Clinical Chiropractic (2003) 6, 63—66

CASE REPORT

Atypical knee pain: the biomechanical and

neurological relationship between the pelvis,
hip and knee–—a case report
Laura Cookson*

Fraser House Clinic, 75 Upper Gungate, Tamworsh, Staffordshire B79 8AX, UK

Received 30 May 2002; accepted 27 February 2003

KEYWORDS Abstract This case report describes the case of a 31-year-old male marathon runner
Athletic injuries; with right knee and hip pain and associated right sacroiliac joint dysfunction. The
Biomechanics; biomechanical and neurological relationships between joints of the lower extremity
Chiropractic and pelvis are discussed including injuries within the kinetic chain.
manipulation; ß 2003 the College of Chiropractors. Published by Elsevier Science Ltd. All rights
reserved.
Knee injuries;
Knee joint; Hip joint;
Human; Male; Neurology

Introduction injury that had occurred as a consequence of a

Runners have a higher reported incidence of hip
pain than any other athletes. Furthermore, long-
distance runners are prone to an increased lifetime
risk of hip pain.1
Athletes presenting with hip and/or knee pain
will frequently only receive a regional examination
of the symptomatic area. Such an approach can
often miss the true aetiology of the problem.2
This case report discusses the relationship
between the biomechanical and neurological com-
ponents of lower extremity and pelvic lysfunction.
Moreover, the significance of pain referral patterns
is discussed and the possible aetiologies of pain
referral are also examined.
Case report
A 31-year-old Caucasian male presented with a
2-week history of right knee pain following a running


Tel.: þ44-121-308-6898.
E-mail address: lauracookson@hotmail.com (L. Cookson).
1479-2354/03/$30.00 ß 2003 the College of Chiropractors. Published by Elsevier Science Ltd. All rights reserved.
doi:10.1016/S1479-2354(03)00021-X
training session along a canal side. The patient
had been in preparation for the London marathon.
At the time of presentation (only 5 days prior to
the marathon), the patient had routinely been run-
ning 20 miles on a twice-weekly basis for 4 weeks.
During the case history, he suggested that an injury
possibly occurred after slipping on a muddy and
uneven path at a canal side. However, the patient
was not immediately aware of any pain.
The onset of symptoms included a dull and deep-
rooted ache in the right knee that commenced after
the running session but went away after a few days
rest. However, the symptoms escalated from that
point forward and, during every running session, the
right knee symptoms included a deep, sharp pain,
7/10 on the Visual Analogue Scale (VAS). This
occurred after running for approximately 30 min
and, consequently, the severity would force the
patient to walk. The patient’s normal pattern of
symptomatic recovery included rest and ice to
the anterior right knee for 4 days. Initially there
would be right hip and knee soreness for 1—2 days
and then only right knee soreness for the 2 remain-
ing days (3/10 on VAS). Aggravating factors included
64
weight-bearing movement on the right leg, parti-
cularly when walking down stairs.
Further case history evaluation revealed that the
patient worked as a farm labourer, however, his
heavy workload of lifting and carrying remained
unaffected. Furthermore, the patient had a history
of long-distance running since childhood and on
occasions had noticed bilateral achy and uncomfor-
table knees for many years.
Previous medical history and systems review
were unremarkable. Immediate family history
included a father with moderate bilateral knee
osteoarthritis and a mother with hypertension.
Clinical examination revealed mild postural
alterations including: forward head carriage, a
depressed right shoulder, mild bilateral forefoot
hyperpronation and bilateral pes planus. Full neuro-
logical examination was found to be normal. The
orthopaedic examination revealed an asymptomatic
but restricted right sacroiliac (SI) joint confirmed by
motion palpation, prone SI joint challenging, Hibb’s
and Yeoman’s tests. Static and motion palpation of
the right knee revealed a mild posterior positioning
of the proximal tibia on the femur when compared to
the left knee, but there was no weakness of the right
popliteus muscle on testing.3 Soft tissue palpation of
the surrounding right knee structures identified a
non-tender but hypertonic Ilio-Tibial Band (ITB),
particularly in the distal third. Active and passive
joint Range of Motion (ROM) of the right hip revealed
a 158 restriction in internal rotation when compared
to the left hip. Orthopaedic examination of the right
knee was unremarkable.
The initial working diagnosis was acute tibio-
femoral biomechanical dysfunction with concomi-
tant right SI biomechanical dysfunction compli-
cated by right hip dysfunction and ITB spasm,
secondary to recently increased training intensity.
An intensive plan of management was com-
menced, with a view to regaining function in time
for the marathon. Consequently, the patient was
treated with right SI manipulation (diversified
adjustment), supine long-axis hip mobilisation (at
908 with internal rotation) and with a supine poster-
ior proximal tibia manipulation technique.3 On fol-
low-up the next day, the patient reported having had
no discomfort in the right knee but that the ache had
moved to the right hip. Furthermore, on presenta-
tion the following day, the patient reported that
after the second treatment he had complete relief
from knee and hip discomfort. This was mirrored by
his report that he had completed a 4-mile run in
30 min the previous evening without any pain. A third
treatment was repeated 2 days prior to the London
marathon. When the patient returned for re-evalua-
tion the next week, he reported that he had success-
L. Cookson
fully completed the event symptom free and had
posted a time just below 5 h. The patient followed up
3 weeks later stating that he had experienced no
further knee or hip discomfort and had resumed his
more leisurely evening runs.
Discussion
The sequential discovery of right hip and SI patho-
mechanics in isolation from obvious knee findings
have previously been considered.4 This is particu-
larly apparent in patients with knee pain, especially
with no definitive structural injury to the knee in
question.4,5 Thus, the importance of SI and hip joint
involvement should not be overlooked in the eva-
luation of knee symptoms.
When assessing a patient with hip and/or knee
pain, there are complex links to investigate when
identifying possible connections or interactions
between the joints. Therefore, the biomechanical
and neurological components of joint involvement
within the kinetic chain should be considered.
Biomechanically, the knee is the proximal joint
to the hip in the kinetic chain and, therefore,
both joints can be described as having a direct
biomechanical relationship.4,6 An example of this
biomechanical relationship can be demonstrated
by coxarthrosis. In coxarthrosis, there are certain
limitations of ROM. In particular, the movements
that are most restricted follow the common capsular
pattern of internal rotation, flexion and extension
motions.4 These changes in ROM may, in turn, lead to
compensatory biomechanical alterations including
increased anterior pelvic tilt and lumbar lordosis;
rotation of the pelvis and knee flexion.6 Conse-
quently, such structural and postural changes could
result in increased stress upon the musculature and
other structures around the hip and in the joints
above or below.6 The knee, being an adjacent joint
in the kinetic chain, may be particularly affected.
The kinetic chain can be expanded upon by
describing the involvement of all aspects of the
body during the sequencing of tasks. Sequencing
malfunctions can be as a consequence of many
different factors of which injury is one of the most
common. Consequently, a system may not function
properly during the completion of a specific task
when under load or when altered biomechanics
exist.7 An example of such sequencing is provided
by Michaud,8 who suggests that there are a number
of potential injuries related to the postural effects
of excessive foot pronation.8 This hypothesis may
help to explain the aetiology of this patient’s pro-
blem; specifically, sub-talar pronation causing the
talus to adduct and plantar flex, resulting in exces-
Atypical knee pain
sive internal rotation and lowering of the entire
lower extremity. Consequently, tensile strain on
the iliopsoas and piriformis muscles increases,
resulting in a narrowing of the greater sciatic notch
(thereby predisposing to entrapment of the sciatic
nerve). Furthermore, as the lower extremity drops
inferiorly, the ipsilateral innominate lowers in obe-
dience of Freyette’s Law (thus involving the SI
joints), causing the body of L5 to rotate toward
the functionally shortened leg.8
Michaud8 proceeds to explain that, as a result of
this sequence, the lumbar spine attempts to
straighten itself by laterally flexing toward the long
leg, compressing the lateral aspects of the ipsila-
teral discs and forcing the facets on the concave
side into a hyperextended or close packed position.8
Conclusively, over a period of years, these actions
may lead to a variety of overuse injuries.
Downes7 describes the pelvis as being the transi-
tion area for forces moving superiorly from the
lower extremity and inferiorly from the spine,
hence both directional forces move towards the
pelvis.7 However, the knee is a more common site
of injury in athletes (particularly long-distance run-
ners)9 and, thus, the forces moving superiorly in the
lower extremity are more pertinent to this case.
Further to Downes7 hypothesis, the SI joints are
described as being stress relief regions within the
kinetic chain10 and, therefore, activities such as
running would magnify these stresses upon the
pelvis.7 When an athlete sustains an immediate
injury or acquires, over a number of years, sufficient
reduction in their physiological adaptive range to
result in biomechanical breakdown, the proper
sequencing of the kinetic chain will be altered.7,8
Either could be applicable to this case. Further-
more, it has been reported that athletes with lower
extremity overuse injuries or acquired ligamentous
laxity may be at risk of the development of non-
contact low back pain (LBP) during athletic compe-
tition.11 These clinical observations are, therefore,
indirectly describing alterations to the lower extre-
mity in terms of injury and alteration to the normal
sequencing of the kinetic chain, consequently man-
ifesting as symptoms of LBP.
This complex link between the knee, hip and
SI joints as described elsewhere in this report can
also be described in terms of a neurological
relationship. When pain referral patterns are
observed in clinical practice, the aetiology for such
pain referral may not always be straightforward.
The neurological interrelationship of the knee, hip
and SI regions are considered, inferences can be
drawn that help to explain the relationships between
arthralgias.4,5,12 The lumbosacral region and the
buttock share a segmental nerve supply.
65
This differs slightly depending on author, how-
ever, an unofficial consensus seems to consider L4,
L5, S1 and S2 to comprise this supply.13—17 The
ventral rami of these segmental nerves innervate
the deep tissues of the buttock area as they man-
ifest themselves as the superior and inferior gluteal
nerves.13—16 Therefore, buttock and iliac crest pain,
through their common innervation, have a direct
link. This is also true for the SI joint and the poster-
ior thigh. The posterior thigh receives cutaneous
innervation from the posterior femoral cutaneous
nerve, which in turn shares a common origin to the
nerves that supply the SI joint.13,14,16 Furthermore,
pain referral from the SI joint does not appear to be
limited to the lumbar region and buttock. Eighteen
patterns of pain referral from the SI joints have
been previously reported, with 50% of subjects
having described associated lower-extremity pain
after SI joint injection.12 Slipman et al.12 described
several reasons for the variable patterns of pain
referral that was observed including: (a) the SI
joint’s complex innervation; (b) sclerotomal pain
referral; (c) irritation of adjacent structures and (d)
varying locations of injury within the SI joint.12
Suter et al.5 report on a common clinical link
between sacroiliac joint dysfunction and anterior
knee pain and consider spinal manipulation to be an
effective treatment for the muscle inhibition in the
lower limb that they regard as the causative link
between the two areas of dysfunction.5
The neurological relationship between the hip and
knee may be illustrated by again using the example of
coxarthrosis. The hip is supplied by branches from
the sciatic, femoral and obturator nerves, all of
which give branches to the knee joint.13,14,16 In order
to understand the process by which coxarthralgia can
cause referral to the knee, it is first necessary to
understand the mechanism of chronic nociception.
The chemical changes that occur within a damaged
hip persist long after the precipitating cause. These
substances, such as bradykinins, prostaglandins, ser-
otonin, cytokines and growth factors are responsible
for the continued reduction in threshold of the
already chemosensitive neurones.18,19 Furthermore,
the combination of aberrant proprioception and
altered biomechanics means that minor movements
may be aggravational and result in a viscious circle
where there is both continued sensitisation and che-
mical release.18
The convergence hypothesis best explains the
concept of both interrelated and referred joint
pains.17,18 This is particularly noted in the hip and
knee (although is true of other adjacent joints), but
may also explain the referral of pain from joints
with multiple innervation, such as the SI, to remote
areas. This process occurs within the spinal cord and
66
the thalamus. When sensory neurones from joints
and their surrounding structures are activated, the
information converges onto common neurones that
in turn relay to higher centres.17,18 In the absence of
further afferent sensory input, the brain is unable to
decipher the actual source of this input to the
common neurone.17—19 Therefore, the identifica-
tion of the pain source is difficult or even impossible
to locate and is therefore assigned a generalized
dermatomal or sclerotomal pattern.17,18 The appre-
ciation of the complex interrelationship of both
biomechanics and neurophysiology in the lower
kinematic chain is of great clinical benefits when
considering the symptoms and outcomes experi-
enced in this, and similar cases.
Conclusion
Clearly the relationship between lower extremity
symptoms and pelvic dysfunction is complex. This
report has discussed the relevant biomechanical
and neurological hypotheses that help to explain
this complex relationship. Therefore, it is of utmost
importance that the clinician, particularly those
such as chiropractors who advocate an holistic
approach, fully consider all sources of lower extre-
mity problems rather than concentrating only on
the symptomatic region. This can only be achieved
by having an awareness and understanding of the
kinetic chain, relevant anatomy, neuroanatomy and
physiology of the regions concerned. Furthermore,
this case has demonstrated that, through logical
and systematic reasoning, successful outcomes can
be achieved quickly and most effectively in athletes
who require maximum efficiency for optimal per-
formance.
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