Biomechanical Links Between Knee Posture, Strength, and Low Back Pain: A Narrative Review

Abdullah Faleh Alhumayani; Lamiaa K. Elsayyad; Chua Siew Kuan

doi:10.61919/fe848d77

Authors

Abdullah Faleh Alhumayani School of Physiotherapy, Faculty of Nursing and Applied Science, Lincoln University College, Petaling Jaya, Malaysia:, Department of Medical Rehabilitation and Physiotherapy, Children's Hospital, Taif Health Cluster, Taif, Saudi Arabia Author
Lamiaa K. Elsayyad Assistant Professor, Department of Biomechanics, Faculty of Physical Therapy, Cairo University, Cairo, Egypt Author
Chua Siew Kuan School of Physiotherapy, Faculty of Nursing and Applied Science, Lincoln University College, Petaling Jaya, Malaysia; School of Physiotherapy, Faculty of Medicine, Nursing and Health Sciences, SEGi University, Kota Damansara, Selangor, Malaysia Author

DOI:

https://doi.org/10.61919/fe848d77

Keywords:

Low Back Pain; Knee Joint; Biomechanics; Posture; Muscle Strength; Lumbopelvic Alignment; Kinetic Chain; Rehabilitation.

Abstract

Background: Low back pain is a major cause of disability worldwide and is increasingly understood as a multifactorial condition influenced by interactions among the lumbar spine, pelvis, hips, knees, and distal lower limbs. Although traditionally managed as a spinal disorder, biomechanical alterations in knee posture, knee range of motion, muscle strength, and neuromuscular control may affect lumbopelvic alignment, spinal loading, gait mechanics, and functional movement. Objective: This narrative review aimed to synthesize current biomechanical and clinical evidence on the relationship between knee posture, knee muscle strength, lumbopelvic alignment, and low back pain, with emphasis on kinetic-chain mechanisms and implications for assessment and rehabilitation. Methods: Relevant literature was identified through searches of PubMed, Scopus, Web of Science, Google Scholar, and ScienceDirect using terms related to low back pain, knee alignment, knee osteoarthritis, knee extension limitation, quadriceps strength, hamstring strength, lumbopelvic alignment, sagittal balance, kinetic chain, gait, lifting, neuromuscular control, and rehabilitation. Evidence from biomechanical studies, observational studies, systematic reviews, clinical trials, gait analyses, and rehabilitation literature was synthesized narratively using a kinetic-chain framework. Results: The strongest evidence supports an association between restricted knee extension, knee flexion contracture, knee osteoarthritis, sagittal imbalance, and increased lumbar loading. Biomechanical studies indicate that knee extension limitation can increase lumbar extension moments, paraspinal activation, and lumbar or thoracolumbar compressive forces during gait. Moderate evidence suggests that quadriceps and hamstring weakness may impair shock absorption and alter force transmission to the pelvis and lumbar spine. Emerging evidence supports neuromuscular and myofascial pathways linking knee dysfunction with altered trunk control, proprioception, and movement compensation. Conclusion: Knee posture, mobility, strength, and neuromuscular control are clinically relevant contributors to lumbopelvic biomechanics and low back pain. Integrated assessment and rehabilitation should address knee alignment, knee range of motion, lower-limb strength, gait mechanics, and trunk–pelvis–knee coordination

References

1. Abbasi S, Mousavi SH, Khorramroo F. Association between lower limb alignment and low back pain: a systematic review with meta-analysis. PLoS One. 2024;19(10):e0311480.

2. Abdollahi S, Sheikhhoseini R, Roostayi MM, Huddleston WE. The effect of fatigue on electromechanical response times in basketball players with and without persistent low back pain. Sci Rep. 2022;12(1):17849.

3. Ahmad N, Shabbir S, Raheem S, Latif K, Liaqat M, Akram MJ. Association of iliotibial band tightness with lumbopelvic pain and hip joint outcome. J Riphah Coll Rehabil Sci. 2023;11(1).

4. Almansoof HS, Nuhmani S, Muaidi Q. Role of kinetic chain in sports performance and injury risk: a narrative review. J Med Life. 2023;16(11):1591.

5. Amarasinghe P, Wadugodapitiya S, Weerasekara I. Biomechanical and clinical relationships between lower back pain and knee osteoarthritis: a systematic review. Syst Rev. 2023;12(1):28. doi:10.1186/s13643-023-02190-7.

6. Arun C, Raman SA, Sivaraman A, Chelladurai A, SS N. Biomechanical evolution in longitudinal analysis of lumbar stress injuries in fast bowlers: a systematic review. Cureus. 2025;17(12).

7. Berenshteyn Y, Gibson K, Hackett GC, Trem AB, Wilhelm M. Is standing balance altered in individuals with chronic low back pain? A systematic review. Disabil Rehabil. 2019;41(13):1514-1523.

8. Bogduk N. Clinical anatomy of the lumbar spine and sacrum. 3rd ed. Edinburgh: Churchill Livingstone; 1997.

9. Bogduk N, Baker RM. Clinical and radiological anatomy of the lumbar spine. 5th ed. Edinburgh: Churchill Livingstone Elsevier; 2012.

10. Brown EC, Kilgore LJ, Pierce K, Knox A, Haworth JL. Movement pattern definitions for resistance training behavior measurement in diabetes. Front Clin Diabetes Healthc. 2024;5:1447595.

11. Cai C, Kong PW. Low back and lower-limb muscle performance in male and female recreational runners with chronic low back pain. J Orthop Sports Phys Ther. 2015;45(6):436-443.

12. Cameron M, Smith D, Jones R. The role of the patella in knee joint function. J Orthop Res. 2021;39(2):345-352. doi:10.1002/jor.24896.

13. Cannon J, Cambridge ED, McGill SM. Increased core stability is associated with reduced knee valgus during single-leg landing tasks: investigating lumbar spine and hip joint rotational stiffness. J Biomech. 2021;116:110240. doi:10.1016/j.jbiomech.2020.110240.

14. Cheng M, Xue Y, Cui M, Zeng X, Yang C, Ding F, et al. Global, regional, and national burden of low back pain: findings from the Global Burden of Disease Study 2021 and projections to 2050. Spine. 2025;50(7):E128-E139.

15. Choi H, Kim J, Lee K. The functional anatomy of the cruciate ligaments: implications for surgical repair. Knee Surg Sports Traumatol Arthrosc. 2022;30(7):2341-2349. doi:10.1007/s00167-021-06330-5.

16. Criss CR, Melton MS, Ulloa SA, Simon JE, Clark BC, France CR, et al. Rupture, reconstruction, and rehabilitation: a multi-disciplinary review of mechanisms for central nervous system adaptations following anterior cruciate ligament injury. Knee. 2021;30:78-89.

17. Croisier JL, Ganteaume S, Binet J, Genty M, Ferret JM. Strength imbalances and prevention of hamstring injury in professional soccer players: a prospective study. Am J Sports Med. 2008;36(8):1469-1475.

18. Da W, Liu S, Zhu B, Chen L, Xue F, Sun P, et al. Evaluating the clinical efficacy of five-step knee adjustment manipulation based on the “muscle and bone balance” principle in treating KOA and the influence on the biomechanical characteristics of soft tissues. 2024.

19. Davenport FR, Leestma JK, Staten A, Bhakta K, Fernandez J, Mazumdar A, et al. Electromyography-informed estimates of joint contact forces within the lower back and knee joints during a diverse set of industry-relevant manual lifting tasks. J Appl Biomech. 2025;41(2):151-160.

20. De Sousa CS, de Jesus FLA, Machado MB, Ferreira G, Ayres IGT, de Aquino LM, et al. Lower limb muscle strength in patients with low back pain: a systematic review and meta-analysis. J Musculoskelet Neuronal Interact. 2019;19(1):69.

21. Edwards N, Dickin C, Wang H. Low back pain and golf: a review of biomechanical risk factors. Sports Med Health Sci. 2020;2(1):10-18.

22. Elmannan AAA, AlHindi HA, AlBaltan RI, AlSaif MS, Almazyad NS, Alzurayer RK, et al. Non-specific low back pain among nurses in Qassim, Saudi Arabia. Cureus. 2021;13(11). doi:10.7759/cureus.19594.

23. Farahpour N, Jafarnezhadgero A, Allard P, Majlesi M. Muscle activity and kinetics of lower limbs during walking in pronated feet individuals with and without low back pain. J Electromyogr Kinesiol. 2018;39:35-41.

24. Fatoye F, Gebrye T, Mbada CE, Useh U. Clinical and economic burden of low back pain in low- and middle-income countries: a systematic review. BMJ Open. 2023;13(4):e064119.

25. Ferreira ML, De Luca K, Haile LM, Steinmetz JD, Culbreth GT, Cross M, et al. Global, regional, and national burden of low back pain, 1990–2020, its attributable risk factors, and projections to 2050: a systematic analysis of the Global Burden of Disease Study 2021. Lancet Rheumatol. 2023;5(6):e316-e329.

26. Fu P, Xu W, Xu P, Huang J, Guo JJ. Relationship between spinal imbalance and knee osteoarthritis by using full-body EOS. BMC Musculoskelet Disord. 2023;24(1):402. doi:10.1186/s12891-023-06438-6.

27. Genç H, Demircioğlu G. Age-related differences on low back pain and lower extremity isokinetic muscle strength and balance. J Back Musculoskelet Rehabil. 2025;38(1):165-170.