Knee Pain: Common Causes and When Should You Get It Assessed?

Part 5 of our Move Better, Feel Better: Pain & Movement Explained series

Written by Jessica Brown, Osteopath and Owner of One Health Osteopathy Clinic, Tunbridge Wells

Knee pain is extremely common and can affect people at almost any age. It may begin suddenly after sport or an awkward movement, gradually appear when running or exercising, or develop over time without one obvious injury.

Sometimes the knee feels stiff or achy. You may notice discomfort going downstairs, getting up from a chair or walking for longer distances. At other times there may be swelling, clicking, pain around the kneecap or discomfort when running, squatting or kneeling.

One of the most common questions we hear is:

“What is actually causing my knee pain?”

The answer is not always as simple as pointing to one structure.

The knee contains bones, joints, cartilage, ligaments, tendons, muscles, bursae and other soft tissues. How the knee functions is also influenced by the hip, ankle and foot, together with strength, movement, activity levels and how much load your body is currently accustomed to.

At One Health Osteopathy Clinic in Tunbridge Wells, we assess people with knee pain from Tunbridge Wells, Tonbridge, Sevenoaks and surrounding areas of Kent.

In this guide, I explain some of the most common causes of knee pain, what can help, when exercise is beneficial and when it is sensible to have your knee assessed.

Knee pain at a glance

Knee pain does not always mean something is damaged. Joints and surrounding tissues can become sensitive for many reasons, and the intensity of pain does not necessarily tell us how serious the problem is.

There are many possible causes. Muscles, tendons, ligaments, cartilage, joints and other tissues may contribute.

Where you feel the pain gives us useful clues. Pain at the front, inside, outside or back of the knee may point us towards different possible causes, although symptoms need to be considered alongside an examination.

Exercise is often part of the solution. Appropriate strengthening and general activity are particularly important for many common knee problems, including knee osteoarthritis.

Rest can be useful, but complete rest is rarely the long-term answer. Temporarily reducing activities that strongly aggravate your knee while maintaining comfortable movement can help symptoms settle without unnecessarily losing strength or confidence.

Most knee pain does not need an immediate scan. Clinical assessment will often provide enough information to begin appropriate management.

Some knee symptoms need more urgent assessment. A very swollen or hot knee, inability to bear weight, significant trauma, locking or feeling systemically unwell should not be ignored.

What causes knee pain?

The knee is often described as a simple hinge joint, but in reality it is a complex structure that needs to manage considerable forces during walking, running, stairs, squatting, jumping and everyday activity.

The knee contains two main articulations: the joint between the thigh bone and shin bone, and the joint between the kneecap and thigh bone.

It also relies on:

• ligaments for stability;
• menisci to help distribute load;
• cartilage covering the joint surfaces;
• tendons transmitting force from muscles;
• muscles controlling movement;
• bursae reducing friction around certain structures.

Knee pain may involve one or several of these tissues.

Just as importantly, pain is influenced by what you are asking the knee to do.

A sudden increase in running mileage, a new gym programme, more walking on holiday, returning to sport after a break or spending a weekend gardening can all expose the knee to more load than it has recently been accustomed to.

Sleep, general health, recovery, previous injuries and confidence in movement may also influence how symptoms behave.

Does the location of knee pain tell you what is wrong?

It can give us useful clues, although it is not enough to make a diagnosis on its own.

Pain at the front of the knee

Pain around or behind the kneecap is very common. One frequent cause is patellofemoral pain, where symptoms arise from the joint between the kneecap and the thigh bone and the surrounding tissues.

It may be aggravated by:

• stairs;
• squatting;
• running;
• sitting with the knee bent for a long time;
• hills;
• getting up from a chair.

Patellofemoral pain is particularly common among active people, but you do not have to be a runner or athlete to experience it.

Strengthening the muscles around the knee and hip, managing activity appropriately and gradually increasing the knee’s capacity to tolerate load are commonly important parts of rehabilitation.

Pain below the kneecap

Pain around the tendon just below the kneecap may be related to the patellar tendon.

Patellar tendinopathy is more common in sports involving jumping, running and repeated acceleration, but can occur in other situations too.

Tendons respond to load. This means simply resting a tendon indefinitely is rarely the ideal long-term strategy. Rehabilitation usually involves temporarily adjusting aggravating activities and progressively rebuilding the strength and load tolerance of the tendon.

Can shockwave therapy help tendon pain?

For some persistent tendon problems, shockwave therapy may be considered as part of a wider rehabilitation plan.

Shockwave uses acoustic pressure waves applied to the affected area and is most commonly used for longer-standing tendinopathies that have not improved sufficiently with exercise and load management alone. It is not a stand-alone treatment and works best alongside progressive strengthening and appropriate activity modification.

At One Health, shockwave may be considered for suitable tendon problems after assessment, depending on the diagnosis, how long symptoms have been present and how the tendon has responded to previous rehabilitation.

Pain on the inside or outside of the knee

Pain around the inner or outer knee can arise from a number of structures, including ligaments, tendons, joints and the meniscus.

The history is particularly important.

Did symptoms begin after twisting?

Was there a collision?

Has the pain developed gradually?

Is there swelling, locking or instability?

Are certain movements particularly painful?

These details, combined with clinical testing, help determine which structures may be involved.

What is a meniscus injury?

The menisci are two crescent-shaped fibrocartilage structures inside each knee that help distribute load and contribute to joint stability.

Meniscal symptoms can follow a twisting injury, particularly in younger or more active people.

As we get older, changes within the meniscus become increasingly common and may be present even without a clear injury.

Symptoms can include:

• pain along the joint line;
• swelling;
• discomfort twisting or squatting;
• catching or clicking;
• occasionally locking.

Importantly, finding a meniscal change on an MRI does not automatically mean surgery is required.

Clinical assessment, symptoms, function, age and how the knee responds to rehabilitation all contribute to decisions about management.

What about ligament injuries?

The knee contains several important ligaments, including the anterior cruciate ligament, or ACL, posterior cruciate ligament and the collateral ligaments on either side of the knee.

Ligament injuries are more commonly associated with trauma, sport or sudden changes of direction.

You may notice:

• a pop at the time of injury;
• rapid swelling;
• difficulty continuing activity;
• instability or giving way;
• pain around the injured ligament.

A suspected significant ligament injury warrants appropriate assessment, particularly if the knee feels unstable.

Depending on the injury, rehabilitation can play an important role whether or not surgery is eventually considered.

What is knee osteoarthritis?

Knee osteoarthritis is one of the most common causes of knee pain, particularly as we get older.

Osteoarthritis involves changes throughout the joint, including cartilage, bone and surrounding tissues.

Symptoms may include:

• pain with activity;
• stiffness;
• reduced movement;
• swelling;
• difficulty with stairs;
• discomfort walking longer distances;
• stiffness after sitting or first getting moving.

It is important to understand that osteoarthritis is not simply a case of a joint being “worn out”.

The severity of changes seen on an X-ray does not always match the amount of pain somebody experiences. Some people have considerable changes on imaging but relatively few symptoms, while others experience significant pain with more modest radiographic findings. For many people, there is also plenty that can be done to improve pain, strength and function.

Should you exercise if you have knee osteoarthritis?

Yes, in most cases exercise is one of the most important parts of management.

NICE recommends therapeutic exercise tailored to the individual, including local muscle strengthening and general aerobic activity, for people with osteoarthritis.

Importantly, discomfort can sometimes increase slightly when exercise is first introduced.

This does not necessarily mean that exercise is damaging the joint. Regular and consistent exercise can improve pain, function and quality of life over time.

A large body of research supports exercise for knee osteoarthritis, although there is no single exercise programme that is best for everyone. Strengthening, aerobic exercise, neuromuscular exercise and combinations of different approaches can all be useful.

The key is finding a starting point your knee can tolerate and progressing gradually.

Does knee osteoarthritis mean I will need a knee replacement?

No.

Many people manage knee osteoarthritis without surgery.

Treatment may involve:

• education about the condition;
• appropriate exercise;
• strengthening;
• maintaining general physical activity;
• weight management where relevant;
• pain-management strategies;
• adapting activities during flare-ups.

Joint replacement may eventually be appropriate for some people whose pain and loss of function significantly affect their quality of life and have not responded sufficiently to non-surgical management.

But osteoarthritis on an X-ray does not automatically mean surgery is inevitable.

Can menopause contribute to knee and joint pain?

Joint aches and stiffness are commonly reported during perimenopause and menopause.

Falling oestrogen levels may influence several systems involved in musculoskeletal health, including bone, muscle, tendons and joints. The NHS includes aching and painful joints among symptoms that can occur during perimenopause and menopause.

However, knee pain during menopause should not automatically be attributed to hormones. A woman may simultaneously have osteoarthritis, tendon-related pain, a change in exercise load, reduced muscle strength or another musculoskeletal problem.

As with most knee pain, it is useful to consider the whole clinical picture rather than assuming there is one cause.

Why does my knee click or crack?

Knees make noise. Clicking, popping, cracking and grinding sensations are extremely common and often occur without pain. The medical term for these joint noises is crepitus.

A painless clicking knee does not automatically mean that cartilage is being damaged. If clicking is accompanied by pain, swelling, locking, instability or follows an injury, it may be more relevant and worth assessing.

The NHS similarly notes that painless clicking is common, while painful clicking, locking or giving way warrants more urgent advice.

What causes swelling around the knee?

Swelling can develop for many reasons. After an acute injury, swelling may occur because tissues inside or around the knee have been irritated. Osteoarthritis can sometimes produce episodes of swelling. Bursitis can cause more localised swelling, particularly around the front of the knee. A Baker’s cyst, which is a collection of fluid at the back of the knee, may develop when excess joint fluid moves into a small sac behind the knee. Other causes include inflammatory arthritis, gout and, more rarely, infection.

A knee that becomes suddenly very hot, red, swollen and extremely painful, particularly if you also feel feverish or unwell, requires urgent medical assessment.

Should you rest when you have knee pain?

Sometimes doing less for a short period is sensible.

If you have suddenly increased your running, walking or gym activity and the knee has become highly irritated, continuing the same amount regardless of your symptoms may simply keep aggravating it.

But this does not necessarily mean you should stop moving altogether.

Relative rest means temporarily reducing or modifying the activities that are provoking your symptoms while maintaining movement and exercise that your knee tolerates comfortably.

For example, you might:

• shorten a walk;
• reduce running mileage;
• temporarily reduce deep squats;
• change a particular gym exercise;
• swap a high-impact activity for a lower-impact one;
• build in additional recovery.

As symptoms settle, activity can then be progressively increased.

The aim is to find the balance between giving irritated tissues an opportunity to settle and maintaining enough movement to preserve strength, mobility and confidence.

Are mobility exercises helpful for knee pain?

Yes.

Comfortable mobility exercises can be useful if your knee feels stiff or if pain has reduced your normal movement.

Movement encourages normal circulation and fluid exchange through the tissues and joint, while regularly moving through a comfortable range can help maintain mobility and reduce the feeling of stiffness.

Useful mobility work might include gentle:

• knee bending and straightening;
• heel slides;
• cycling;
• ankle movement;
• hip mobility;
• controlled squats within a comfortable range.

The hip and ankle are particularly relevant because the knee functions between them.

Reduced movement or capacity elsewhere does not automatically cause knee pain, but assessing how the whole lower limb moves can help identify factors that may be useful to address.

Is stretching useful for knee pain?

Stretching can be helpful, particularly if muscles around the thigh, calf or hip feel stiff.

Comfortable stretching can:

• reduce the sensation of tightness;
• introduce movement after prolonged sitting;
• improve comfortable range of motion;
• complement strengthening and rehabilitation.

Depending on the individual, stretches might focus on the quadriceps, hamstrings, calves or hips.

Stretching should generally feel comfortable rather than forced.

For recurring knee problems, it is usually most effective when used alongside strengthening and progressive loading, rather than relying on flexibility alone.

Why is strengthening so important for knee pain?

Your knee does not function by itself.

Muscles around the thigh, hip and calf help control the forces passing through the knee during walking, stairs, running and sport.

Improving muscle strength gives the body more capacity to cope with these demands.

Depending on the problem, rehabilitation may include:

• quadriceps strengthening;
• hamstring exercises;
• calf strengthening;
• hip and gluteal strengthening;
• sit-to-stand exercises;
• squats;
• step-ups;
• balance and control exercises;
• progressive resistance training;
• running or sport-specific rehabilitation.

The right exercises depend on your symptoms, ability and goals.

A 70-year-old wanting to walk comfortably on holiday will need a different rehabilitation programme from a 25-year-old trying to return to football.

The underlying principle is the same: build the capacity required for the activity you want to do.

What about knee pain when running?

Knee pain does not necessarily mean you need to stop running permanently.

Running places significant but normal forces through the knees, and healthy joints are designed to respond to load.

Problems can occur when training demands increase faster than your tissues are prepared for.

Common examples include:

• suddenly increasing weekly mileage;
• adding more hills;
• increasing running speed;
• returning after a long break;
• introducing more races or training sessions;
• combining increased running with a new gym programme;
• insufficient recovery.

The solution is therefore not always simply “stop running”.

It may involve temporarily adjusting training, identifying what the knee currently tolerates and progressively rebuilding strength and running load.

We will explore running and sports injuries in more detail in the next Active for Life: Sports Injury, Recovery & Rehabilitation series.

Do I need an X-ray or MRI for knee pain?

Not always.

Many common knee problems can be assessed clinically based on your history, symptoms and physical examination.

For knee osteoarthritis specifically, NICE states that diagnosis can usually be made without imaging in people aged 45 or over with activity-related joint pain and either no morning stiffness or stiffness lasting no longer than 30 minutes, provided there are no unusual features. (nice.org.uk)

Imaging may be appropriate if:

• significant trauma has occurred;
• a fracture is suspected;
• the diagnosis is uncertain;
• symptoms suggest a significant internal injury;
• there are unusual clinical features;
• symptoms are not progressing as expected;
• the result is likely to change management.

Scans can be extremely useful when clinically indicated, but an abnormality on a scan does not automatically tell us what is responsible for your pain.

When should knee pain be assessed?

Consider having your knee assessed if:

• pain has persisted for several weeks;
• it is getting worse rather than better;
• symptoms keep returning;
• swelling repeatedly develops;
• the knee feels unstable or gives way;
• you cannot comfortably bend or straighten it;
• running, walking or sport is becoming increasingly difficult;
• stairs or everyday activities are being affected;
• you are avoiding activity because you are worried about your knee;
• an injury is not recovering as expected;
• or you simply do not know what you should and should not be doing.

Having symptoms assessed earlier can often be helpful, particularly when they are not settling as expected. Identifying what may be contributing, modifying aggravating activities and beginning appropriate rehabilitation can help prevent a relatively straightforward problem from becoming more persistent.

In some cases, earlier advice and rehabilitation may also mean a simpler course of care is needed than when pain, weakness and altered movement patterns have been present for a long time.

When is knee pain more urgent?

Seek urgent medical advice if:

• your knee is extremely painful;
• you cannot move it or put weight through it;
• it becomes badly swollen;
• it has visibly changed shape;
• it locks and you cannot straighten it;
• it repeatedly gives way after an injury;
• you have significant swelling following trauma.

You should also seek urgent medical assessment if your knee becomes hot, red and swollen and you feel feverish, shivery or generally unwell, as infection needs to be ruled out.

The NHS advises contacting NHS 111 for very painful knees, inability to bear weight, significant swelling or deformity, painful locking or giving way, and a hot red knee accompanied by fever or feeling unwell.

Can an osteopath help with knee pain?

Osteopaths are regulated healthcare professionals trained to assess and manage musculoskeletal conditions, including many common causes of knee pain.

At One Health, we begin by understanding how the problem started and how your symptoms behave.

We may ask:

• where exactly you feel the pain;
• whether symptoms came on suddenly or gradually;
• whether there was an injury;
• what activities aggravate or relieve it;
• whether the knee swells;
• whether it locks or gives way;
• what exercise or sport you do;
• whether your activity levels have recently changed;
• whether you have previous knee problems or surgery;
• how the symptoms are affecting your everyday life.

Your physical assessment may include the knee itself, together with relevant assessment of the hip, ankle and lower back.

We may assess:

• joint movement;
• muscles and tendons;
• ligament stability;
• meniscal signs;
• strength;
• balance and control;
• gait;
• squatting or stepping;
• movements related to your sport or everyday activities.

The purpose is not simply to identify where the pain is.

It is to understand why the knee may currently be struggling with the demands being placed on it and what can be done to help.

Our osteopathic approach to knee pain

Osteopathy considers how the different parts of the musculoskeletal system work together.

Although your knee may be the painful area, it sits within a chain involving the foot, ankle, hip, pelvis and lower back.

We assess these areas where they appear relevant rather than assuming every knee problem originates elsewhere.

Where appropriate, osteopathic treatment may include:

• joint mobilisation and articulation;
• soft-tissue and massage techniques;
• myofascial techniques;
• stretching and mobility work;
• muscle energy techniques;
• treatment of relevant hip, ankle or lower-back restrictions;
• neuromuscular and movement retraining;
• balance and proprioception exercises;
• progressive strengthening;
• tendon rehabilitation;
• return-to-running or sport rehabilitation;
• advice about activity and load management.

Movement also encourages normal circulation and fluid exchange through muscles and surrounding tissues, while progressive exercise helps improve strength, coordination and the physical capacity needed to tolerate everyday activities.

Treatment is tailored to the individual. Someone with an acutely irritated knee may initially benefit from hands-on treatment, mobility work and temporary activity modification.

A person with knee osteoarthritis may require a greater emphasis on strengthening, general physical activity and maintaining long-term joint function.

Someone experiencing running-related pain may need progressive strengthening combined with careful adjustment and rebuilding of running load.

The aim is not simply to make the knee feel better during treatment. It is to help you move more comfortably, build strength and confidence, and return to the things you want to do.

What do NICE guidelines recommend for knee osteoarthritis?

For knee osteoarthritis, NICE places therapeutic exercise at the centre of management. Exercise should be tailored to the individual and may include local muscle strengthening and general aerobic activity. NICE also advises that some discomfort can occur when exercise is first introduced, but regular and consistent exercise is beneficial for pain, physical function and quality of life over time. Routine imaging is not required to diagnose typical osteoarthritis, and scans are not routinely recommended simply to monitor it.

This supports an active approach to knee health rather than assuming a painful or arthritic knee should simply be rested.

Knee pain treatment in Tunbridge Wells

If knee pain is affecting your walking, running, sport, exercise or everyday life, having it properly assessed can help you understand what may be contributing and what your next steps should be.

One Health Osteopathy Clinic is based in central Tunbridge Wells and welcomes patients from Tunbridge Wells, Tonbridge, Sevenoaks and surrounding areas of Kent.

Our registered osteopaths assess people with a wide range of musculoskeletal knee problems, including:

• knee pain and stiffness;
• patellofemoral pain;
• tendon-related knee pain;
• knee osteoarthritis;
• pain with stairs or squatting;
• running-related knee pain;
• sports injuries;
• recurring knee problems;
• difficulty returning to exercise following injury.

Our approach combines careful clinical assessment with hands-on osteopathic treatment where appropriate, together with mobility work, strengthening, rehabilitation and practical advice about activity.

We want you to understand your knee, know what you can safely do and feel confident returning to the activities that are important to you.

Frequently asked questions about knee pain

Why does my knee hurt when I go downstairs?

Stairs place greater demands on the muscles and joint around the kneecap than level walking.

Pain on stairs is common with patellofemoral pain and knee osteoarthritis, although other causes are possible. Assessment can help identify which structures and contributing factors are relevant.

Why does my knee hurt when I squat?

Squatting increases the load through the knee and requires good movement and strength through the hips, knees and ankles. Pain may be associated with the patellofemoral joint, tendons, osteoarthritis or other structures. This does not necessarily mean squatting is damaging your knee.

Is walking good for knee pain?

For many common knee problems, walking is a useful form of activity. If your knee is very irritable, temporarily reducing the distance or intensity may be helpful. The aim is usually to gradually rebuild what your knee can tolerate rather than avoiding walking indefinitely.

Is cycling good for knee pain?

Cycling can be an excellent way to maintain knee movement and cardiovascular fitness while placing different demands on the joint than walking or running. Seat position, resistance and the underlying knee problem may influence how comfortable it feels.

Should I exercise with knee osteoarthritis?

Yes, in most cases. Strengthening and general aerobic exercise are key parts of osteoarthritis management and can improve pain and function. Exercise should be tailored to your starting point and progressed gradually.

Does clicking mean my knee is damaged?

Not necessarily. Clicking and cracking noises are extremely common, particularly when they are painless. Painful clicking accompanied by swelling, locking or giving way is more relevant and should be assessed.

Does knee pain always mean arthritis?

No. Tendons, muscles, ligaments, the meniscus, patellofemoral joint and other structures can all cause knee pain. Arthritis becomes more common as we age, but it is only one possible explanation.

Can knee arthritis be diagnosed without an X-ray?

Often, yes. Typical osteoarthritis can frequently be diagnosed from your age, symptoms and clinical assessment without an X-ray. Imaging may be useful when symptoms are unusual or when the result would change management.

Should I rest a painful knee?

A short period of reducing aggravating activity can be helpful. However, complete rest is rarely the best long-term strategy for common musculoskeletal knee problems. Comfortable movement followed by gradual strengthening and return to activity is often more useful.

Can menopause cause knee pain?

Joint aches can occur during perimenopause and menopause and hormonal changes may influence musculoskeletal symptoms. However, knee pain should not automatically be attributed to menopause because osteoarthritis, tendons, activity, strength and other factors may also contribute.

Should I see an osteopath for knee pain?

An osteopath can assess the knee together with relevant joints, muscles, tendons, ligaments, strength and movement to help establish what may be contributing to your symptoms. Where appropriate, treatment may include hands-on osteopathic care, mobility exercises, strengthening, activity advice and rehabilitation.

Coming next

Hip Pain: Is It Coming From Your Hip, Back or Somewhere Else?

Part 6 of our Move Better, Feel Better: Pain & Movement Explained series.

The Move Better, Feel Better: Pain & Movement Explained series

1. Lower Back Pain: What Causes It and When Should You Get It Checked?
2. Sciatica: What Does It Feel Like and When Should You Get Help?
3. Is Sitting Really Bad for Your Back?
4. Neck and Shoulder Pain: What Could Be Causing It and What Actually Helps?
5. Knee Pain: Common Causes and When Should You Get It Assessed? (you are here)
6. Hip Pain: Is It Coming From Your Hip, Back or Somewhere Else?

About the author

Jessica Brown is a registered osteopath and owner of One Health Osteopathy Clinic in Tunbridge Wells.

Jessica holds a Master’s degree in Osteopathy from the University College of Osteopathy, where she received awards for academic achievement and her dissertation. She also has postgraduate training in women’s health osteopathy.

Her clinical approach combines careful assessment, hands-on osteopathic treatment where appropriate, movement, rehabilitation and clear, evidence-informed advice. She is particularly interested in helping people understand their symptoms, regain confidence in their bodies and return to the activities that matter to them.

Evidence and further reading

This article is informed by current UK health guidance and contemporary evidence relating to knee pain and knee osteoarthritis.

The NHS provides guidance on common causes of knee pain and symptoms requiring urgent assessment, including inability to bear weight, significant swelling, locking, instability and a hot, red knee associated with fever or feeling unwell.

For osteoarthritis, NICE recommends tailored therapeutic exercise, including strengthening and aerobic activity, and advises that regular exercise can improve pain, function and quality of life. Routine imaging is not required for typical presentations of osteoarthritis.

Recent systematic reviews continue to support exercise as a central component of knee osteoarthritis management, although no single exercise approach appears appropriate for everybody and programmes should be tailored to the individual.

Clinical evidence continues to evolve and this article should be reviewed periodically as new research becomes available.

One Health Osteopathy Clinic
Oxford House, 15–17 Mount Ephraim Road
Tunbridge Wells, Kent TN1 1EN

This article provides general health information and does not replace an individual medical assessment.

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