Knee pain may arise due to injury of several structures both inside & surrounding the knee joint. The knee is stabilized externally by a joint capsule and the collateral ligaments that run down either side of the joint line. Internally, knee joint stability & control of rotation is provided by the anterior & posterior cruciate ligaments & the meniscus (cartilage). The anterior cruciate ligament is smaller & more vulnerable than the posterior cruciate ligament. The anterior cruciate is roughly the size of your little finger.

Causes of Knee Pain

Because the knee is a weight-bearing joint it undergoes significant load during walking & running; therefore, it is particularly prone to injury. There are several causes of knee pain & expert physiotherapy assessment is necessary to differentiate between the many causes of this condition. Below is a list of the most common causes of knee pain:

  • Muscular
  • Bursitis & tendonitis
  • Cruciate injury
  • Meniscus/Cartilage injury
  • Lateral ligament injury
  • Osgood Schlatter disease: this is an irritation of the patella ligament where it inserts into bone & is most common from 9-16 years of age.
  • Referral from: lumbar spine, pelvis or hip
  • Vascular conditions may also give rise to knee pain
Knee pain treatment at the Physio Clinic - Naas & Newbridge

Ross Allen is a former Ireland rugby International & County Football Player. Ireland’s only dual qualified Chartered Physiotherapist & Chiropractor.

Knee Joint Assessment

If knee pain occurred due to trauma then evaluation will focus on the knee joint itself. Potential structures involved include the muscles, anterior cruciate ligament and meniscus. If, as in most cases, the knee joint pain arose due to overuse, then biomechanical evaluation of the whole lower limb & lumbopelvic region is warranted. Abnormal alignment of the hip or knees such as present with knocked knee posture may predispose some individuals to knee pain.

Swelling, clicking or giving way are all strong indicators of knee joint pathology and should be investigated immediately. Causes of such complaints include ACL & meniscus injuries or a loose body (cartilage or bone) within the joint. Pain in the front of the knee which is made worse with running & jumping may indicate patellar ligament overload or Osgood-Schlatter disease (irritation of the patellar ligament where it inserts into bone).

Why does my knee click?

Cracking of the knee is commonly reported in those suffering from patellofemoral pain syndrome. Cracking below the kneecap may also occur due to a condition called chondromalacia patella. This involves fissuring of the cartilage below the kneecap & is quite common.

Causes of Joint Cracking:

1) Gas bubbles inside the joint will expand as the joint is distracted and pop as a result
2) A fine grating noise is commonly an indicator of patellofemoral joint involvement (kneecap). This can be normal or due to degeneration of the cartilage below the kneecap.
3) If the noise is more like a creak (a closing door sound) then this may indicate arthritis of the knee.

Physiotherapy for Knee Pain

Knee pain or clicking should never be ignored and the earlier in the process the problem is dealt with, the better the long-term outcome from care. It is my experience that knee pain can be particularly responsive to appropriate physiotherapy management. Thankfully, the majority of knee complaints can be resolved without requiring surgical intervention.

If swelling is present then the first goal should be to bring this under control with use of a R.I.C.E. protocol (Rest, Ice, Compression, Elevation). An active physiotherapy & exercise intervention can then be commenced which will prioritise progressive strengthening of the involved area as well as addressing biomechanical deficiencies that may have given rise to the injury. Patients frequently ask about the benefits of swimming for knee pain. While swimming is a low impact activity & therefore is unlikely to aggravate the knee it also is unlikely to improve strength & muscle control around the joint. Therefore, I prefer weight-bearing exercises, where possible, to address the deficiencies which are identified during the physical examination.

Many people are often fearful of loading a degenerative or painful knee but you can rest assured that the research does not support a link between exercise or knee joint loading & knee arthritis (Chakravartv et al. 2008). One study by Roos & Dahlberg (2005) demonstrated that exercise improved knee cartilage quality in a group of individuals at risk of knee joint arthritis. This suggests that exercise is protective as opposed to being harmful in this population. There are also animal studies demonstrating that cyclic loading (where load is applied to the joint & then released) applied to cartilage encourages healthy cell division & cartilage quality. This cyclic loading mimics running & walking activities. Prolonged force application without rest on the other hand, can give rise to cartilage degeneration in animal studies. This may partially explain the higher incidence of knee arthritis in overweight individuals. Research suggests that individuals who are overweight or obese have three times the risk of developing knee arthritis. Therefore a weight management component should form an important element in managing knee pain in those suffering from arthritis.

Interestingly, long-term studies in runners do not demonstrate an increased rate of knee arthritis in this group. Most people are surprised to hear this as they assume that more exercise will lead to a higher incidence of degeneration. Research from the University of Maryland has demonstrated that, although the forces applied to the knee are high during running, the overall load on the knee is comparable to walking over the equivalent distance. This is because the longer stride used for running leads to less contact time with the ground compared to walking.

Is Knee Surgery the Answer?

According to Professor Andrew Carr who is a leading surgeon, many keyhole surgeries are no more effective than painkillers. He states that the success of many such procedures is down to the placebo effect. The placebo effect is where patients feel better as a result of their belief in the treatment. He also warned that keyhole surgeries carry serious complications such as infections or pulmonary embolisms. One in 1,000 people died as a result of the procedure.

The research from Lund University in Sweden involved a systematic review of the research to date on arthroscopic procedures carried out on individuals with cartilage tears or arthritis. The authors found that rehabilitation exercise for such conditions was almost as effective but without the serious side-effects involved in surgery.

Bart Ferket of Mount Sinai Health System, New York, says it’s best to treat the person, not the X-ray. X-ray and MRI findings don’t correlate well with symptoms; you can have an awful-looking X-ray but not suffer much pain or stiffness, and vice versa. He has carried out a study in the US to look at the cost-effectiveness of knee replacements. Most people with knee symptoms do report an improvement in symptoms after this major operation but, unsurprisingly, the worse you are before the op, the bigger the improvement. It is recommended that knee replacement surgery should only be attempted after other interventions such as physiotherapy guided exercise regimes, weight-loss and painkillers have been attempted.

Thorlund et al. (2015). Systematic Review of the Literature

The authors performed a randomised controlled trial assessing the benefit of arthroscopic knee surgery in middle aged and older patients with knee pain and degenerative knee disease. When analysed over time of follow-up, interventions including arthroscopy showed a small benefit of 3-5 mm for pain at three and six months but not later up to 24 months. No significant benefit on physical function was found.
The authors concluded that ‘the small inconsequential benefit seen from interventions that include arthroscopy for the degenerative knee is limited in time and absent at one to two years after surgery’. Knee arthroscopy is also associated with harmful side effects including deep venous thrombosis, pulmonary embolism, infection, and death.

‘These incidents occur at a rate of 4.13 per 1000 procedures. Taken together, these findings do not support the practise of arthroscopic surgery for middle aged or older patients with knee pain with or without signs of osteoarthritis’.

Knee operations for UAE’s elderly ‘expensive and unnecessary’. The National, UAE. July 31, 2016. 

The BMJ reviewed 18 studies on knee surgery compared with exercise and a placebo operation, for patients in Denmark and Sweden between 48 and 63 years old. No significant benefit to the knee’s function was found after surgery.

Nine more studies were evaluated to assess the degree of harm that patients were at risk from. Deep vein thrombosis was the most frequently reported adverse effect.

‘Knee surgery is often only necessary when arthritic changes are so advanced that the patient cannot walk, but rarely in anyone under 55’.

Orthopaedic surgeon Dr Anurag Sapolia performs up to 20 knee procedures every month at Medeor Hospital in Dubai. “It has been a proven fact that arthroscopic surgery for pain management in older patients is often not necessary,” he said. “Physical therapies are a better option. Surgery is always a last resort.”

“I don’t recommend surgery in older people unless there is structural damage, maybe only one patient every three months or so,” Dr Sapolia said. “Other clinics are definitely pushing these kind of surgeries when they are unsuitable.”

Manual Therapy for Treating Knee Arthritis

Pain is driven through activation of nerve endings which refer signals along the spinal cord to the brain where pain is experienced. The treatment benefits of joint mobilisation

may occur in part by decreasing excitability of central nociceptive pathways. Impaired conditioned pain modulation (CPM) has been found experimentally in persons with knee and hip osteoarthritis, indicating impaired inhibition of central nociceptive pathways. We hypothesized increased effectiveness of CPM following application of joint mobilization, determined via measures of deep tissue hyperalgesia.


An examination of 40 individuals with moderate/severe knee osteoarthritis identified 29 (73%) with impaired CPM. The subjects were randomized to receive 6 minutes of knee joint mobilization (intervention) or manual cutaneous input only, 1 week apart. Deep tissue hyperalgesia was examined via pressure pain thresholds bilaterally at the knee medial joint line and the hand at baseline, postintervention, and post-CPM testing. Further, vibration perception threshold was measured at the medial knee epicondyle at baseline and post-CPM testing.


Joint mobilization, but not cutaneous input intervention, resulted in a global increase in pressure pain threshold, indicated by diminished hyperalgesic responses to pressure stimulus. Further, CPM was significantly enhanced following joint mobilization. Diminished baseline vibration perception threshold acuity was enhanced following joint mobilization at the knee that received intervention, but not at the contralateral knee. Resting pain was also significantly lower following the joint intervention.


Conditioned pain modulation was enhanced following joint mobilization, demonstrated by a global decrease in deep tissue pressure sensitivity. Joint mobilization may act via enhancement of descending pain mechanisms in patients with painful knee osteoarthritis.

In individuals with osteoarthritic knee pain, hyperexcitability of central nociceptive pathways has been demonstrated. It has also been shown that central sensitization produces an enhanced pain response, which could possibly lead to chronic pain.This study shows that joint mobilization enhances controlled pain modulation in patients with painful knee OA.

The imbalance in supraspinal mechanisms may be caused by the input from the periphery or central processes, such as hypervigilance or catastrophizing. Conditioned pain modulation (CPM) is a way to examine pain inhibitory mechanisms; in short, the application of a noxious stimulus at a remote site causes inhibition of pain at the initial site.

The aim of this study was to determine if CPM is effective in individuals with painful OA together with joint mobilization of the knee. Subjects were randomized to receive 6 minutes of knee joint mobilization or manual cutaneous input only. Deep tissue hyperalgesia was examined via pressure pain thresholds bilaterally at the knee medial joint line and the hand at baseline.

Previous studies have shown that joint mobilization is effective in individuals with OA knee pain; it has been speculated that manual therapy may alter the imbalance in the supraspinal mechanisms. This study shows that joint mobilization enhances CPM in patients with painful knee OA. There was a decrease in deep tissue sensitivity to pressure and an enhanced somatosensory acuity.


  1. Blagojevic, M., Jinks, C., Jeffery, A., Jordan, K.P. (2010). Risk factors for onset of osteoarthritis of the knee in older adults: a systematic review and meta-analysis. Osteoarthritis Cartilage; 18(1): 24-33.
  2. Roos EM, Dahlberg L. (2005). Positive effects of moderate exercise on glycosaminoglycan content in knee cartilage: a four-month, randomized, controlled trial in patients at risk of osteoarthritis. Arthritis Rheum; 52(11): 3507-3514.;jsessionid=6E4DB3FB9C5C365C7133D824D863F040.f04t04
  3. Chakravartv, E., Hubert, H., Lingala, V., Zatarain, E., Fries, J. (2008). Long Distance Running & Knee Osteoarthritis. A prospective Study. American Journal of Preventative Medicine; 35(2): 133-138.
  4. Knee operations are no better than painkillers, says leading surgeon – so is keyhole surgery all in the mind?
  5. Thorlund, B. (2015). Arthroscopic surgery for degenerative knee: systematic review and meta-analysis of benefits and harms. BMJ; 350:h2747.
  6. Knee operations for UAE’s elderly ‘expensive and unnecessary’. The National, UAE. July 31, 2016. Author: Nick Webster.
  7. Courtney et al. (2016). Joint Mobilization Enhances Mechanisms of Conditioned Pain Modulation in Individuals With Osteoarthritis of the Knee. The Journal of Orthopaedic and Sports Physical Therapy;46(3):168-76.


To find out more regarding Knee pain, contact Naas Physio Clinic on:
(045) 874 682

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