Knee Pain in Kirkland
Knee pain is another one of the most common musculoskeletal complaints seen in already active adults and those trying to become more active. While some knee injuries are traumatic and may require immediate orthopedic evaluation, the majority of knee pain seen in clinical practice tends to be more gradual and non-surgical in nature.
Many people begin noticing knee discomfort during activities like:
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Squatting
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Stairs
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Hiking
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Running
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Getting up from chairs
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Prolonged sitting
Knee pain can be due to one or a combination of the following:
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Joint irritation
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Tendon sensitivity
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Decreased load tolerance
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Movement compensation
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Reduced strength
Contemporary research increasingly supports that knees are adaptable structures that respond to progressive loading over time. Problems often develop when the demands being placed on the knee exceed what the surrounding muscles, tendons, and joints are currently prepared to tolerate.
Common Types of Knee Pain
While there are numerous structures in the knee that could experience traumatic injury, chronic, overuse, and gradual wear-and-tear conditions are commonly seen at Integrity Chiropractic among active working adults.
These generally are:
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Patellofemoral Pain
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Quadriceps or Patellar Tendinopathy
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Pes Anserine Tendinopathy
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IT Band Syndrome
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Degenerative & Arthritic Knee Pain
This is not an exhaustive list, but these are some of the most common cases of slower-developing and ongoing knee pain. As you read, keep in mind that these can sometimes overlap and interact with each other, which requires a thorough evaluation to help figure out how to systematically address each of the issues.
Patellofemoral Pain Syndrome
Typically, this has been considered a diagnosis for knee pain when other more probable issues have been excluded, although it is now recognized as a clinical condition with its own characteristic presentation. This type of knee pain generally describes pain occurring around or behind the kneecap, where it glides over the front surface of the femur. This pain tends to occur with squatting and lunging and tends to come up in higher-intensity gym classes, certain types of dance, and going up and down stairs or hills.
While it is not generally considered a degenerative or traumatic type of pain, and imaging often does not identify a specific structural cause, it could be reasonably thought of as a sign that the knee is not tolerating the demands of a particular activity well. This may be related to the amount of loading, individual biomechanics, muscle strength, or movement control. However, this does not necessarily indicate damage to the joint surfaces or that the knee is progressing toward a degenerative condition.
Quadriceps and Patellar Tendon Pain
This is very similar to patellofemoral pain syndrome in its presentation, but tends to be more easily localized to above or below the kneecap by the patient and doctor. The kneecap, or patella, is a bone embedded within the quadriceps tendon as it passes over the knee joint to transfer force to the shin bone. There is tendon tissue above and below the kneecap. Above the kneecap it is referred to as the quadriceps tendon and below it is referred to as the infrapatellar or patellar tendon. The condition commonly called Jumper's Knee refers to patellar tendinopathy, while Runner's Knee is more commonly associated with patellofemoral pain.
The primary functions of the quadriceps muscle are to straighten the knee when standing up from a bent position such as a squat and to control the bending speed of the knee to absorb force, such as when landing on the foot during walking or running. With substantially higher magnitudes of loading experienced across the quadriceps during these activities, coupled with an increased volume of contractions, this type of pain tends to become aggravated when the loading demands start to exceed the rate at which the tendon is able to adapt and recover.
Pes Anserine Tendinopathy
This knee pain is often mistaken for a degenerative joint or ligamentous type of pain by patients as it can be vague and hard to pinpoint because it is not a commonly understood part of the anatomy of the knee. Three of your long thigh muscles (semitendinosus, sartorius, and gracilis) from different areas run and eventually terminate into tendons that attach to the upper and inner part of your upper shin bone at the knee to provide leverage and control across the knee joint for movement. They are collectively named the pes anserinus as they look like the webbed foot of a goose.
Typically, pain develops in some individuals here when the volume of squatting or running is increasing. These muscles help to assist control of the multiplanar motion of the knee, and factors such as anatomy, strength, and motor control may influence how much stress is placed on these tendons as they work harder. The nearby bursa can also become irritated and produce similar symptoms. Because pain along the inside of the knee can also come from the joint, meniscus, or ligaments, a thorough examination is important to distinguish between these possibilities.
IT Band Syndrome
This type of knee pain afflicts the outside of the knees. It's a common complaint in runners and hikers and tends to be more noticeable when going downhill. The iliotibial band is a thick, broad, fibrous band of tissue that your tensor fascia lata and gluteus maximus attach to, aiding with movement of the hip and thigh as well as providing stability to the knee. This condition is generally an overuse condition. While it used to be believed that a tight IT band leads to increased friction as it passes over a bony landmark in the outer knee, more modern research suggests that pain may be due to compression of sensitive structures underneath it instead. The exact mechanism is still being studied. It is also not as pliable as once thought, making this more than simply a mobility issue. Rather, the issue may come down to a combination of biomechanics, tissue loading adaptability, and training volume.
Degenerative & Arthritic Knee Pain
These changes tend to be found more commonly in the older adult population, particularly in those with a past history of knee injury or other risk factors. However, leading a very active lifestyle does not necessarily mean that someone will develop arthritis. In more serious cases, these patients will complain of symptoms like catching, aching, stiffness, or swelling while active during the day and may self-limit their time with activities to manage symptoms.
It is not uncommon that many of these patients have already had X-rays that identified bone spurs, degenerative cysts, or joint-space narrowing. If MRI imaging has been done, it may have identified chronic degenerative tears in the menisci of the knees as well as cartilage surface wear. Much like the low back, imaging findings can range from mild to severe in various structures, but do not always necessitate surgical interventions right away, as findings on imaging do not always correlate well with pain levels and function.
With measured and progressive work, many degenerative knees can still adapt to take on more load and activity, allowing patients to maintain their physical function and potentially delay orthopedic interventions, which is often desirable for many patients. Strengthening is an important part of this process, but aerobic activities such as walking, cycling, and aquatic exercise can also help improve pain and function. While exercise may not reverse the underlying degenerative changes, it can improve how well the knee functions despite those changes.
Some of these patients may also explore injection-based treatments such as corticosteroids, hyaluronic acid, or platelet-rich plasma, although the evidence for their effectiveness varies. Stem-cell injections are also being marketed for degenerative knees, but their effectiveness and safety remain uncertain, and they are not established treatments for restoring cartilage. Ultimately though, it may be found that some cases are best served with orthopedic interventions sooner rather than later.
What Leads to Knee Pain and Why the Pain Often Keeps Returning
Often, what is common in these conditions is that they tend to correlate well with the volume and intensity of the activity and training.
Adult patients tend to demonstrate patterns where they go from large windows of minimal loading to overloading. Here's a common list of situations that patients often find themselves in:
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Your office team started a daily 10K walking challenge and you've had significantly fewer daily steps before.
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You started training for a half or full marathon which is having you run 3-4 times a week with minimal or no running volume before.
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Doing increasingly difficult hikes to ramp up for a difficult hike like Rainier or the Enchantments.
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Joining a HIIT class or app to lose weight at the beginning of the year with no exercise or ramp-up prior.
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Increasing training loads and volumes to prepare for a regional or Open competition in CrossFit.
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Went to sprint with kids or friends as you used to do this competitively when young but haven't done it in years.
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Starting an intense dance routine with no prior physical training.
While our bodies tend to be very resilient when we are younger, the reality is that many adult bodies do not tolerate rapid increases in intensity well, particularly after long periods of reduced activity.
It is not unusual that many patients have already had one or more rounds of physical therapy, which oftentimes were successful at addressing pain while they were under active treatment and initially compliant with their home exercises. However, many patients drop their home care program after they have gone some time without symptoms. For many reasons, busy adults often don't put in the preparatory and maintenance work to keep the musculoskeletal system in a state that allows them to participate more intensely in the activities they enjoy, which is one reason pain may gradually return.
For some patients, they may have tried to overcome these issues by "toughing it out" without success. Overtraining, even when receiving the best care, can counteract its effects. This is because tissue adaptation and loading tolerance sometimes require a pace that doing the actual activity doesn't respect. It is difficult for some patients to temporarily slow down as it can feel unproductive.
In some cases, patients develop avoidance of certain activities altogether due to fear, when the activity may not have been the issue, but the ramp-up to it.
Unfortunately, the general population is not well trained in exercise physiology, and information is constantly changing our understanding of training and injuries.
Adult bodies tend to bring years of accumulated issues to the table such as prior injuries, deficient or altered biomechanics, poor motor control, and reduced muscle and tendon conditioning on top of potentially slower adaptation. In clinical practice, it can often be observed that rebuilding the physical capacity needed for demanding activities can take several months or longer in some adults, particularly when the problems have been present for years. However, the time required varies considerably depending on the condition, the individual, and how consistently they are able to participate in their rehabilitation.
Many knee pains are not insurmountable, but they require adherence to a well-thought-out and comprehensive plan along with patience and the development of good self-care habits because many of these issues developed over a long period of time.
What Research Says About Conservative Care for Non-Traumatic Knee Pain
Modern research is supportive of conservative interventions as a first option for dealing with many non-traumatic knee pains as discussed above. Despite each of the different knee pains having unique characteristics, you will find that there are often common overlapping themes when it comes to treatment.
Strengthening of the hips and muscles around the knee is commonly cited in research as a good option to reduce pain and improve function. It is generally thought amongst clinicians that this works in part because the hips help to maintain control of the knee during movement, which may better allow the muscles that cross the knee joint to work and manage the loads placed on the knee. However, research also suggests that strengthening at just the knee joint may yield meaningful benefits in pain and function as well, and that combining hip and knee strengthening may be more helpful for some conditions than others. This means that while there are positive findings with different treatments, there is room to interpret what is actually best for the knee.
Clinically, it is found that there are other factors that may be at play as well. Pure strength does not necessarily equate to good dynamic control, which may be important depending on the offending activity. Core strength, ankle mechanics, and foot strength also can affect what happens at the knee as what is above and below the knee can influence function in different scenarios. Your anatomy, due to genetics or how you interacted with your environment during development, can also play a factor in addition to your natural ability to tolerate and adapt to loads. Mobility issues can also play a factor in stressing some tissues. Lastly, pre-existing injury also brings an element of complexity that must be considered and contended with.
However, it is also important to recognize that not every difference in movement or anatomy is necessarily a problem. People naturally move differently, and the goal is not to make everyone move in exactly the same way, but to identify whether any particular limitation is relevant to the pain or activity in question.
The knee is complex in that it must manage movement and help dissipate impact from the ground while working between two other joints that often bring local biomechanical challenges of their own. The best care takes into consideration what research informs along with what factors each individual brings to the table to create care that is truly tailored to you.
Treatment at Integrity Chiropractic
Whether your knee pain occurs during squatting, running, hiking, or simply getting up from a chair, understanding what activities provoke your symptoms and how your knee responds to loading is an important part of determining where to focus treatment. Treatment at Integrity Chiropractic starts by understanding your background and training history and conducting a detailed physical exam that may look at:
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Gait
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Ankle and knee mobility
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Hip mobility and strength
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Anatomical considerations in the hip and knee
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Movement compensations
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Knee mobility and control
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Core strength
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Squat, lunge, and jump mechanics
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Orthopedic testing of the knee's ligaments, menisci, and tendons
Depending on the symptoms, the examination may also consider whether pain is being referred from the hip or low back.
This helps to narrow in on where to prioritize and implement interventions to help you control the pain and start to progressively adapt to take on more load over time.
Treatment includes some combination of:
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Manual therapy / soft tissue release
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Joint mobility work
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Tendon loading management
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Progressive strengthening
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Exercise progression
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Return-to-activity planning
Patients' prior treatment experience tends to reveal that they were previously receiving primarily passive or active care for their knee pain, more often the latter. Hands-on care may be helpful for managing symptoms, but progressive strengthening and loading are often what prepare the knee to tolerate more demanding activities again. At Integrity Chiropractic, both are utilized to help the patient comfortably recover and return to their previous activities.
For patients who have completed rehabilitation but still need to rebuild their general physical capacity before returning to more demanding exercise, our Movement Fundamentals program provides a structured progression back toward training.
A Common Presentation of Knee Pain
The following is a fictional clinical example of a common type of knee pain that presents at Integrity Chiropractic.
A patient in her forties has been an avid hiker for several years and has experienced prior right knee pain that was successfully resolved with physical therapy a few years ago. She used to be consistent with her homework for the first year, but eventually stopped as she was feeling better. Life got busy and she took a break from hiking, getting a little out of shape, but is generally healthy. She gradually started to return to hiking in the past year and noticed some knee pain started to occur on the right side again, especially when coming downhill during her hikes, that was general and vague. In the past two months she also started participating in a group strength training class twice a week thinking that would be helpful for her knee pain, but it has continued to get worse as bending down at home or coming down the stairs are becoming more painful. Inquiry about the class finds that she does a lot of squats and lunges in her training class.
Physical examination finds that her knee demonstrates normal functional range of motion that is pain-free. Orthopedic tests for ligaments and menisci are unremarkable. Trying to provoke the kneecap also does not appear to recreate the pain. Muscle tension screening finds that the right quadriceps is notably tighter compared to the left when moving toward end ranges. Resisted knee straightening is painful at the top of the right knee at some angles and completely pain-free when repeated on the left. Compound movement screens find that lunging or stepping down on that leg demonstrates difficulty maintaining knee alignment compared to the left knee along with pain. There is also lateral core weakness found during screening. Inquiry about her past physical therapy treatment finds that she did lateral hip strengthening exercises that consisted of clamshells and lateral walks with a band along with some basic core stability work.
The patient is diagnosed with probable quadriceps tendinopathy and treatment starts by doing manual therapy and exercises to help reduce the discomfort and muscle tension associated with the quadriceps and improve her tolerance for loading the tendon. Kinesiology taping is utilized as a trial to help temporarily reduce her perception of pain during certain activities. Concurrently, the patient is also started initially on isometrics as a tolerable way to begin loading the tendon, along with focused lateral hip strengthening. As her goal is to continue to hike avidly, the goals of the program are to strengthen her core to bear greater load while wearing a backpack and improve hip and knee strength to successfully navigate the ability to step up large rocks and steps and descend back down with control. Over the course of 10 visits in the next 2-3 months she is gradually shifted from significant hands-on treatment to more active treatment with a focus on developing her lateral core and hip strength along with knee strength and balance in an ever-progressive manner.
Toward the last couple visits of her treatment, she finds she is able to do things such as bear crawls, side planks, single-leg lunges with moderate weight, and single-leg deadlifts. She also notes she has been able to return to her training class and while somewhat apprehensive at times, she has been able to do all the exercises without an issue. There are no problems at home either with moving around the house. She found the rehab was hard at times, but she stuck to the plan and was able to return to hiking.
The strategy is relatively simple: control and reduce pain significantly, introduce mobility and strengthening where needed, and progress from simple to high-level exercises to prepare for what may come.
When Imaging or Surgical Evaluation Matters
While there are many research studies that indicate knee pain can be managed conservatively, even in some traumatic cases, there are times when it is helpful or necessary to receive an orthopedist's evaluation, even though social media tends to overamplify conservative care.
When there is a history of trauma or a recent injury, ligament and meniscus tears must be considered. These contribute to the internal stability and function of the knee, and certain injuries may have implications for future joint health.
Whether you've had a contact or non-contact injury, you may require imaging and an orthopedic consult if examination finds that you are experiencing:
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True mechanical locking or an inability to fully straighten the knee
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Significant instability
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Major or rapidly developing swelling
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Inability to bear weight
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Significant loss of motion or function following an injury
A hot, markedly swollen knee accompanied by fever or feeling systemically unwell also requires prompt medical evaluation because infection and other serious conditions must be considered.
Not all of these findings automatically mean that surgery or advanced imaging is necessary, but they do warrant appropriate assessment. When suspected, a thorough examination at Integrity Chiropractic will check for the potential presence of these injuries and help make the appropriate referral.
Recovery and Long-Term Outlook
The recovery path and outlook for every patient will vary depending on their condition and overall health, but many knee conditions respond well to this kind of conservative care. If your knee pain keeps returning or is preventing you from participating in the activities you enjoy, a thorough evaluation can help identify what may be contributing to the problem and determine an appropriate path forward.
