What Is Dynamic Knee Valgus?

Dynamic knee valgus is more complex than simply seeing the knee move inward.

The movement may involve a combination of:

• Femoral adduction
• Femoral internal rotation
• Knee abduction
• Tibial rotation
• Ankle or rearfoot eversion¹⁻⁵

Together, these movements produce the visible appearance of medial knee collapse.

Therefore:

Dynamic knee valgus is not simply a knee problem.

It represents a kinetic-chain movement strategy involving multiple body segments.

Does Dynamic Knee Valgus Cause Symptoms?

DKV does not have a characteristic symptom pattern of its own.

An athlete can demonstrate considerable dynamic valgus and have no pain at all.

This is an important clinical distinction.

The presence of valgus should therefore not automatically be interpreted as the source of an athlete’s symptoms.

However, DKV has been studied as a biomechanical factor associated with conditions including:

• Noncontact ACL injury
• Patellofemoral pain
• Other knee loading disorders¹,³,⁴

It should therefore be interpreted primarily as information about how an athlete controls load and movement, rather than as a painful diagnosis by itself.

Functional Diagnosis of Dynamic Knee Valgus

There is no pathognomonic orthopedic special test for DKV.

Dynamic knee valgus is better understood as a functional movement pattern than as a pathological diagnosis. Therefore, functional diagnosis should not simply determine whether the knee moves medially.

Instead, the assessment should answer four broader questions:

1. During which task does DKV occur?
2. What movement pattern is actually occurring?
3. What physical or neuromuscular factors may contribute to that pattern?
4. Is the finding clinically relevant to the athlete’s sport, symptoms, or injury history?

This requires movement assessment and clinical reasoning rather than a single positive test.¹,⁴

Step 1: Choose the Right Task

Task selection is one of the most important parts of DKV assessment.

Dynamic valgus is task dependent.

An athlete who demonstrates valgus during one task may not demonstrate the same movement pattern during another.³,⁵,¹⁶

Examples include:

• Runners: Running / Step-Down
• Basketball athletes: Landing / Cutting
• Volleyball athletes: Jump Landing
• Soccer athletes: Single-Leg Landing / Cutting
• Athletes after ACL reconstruction: Single-Leg Squat / Hop Landing

The selected task should therefore resemble the athlete’s Primary Function or the movement that is clinically problematic.

Research has shown that valgus identified during a lateral step-down does not necessarily correlate well with valgus during running.³

Clinicians should therefore avoid assuming that one screening task represents every athletic movement.

Step 2: Identify the Movement Pattern

Once the appropriate task has been selected, the clinician should determine how the entire kinetic chain is moving, rather than observing the knee in isolation.

Important variables may include:

• Pelvic position
• Hip adduction
• Hip internal rotation
• Medial knee displacement
• Knee-flexion strategy
• Tibial rotation
• Rearfoot and foot movement
• Trunk position and lean

The objective is to determine whether the visible knee valgus is part of a broader multiplanar movement strategy involving the trunk, pelvis, hip, knee, tibia, ankle, and foot.

The relevant movement variables may also differ according to the task.

For example, the pattern observed during a controlled single-leg squat may differ considerably from the pattern that emerges during a high-speed cutting maneuver.

Step 3: Assess Strength, Mobility, and Physical Capacity

If DKV is identified, the next step is to evaluate physical qualities that may contribute to the athlete’s movement strategy.

Potential areas include:

• Hip abductor strength
• Hip extensor strength
• Hip external-rotator strength
• Quadriceps and hamstring capacity
• Trunk strength and control
• Ankle dorsiflexion
• Foot mobility
• Balance
• Proprioception¹,⁵,⁷,⁹

However, finding a strength or mobility deficit does not automatically establish causation.

For example:

DKV present → weak gluteus medius → strengthen the hip

is too simplistic.

A physical impairment should become a rehabilitation target only when it appears meaningfully related to the athlete’s movement pattern and functional limitation.

Step 4: Identify Proximal and Distal Contributors

Because DKV is a kinetic-chain movement pattern, factors both above and below the knee should be considered.

Proximal Factors

Assessment may include:

• Hip strength
• Pelvic control
• Hip adduction and rotation strategy
• Trunk position
• Trunk lean
• Lumbopelvic control

Distal Factors

Assessment may include:

• Ankle dorsiflexion
• Rearfoot eversion
• Midfoot mobility
• Foot progression angle
• Foot stability¹,⁵,⁷,⁹

The goal is not to identify as many “abnormalities” as possible.

The goal is to determine which modifiable contributors may actually influence the athlete’s Primary Function.

Step 5: Reassess Under Speed, Repetition, and Fatigue

DKV is not necessarily a fixed characteristic.

Movement quality may change as task intensity increases.

The clinician may therefore progress the assessment by adding:

• Faster movement
• Repeated landings
• Repeated cutting
• Reactive tasks
• Decision-making demands
• Fatigue

An athlete may demonstrate good control during the first few repetitions but progressively lose frontal-plane control after repeated loading.

This may indicate that the primary limitation is not simply maximal strength or movement knowledge, but the ability to maintain neuromuscular control under repeated athletic demand.

Because fatigue may alter landing biomechanics, balance, proprioception, and DKV, assessment in athletes should not necessarily end with a single non-fatigued repetition.⁸

Step 6: Determine Sport-Specific Relevance

The final and most important question is:

Is this movement pattern actually meaningful for this athlete?

The presence of DKV alone does not automatically mean that it must be corrected.

For example, an athlete may demonstrate valgus during a single-leg squat but have:

• No pain
• No functional limitation
• Good landing control
• Good running mechanics
• No difficulty tolerating sport-specific loading

In that situation, the isolated valgus finding may have limited clinical importance.

In contrast, the finding may be more relevant when DKV:

• Appears during the athlete’s problematic sport movement
• Increases with speed or fatigue
• Occurs simultaneously with symptoms
• Appears during return-to-sport testing after ACL reconstruction
• Is associated with reduced performance or movement control

Therefore, the objective of functional diagnosis is not simply to eliminate visible knee valgus.

It is to determine whether the movement pattern contributes meaningfully to the athlete’s symptoms, injury context, performance limitations, or sport demands.

Functional Diagnosis Framework

Task Selection
↓
Movement Analysis
↓
Strength & Mobility Assessment
↓
Proximal / Distal Contributors
↓
Speed / Fatigue Testing
↓
Sport-Specific Relevance

DKV is task dependent. One movement test should not automatically be generalized to every athletic task.

Single-Leg Squat

The single-leg squat is one of the most frequently used clinical screening tasks for dynamic knee valgus.¹,⁵,¹⁴

From a frontal view, the clinician observes the relationship among the:

• Pelvis
• Femur
• Knee
• Tibia
• Foot

A practical visual approach is to determine whether the patella or knee center repeatedly moves excessively medially relative to the foot.

Dadfar and colleagues classified athletes as demonstrating DKV when noticeable valgus was observed in at least 2 of 3 single-leg squat repetitions.⁵

This should be interpreted as a research classification method rather than a universal diagnostic threshold.

Single-Leg Landing

A single-leg landing adds greater velocity, impact, and control demands compared with a squat.

Important observations include:

• Initial-contact position
• Peak knee-flexion position
• Medial knee displacement
• Hip control
• Pelvic control
• Foot position
• Ability to stabilize after landing

A frontal-plane valgus angle greater than 10° has been used as a screening or inclusion criterion in research involving athletes with DKV.¹³

However, 10° should not be interpreted as a universal injury cutoff applicable to every athlete or sport.

Lateral Step-Down / Forward Step-Down

Step-down testing provides a clinically simple method for observing:

• Pelvic control
• Hip adduction
• Knee position
• Foot control
• Trunk strategy³

However, performance during a step-down should not automatically be assumed to represent running, landing, or cutting mechanics.

Drop Vertical Jump

The drop vertical jump is useful when evaluating athletes involved in jumping and landing sports.

The clinician can observe:

• Frontal-plane knee position
• Landing symmetry
• Trunk control
• Hip- and knee-flexion strategies¹¹

It is commonly relevant in ACL injury-prevention and return-to-sport settings.

2D Video Analysis

Two-dimensional frontal-plane video is commonly used clinically because it is inexpensive, accessible, and easy to repeat.

One frequently used measurement is the:

Frontal Plane Projection Angle (FPPA).

Markers around the hip, knee, and ankle are used to quantify frontal-plane knee position during functional movement.¹,³,⁴

Three-dimensional motion capture provides more complete biomechanical information and remains the laboratory reference standard, but 2D video can be highly useful for field and clinical screening.

The MEDIAL Criterion

Erdman and colleagues evaluated a particularly practical 2D criterion:

**Does the knee joint center move inside the medial border of the shoe?**⁶

This MEDIAL criterion demonstrated meaningful associations with several 3D biomechanical measures, including:

• Pelvic obliquity
• Hip adduction
• Ankle eversion
• Foot progression⁶

This makes it a potentially practical visual screen when sophisticated motion-capture equipment is unavailable.

Treatment and Rehabilitation Overview

Rehabilitation should not focus exclusively on forcing the knee outward.

The goal is to identify the modifiable factors contributing to the athlete’s movement strategy and then improve control during the activities that matter for sport.¹,⁷,⁹

Phase 1: Movement and Contributing-Factor Assessment

First determine during which tasks excessive valgus appears.

Then assess potentially relevant contributors, including:

• Hip strength
• Trunk control
• Knee strategy
• Ankle mobility
• Foot mechanics
• Balance
• Proprioception

Treatment should be based on the individual athlete’s findings rather than the appearance of valgus alone.

Phase 2: Capacity Development

When deficits are present, rehabilitation may address capacity of the:

• Hip musculature
• Trunk
• Knee extensors and flexors
• Ankle-foot complex¹,⁷,⁹

However, increasing strength does not automatically change movement behavior.

Studies using relatively short strengthening or functional-training blocks have found small or nonsignificant changes in valgus angle despite some favorable trends.¹⁴,¹⁵

This suggests that training dose, task specificity, and motor learning matter.

Phase 3: Motor Control and Movement Retraining

The next goal is to teach the athlete how to use newly developed physical capacity during functional movement.

Research supports the potential value of:

• Real-time feedback
• Video instruction
• Visual feedback
• Verbal cueing
• Attentional-focus strategies¹²,¹³

The athlete therefore needs more than stronger muscles.

The athlete must learn to apply that capacity to squatting, landing, deceleration, and cutting.

Phase 4: Landing, Cutting, and Sport-Specific Control

Rehabilitation should progressively return the athlete to:

• Landing
• Jumping
• Deceleration
• Cutting
• Single-leg tasks
• Sport-specific movement

Combined neuromuscular approaches and structured warm-up programs have demonstrated improvements in landing and lumbopelvic measures in athletic populations.¹¹

The consistent concept is that rehabilitation should combine:

strength + balance + proprioception + movement training + feedback

rather than relying on isolated strengthening alone.

Phase 5: Fatigue-Resistant Control

One technically good landing is not enough for sport.

Athletes must repeat high-demand movements throughout practices and competition.

Rehabilitation should therefore eventually evaluate control during:

• Repeated landings
• Higher speeds
• Reactive situations
• Decision-making tasks
• Sport-specific fatigue

Because fatigue can worsen DKV and landing mechanics, maintaining movement quality under fatigue may be an important final component of return-to-sport assessment.⁸