3 Ways We Get Knee Pain VERY Wrong!

Jessica Bento, Physical Therapist (Creator DVRT Restoration Certification, DVRT Rx Shoulder, Knees, Pelvic Control, & Gait Courses)

If I told you that something affects 25% of the U.S. population (1), you’d probably think it’s a BIG deal. Now, what if I told you I was talking about knee pain? You might not be too surprised—after all, knee pain is one of the most common complaints I encountered with patients, and it’s a challenge many fitness pros and strength coaches face regularly. However, the solutions might surprise you.

Despite how common knee pain is, misinformation—especially on social media—has made it more confusing than ever to understand what actually helps. Before diving into the three biggest mistakes we make with knee pain, let’s clear up a major misconception.

Many assume that because being overweight is a risk factor for knee pain (2), the simple solution is to “just work out.” While exercise is important, the reality is that chronic pain (lasting over three months) makes it much harder for individuals to lose weight and change behaviors (3). Telling people to exercise, diet, and modify their lifestyle without addressing their pain often isn’t effective. That’s why we need a more comprehensive approach to knee pain—one that truly improves people’s lives.

1. “THIS” Muscle Is Weak

One of the most common approaches to knee pain is blaming a single weak muscle—most often, the quadriceps. This seems logical since the quads directly impact the knee, and research does show that strengthening them can help with certain types of knee pain (4).

However, there are two key issues with this thinking. First, when someone is in pain, any muscle closely related to the affected joint often tests weak—not necessarily because it was weak before the pain started, but because pain itself can cause strength loss and alter muscle function in daily activities (5). This is known as the strength inhibition theory, which states:

“Strength assessments may be considered invalid when in the presence of pain due to generalized inhibition.” (6)

So, while strengthening the quads can help with knee pain, that doesn’t mean quad weakness was the cause. Strong quads help absorb impact, distribute force across the knee, and improve joint stability. But research also shows that strengthening the hamstrings (7), glutes (8), and incorporating core, hip, and knee exercises leads to better results (9).

 

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If we were to blame one muscle, we’d quickly see that multiple muscles contribute to knee function. The key takeaway? Instead of isolating muscles, training movement patterns is far more effective. Not only is it more efficient, but it also improves motor control, which plays a crucial role in restoring function and preventing injuries.

2. Your Knees HAVE To Go Over Your Toes

This topic deserves an entire article of its own, but let’s tackle the biggest misconception: there’s a difference between having the ability to move your knees over your toes and forcing it as a solution for knee pain. Unfortunately, the research behind this claim is often misunderstood but continues to be widely shared.

One of the most commonly cited studies—co-authored by my friend, Dr. Brian Schilling—compared a barbell squat with unrestricted knee movement to one where forward knee movement was blocked. The study involved seven pain-free, young men (average age 28) squatting flat-footed without a wedge. The results?

When subjects allowed their shins to move forward naturally, knee stress increased—but at a level tolerable for healthy knees. When their shins were blocked, stress on the knees decreased, but hip and lower back stress increased significantly (10).

Despite what’s often claimed, this study doesn’t conclude that everyone needs to push their knees forward. Instead, a better takeaway is that having proper ankle and hip mobility allows for natural lower-body mechanics, enabling the body to absorb forces efficiently.

Both poor ankle dorsiflexion (11) and limited hip mobility (12) are linked to increased knee pain risk. Instead of forcing the knees over the toes, improving ankle and hip mobility is a far more effective and research-backed strategy for healthier knees.

3. The Mind-Body Connection in Knee Pain

Early in my career as a physical therapist, the mind-body connection wasn’t a major focus. Our job was to assess the painful area, improve its function, and reduce discomfort—primarily through structural and mechanical approaches. We examined movement patterns, but the role of the mind in pain was largely ignored.

Yet, in today’s world, chronic stress plays an increasingly significant role in pain. To illustrate this, let’s look at some fascinating research:

In several studies, patients undergoing sham knee surgeries (where they were told they had surgery but actually did not) reported the same pain relief as those who had real surgical procedures (12,13,14).

Does this mean no one needs knee surgery? Of course not. However, in cases where pain is generalized and structural damage is questionable, we need to harness the power of the mind as part of treatment.

When it comes to osteoarthritis, one of the most common causes of knee pain, mind-body interventions have been shown to significantly reduce pain, improve function, and enhance overall well-being (15,16). In fact, some studies have found that these interventions can be just as effective as physical therapy, while also providing additional benefits for mental and emotional health (17).

Unfortunately, mind-body strategies are still underutilized in both physical therapy and fitness. With pain being multi-factorial, we need to expand our perspective beyond just mechanics.

The International Society for the Study of Pain defines pain as:

“An unpleasant sensory and emotional experience associated with, or resembling that associated with, actual or potential tissue damage.”

This definition reinforces the need to treat the whole person, not just the painful joint. Simple education alone has been shown to reduce pain (18), and incorporating progressive mind-body techniques into training and therapy can be incredibly valuable—especially as chronic pain becomes a growing issue in our society.

Keep In Mind

Knee pain is complex, and outdated, oversimplified solutions often don’t work. Instead of focusing on one weak muscle, we should train movement patterns. I hope you will join us April 15th for our NEW masterclass, “The Client In Pain: How To Train With Chronic Pain” to learn more and what strategies will give you the best chance to improving your clients’ quality of life. You can save 15% with code “pain” HERE and we have a few more days left to get any of my DVRT Rx courses 35% off HERE (not applicable to our new masterclass) with code “education”. We want you to be empowered to find real change.