Few symptoms generate more conflicting advice than knee pain. Rest it. Run on it. Ice it. It is your meniscus. It is just arthritis. Your kneecap is off track. The knee is a simple hinge with complicated neighbourhoods, and the right plan depends on which structure is complaining and why. Let us sort the usual suspects the way we do in an assessment.
The common patterns
Gradual onset, over 50, stiff in the morning, worse with stairs and hills: osteoarthritis leads the list. The pain is usually in the joint line, often on the inner side, and it warms up as you get moving.
Pain around or behind the kneecap, worse with stairs, squats, and sitting through a movie: patellofemoral pain, the kneecap joint overloaded, usually because hip and thigh strength or training load management has fallen behind what the knee is being asked to do. Common in younger, active people.
A specific twisting injury, then swelling, catching, or the knee locking: meniscus or ligament injury moves to the top. A knee that truly locks, physically will not straighten, needs prompt orthopaedic input.
Pain just below the kneecap in a jumping athlete: patellar tendinopathy, a load-management and progressive-strength problem like other tendinopathies.
About scans
Here is the uncomfortable fact: MRI findings and pain correlate loosely at best in middle-aged knees. Meniscus “tears” appear on scans of pain-free knees all the time, and the FIDELITY trial showed that for degenerative meniscus tears, trimming the meniscus arthroscopically did no better than sham surgery. A scan is a picture of structure; pain is an experience produced by a sensitised joint and the loads placed on it. Both matter, but treating the picture instead of the person leads to operations that do not help. Scans earn their place for suspected serious injury, locked knees, and cases that stall for no clear reason.
What physiotherapy does
Whatever the label, most knee plans share a backbone:
- Strength. Quadriceps and hip strength are the knee’s support system. Cochrane’s review of exercise for knee osteoarthritis found real, if modest, improvements in pain and function, and strength work is the core of it.
- Load management. Not rest, adjustment. Finding the activity dose your knee currently tolerates, then expanding it as capacity grows.
- Movement quality. How you climb stairs, rise from a chair, land from a step. Small changes in mechanics change joint loads a lot across thousands of repetitions a week.
- Weight, where relevant. Every kilogram lost is several kilograms less force across the knee per step. Said without judgement: it is simple leverage, and it adds up.
Red flags
A knee that is hot, red, and very painful with fever; a locked knee; giving way after a significant injury; or swelling that appears within an hour or two of an injury (suggesting bleeding inside the joint), these need medical assessment promptly, not a wait-and-see.
References
- Fransen M, McConnell S, Harmer AR, Van der Esch M, Simic M, Bennell KL. Exercise for osteoarthritis of the knee. Cochrane Database of Systematic Reviews. 2015;(1):CD004376. Summary: PMID 26405113
- Sihvonen R, Paavola M, Malmivaara A, et al. Arthroscopic partial meniscectomy versus sham surgery for a degenerative meniscal tear (FIDELITY). New England Journal of Medicine. 2013;369:2515–2524. doi:10.1056/NEJMoa1305189
General information only, not medical advice. Knee pain that is new, traumatic, or not settling deserves an in-person assessment.