can, then push back up through your heels, repeat.
  • Repeat exercise with weight through the balls of your feet.

David Reavy, founder of Chicago-based React Physical Therapy, is the creator of the Reavy Method, a whole body approach to physical therapy and exercise. Reavy works with numerous pro athletes from the NFL, NBA, MLS, and the WNBA.