We learned everything we needed to know about our skeleton in kindergarten . . . Recall a section of the lyrics from the children’s song Dem Bones:

“The ankle bone's connected to the leg bone,
. . .
The leg bone's connected to the knee bone,
The knee bone's connected to the thigh bone,
The thigh bone's connected to the hip bone . . .”

In short, the knee bone(s) are connected to the ankle and hip bones, and these bones are connected to all of our other bones in the body. Specifically, the knee joint is the intersection of the leg bone (femur) at the top, and ankle bones (tibia and fibula) on the bottom. Together, these joints—ankle, knee, and hip—comprise three of our four load bearing joints. (The fourth is the shoulder.) Consequently, the health of your knee joint depends on the alignment and interaction between all of these joints. Let’s explore this further.

Knee Anatomy and Motion

As you can see in the picture of the knee anatomy, the femur, which connects the top of the knee to the hip, has two rounded bone ends called condyles (not labeled). These condyles are colored white because they are covered by cartilage. Cartilage is a smooth soft tissue that allows for fluid joint movement. These femoral condyles sit on the flatter tibia bone that connects the bottom of the knee to the ankle. Between these two bones sits the lateral and medial meniscus, which are also composed of cartilage. They are shown in white.

The knee is primarily a stability joint that acts as a hinge, flexing forward and extending backward in the sagittal plane. Additionally, the knee has limited rotational and side-to-side movement.  

Knee Alignment

When the knee joint is in a neutral alignment, the femur is centered on the tibia, and the patella (kneecap) points straight ahead, as you can see in the image. In this position, loads, such as body weight, and forces, such as gravity and ground reaction, are distributed evenly throughout the joint, particularly through the soft tissues—cartilage and meniscus—without damage. Often, however, the kneecap is not positioned directly in the center of the knee joint. When it’s correctly positioned, it’s pointing straight ahead. However, for many people, the kneecap is rotated to point outward or inward. The amount of rotation can be slight to extreme. It can also be different between your left and right knees. With significant external knee rotation, the legs can appear bowed, in the image to the left in which the knees are pulling away from each other. Likewise, significant internal knee rotation can make the legs appear knock-kneed, as shown in the image to the right in which the knees have come closer together and are almost touching.

The cause of the kneecap rotation does not lie within the knee joint itself. Instead, it is a consequence of the hip position. The hip is the other end of the femur bone! Note the dark purple bone in the image to the right. Clearly, any postural misalignment at the hip is reflected at the knee.

Similarly, the position of the tibia and fibula bones that connect the bottom of the knee joint to the ankle and feet also affects knee alignment. Hence the use of orthotics and supportive shoes to correct ankle alignment to relieve knee pain.

To complete this picture, imagine a knee joint where the femur is rotated inward while the foot and subsequent lower leg bones—tibia and fibula—are rotated outward. When these bones come together at the knee joint, they do not line up. The knee is twisted with uneven contact throughout the joint, creating excess stress and strain in the soft tissues (think meniscus). Now, flex and extend that joint repeatedly. You could even imagine adding in some running to compound the forces going through the knee to about five times your body weight. How long is the joint going to be able to sustain that type of trauma? Meniscus tear, anyone? I’ve had my share. :-)

Exercises

To change knee position, we need to work from above and below the joint. How well the hip (femur) and the ankle bones (tibia and fibula) are aligned directly affect the position of the knee itself. The rest of the skeleton, including the shoulder, also influences the posture of the hip and ankle. So, what do we do to fix all of this? Align everything! These exercises are from the Egoscue Method^©. The first two exercises target knee alignment. The final position integrates the upper body while isometrically strengthening the improved knee position.

Sitting Double Double

This exercise externally rotates the hips and internally rotates the ankles. This is especially good if you have internally rotated kneecaps. To analyze which direction your kneecaps face, stand barefoot in shorts in front of a full-length mirror with your feet straight. Internally rotated kneecaps will point inward or toward each other, while externally rotated knee caps will point outward. Your left and right kneecaps may point in different directions.

1. Sit on a chair or similar surface. 
• Your knees and hips should be parallel to the floor, or you can have your knees slightly lower than your hips.
• Feet are flat on the floor, pointing straight ahead.
• Your sit bones on the bottom of your pelvis should be pointing straight down.
• Hips and shoulders are aligned with each other.
• Your spine is in its natural curves. 
2. Place a non-elastic strap just above your knees.
3. Pull your knees out into the strap. Your knees should not go outside your hips. It is a small range of motion. Feel the engagement through your outer hip and glutes.
4. Place a small block, firm pillow, or ball (4-6”) between your feet. 
5. Simultaneously pull out into the strap and squeeze your feet into the block without allowing your feet to rotate. This is aligning your knees to neutral. It is helpful to use a mirror to watch your movement.
6. Hold the contraction for 2-3 seconds. Then relax.
7. Exhale out your mouth as you contract. Inhale through your nose as you relax.
8. Repeat 10 slow, mindful repetitions. Do up to three sets.

Sitting Double Switch

Now you’ll do the opposite movement. This exercise internally rotates the hips and externally rotates the ankles. This is especially good if you have externally rotated kneecaps.

1. Sit on a chair or similar surface. 
• Your knees and hips should be parallel to the floor, or you can have your knees slightly lower than your hips.
• Feet are flat on the floor, pointing straight ahead.
• Your sit bones on the bottom of your pelvis should be pointing straight down.
• Hips and shoulders are aligned with each other.
• Your spine is in its natural curves. 
2. Place a small block, firm pillow, or ball (4-6”) between your knees. Squeeze into the block using the muscles of your inner thighs. The movement should be initiated from your hips. 
3. Place a non-elastic strap just above your ankles.
4. Simultaneously squeeze into the block with your knees and pull out into the strap with your feet without allowing your feet to rotate. This is aligning your knees to neutral. It is helpful to use a mirror to watch your movement.
5. Hold the contraction for 2-3 seconds then relax.
6. Exhale out your mouth as you contract. Inhale through your nose as you relax.
7. Repeat 10 slow, mindful repetitions. Do up to three sets.

Counter Stretch Wall

This exercise engages the quads to lock in your improved knee position while loading in alignment against gravity. Additionally, you are integrating the shoulder joint with your other load bearing joints.

1. Stand a few feet from the wall with your feet pointing straight ahead.
2. Place your hands on the wall at shoulder height. 
3. Walk your feet back and lengthen through your spine. Keep your elbows straight.
4. Press your butt back so that your hips and ankles are in horizontal alignment with each other and perpendicular to the floor.
5. Tighten your quads by lifting your kneecaps up.
6. Keep your weight evenly distributed in your feet.
7. Drop your chest down toward the ground, attempting to bring your shoulder blades together. 
8. Keep your ear in line with your upper arm. Don’t let your head drop down.
9. Breathe into your diaphragm all around your torso–front, back and side—and be sure to take nice long, slow breaths.
10. Hold for 1-2 minutes.

Summary

Knee pain is often due to misalignment of the joint. When the femur bone, which is connected to the hip above, and the tibia and fibula bones, which are connected to the ankle and foot below, are misaligned, so is the knee. Position of the knee is dependent on these joints above and below. If the knee joint is twisted, loads and forces are not evenly distributed throughout the joint, which can cause pain and break-down (“wear and tear”) in the soft tissues, e.g., cartilage and meniscus. Aligning your knee can bring lasting relief for chronic knee pain.