Dynamic Knee Valgus: causes, biomechanical factors, and correction strategies based on scientific evidence

Dynamic knee valgus is a misalignment of the lower limb that occurs when, during movement, the knee collapses toward the midline of the body. This abnormal pattern frequently appears during functional tasks such as squats, jumps, or landings and is closely related to an increased risk of anterior cruciate ligament (ACL) injury, patellofemoral syndrome, and anterior knee pain.

Scientific literature has shown that this phenomenon does not depend on a single joint, but on a complex interaction between proximal factors (hip and trunk) and distal factors (ankle and foot), as well as deficits in strength, mobility, and neuromuscular control.

What are the biomechanical mechanisms of dynamic knee valgus?

Dynamic valgus represents the expression of an altered kinetic chain. During leg flexion and extension movements, the combination of femoral adduction and internal rotation, along with foot pronation and tibial internal rotation, generates medial displacement of the knee. This pattern redistributes joint forces, increases load on the medial knee structures, and reduces functional stability.

What are the proximal factors of dynamic knee valgus?

Proximal factors originate in the hip and trunk. Their influence on the knee is crucial for maintaining alignment during movement.

How does hip muscle weakness influence dynamic knee valgus?

The hip abductors and external rotators are essential for stabilizing the femur and controlling knee position. Weakness in these muscles facilitates femoral adduction and internal rotation during movements such as squatting or jumping, increasing the risk of dynamic valgus.

Why do trunk alterations influence dynamic knee valgus?

The trunk acts as the “control center” of movement. When there are deficits in neuromuscular control or trunk strength—especially in the core and hip muscles—poor pelvic and center of mass alignment occurs, which can cause or worsen dynamic knee valgus. The main trunk alterations influencing dynamic knee valgus are:

1. Contralateral trunk lean: During single-leg activities, if the trunk leans toward the opposite side of the supporting leg, the center of mass shifts medially, creating a hip adduction moment and promoting valgus. Common cause: weak gluteus medius or poor lateral core control (obliques, quadratus lumborum).
2. Ipsilateral trunk lean: If the trunk leans toward the same side of support, it may be a compensatory attempt to reduce hip load. However, combined with internal trunk and pelvic rotation, it worsens femoral and tibial alignment, reinforcing DKV. Common in fatigued athletes or those with weak gluteus maximus.
3. Internal trunk and pelvic rotation: Pulls the pelvis and femur inward, increasing femoral internal rotation and causing medial knee collapse. Frequent in jump landings or changes of direction.
4. Excessive anterior pelvic tilt: Increases hip internal rotation and alters gluteus maximus activation, reducing rotational control of the femur. Common in individuals with lumbar hyperlordosis or deep core weakness (transverse abdominis, multifidus).
5. Core weakness or poor lumbopelvic control: Without a “stable block” in the trunk, the hip collapses into adduction and internal rotation, resulting in valgus.

What are the distal factors of dynamic knee valgus?

Distal factors, located in the ankle and foot, play a key role in the manifestation of dynamic valgus.

The restriction in ankle dorsiflexion is one of the main distal factors. This dorsiflexion deficit causes compensations such as excessive foot pronation and tibial internal rotation, promoting medial knee collapse. Improving ankle dorsiflexion is a fundamental component for correcting dynamic knee valgus from distal factors. The motion restriction is often related to shortening of the gastrocnemius and soleus muscles, limiting tibial progression over the foot during functional movements such as squats, jumps, or landings. Increasing flexibility of these muscles through specific stretching allows for greater dorsiflexion range, reducing excessive foot pronation and tibial internal rotation that contribute to medial knee collapse. Furthermore, combining increased mobility with balanced strengthening of dorsiflexors and plantar flexors optimizes distal ankle function, improving knee alignment and reducing joint load during dynamic gestures.

How does weakness of the ankle dorsiflexors and plantar flexors influence dynamic knee valgus?

The dorsiflexors and plantar flexors work synergistically to control ankle movement and stabilize the leg. Their weakness promotes compensatory strategies that increase valgus. Individuals with excessive medial knee displacement show weakness in the plantar muscles and greater stiffness in distal ankle musculature, contributing to medial knee collapse during functional tasks. Prevention and correction programs should include specific strength and flexibility exercises.

How to improve dynamic knee valgus through training? Evidence-based interventions

Corrective and strengthening exercises

Training programs focused on hip, ankle, and trunk strength are effective in reducing dynamic valgus. Strengthening the hip abductors and external rotators, along with the ankle plantar and dorsiflexors, improves lower limb alignment and decreases joint stress.

• Strengthening hip abductors and external rotators: See hip abductor strengthening exercises
• Strengthening intrinsic foot muscles, controlling excessive pronation, improving ankle dorsiflexion: See Foot Core exercises
• Core strengthening: transverse abdominis, multifidus, obliques, quadratus lumborum. See core strengthening exercises. See CORE and lumbopelvic control strengthening exercises
• Lumbopelvic control training: See CORE and lumbopelvic control strengthening exercises
• Trunk control work in functional tasks: single-leg squats with visual feedback, tilt control.
• Integrated hip–core–knee exercises.

Neuromuscular and proprioception training

Programs focused on movement control and visual feedback to re-educate knee position. Regular practice of dynamic balance exercises, controlled jumps, and directional changes improves motor response and reduces valgus.

Conclusions

• Dynamic knee valgus is a multifactorial phenomenon involving proximal and distal factors.
• Weakness of hip stabilizing muscles, limited ankle dorsiflexion, weakness of plantar and dorsiflexors, excessive foot pronation, and trunk and pelvic alterations are key elements.
• The most effective approach is comprehensive, combining strengthening, neuromuscular re-education, mobility improvement, and technical movement control, optimizing efficiency and reducing injury risk.

References

• Bell, D. R., Oates, D. C., Clark, M. A., & Padua, D. A. (2013). Two- and three-dimensional knee valgus are reduced after exercise intervention in young adults with demonstrable valgus during squatting. Journal of Athletic Training, 48(4), 442–449. https://doi.org/10.4085/1062-6050-48.3.21
• Bell, D. R., Padua, D. A., & Clark, M. A. (2008). Muscle strength and flexibility characteristics of people displaying excessive medial knee displacement. Archives of Physical Medicine and Rehabilitation, 89(7), 1323–1328. https://doi.org/10.1016/j.apmr.2007.11.048
• Papadakis, Z., et al. (2023). Addressing biomechanical errors in the back squat for proper technique. Cureus, 15(6), e40321. https://doi.org/10.7759/cureus.40321
• Rinaldi, F. A., et al. (2022). The influence of gluteal muscle strength deficits on dynamic knee valgus: A scoping review. Journal of Functional Morphology and Kinesiology, 7(3), 62. https://doi.org/10.3390/jfmk7030062
• Bell, D. R., et al. (2024). The impact of lumbar hyperlordosis on dynamic knee valgus during single-leg jump landing and squat in male college football players. International Journal of Environmental Research and Public Health, 21(2), 975–987.
• Souza, R. B., & Powers, C. M. (2009). Differences in hip kinematics, muscle strength, and flexibility between subjects with and without patellofemoral pain. Journal of Orthopaedic & Sports Physical Therapy, 39(1), 12–19. https://doi.org/10.2519/jospt.2009.2885
• Dierks, T. A., Manal, K. T., Hamill, J., & Davis, I. S. (2008). Proximal and distal influences on hip and knee kinematics in runners with patellofemoral pain during a prolonged run. Journal of Orthopaedic & Sports Physical Therapy, 38(8), 448–456. https://doi.org/10.2519/jospt.2008.2490

Frequently Asked Questions about Dynamic Knee Valgus

1. What is dynamic knee valgus? Dynamic knee valgus occurs when, during a movement such as a squat or jump, the knee moves inward toward the body’s midline. It is not just a knee problem—it usually results from weakness or poor coordination in the hip, trunk, or ankle.
2. Why does dynamic knee valgus occur? It results from a combination of muscular and movement control factors. The most common causes are gluteal weakness, poor ankle mobility, and lack of core stability. All these contribute to leg misalignment during movement.
3. Is dynamic knee valgus dangerous? Yes, if not corrected, it can increase the risk of injuries such as anterior cruciate ligament (ACL) tear, patellofemoral syndrome, or anterior knee pain. Detecting and correcting it early is key to preventing sports injuries.
4. How do I know if I have dynamic knee valgus? You can observe yourself in a mirror while doing a squat or jump: if your knees move inward instead of staying aligned with your feet, you probably have dynamic valgus. A physiotherapist can confirm it with a biomechanical assessment.
5. Does dynamic knee valgus only appear in athletes? No. Although common in athletes, it can also appear in sedentary people or those who exercise with poor technique. The most frequent causes are muscle weakness and poor posture.
6. Which muscles should I strengthen to correct dynamic knee valgus? Mainly the gluteus medius and maximus, the core (deep abdominals, obliques, and multifidus), and the ankle muscles. These help keep the leg aligned and stable during movement.
7. Which exercises help correct dynamic knee valgus? Some recommended exercises are: single-leg squat with trunk control, glute bridge with elastic band, “monster walks” or lateral band walks, bird-dog and side plank for the core, and calf and soleus stretches to improve ankle dorsiflexion.
8. Can dynamic knee valgus cause pain? Yes. Medial knee collapse increases pressure on the patella and internal structures, which can lead to patellofemoral pain or anterior knee discomfort.
9. Can dynamic knee valgus be corrected with physiotherapy? Definitely. A physiotherapist can design a personalized exercise program including strengthening, movement control, and mobility work. With consistency, alignment can significantly improve.
10. Can insoles or footwear help? Yes, in some cases. If there is excessive foot pronation or ankle limitation, custom insoles or supportive footwear can help improve alignment and reduce valgus.
11. How long does it take to correct dynamic knee valgus? It depends on the person. With consistent exercise and good technique, improvements can be seen in 6 to 12 weeks. However, full correction requires long-term training and postural awareness.
12. What happens if I don’t treat dynamic knee valgus? If not corrected, it can cause medium- and long-term knee injuries such as tendinopathies, cartilage wear, chronic pain, or even ligament rupture in athletes.
13. Does fatigue influence dynamic knee valgus? Yes. When muscles fatigue, they lose the ability to maintain proper alignment. This is often seen in athletes who, at the end of training or competition, show greater knee collapse upon landing or changing direction.
14. Does dynamic knee valgus affect women or men more? It affects both, but it is more common in women, especially young female athletes. This is due to anatomical, hormonal, and neuromuscular control differences that make medial knee collapse more likely.
15. What role does the core play in controlling dynamic knee valgus? A strong and stable core acts as the base for movement. If the trunk and pelvis are not well controlled, the leg collapses inward. Therefore, core exercises are essential in any dynamic valgus correction program.

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