Knee pain is always concerning to those who have it – because it’s often achy, and can be sharp on straightening the leg, or walking.
There are only a handful of ways that people feel pain in the knee, and this article will attempt to explain how an why knee pain occurs.
Knee pain causes largely depend on your age, and activity levels.
1. Knee Pain Causes
The causes of knee pain are either:
- Local, or
Local knee pain
This is pain in the knee caused by structures in or around the knee, i.e. not “referred” from another structure.
There are many structures around the knee that will cause pain at the knee.
It’s slightly easier than many other joints and areas because often you can see the issue – or easily feel the problem.
The reason for knee pain largely depends on stage of life and/or activity levels and direct injuries.
The knee has many ligaments, any of which can cause pain when strained or torn.
The most common issues arise with:
- The collateral ligaments, or
- The cruciate ligaments.
The Collateral ligaments can give you pain in the inside or the outside of the knee. This is almost always as a result of trauma or impact – and is relatively easy to tell because the structure is so superficial.
The cruciate ligaments are also injured in trauma – you can have an anterior cruciate injury or a posterior cruciate injury.
Many tendons insert in and around the knee, so if there’s a tear or overuse, you can feel it in the knee.
Most commonly the issues arise with:
- Insertion of the quadriceps and patellar tendons in the front of the knee
- Insert of the “ITB” giving “ITB Friction syndrome” on the outside of the knee
- Insertion of the Sartorius giving pain in the front inside of the knee.
Clearly the knee is a large joint – with lots of force going through it, so has the potential for degenerative change.
Knee arthritis is very common, as are degenerative changes under the knee cap itself.
There are many soft tissue “bursas” around the knee joint, that can cause significant pain. The main ones we see having problems are:
- Infrapatellar bursa
- Prepatellar bursa
- Pes Anserine bursa
If you’re active, or kneeling a lot, inflammation of these bursas can cause significant pain!!
Many nerves run past the knee – and it’s injury to these nerves on their course that can present as “knee pain”.
Most common is the sciatic nerve, and referred pain from the L3 spinal segment in the lower back.
The inside of the knee has soft structures that help “guide” the knee. These are called the medial and lateral meniscus.
Injury to these will give you joint line pain and possibly swelling on the inside and outside of your knee.
They can become injured over time through normal “wear and tear” or via direct impact injuries e.g. in sport.
Many muscles cross the knee! So several of them can cause knee pain.
The most common that we see causing actual knee pain are:
- Vastus Medialis “VMO” (front of knee)
- Popliteus (back of knee) and
- Adductors (inside of knee)
Even though there are other muscles that have tendons that cause knee pain e.g. Tensor Fasciae Latae (TFL) , the above are very commonly associated.
This is one type of pain that depends on your age.
If younger, we have to think “growth plate” related issues – as when you’re growing long bones, the growth occurs near the ends of the bones.
The most commonly known is “Osgood Schlatters” disease.
If older – we have to think Arthritic causes and unfortunately, tumour causes (although not too common!).
This is relatively unknown “cause” of knee pain, and it’s questionable whether the lymphatics itself actually cause the pain.
But fluid congestion can definitely contribute to poor circulation, which may lead to more knee pain.
Referred knee pain
This is pain in the knee caused by structures away from the knee, i.e. not “local” to the knee itself.
Lower back causes of knee pain
Your lower back nerves supply the knee with sensation.
When they become compressed or injured they can cause pain in any area that they supply, including the knee.
Hip causes of knee pain
It’s amazing how the brain will give you pain in the KNEE when you’ve got a hip issue!
The hip joint itself or (more often) the muscles around the hip can make you “feel” pain that you’d swear is right “inside” your knee!
Ankle causes of knee pain
Your ankle is the most important joint in your body!
If your ankle is injured, there’s a very high chance your knee will have issues at some point, as the bones are the same.
Osteopaths are trained clinicians who see and help diagnose knee pain on a daily basis. We’re more than qualified to help.
2. Knee Pain Assessment
Knee pain has so many possible local (and not local) causes Knee pain assessment requires several key steps:
Osteopaths will look at your knee based on the history.
History questions can include (but not limited to):
- How long have you had this pain?
- Was there an injury? How did it happen?
- Where exactly is the pain?
- What does it feel like? i.e. is it sharp or achy etc
- Does it hurt to do any movements?
- Can you take the pain away?
If there is a genuine tear in a structure, the ways that you reproduce pain are going to match how we reproduce pain.
Sometimes, you’ll report pain in (for example) the side of your knee and you will test as if you’ve got a meniscus related issue.
We can recreate your exact pain with specific movements, but then… we can then eliminate this pain in seconds just by getting you to activate an inside thigh (adductor) muscle in a specific way.
So easy for clinicians to miss things like this when you’re not trained as well as an Osteopath…
Sometimes you might do a specific movement and it hurts every single time.
All of these “tricks” enable us to figure out whether or not you’ve got a pathology, and need referral for further examination or an MRI.
But generally, before we go down this pathway, we’ve done the standard sequence of:
- Active range of motion
- Passive range of motion
- Active resisted strength tests
- Special tests
3. Knee Pain Diagnosis
To diagnose knee pain, Osteopaths will:
Check active knee range of motion.
We’re trying to see how good your movement is. How far can you bend the knee??
Can you squat? Can you stand out of a chair easily?
Is there pain at any point in movement? At what stage of the movement is it sore?
Check passive knee range of motion.
Can we take your knee through range?
Will your brain let us?
If it doesn’t – the overriding “protection” strategies are at play – usually indicating a structure that’s injured such as joint, tendon, or ligament – in the knee your brain will certainly lock you down!
This might be a pathology in the knee joint.
Check “active-resisted” muscle strength.
Remember, your brain is in control at all times…
We’ll test your strength against us – in specific ways. Can you do it reliably? Is it easy for you? Is it difficult?
Can you activate what you want to activate – or do you fail on some movements?
We then look to see WHY it’s like this. Is there a pathology? Is there something else at play? What would cause you to protect?
Is there a specific structure at fault?
Check “special” Orthopaedic tests.
There are several tests which, when positive, lead us more down a path that requires you to possibly have another opinion, as manual therapy can only go “so far”.
For example – if you’ve ruptured a cruciate ligament, the last place you should be is with us, you’ll need an Orthopaedic opinion.
When combining all the above, and looking at the possible reasons the pain is there, we can arrive at a knee diagnosis, sometime immediately, sometimes after further imaging.
Most of the time, knee pain is relatively straight forward, and can be treated by an Osteopath successfully, and quickly.
4. Knee Pain Exercises
There are two types of exercises for the knee:
- “Open Chain” exercises and
- “Closed Chain” exercises
Open chain exercises:
These are exercises where your foot is NOT in contact with the ground.
Typically – you wouldn’t start an exercise program with open chain exercises – unless the knee and muscles around it can handle it, and if you do – with none or little weight.
Examples of open chain exercises are:
- Leg extensions
- Leg flexion
Closed chain exercises:
These are exercises where your foot IS in contact with something like a bike pedal or the ground.
Usually you’d start with something very basic, like stationary bike – with no or very little resistance.
Examples of closed chain exercises are:
- Stationary bike
Exercises you need for your knee might be very very basic, or part of a more complicated plan, to help “build” your strength from scratch.
5. Knee Pain Relief
To get relief from knee pain, you must have an accurate diagnosis.
Most knee pain is relatively simple, and to get relief, you follow a step by step process to help reduce inflammation and encourage healing, just like any other joint.
If the cause is more “serious” your Osteopath will know this and refer you for appropriate intervention to help you faster.
Osteopaths aren’t interested in seeing you “just for the sake of it”.
If the cause is muscular, we look to initially help take pressure off surrounding structures and limiting movement.
Perhaps there is a tear in a tendon/muscle – it takes time to heal, and the only way it’s going to do this is if it’s “allowed” to heal.
Continuing to use a structure that’s broken, it’s going to stay broken, or at the very least – not heal for a very long time.
If you keep kneeling on a structure that hurts when you kneel on it… it’s keep on giving you pain!
Osteopathic treatment of any knee pain – always have us looking away from the site of pain.
If your knee is sore – there is absolutely no way your walking will be even, or efficient. You’ll ALWAYS be compensating for this.
It goes without saying that we’re not a fan of taking painkillers and or anti-inflammatories so that you can keep using the affected area – it just doesn’t make sense, unless you don’t really care about getting the problem solved.
The ONLY time we recommend this is if the pain affects some vital activity – like sleeping.
6. Knee Pain Prevention
Writing this, we’re laughing because there is no proven ways of eliminating or preventing knee pain from ever occurring.
If you currently have knee pain – then there are ways of “reducing” knee pain.
It comes down to what structure and actions cause your pain.
If you have a sore front of your knee, and it hurts kneeling… it makes sense to reduced this aggravating factor.
But what if you’re (for example) a tiler, and have got to kneel to do your work?
It’s very easy for us to say “don’t kneel” – but it may not be practical for you.
So you look at braces, guards and ways of protecting the knee as much as possible, and know that your recovery will be a lot slower.
Generally speaking, if you have NO knee pain, it makes sense to be strong in the quads, hips and ankles.
One of the best generic things to do is yoga – can be very effective and promoting both strength of the legs and mobility of the ankle and hips.
7. Osteopathic Treatment of Knee Pain
Osteopaths will never only look at the site of pain in your knee.
There is ALWAYS a compensation pattern going on. You will limp – you’ll use your arms differently when you walk.
Usually – treatment would involve a combination of:
- Dry needling
- Mobility exercises
- Immobility advice
- Postural advice
It just depends on the actual presentation of your knee pain.
Most of the time, Osteopaths can really help your pain very quickly.
If they can’t – they will refer you for further tests and opinions as to how to get you better as fast as possible.