“Is It Really Your Knee?” Why Knee Pain Often Starts at the Hip, Ankle, or Even the Toes
When someone experiences knee pain, the natural assumption is that something must be wrong with the knee itself. But here’s the truth: in many cases, the knee is not the problem—it’s the victim of dysfunction elsewhere.
The knee is a hinge joint sandwiched between two highly mobile joints—the hip and the ankle. It primarily moves in one plane (flexion and extension) and depends heavily on the stability and mobility of its neighboring joints to function properly. If either the hip or the ankle isn’t doing its job, the knee often takes on abnormal loads and forces that lead to pain, inflammation, or injury.
The hip is a ball-and-socket joint designed for a wide range of motion. When hip mobility is limited—whether due to tight hip flexors, glutes, or restricted joint capsule motion—it can lead to compensatory patterns that place excess stress on the knees.
For example, limited hip internal rotation or poor glute activation can lead to dynamic knee valgus (inward collapse of the knee) during walking, running, or squatting. This dysfunctional movement is a key contributor to conditions like patellofemoral pain syndrome (PFPS), iliotibial band syndrome (ITBS), and ACL injuries.
The ankle needs to provide both mobility (especially dorsiflexion) and stability. When ankle dorsiflexion is limited, it changes how the body loads during movements like squatting, jumping, or descending stairs. This can force the knee to move forward excessively, increasing stress on the patellar tendon and the anterior knee.
Additionally, ankle instability—such as from previous sprains—can disrupt balance and gait mechanics, pushing more reactive force up into the knee joint and creating abnormal loading patterns.
While often overlooked, the toes—especially the big toe—play a crucial role in walking and running. Lack of extension in the first metatarsophalangeal joint (big toe joint) can interfere with proper push-off during gait, leading to compensatory changes up the kinetic chain. When this joint can’t move properly, it affects stride length, foot positioning, and ultimately alters knee tracking.
Small problems in the foot and toes can translate into large problems for the knee over time.
If you're foam rolling your quads and icing your knees with no lasting relief, it's time to look above and below the joint. The knee might be where you feel the pain, but that doesn’t mean it’s where the problem started.
To truly resolve knee issues, assess:
Hip mobility and strength (especially glutes and rotators)
Ankle range of motion and stability
Toe extension and gait mechanics
A systems-based approach is key to long-term relief.
Powers, C. M. (2010). The influence of abnormal hip mechanics on knee injury: a biomechanical perspective. Journal of Orthopaedic & Sports Physical Therapy, 40(2), 42-51. https://doi.org/10.2519/jospt.2010.3337
Dill, K. E., Begalle, R. L., Frank, B. S., Zinder, S. M., & Padua, D. A. (2014). Altered knee and ankle kinematics during squatting in those with limited weight-bearing-lunge ankle-dorsiflexion range of motion. Journal of Athletic Training, 49(6), 723–732. https://doi.org/10.4085/1062-6050-49.3.29
Ferber, R., Davis, I. M., & Williams, D. S. (2003). Gender differences in lower extremity mechanics during running. Clinical Biomechanics, 18(4), 350–357. https://doi.org/10.1016/S0268-0033(03)00025-1
Lee, D., & Lee, S. (2021). The effect of big toe extension restriction on lower limb kinematics and gait in adults. Journal of Physical Therapy Science, 33(1), 10–15. https://doi.org/10.1589/jpts.33.10
