44 Knee Pain

Knee Pain

Physicians now more than ever are recommending conservative treatment including but not limited to low-impact exercise, acupuncture, and manual therapy as part of a multi-modal approach for patients suffering from knee pain.


Patellofemoral Pain Syndrome is an umbrella term used to describe pain around or behind the patella, it is common in individuals between 10 and 50 years of age. Patients often present with pain during daily activities such as stair walking, squatting or running (Winters et al., 2020).

Degenerative meniscus and osteoarthritis of the knee is a common finding in the general population, and in a majority of cases these degenerative knee changes are asymptomatic (Hortga et al., 2020). However in some cases this condition involves sensitization of nociceptive pathways, which may result in patients with osteoarthritis perceiving relatively low level stimuli as being overtly painful (Hunter & Bierma-Zeinstra, 2019).

Patellar tendinopathy is the preferred term for persistent patellar tendon pain and loss of function related to mechanical loading.


Knee Pain
Physicians, now more than ever are recommending conservative treatment options for patients suffering from knee pain.


A thorough health history intake can be done to gather information about patients’ limitations, course of pain, and prognostic factors for delayed recovery (e.g., low self-efficacy, fear of movement, ineffective coping strategies, fear-avoidance, pain catastrophizing) and answers to health-related questions. Screen patients to identify those with a higher likelihood of serious pathology/red flag conditions. Then undertake a physical examination: neurological screening test, assess mobility and/or muscle strength.

Incorporate one or more of the following outcome measurements when assessing and monitoring patient progress:

  • Self-Rated Recovery Question
  • Patient Specific Functional Scale
  • Brief Pain Inventory (BPI)
  • Visual Analog Scale (VAS)
  • The Western Ontario and McMaster Universities Arthritis Index (WOMAC)
  • Lower Extremity Functional Scale (LEFS)

Physical Examination

Incorporate one or more of the following physical examination tools and interpret examination results in the context of all clinical exam findings.

  • Bounce Home
  • Apley’s Test (Compression/Distraction)
  • McMurry’s Test
  • Valgus Stress Test (Medial Collateral Ligament)
  • Varus Stress Test (Lateral Collateral Ligament)
  • Noble’s Compression
  • Lachman’s Test
  • Anterior Drawer Test
  • Posterior Drawer Test
  • Posterior Sag Sign
  • Coronary Ligament Stress Test
  • Patellar Grind Test (Clarke’s Sign)
  • Thessaly Test
  • Bragard’s Sign
  • Mediopatellar Plica Test (Hughston Plica Test)
  • Plica “Stutter” Test
  • Ballotable Patella (Major Effusion or Patellar Tap Test)
  • Brush Test (Minor Effusion, Stroke, OR Wipe Test)
  • Fluctuation Test
  • Waldron’s Test
  • McConnell Patellofemoral Knee Test
  • Q-Angle
  • Patellar Apprehension Test



Provide reassurance and patient education on condition and management options and encourage the use of active approaches (lifestyle, physical activity) to help manage symptoms.

Manual Therapy

A massage therapy treatment plan should be implemented based on patient-specific assessment findings and patient tolerance. Structures to keep in mind while assessing and treating patients suffering from hip pain may include neurovascular structures and investing fascia of:

  • Erector Spinae (iliocostalis, longissimus, spinalis) & Multifidus
  • Quadratus Lumborum
  • Thoracolumbar Fascia & Latissimus Dorsi
  • Hip Adductors (adductor brevis, adductor longus, adductor magnus, pectineus, gracilis)
  • Quadricep Muscles (rectus femoris, vastus lateralis, vastus medialis, vastus intermedius)
  • Gluteal Muscles (gluteus maximus, gluteus medius, gluteus minimus, and tensor fasciae latae)
  • Hamstring Muscles (semimembranosus, semitendinosus and biceps femoris)
  • Anterior Compartment of the Leg (tibialis anterior, extensor hallucis longus, extensor digitorum longus, peroneus tertius)
  • Superficial Posterior Compartment of the Leg (gastrocnemius, soleus, plantaris)
  • Deep Posterior Compartment of the Leg (flexor hallucis longus, flexor digitorum longus, tibialis posterior, popliteus)
  • Proximal Tibiofibular Joint
  • Ankle Joint (talocrural joint, subtalar joint and inferior tibiofibular joint)

Self-Management Strategies

Massage therapists not only provide hands-on treatment they can also develop self-management programs to help patients manage symptoms. Simple home-care recommendations such as hydrotherapy, stretching, and strengthening exercises have been shown to be useful for patients with knee pain (Kolasinski et al., 2020; Willy et al., 2019).

Massage Sloth: Massage Tutorial – Knee Pain


Physicians now more than ever are recommending conservative treatment options for patients suffering from knee pain. Two recent randomized clinical trials have highlighted the effect of conservative treatment options for patients suffering from osteoarthritis related knee pain. In one randomized clinical trial published in the Journal of General Internal Medicine massage therapy was shown to improve function in patients who suffer from osteoarthritis related knee pain (Perlman et al., 2019). In addition, a randomized trial published in The New England journal of medicine demonstrated the benefits of a conservative multimodal approach (manual therapy + exercise) for patients with symptomatic osteoarthritis of the knee (Deyle et al., 2020).

Key Takeaways

Contemporary multimodal massage therapists are uniquely suited to incorporate a number of rehabilitation strategies for knee pain based on patient-specific assessment findings including, but not limited to:

  • Manual Therapy (soft tissue massage, neural mobilization, joint mobilization)
  • Education that is Person-Centered (e.g., biopsychosocial model of health and disease, self-efficacy beliefs, active coping strategies)
  • Stretching & Loading Programs (e.g., concentric, eccentric, isometric exercises)
  • Hydrotherapy (hot & cold)
  • Self-Management Strategies (e.g., engaging in physical activity and exercise, social activities, and healthy sleep habits)

References and Sources

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