A Comprehensive Guide to Knee Pain

Your knees bear a lot of your body’s weight (they are the largest joints in your body for a good reason!). Because of their heavy loads, your knees also get a lot of aches and pains. One out of every four adults in the United States feels pain in their knees right now—ouch!  

The causes of knee pain can vary depending on your age, activities, and overall health. But the good news is: Most knee pain gets better without surgery or injections. There is so much you can do to improve and prevent knee pain. This guide can help you understand what you are experiencing and the best ways to treat your pain.

Getting to know your knees

Your knees are joints (place where bones meet) that connect your thigh to your lower leg. They allow you to bend and straighten your legs so you can walk up stairs, run for the train, and sit down at the end of a long day.

Your knees may seem simple to the touch, but they are actually complex structures made up of several parts including bones, tendons, muscles, ligaments, cartilage, specialized cushions called menisci, and more. All of these parts help move and support your knee—and all of them can be a source of pain.  

Common causes of knee pain

Because your knees are located in a prominent spot in your body, they often get hurt as a result of sudden (acute) trauma, such as from a car accident or sports injury. Common acute injuries to the knee include a ligament sprain or tear, meniscus injury, or muscle strain.  

Knee conditions can also develop over time without one specific incident causing the problem. Osteoarthritis (OA), the most common type of arthritis and a very common knee condition, can develop overtime and can contribute to knee pain and stiffness. Another example of an injury coming on with time is a tendinopathy (also called tendinitis). When the tendon of a muscle is stressed more than it can tolerate, it can becomes irritated and painful. This often happens with overuse injuries like jumper’s knee (also called patellar tendinitis).  

Knee conditions can also develop over time without one specific incident causing the problem.

Beyond the most common causes of knee pain, there are many other sudden and over time conditions that affect the knee. Several of these include kneecap tracking issues, fractures (broken bones), dislocations (where the bones no longer meet as normal), infection, gout, and autoimmune conditions like rheumatoid arthritis or psoriasis.  

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Do I need to see a doctor?

If you have knee pain, it is important to get a thorough medical evaluation. A medical doctor who specializes in muscle and joint conditions can help you understand what is causing your pain and get you started on the right course of treatment. 

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Do I need imaging?

Not necessarily. The need for imaging, such as an x-ray, MRI, or CT scan, will depend on a number of factors related to your pain. Imaging of the knee is more common after a specific or traumatic injury, as well as to diagnose osteoarthritis. With osteoarthritis, an x-ray will often show “narrowing” of the joint space or other bone-related changes such as bone spurs.

Your medical team will determine the need for imaging by asking questions about how your pain started and the nature of your symptoms. Your care team will also thoroughly examine your knee.  

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Should I worry about my x-ray or MRI?

If you do end up getting an image, it’s important to remember that these pictures represent only one piece of the puzzle. Research has shown no correlation between the severity of knee osteoarthritis seen on x-ray and an individual’s pain and function (Steenkamp, 2022). This means that some people with arthritis who have an x-ray that shows “bone-on-bone” (meaning a very narrowed joint space) can have very few symptoms, while others with the same x-ray findings may have great difficulty walking.

Research has shown no correlation between the severity of knee osteoarthritis seen on x-ray and an individual’s pain and function.

Another study looking at knee MRIs showed similar results. It found that the majority of people who were imaged (97 percent) showed “abnormalities” on their MRI, including 30 percent with meniscus tears. But guess what? Not a single one of these individuals had any pain (Horga, 2020).

These studies tells us that imaging findings do not always match up to a person's pain. They may often be a normal part of aging versus a problem that needs to be solved. If you do end up getting an x-ray or MRI, remember that the picture does not need to be clear of findings for you to feel your best and have great knee function!  

Do I need surgery?

Most knee conditions do not require surgery. The need for surgery depends on several factors including how the injury happened, the activities you would like to participate in, and how you have responded to various treatments.  

Acute and traumatic injuries to one or more structures of the knee may warrant surgery, but in every case, it’s important to know the risks of surgery and speak with your care team about all of your goals and options. For example, while some ligament and meniscus injuries require surgery, many do not. Some individuals who experience an anterior cruciate ligament (ACL) tear, a common athletic injury, do not need surgery and can return to high-level activity following physical therapy (Paterno, 2017).

Most knee conditions do not require surgery.

Many knee surgeries are also performed unnecessarily. If you have a torn meniscus, you may have heard of the popular procedure of getting your knee ‘scoped’ to remove the damaged pieces. For meniscus tears that happen over time (as opposed to from trauma), research shows there is no additional benefit to these surgeries compared to exercise-based physical therapy (Noorduyn, 2022). Even in a study with young adults, many of whom had traumatic meniscus tears, early meniscal surgery was not found to be any more effective than exercise and pain education (Skou, 2022). And, of course, there are risks to even a relatively simple operation like a knee scope.  

For knee osteoarthritis, a total or partial knee replacement (arthroplasty) may be performed if pain has not responded to other treatment. The decision to have this procedure should be based on your quality of life and the impact your pain has on it—not what your x-ray looks like.  

In all cases, if surgery is on the table, make sure to have a thorough conversation with your care team about your goals and options. It is also important to make sure you are medically ready for the procedure to optimize your success and speed your recovery.

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Will I get better?

Most likely, yes! Whether your injury happened suddenly or developed over time, there are a number of highly-effective treatments to get you back to feeling your best including physical therapy, non-opioid medication, anti-inflammatory nutrition, and pain education.  

Even if you have osteoarthritis, a knee replacement is not the first or only option for relief. Weight loss is commonly recommended for individuals with knee osteoarthritis that are overweight, because even small changes can make a big difference. Losing one pound of weight lowers the pressure felt by the knee by four times (Messier, 2005); that means losing just 10 pounds would relieve 40 pounds of pressure from your knees.

The Vori Health approach to knee pain

Treatment for knee pain can depend on a number of factors, but, most importantly, it should be personalized to you. At Vori Health, our care teams develop a custom-tailored plan to help you take control of your pain. Commonly recommend treatments include:  

• Rest and activity modification: Sudden and overuse injuries often require some amount of rest to give your body time to recover. Modifying activities can allow you to keep doing the things you love in some capacity while preventing your pain from getting worse.

• Exercise: Have you ever heard the saying “motion is lotion?” Well, it’s true! Specific and individualized exercise to maintain or improve strength, flexibility, and function should be at the center of your treatment plan for knee pain. Our doctors of physical therapy can support you with recommendations for activities that will allow you to keep moving without worsening your pain. And contrary to popular belief, running at a recreational (non-professional) level does not cause knee osteoarthritis and can actually be protective to your joints. Weight-bearing exercise, such as walking and running, as well as strength-training, improves the health of your knees. Our bodies adapt to the stressors to which we expose them and they become stronger. This means that as long as you listen to your body, you can and should keep moving!  

Running at a recreational (non-professional) level does not cause knee osteoarthritis and can actually be protective to your joints.

• Pain education: Not all pain is related to tissue damage. Sometimes knee pain can occur from stress or an overactive nervous system. Strategies that help you understand how pain works can help you take control of your symptoms and feel a whole lot better.  

• Nutrition: Increasing the amount of anti-inflammatory foods in your diet and decreasing foods that contribute to inflammation can improve your pain and support healthy weight loss.  

• Ice and heat: Ice is typically most beneficial for injuries that happened within the last few days, or if you are having swelling that limits your range of motion. Heat and/or ice can be used for pain that has been around longer. Remember to place a cloth between your skin and the ice or heat pack, and only apply for 20 minutes or less at a time (with at least 20 minutes between sessions). Check your skin to ensure no irritation occurs.  

• Medications: Over the counter non-steroidal anti-inflammatory (NSAID) medications can be helpful for knee pain but should be used with caution. NSAIDs are not meant to be taken long term due to harmful side effects. Topical NSAIDs (gels or creams) have been found to be beneficial for joint pain as an alternative to oral medications (Zeng 2018). It’s important to speak with your medical team to determine which option is best for you.  

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A personalized solution for you

At Vori Health, we use a team approach to support you as a whole person and address your pain. Your Care Team will include an expert muscle and joint pain doctor, physical therapist, health coach, and registered dietitian nutritionist. With this comprehensive approach, you and your care team can develop a plan to get you feeling your best, including a look at other factors in your life that may be contributing to your knee pain.  

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REFERENCES

1. Alentorn-Geli, 2017:  Alentorn-Geli E, Samuelsson K, et al. The Association of Recreational and Competitive Running With Hip and Knee Osteoarthritis: A Systematic Review and Meta-analysis. Journal of Orthopaedic & Sports Physical Therapy 2017;47(6): 373-390.  

2. Lo, 2018: Lo G, Musa S, et al. Running does not increase symptoms or structural progression in people with knee osteoarthritis: data from the osteoarthritis initiative. Clin Rheumatol 2018;37(9):2497-2504.  

3. Horga, 2020: Horga L, Hirschmann A, et al. Prevalence of abnormal findings in 230 knees of asymptomatic adults using 3.0 T MRI. Skeletal Radiol. 2020;49(7):1099-1107.

4. Messier, 2005: Messier S, Gutekunst D, et al. Weight loss reduces knee-joint loads in overweight and obese older adults with knee osteoarthritis. Arthritis Rheum 2005;52(7):2026-32.  

5. Noorduyn, 2022: Noorduyn J, van de Graaf V, et al. Effect of Physical Therapy vs Arthroscopic Partial Meniscectomy in People With Degenerative Meniscal Tears: Five-Year Follow-up of the ESCAPE Randomized Clinical Trial. JAMA Netw Open. 2022;5(7):e2220394.

6. Paterno, 2017: Paterno M. Non-operative Care of the Patient with an ACL-Deficient Knee. Curr Rev Musculoskelet Med. 2017 Sep;10(3):322-327.

7. Skou, 2022: Skou S, Hölmich P, et al. Early surgery or exercise and education for meniscal tears in young adults. NEJM Evidence 2022;1(2). Steenkamp W, Rachuene PA, Dey R, Mzayiya NL, Ramasuvha BE. The correlation between clinical and radiological severity of osteoarthritis of the knee. SICOT J. 2022;8:14. doi: 10.1051/sicotj/2022014. Epub 2022 Apr 6. PMID: 35389338; PMCID: PMC8988866.  

8. Steenkamp, 2022: Steenkamp W, Rachuene P, et al. The correlation between clinical and radiological severity of osteoarthritis of the knee. SICOT J 2022;8:14.  

9. Zeng 2018: Zeng C, Wei J, et al. Relative efficacy and safety of topical non-steroidal anti-inflammatory drugs for osteoarthritis: a systematic review and network meta-analysis of randomised controlled trials and observational studies. Br J Sports Med. 2018;52(10):642-650.

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