Knee Pain Relief & Recovery: How an Exercise Physiologist Can Help

Knee pain is a common issue that can result from injury, overuse, or underlying conditions like arthritis.

It can make walking, bending, and even standing uncomfortable.

As an Exercise Physiologist, Nick develops targeted rehabilitation programs to help reduce pain, improve knee function, and enhance mobility.

This guide explores common knee conditions and how exercise therapy can support recovery.

Knee Osteoarthritis

The knee joint is made up of the femur (thigh bone) and the tibia (the shin bone). On top/between these two bones sits the patella (kneecap). Within the joint are two menisci, articular cartilage, and the main supporting ligaments of the knee. The weight-bearing nature of the knee joints predisposes the knees to gradual wear and tear, which can impact the articular cartilage of the joint, leading to osteoarthritis (OA).

Signs and Symptoms

Pain around the knee joint or shin
Pain after long walks, or after standing for a long duration
Joint stiffness, usually in the morning
Pinching type pain with particular movements, sometimes associated with sharp “locking”-type pain
Pain is usually intermittent, off/on pain, of varying severity
Pain with activities involving loading the knees, such as walking uphill or climbing stairs.
Noticeable loss of joint space between the femur and tibia, on X-Ray

Treatment approach

Keep Moving! When people experience pain from OA, they can become less active, which often makes their pain worse. Light stretching, walking, and general exercise decreases stiffness and weakness and improves pain, and preserves the strength of the knee joints!

Tailored Clinical Exercise will help to strengthen the muscles that support your knees (including your quadriceps, hamstrings, calves, as well as hip stabilisers and rotators), thus decreasing the severity and re-occurrence of your knee pain. Osteoarthritis in general is an irreversible condition BUT building muscle bulk and strength around the affected joints can help reduce the symptoms of OA.

Referral – If the Knee OA pain is unrelenting, or the joint degeneration is severe enough, referral to an orthopaedic surgeon may be indicated, for a potential Total Knee Replacement.

Other things to be aware of:

Flare ups: Re-occurrences of osteoarthritic pain often occur, but it is important to remember that this is a normal pain behaviour for the condition. Complete rest (such as bed rest) is NEVER the answer – keep moving, keep positive – your symptoms will eventually settle down.

Take medication:

During acute flare ups, painkillers and anti-inflammatories can help control the severity of your symptoms. Ask your doctor or pharmacist what medication is right for you and be aware of possible side effects. In severe cases, medication can control the pain so that physical activity can begin.

Patellofemoral Pain Syndrome (Runner’s Knee)

The patella-femoral joint (or PFJ) is the articulation of the kneecap on the femur (thigh bone). PFJ pain is an umbrella term relating to anterior knee pain due to irritation of the PFJ.

This can be caused by a number of contributing factors.

What causes PFJ pain?

PFJ pain can be caused by:

PFJ joint stiffness
PFJ osteoarthritis
PFJ mechanical irritation from maltracking of the patella (also called runner’s knee)
Weakness of the quadriceps muscle group (particularly the VMO muscle)
Other biomechanical factors i.e. Flat feet, hip weakness/internal rotation

Signs and Symptoms

Sharp anterior knee pain +/- referral down shin
Pain with climbing/descending stairs, running or walking uphill
Pain with squat/lunge type movements
Knee stiffness in the morning

Treatment

Tailored Clinical Exercise – improving the strength of the kneecap stabilisers (including the quads and VMO, hip rotators and foot musculature) is the best, most proven way of reducing/managing PFJ pain. Consult a Physiotherapist or Exercise Physiologist to get a thorough assessment and to help you address the contributing factors to your PFJ pain.

Manual therapy – mobilisation techniques can be beneficial in addressing PFJ stiffness if this is contributing to your pain.

Gradual return to full activity – As pain permits, slow re-introduction into full activity/training. This can be of variable timeframes, depending how irritable the PFJ is, or how strong the quads are.

Meniscus tear

There are two menisci in the knee joint – the medial meniscus and the lateral meniscus. These menisci act as shock absorbers for forces through the knee joint, but also serve to increase the stability and congruence of the knee. Meniscus injuries are generally put into 3 categories: Irritations, Non-obstructive tears, and Obstructive tears.

What causes Meniscus irritation/tears?

Like any structure in the body, the menisci of the knee can deteriorate over time. Particularly in people over 40 years old, irritation of the menisci can occur as a result of overload, having the knee in an awkward position for a long period, or just as a normal result of ageing. Tears of the menisci generally occur as a result of a fast, uncontrolled twist of the knee, which puts abnormal forces through the menisci, causing tears of the fibres. Non-obstructive tears occur with fraying or general tearing of the edges of the meniscus, but the patient can still fully weight-bear through the knee, the joint doesn’t lock or give way, and the knee has full range of motion. Comparitively, Obstructive meniscal tears involve an inability to fully weight-bear, locking or giving way of the knee joint, and noticeable loss of range of motion of the knee. The medial meniscus of the knee is much more commonly injured than the lateral meniscus of the knee. It is very common for meniscus irritation to occur in people with knee osteoarthritis.

Signs and symptoms of meniscal injury/irritation

Medial or lateral knee pain, most commonly at the anterior aspect of the knee joint
Pain worsens following moderate to intense activity, with pain/throbbing at night after these activities.
Pain with twisting motions of the knee.
Occasional referral of pain down aspects of the shin.
For acute tears, significant pain and swelling on one side of the knee joint.

Treatment

*Treatment for meniscus injuries varies, depending on the severity of injury*.

For meniscal Irritations and Non-obstructive tears, conservative management via exercise is the best, most evidence-based, and most proven way of returning to full function. For obstructive meniscal tears, a surgical opinion is often indicated, with an arthroscopy likely needed (followed by exercise-based rehab) to fully restore function in the knee.

Tailored Clinical Exercise will help to strengthen the knee stabilising muscles that support and control the movement of your knees and help offload the pressures on the meniscus. This is the most important part of your meniscus rehab! This itself can often relieve pain and works best to reduce pain in the long-term. Other exercises strengthening the calves, hamstrings and deep hip musculature are also an important part of this process.

Referral – if your symptoms do not reduce after about 3 months of exercise-based rehab, our staff may choose to refer you to a knee surgeon to explore further options. *For non-obstructive tears, this timeframe may be longer!

ACL tear

A ligament is a strong band of connective tissue that connects bone to bone. The Anterior Cruciate Ligament (ACL) is the first of the major internal ligament that stabilises the knee, together with the Posterior Cruciate Ligament. It stops the lower bone of the knee (Tibia) sliding forward uncontrollably on the upper bone (Femur). Without this ligament, whenever you twist or change direction the knee collapses, so you cannot play pivoting sports such as football, soccer, netball and hockey without this ligament.

How does it happen?

This injury most commonly occurs with activities involving a rapid change in direction, especially twisting, such as during netball, basketball, football and volleyball. It can be a small twist that just felt a bit awkward, but unfortunately can be enough to tear the ligament. It can also be ruptured with forceful knee hyperextension.

Signs and Symptoms of an ACL Tear

There can sometimes be a popping sound (not always), and the knee feels like it gives way. The knee usually swells up immediately and it is very hard to continue with the activity that you are doing, you may not be able to straighten the knee fully and if you continue your activity, you’ll find the knee gives way. If you suspect you have done this injury, you need to be seen by a physiotherapist/exercise physiologist or sport doctor WITHIN THE FIRST HOUR, as it is much easier to test this injury before it swells too much than afterwards. An MRI can also be performed if indicated to confirm any ligament damage in the knee and determine the extent of the damage.

Prognosis

The management of this injury does vary depending on the demands you place on your knee through your life, but your options should be discussed in detail with your physiotherapist/exercise physiologist or sports doctor. There are 2 main options:

Knee re-construction – Most people will choose to undergo a knee reconstruction. This is appropriate if
1. You want to continue to play sport throughout your life
2. The knee continues to give way
3. The is also a Meniscal injury

The rehabilitation for this operation takes 12-18months (yes that long, unless you are an elite-level athlete) and if you are not prepared to do this, the operation will be unsuccessful, and you should not proceed. However, you will be restricted in the activities you can do for the rest of your life.

Rehabilitation only – A specific strengthening program can help manage this problem if you choose not to have a re-construction, however, you will be limited in your activities and will not be able to play sports that involve pivoting activities again.

Diagnosis & Investigations

Usually a thorough assessment by an experienced physiotherapist/exercise physiologist will be enough to have a suspicion of an ACL tear, that will need to be confirmed by a surgeon. They will order at least an x-ray and usually an MRI scan, that will confirm the diagnosis, guide the need for surgery and rule out other potential injuries e.g. knee fracture.

Physiotherapy & Treatment for an Anterior Cruciate Ligament tear

It is important that you follow physiotherapist/exercise physiologist’s instructions and advice as the rehabilitation process will dictate the extent that this will affect your life in the long term.

If you are going to have surgery, an excellent pre-habilitation before the operation will dictate how long and how well you will recover after the operation. The stronger your muscles are before the operation, the better and faster the recovery afterwards. The rehabilitation will take 12-18 (for full recovery and return to sport) months as it takes this long for the new ligament to become strong again, but you strength and control will feel better after 3-4 months, if your strengthening program is guided by our physiotherapists/exercise physiologists and must be consistent

If you are not going to have surgery, a rehabilitation program is essential as the muscle control of the knee is the only thing stopping the knee from collapsing. Again, it will take 3-4 months, needs to be guided by our physiotherapists/ exercise physiologist and needs to be consistent. However, if it continues to give way, this will lead to a larger risk of other structural damage, and you will need to re-consider having a re-construction.

Return to Sport

To be cleared to return to your given sport and full-training, you will need to pass a series of hop tests and a questionnaire. These will need to prove that the operated knee is at least 90% as strong as the non-operated knee. This can reduce the incidence of ACL re-rupture significantly.

Other ligament tears (MCL)

The medial collateral ligament of the knee (or MCL), sits on the medial side of the knee joint. It works to resist valgus forces (buckling inwards) on the knee. It is “tight” at full extension of the knee, and at its most “lax” at 30degrees of knee flexion/bend.

What causes an MCL strain?

Generally, a twisting or hyperextension injury of the knee can cause some damage to the MCL. Another mechanism of injury is a direct blow to the outside of the knee that forces the knee to buckle inwards. It is not uncommon for other injuries to occur in conjunction with an MCL injury, namely involving the ACL and/or medial meniscus.

Signs & Symptoms

Medial knee pain and swelling
Inability to fully straighten the knee
Feeling of knee buckling/instability when walking or changing direction
MCL injuries are graded from Grade I to III.

Grade I – stretching of the ligament fibres, but most fibres intact. Mild pain +/- swelling.
Grade II – damage to a percentage of the ligament fibres, moderate to severe pain and swelling.
Grade III – most or all of the ligament fibres are torn or compromised. Significant swelling present, +/- pain.

Treatment

Limiting Range of Motion – depending on the grade of injury, limiting the range of motion of the knee helps to heal and restore the fibres of the MCL. This is generally done in a limited motion knee brace for grades II to III, or with rigid taping techniques for grade I. this helps reduce the stretching forces on the ligament, so the disrupted ends of the ligament can heal back together.

Tailored Clinical Exercise – this can be done as soon as pain permits. This will help to strengthen the quadriceps, hamstrings and calf muscles, restoring the knee’s strength and function over time. which help provide a suction effect on the hip joint.

Plyometrics and return to sport – Plyometrics (activities involving jumping and landing) is key to returning the injured knee back to full function. This helps the patient with their ability to control the knee with these activities, preventing valgus forces and reducing the risk of re-injury. In order to return to sport, the injured knee should be within at least 90% strength of the uninjured knee and should be able to pass a series of hop tests.

Referral – Your Physiotherapist or Exercise Physiologist may choose to refer you for an MRI scan to determine the extent and grade of your MCL injury. If you have suffered a suspected grade III MCL tear, referral to a specialist knee orthopaedic surgeon may be indicated. Occasionally, grade III ligament injuries may not have the capacity to heal themselves with limiting range and exercise.

Knee Tendinopathy (Jumper’s Knee)

Knee (or really, patella) tendinopathy (previous called patella tendonitis) is an overuse injury that causes anterior knee pain in active adults.

This condition usually coincides spikes in activity or exercise intensity, which causes irritation and breakdown of the patella tendon due to a lack of load-bearing capacity.

What causes it?

As mentioned above, Patella tendinopathy usually coincides with spikes in a combination of: exercise load, intensity, duration, or frequency. The tendon is not capable of supporting this spike and becomes irritated and starts to breakdown. This can happen in people who do a lot of running and jumping as part of their sport/training.

Signs and Symptoms

Pain felt just below the kneecap, at the inferior pole of the patella (most common area) but can also occur at the tibial tuberosity (less common).
Pain worse initially into activity but improves as the tendon “warms up”.
Pain worse after activity, particularly in the morning
Pain aggravated by kneeling, deep squatting, jumping/landing from jumping, direct pressure over the inferior pole of the patella, going up or down steps or running.

Treatment

Activity modification – Reducing or modifying any aggravating activities or exercises. As a general rule, pain shouldn’t be higher than 3-4 out of 10 either during or after any given activity or exercise. If this is higher, the load/intensity of this exercise needs to be reduced.

Isometric Exercises, or ISOs – In the initial stages of rehab, Isometrics (or ISOs) of the quadriceps muscles can help gradually build-up load capacity again with low risk of re-injury or pain flare-ups. In fact, ISOs can also have an analgesic effect on the patella tendon, reducing pain immediately after the exercise. An Exercise Physiologist or Physiotherapist can help guide you on the correct dosage and intensity of your ISO exercises.

Gradual return to full activity – As pain permits, slow re-introduction into full muscle contractions of the quads, with a focus on technique. Again, pain levels should not rise to higher than 3 or 4 out of 10 when these types of exercises get introduced. Once these are more tolerable, a gradual return to full activity can start to occur. If you are returning to sport, introduction of plyometric (jumping and landing) exercises is strongly recommended.

Other things to be aware of:

Avoid compression and stretching – a tightness feeling can occur in the quads/hamstrings/anterior knee when you have patella tendinopathy. If this happens, avoid stretching the area, as the tendon does NOT tolerate stretching well! Instead, try some ISOs. Avoid compression of the area too – kneeling, deep squatting with knees flexed past 90degrees, and long periods of sitting can aggravate this issue.

Injections – unless you have the co-injury of prepatella bursitis, corticosteroid injections can actually be detrimental to the integrity of the patella tendon, so these are to be avoided.

Knee pain doesn’t have to limit your mobility.

With the right exercise therapy and rehabilitation program, you can regain strength, stability, and confidence in movement.

Book an assessment with Nick to start your recovery journey today.