Tibial Rotation and Valgus Knee


Based on the foundational work of Erik Dalton’s Myoskeletal Alignment Techniques (MAT), Grey Cook’s Functional Movement Screen (FMS), and the Gait Guys.

As manual therapists, we get recurring complaints of knee pain. Often, we hear the complaint is on the left side. Why? Is it a true knee issue, a hip issue, or an ankle issue, or maybe– all the above?

Let’s look at the foot. When the foot complex is a little weak, the arch can collapse more than it should, causing pronation. This means the talus will adduct, plantarflex. and medially rotate more than it should. Since the tibia sits on top of this talus, it must follow. This creates more medial rotation, which in turn drags the knee down causing it to collapse in or create the valgus knee. Basically, what the foot-ankle complex does, the knee follows. Plus, when the knee moves medially, the foot will move medially.


What are some possible methods to correct this? Orthotics? Stability shoes? Or, what about good old-fashioned learning how to control this dysfunction through manual therapy treatment and motor control training? I say we go with the third option. I remember attending a Paul Kelly workshop where he briefly mentioned doing “toe taps.” Really, what we are doing here is that as you raise the toes the arch will rise, which in turn helps the client find more appropriate posture with the help of the anterior compartment (Tibialis Anterior) and affect the 1st MPT hallux joint. This alone will help the client control the rate of medial knee collapse. Try it! You will see that as you raise the toes up, the knee becomes more balanced.

So, when we see this dysfunction, we have to look at the entire complex. Does the knee stack over the ankle, and does the hip stack over the knee? Build strength in the anterior compartment to achieve posterior strength. As Gray Cook and the Gait Guys say, “. . .You have to build skill, endurance, and strength.” This is very helpful when it comes to dorsiflexion, which is the most important movement in the ankle. When we have collapsed arches and valgus knee, we severely limit our dorsiflexion. Just stretching and mobilizing is not enough. The client has to learn and own the skill endurance and strength. When you see this, clients will often gait forward with tibial progression through subtler joint and present with over pronation and rear foot over eversion. Obviously, this creates internal limb spin and knee valgus loading risks.

You may have a client present with great ankle dorsiflexion but still complain of knee pain. But notice how they walk. Do they have eccentric loading control of that anterior compartment? You may see or hear their foot slapping against the ground meaning, yes–they have the mobility but do not have the skill, endurance, and strength to control it.


These are just some of the things to look at when your client comes in with knee pain. Do not be one of the therapists who just chases the pain and does not determine the true cause of the symptoms. Be sure to assess and evaluate so you can treat correctly. You can always visit our FB page to see videos on assessments and treatments.