Referred pain in general

Referred knee pain is just one example of a phenomenon seen all over our body.

For pain originating from muscles and joints, bones and internal organs, our brain may only know that the pain has come via a particular nerve.

We may then feel the pain wherever in our body that nerve brings messages from.

One example of this is feeling pain at the tip of our shoulder which has actually originated in our diaphragm (which is the sheet of muscle between our chest and stomach.) These two spots are both innervated by nerves from the 3rd and 4th neck segments.

Pain thus felt at a distance from its' source, is called referred pain.

Along with the pain, a number of other phenomena occur. Swelling due to changes in tiny blood vessels, tenderness over bony prominences, coldness of a limb and color changes, can be seen.

That being said, generally if a pain is caused by something right there, the cause will often be obvious to see right there. If nothing much appears to be wrong, look for sources of referred pain further towards the spine. Pain usually spreads away from spine around the trunk, down a limb or up into the head.

Referred knee pain

Knee pain commonly is at least aggravated by referral of pain from the Gluteus and Adductor muscles.

Press firmly all over the area between your hip bone (Pelvis) and thigh bone (Femur) at the side. This is the Gluteus Medius muscle.

Push firmly into the upper inner thigh below the inner groin. This is the Adductor muscles.

If you find tenderness, they are almost certainly tight and in need of stretching.



See the muscle stretching page for a general discussion of these.

These can give immediate relief of knee (and other) pain.

Stretching gluteus medius and tensor fascia lata

To stretch gluteus, lay flat on your back. Keeping your shoulders flat on the surface, swing them away from the side you will stretch, bending at the waist.

Raise your arm on the side to be stretched, above your head.

Now also swing the opposite lower limb to a position away from the side to be stretched.

Now follow with the leg on the side your are stretching, and hook this foot over the other ankle. You should now be laying flat on your back, with your whole body curved away from the side being stretched.

If this causes no pain, unhitch legs and swing the other leg further out before crossing them. If there is too much pain, swing it in further.

See below for next step.

stretching these muscles

An alternative method for stretching Gluteus medius is done siting or laying on your back.

Lift the foot on the side you wish to stretch onto your other thigh just above the knee. Now grasp under this foot and pull it towards you as you push the knee away from you with the other hand.

Yet another method is to lean sideways with gluteus medius against a corner on a piece of furniture, using one's body weight to splay the muscle out over that point.

Adductor stretch

To stretch your adductors, lean your weight on a table, and bend the other leg. Move the foot out on the side being stretched, until you feel some tension and slight discomfort in the inner thigh.

Keep your body above the other leg, and lower it as you move the leg out sideways.

If you have something about the right height , you can do this sitting, with your leg out sideways.

Try a kitchen chair. Sit facing forwards and shift sideways until this buttock is off the edge of the chair. Now swing this leg round until you feel stretch in the inner thigh. Keep that knee straight.

On your side in bed, with legs one on top of the other, a fist or similar firm object between the thighs stretches both the adductors at once. The weight of the upper thigh splays them out over and under the lump. If you don't bruise easily, this is a good method. Wait until the pain subsides, then shift the fist or cricket ball further up and down to find other sore spots to stretch.

Otherwise, for both these stretching exercises, hold the positions until you feel the discomfort and tension ease. This will probably take at least 2 minutes. You can then increase the stretch and again wait for the muscles to relax.

One way to increase the gluteus stretch easily, is to have the foot of the other side just over the edge of your bed to start with, and slide the foot and leg progressively further over the edge. Gravity helps this. You may not need to unhitch your feet to do it.

Alternatively, you can uncross your feet, draw up your legs, dig your feet in, lift your bottom and shift it towards the side you're stretching. It is still easier to hold the stretching position if the heel of the other side is just off the edge of your bed to stop it from sliding back.

Continue this until further stretch is painless or impossible.

Quadriceps femoris - vastus medialis muscle stretch

Look here when you find tenderness more above or below the joint line, on the inner side of your knee.

Press systematically over this inner thigh muscle, about a hands breadth above your knee, for the tender muscle fibers causing referred knee pain.

If you find soreness here, the stretch is one you often see people doing up against a tree.

Lean on something and with your knee fully bent take the ankle in your hand. If this hurts too much, use something in your hand as a sling.

The stretch is performed by keeping your body still as you move the knee backwards. Ensure that you don't lean forward as you move the knee back.

It is also quite suitable to stretch it by simply continuing to press on the sore spots you find. Place one thumb on the other, to make it easier. Press until it softens and hopefully is less tender.

If a muscle is tight and very tender, it may relax but stay just as tender until you remove the pressure.

Hamstring muscle stretching

This is needed commonly for patello-femoral joint pain, as tight hamstrings force the quadriceps to work harder. This increases the pressure between the knee cap and the thigh bone.

The back of your knee cap is likely to be tender if this is the problem.

The hamstring muscles don't seem to cause referred knee pain as such.

From referred knee pain page to patella femoral syndrome

after stretching for referred knee pain, strengthen for stability

Betting each way - from knee jt. plus above.

After stretching the soreness out of your muscles, you need to reassess the knee joint tenderness.

The joint line may now be more tender than adjacent bone, indicating that there is joint pathology as well as referred pain.

Spread of pain from compensation

Nothing to do with workers compensation, but rather our own.

I use the term to "favour" a knee, when one limps as it is sore. This does no favour to the other knee. In compensating, we increase its work load and sometimes making it sore as well.

It's not good for the first knee either, as the quadriceps muscle wastes very rapidly when we limp, increasing the risk of further damage.

Whatever the reason for your knee getting sore, it's really important to get straight into quadriceps strengthening exercises. Try to walk as normally as you can, as well.

One thing leads to another. One can get a low back problem, referred knee pain, limp because of it and end up with corns and bunion on ones foot.
The limp may be very slight and not really noticed, but be enough to eventually cause weakness of the small muscles of the foot. The forefoot splays out with that result.

Spread of pain directly from structures in one's low back

Even without pressure on the sciatic or femoral nerves, pain can spread to here from ligaments and joints in the lumbar spine.

This was demonstrated last century by Kellgren, Hockaday, Whitty and Feinstein. If you search the subject with these names, lots of their diagrams come up. They injected salt to cause the pain.

This is mentioned last as there is not a lot you can do about it yourself. It can be sorted out using local anaesthetic injections into the suspect back structures. This is done with imaging to ensure correct needle placement.


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