Regional Interdependence: Treat the knee without treating the knee.


By Josh Bixler PT, DPT

           Picture this: You’re an avid runner and you’ve recently ramped up your training for the upcoming mini-marathon.  In doing so, you’ve developed some nagging pain in your right knee.  Being the pro-active person you are, and aspiring to do well in the race, you decide to seek the care of a physical therapist.


During the evaluation, the physical therapist takes a thorough history from you, examines your right knee, but also assesses the rest of your body.  They end up treating your left foot and providing home exercises for your hips and trunk.  Curious as to why this was the choice of treatment, since the right knee is clearly the source of pain, not the hips or the foot, you ask the therapist for clarification.  The therapist responds “regional interdependence.”  They explain that your left foot lacks the mobility (motion) you need, your hips and trunk are weak, and it appears these deficits caught up with you during your training.


In this instance the right knee was the victim, and the foot and hips were the problem.  The therapist went on to explain the importance of looking at the body as a whole, and not chasing symptoms.  With this treatment approach, they feel confident you’ll be back to pain-free running in no time.


The aforementioned case is one example of the musculoskeletal examination model termed “regional interdependence.”  Regional interdependence is the concept that potentially unrelated impairments above and/or below the patient’s area of complaint; this is necessary to determine if those areas are contributors or not.  Intervention is then applied to those areas deemed as impaired with the expectation of producing a result at the source of complaint.  The interventions could be anything from hands on techniques to exercise.  The result could be improved range of motion, decrease pain, or improved strength just to name a few.  Now this is not to say the area of symptoms is not impaired, it very well may be, however there are often additional areas involved that may have contributed to the problem and deserve attention.


The regional interdependence model came about due to the need for a better approach to explaining and treating musculoskeletal and treating musculoskeletal disorders.  As the field of rehabilitation has progressed, so too has our knowledge of how the body works and the limitations of the old approaches to treatment.  It is important to note that regional interdependence applies to addressing impairments above and below one’s source of symptoms, and not that of referred pain, or pain being felt in a different area from the actual source.


Given this information, you might be saying to yourself, “This concept sounds great in theory, but is there evidence to support it?”  Absolutely!  The current literature has many articles referencing regional interdependence either directly or indirectly.  The literature contains thoracic spine (mid-back) interventions for the cervical spine interventions for the shoulder; cervical spine interventions for the elbow; hip interventions for lumbar spine (low back); hip, ankle, and foot interventions for the knee.


Clinically speaking, assessments of an athletic population may involve impairments even further up or down the body.  When assessing a baseball pitcher with elbow or shoulder pain, one must not only look at those areas, but also consider the neck, shoulder blade, thoracic spine, lumbar spine, hips, legs, knees, and feet.  This approach is similar for runners, where abnormal breathing patterns could also potentially contribute to impairments.


With the acceptance and growth of the regional interdependence examination model, assessments have been developed to further assist healthcare professionals.  One of those assessments is the Selective Functional Movement Assessment, or SFMA.  The SFMA is a tool that allows clinicians to assess patient movement patterns starting at the neck and working down to a body-weighted squat. From there, movements identified as “dysfunctional” can be further broken down into mobility versus stability problems.  This approach, along with best current evidence and clinician expertise, can help guide the clinician with decision making.


In a time with rising healthcare costs and with money tight, patients have come to want and expect care that produces meaningful outcomes.  In the case of the runner, the right knee was the victim and a thorough assessment using the regional interdependence examination model helped to “treat the knee without treating the knee.”


DO you have pain or just a want to take a pro-active approach like this runner?  Consult your physician, the professionals at KORT, or visit www.kort.come to learn more.


KORT Old Brownsboro Crossing Clinic Physical Therapist Josh Bixler
 PT, DPT, graduated with his Doctorate of Physical Therapy from Bellarmine University, and also has a BS in Exercise Science from the University of Indianapolis. He is currently finishing up an orthopedic residency and is trained in using both the Selective Functional Movement Assesment and Functional Movement Screen. Josh is a University of Michigan sports fanatic (Go Blue!) and also enjoys rooting for the Colts, White Sox, and Red Wings. His personal interests include anything relating to physical therapy, injury prevention, fitness, nutrition. For more information go to

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