Knee Pain Physiotherapy: A Complete Guide

Why Knee Pain Is So Common

The knee is the largest and one of the most complex joints in the human body. It bears forces of up to 3–4 times body weight during everyday activities such as walking stairs and up to 8 times body weight during running. Given these demands, it is unsurprising that knee pain affects approximately 25% of adults and accounts for a significant proportion of physiotherapy consultations in Australia.

Data from the Australian Institute of Health and Welfare (AIHW) shows that osteoarthritis—the most common chronic knee condition—affects over 2.2 million Australians, with the knee being the most frequently affected joint. Physiotherapy is recognised as a first-line treatment for the majority of knee conditions, often delaying or eliminating the need for surgery.

Knee Anatomy: Understanding the Joint

A basic understanding of knee anatomy helps explain why different conditions cause pain in different areas:

• Bones – the femur (thigh bone), tibia (shin bone) and patella (kneecap) form the knee joint
• Articular cartilage – smooth cartilage covering the bone surfaces that allows low-friction movement
• Menisci – two C-shaped cartilage structures (medial and lateral) that act as shock absorbers between the femur and tibia
• Ligaments – the anterior cruciate ligament (ACL), posterior cruciate ligament (PCL), medial collateral ligament (MCL) and lateral collateral ligament (LCL) provide stability
• Tendons – the patellar tendon and quadriceps tendon connect muscles to bone
• Muscles – the quadriceps, hamstrings, calf muscles and hip muscles all influence knee function
• Bursae – fluid-filled sacs that reduce friction around the joint

Common Knee Conditions Treated by Physiotherapy

1. Knee Osteoarthritis

Osteoarthritis (OA) is the most prevalent chronic knee condition, characterised by progressive cartilage breakdown, subchondral bone changes and inflammation. Symptoms typically include pain with weight-bearing activity, morning stiffness lasting less than 30 minutes, crepitus (grinding or clicking) and reduced range of motion.

The Royal Australian College of General Practitioners (RACGP) clinical guidelines strongly recommend exercise therapy and weight management as first-line treatments for knee OA, ahead of pharmacological or surgical options. A landmark trial published in the BMJ found that a structured physiotherapy exercise programme was as effective as arthroscopic surgery for degenerative meniscal tears associated with OA.

2. Patellofemoral Pain Syndrome

Patellofemoral pain syndrome (PFPS) presents as pain at the front of the knee, around or behind the kneecap. It is particularly common in adolescents, young adults and runners. Evidence suggests that PFPS is driven by a combination of factors including quadriceps weakness, altered hip mechanics, training errors and patella maltracking.

A 2018 consensus statement from international experts recommends a combination of hip and knee strengthening exercises as the primary treatment. Physiotherapy for PFPS also commonly includes load management advice, taping, foot orthoses (in selected cases) and education about the condition.

3. Meniscal Injuries

Meniscal tears can result from acute injury (typically a twisting mechanism) or degenerative change. Symptoms often include pain along the joint line, swelling, catching or locking, and difficulty with deep squatting. While acute traumatic tears in young patients may require surgical repair, evidence increasingly supports conservative (non-surgical) management for degenerative meniscal tears.

A systematic review in the British Journal of Sports Medicine concluded that exercise therapy provides equivalent outcomes to arthroscopic surgery for degenerative meniscal tears in middle-aged and older adults, without the risks of surgery.

4. Patellar Tendinopathy

Commonly known as “jumper’s knee,” patellar tendinopathy causes pain at the bottom of the kneecap where the patellar tendon attaches. It is prevalent in sports involving jumping and rapid changes of direction. The condition is driven by failed tendon healing in response to excessive load.

The evidence strongly supports progressive loading programmes—particularly heavy slow resistance training and isometric exercises—as the most effective treatment. Complete rest is not recommended, as tendons require load to heal and remodel.

5. ACL Injuries

Anterior cruciate ligament injuries are common in sports such as Australian rules football, netball, soccer and skiing. Management may involve surgery (ACL reconstruction) followed by rehabilitation, or conservative management with physiotherapy alone. For more detailed information, see our guide on ACL injury rehabilitation.

6. Other Conditions

Physiotherapists also commonly treat iliotibial band syndrome, pes anserine bursitis, Baker’s cyst, Osgood-Schlatter disease (in adolescents), and post-surgical rehabilitation following total knee replacement or arthroscopy.

Physiotherapy Assessment of the Knee

A comprehensive knee assessment allows your physiotherapist to identify the specific cause of your pain and develop a targeted treatment plan. The assessment typically includes:

1. Subjective history – onset, mechanism of injury, location and nature of pain, aggravating and easing factors, previous injuries and treatment
2. Observation – swelling, muscle wasting, alignment (valgus/varus), gait analysis
3. Range of motion – active and passive flexion, extension and rotation
4. Muscle strength testing – quadriceps, hamstrings, hip abductors and gluteals
5. Special tests – ligament stability tests (Lachman, anterior drawer, valgus/varus stress), meniscal tests (McMurray, Thessaly), patellar tests (Clarke’s, apprehension)
6. Functional assessment – squatting, lunging, hopping, single-leg balance and sport-specific movements where relevant
7. Assessment of adjacent joints – the hip and ankle significantly influence knee function

Conservative Management: The Evidence

For most knee conditions, conservative management with physiotherapy is the recommended first-line approach. Key components include:

Exercise Therapy

Exercise is the single most important intervention for knee pain. Research consistently demonstrates that strengthening exercises improve pain and function across virtually all knee conditions. A comprehensive exercise programme typically includes:

• Quadriceps strengthening – e.g. straight leg raises, wall squats, leg press, terminal knee extension
• Hamstring strengthening – e.g. hamstring curls, bridges, Nordic hamstring exercises
• Hip strengthening – e.g. side-lying hip abduction, clamshells, single-leg squats (hip muscle weakness is a common contributor to knee pain)
• Balance and proprioception – e.g. single-leg stance, wobble board, perturbation training
• Flexibility – stretches for the quadriceps, hamstrings, calf and iliotibial band
• Aerobic conditioning – low-impact options such as cycling, swimming and walking

Manual Therapy

Techniques including joint mobilisation, patella mobilisation, soft tissue massage and dry needling may be used as adjuncts to exercise. While manual therapy alone is not sufficient for long-term improvement, it can help reduce pain and improve range of motion in the short term, facilitating engagement with exercise.

Load Management

Understanding and modifying the loads placed on the knee is crucial, particularly for tendinopathies and patellofemoral pain. Your physiotherapist will help you identify training errors, modify activities and develop a graded return-to-activity plan.

Weight Management

For knee OA, maintaining a healthy weight is one of the most impactful interventions. Research shows that losing just 5–10% of body weight can produce clinically meaningful reductions in pain and improvements in function. The AIHW reports that 67% of Australian adults are overweight or obese, making weight management a critical component of knee OA care.

Bracing and Taping

Patellar taping (McConnell technique) has evidence supporting its use for short-term pain relief in patellofemoral pain. Unloader braces may provide symptom relief in unicompartmental knee OA. These are typically used as adjuncts rather than standalone treatments.

Exercise Rehabilitation Programme

While specific exercises depend on your diagnosis, here is a general framework for knee rehabilitation:

Phase 1: Pain Management and Activation (Weeks 1–2)

• Isometric quadriceps sets
• Straight leg raises (4 directions)
• Gentle range-of-motion exercises
• Ice after activity if swollen
• Activity modification to reduce aggravating loads

Phase 2: Strengthening (Weeks 2–8)

• Progressive resistance exercises (squats, leg press, step-ups)
• Hip strengthening programme
• Balance training
• Low-impact cardiovascular exercise
• Gradual increase in training load

Phase 3: Functional Rehabilitation (Weeks 8–12+)

• Sport-specific or activity-specific drills
• Plyometric exercises (where appropriate)
• Agility and change-of-direction training
• Graded return to sport or full activity
• Maintenance exercise programme

When Is Surgery Needed?

Surgery may be considered when:

• Conservative management has failed – after an adequate trial of at least 3–6 months of quality physiotherapy
• Mechanical symptoms persist – true locking of the knee from a displaced meniscal tear
• Functional instability – recurrent giving way despite rehabilitation (e.g. ACL-deficient knee in a pivoting athlete)
• Severe osteoarthritis – end-stage OA with significant disability despite optimal conservative management may warrant total knee replacement

If surgery is required, physiotherapy is essential both before (prehabilitation) and after (rehabilitation) the procedure. Research shows that patients who are stronger and fitter before surgery recover faster and achieve better outcomes.

Preventing Knee Pain

Evidence-based strategies for knee pain prevention include:

1. Regular strength training – particularly quadriceps and hip muscles
2. Neuromuscular training programmes – programmes like FIFA 11+ and Netball KNEE reduce ACL injury risk by 50% or more
3. Maintaining a healthy weight – reducing mechanical load on the joint
4. Gradual load progression – following the 10% rule for increasing training volume
5. Appropriate footwear – shoes suited to your activity and foot type
6. Warm-up and cool-down – dynamic warm-up before activity, stretching afterwards

Finding a Physiotherapist for Knee Pain

In Australia, all registered physiotherapists hold a minimum of a four-year bachelor’s degree or a two-year graduate-entry master’s degree. For complex knee conditions, you may wish to seek a physiotherapist with additional qualifications in musculoskeletal or sports physiotherapy. The Australian Physiotherapy Association (APA) directory allows you to search for physiotherapists by location and specialisation.

If you are also experiencing lower back pain alongside your knee symptoms, these conditions may be related. See our guide to lower back pain for more information.