Knee pain

What is knee pain?

Knee pain refers to pain arising from the kneecap, joint line or surrounding soft tissue, and it is one of the most common musculoskeletal complaints we see in clinic.

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Patellofemoral pain — pain felt at the front of the knee, often described as "runner's knee" — is thought to affect around 22.7% of the general population annually, rising to almost 29% in adolescents, and is especially common among runners and cyclists (Smith et al., 2018).

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Knee pain can also relate to the iliotibial band, patellar tendon, meniscus or surrounding ligaments, and in some cases reflects longer term joint changes such as osteoarthritis.

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It may come on suddenly following a specific movement or load, or develop gradually through a change in training, footwear, surface or overall activity levels.

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As with other overuse related pain, knee symptoms often reflect an imbalance between the load placed on the joint and its current capacity to tolerate that load, rather than a single injury event.

Symptoms of knee pain

People with knee pain often describe:

• pain at the front, side or behind the kneecap

• pain that worsens with running, squatting, stairs or prolonged sitting

• swelling or a feeling of fullness around the joint

• a clicking, grinding or catching sensation

• stiffness after rest or first thing in the morning

• a feeling of the knee giving way or feeling unstable

• reduced confidence loading or twisting the knee

• pain that builds gradually during or after activity

Common causes and contributing factors

Common contributors include:

• sudden increases in running or training volume

• weakness or poor control through the hip and glutes

• reduced quadriceps or hamstring strength

• changes in footwear, surface or training terrain

• muscular tightness around the hip, thigh or calf

• previous knee injury that has not fully resolved

• returning to sport or exercise too quickly

• biomechanical factors affecting how load travels through the leg

Knee conditions we commonly see

• patellofemoral pain (runner's knee)

• iliotibial band syndrome

• patellar tendinopathy (jumper's knee)

• meniscus related irritation

• ligament sprains and instability

• osteoarthritis related knee pain

• post surgical or post injury stiffness

• general overuse and loading related knee pain

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How we assess and treat knee pain

Our approach focuses on understanding why the knee has become painful and what factors may be maintaining symptoms, rather than treating the joint in isolation.

We look at:

• how your knee behaves during and after activity

• movement and control through the hip, knee and ankle

• strength, mobility and loading capacity

• training history and recent changes in activity

• previous injuries and compensation patterns

Treatment may involve osteopathy, physiotherapy and acupuncture depending on your presentation and goals. We treat the person in front of us, not just the joint that hurts

Structural osteopathy

Structural osteopathy focuses on how load travels through the hip, knee and ankle, and how surrounding tissues are managing that load.

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Treatment may include work on:

• joint and soft tissue mobility

• muscular tension around the hip and thigh

• movement patterns affecting the knee

• areas compensating for reduced knee function

Hands on treatment is used to support mobility and movement efficiency, and works best alongside a structured physiotherapy strengthening programme rather than as a stand-alone approach (Academy of Orthopaedic Physical Therapy, 2019).

Traditional acupuncture

Traditional acupuncture may be used alongside physiotherapy to support pain regulation and muscular tension around the knee.

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The evidence here is genuinely mixed. NICE's current guidance on knee osteoarthritis does not recommend acupuncture as a treatment in its own right (NICE, 2022). At the same time, a National Institute for Health Research funded programme of research comparing acupuncture with other physical therapies for knee osteoarthritis found it to be one of the more clinically effective options, and cost-effective in the higher-quality trials analysed (MacPherson et al., 2017).

Given this, we use acupuncture as a complementary part of a broader, exercise led treatment plan for knee osteoarthritis, in line with NICE's more cautious position, rather than as a stand-alone treatment. For other causes of knee pain, such as muscular tension or general overuse discomfort, it may support relaxation and pain regulation as part of a broader treatment plan (Vickers et al., 2018).

It may help with:

• muscular tension around the hip and thigh

• pain sensitivity and regulation

• overall recovery and relaxation

• supporting engagement with rehabilitation

Physiotherapy

Physiotherapy is one of the most well supported approaches for knee pain, particularly for patellofemoral pain and overuse related presentations, using evidence based assessment and structured, progressive rehabilitation.

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A combined programme of hip and knee strengthening exercises is considered the most effective physiotherapy approach for patellofemoral pain, and tends to outperform knee strengthening exercises alone (Academy of Orthopaedic Physical Therapy, 2019).

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This may include:

• hip and glute strengthening

• quadriceps and hamstring strengthening

• gradual return to running or loading

• movement retraining

• footwear or training load adjustments where relevant

Exercises are tailored to your knee, your goals and your current capacity, with load increased gradually as symptoms allow.

Integrated treatment approach

Often the most effective approach combines osteopathy, physiotherapy and, where appropriate, acupuncture.

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This allows us to:

• address movement and loading patterns contributing to pain

• build strength and control around the knee

• support pain regulation during the early stages of treatment

• reduce the likelihood of symptoms recurring

• support a safe return to running, sport or everyday activity

Treatment is adjusted based on how your knee responds rather than following a fixed protocol.

What to expect during treatment

Your first appointment typically includes:

• a detailed discussion of your symptoms and activity history

• assessment of how your hip, knee and ankle move and load

• identification of contributing factors

• hands on treatment using osteopathy where appropriate

• a physiotherapy led strengthening plan tailored to your knee

• guidance on returning to running, sport or training

Who this treatment may help

This approach may be suitable if you:

• have persistent or recurring knee pain

• experience pain with running, squatting or stairs

• feel unstable or unsure trusting the knee

• are recovering from a knee injury

• want to return to sport or training safely

• prefer a hands on, exercise led approach to recovery

Recovery times and what to expect

Recovery time varies depending on how long symptoms have been present, the underlying cause, training load, and how your knee responds to treatment and rehabilitation.

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Patellofemoral pain in particular can take time to settle and often responds best to a gradual, consistent strengthening programme rather than rest alone (Academy of Orthopaedic Physical Therapy, 2019).

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Clearer expectations can usually be given after a full assessment.