Exercise with Manual Therapy for Knee Pain

If you have been living in the same house or apartment for a while, you would know first hand the repairs — a leaking pipe, a popped tile, or a broken door — that is needed around the house. Our body is like the house we lived in. Our body also needs regular maintenance particularly as we aged. Different parts of the body will need fixing like the house.

Imagine you have a door in the house that won’t open like it should. You have to use force every time you want to open the door. On closer inspection, you find the door isn’t aligned to the frame. When you look at the other side of the door, you discover one of the door hinges has loosened. What do you do?

Figure 1: How would you fix the door? Option 1) Ignore it: apply strength whenever you need to open the door. 2) Saw off the edges of the door to fit the frame. 3) Re-fasten the hinge? We can apply the same choices to knee treatment.

Do you apply more strength to open the door, or cut the door so it fits the frame again, or re-fasten the hinge? You would likely choose to re-tighten the hinge.

The analogy is adapted from strength coach Michael Boyle, who used the analogy of a door, that needs a repair, to illustrate the choices we need to make when we have musculoskeletal pain. Do we ignore the pain and add more weights to an exercise like we use force to push open the door? Do we take an orthopedic approach: cut the bone to treat the pain? Or do we look at the biomechanics of the knee: find out what is restricting movement at the knee joint, and treat the dysfunction?

Michael Boyle is a strength and sport conditioning coach in America who has trained some of America’s best athletes, particularly in the field of ice hockey. He used the analogy in a training video.


Combining manual therapy with exercise offer a functional approach to the treatment of knee pain. Biomechanics of the knees simply means to look at how the knee moves. If bending the knee is causing the pain, or if the pain is felt when you extend the knee, then treating the muscles that are responsible for knee flexion or extension, respectively will restore function back to the knee and remove the source of pain.

The knee joint, ligaments and cartilages are not responsible for movement at the knee joint. The task falls on the muscles around the knee joint which are responsible for knee flexion, extension and rotation.


Muscles and other connective tissues like tendons, ligaments and fascia are known as soft tissues vis-a-vis the bones in the body which are hard tissues. We know massage works best on soft tissues because we usually feel better after a massage. Even a gentle foot rub can be soothing on the feet, so what’s more if the massage is more precise?

Manual or physical therapy is like a massage except more precise, as it is performed in the area that is causing the knee pain. The treatment involves muscle palpation and joint manipulation, performed by hand, to loosen the knots and tension at the knee to relieve the pain. It is also why manual therapy has been described as a “medical massage.”


As with all massage, you would feel better after the massage, but a good massage won’t change the way you walk or move. Including exercise to your knee care program provides a more lasting relief from the pain. The exercise part of the program addresses bad movement habits and strengthens weak muscles at the knee joint. The likelihood of a pain recurrence greatly decreases when the muscles of the knee joint are strong and are working in sync.

Figure 2: Not being able to balance on one leg are predictors of weak thigh muscles and knee osteoarthritis. Strengthening the thigh muscles with exercise can slow down knee osteoarthritis.


A 2000 study in the U.S., showed performing manual therapy and exercise twice a week for four weeks can improve function and reduce pain for patients with knee osteoarthritis. The patients walked further in a six-minute walk test than at the start of the study, and scored better in the Western Ontario and McMaster Universities Arthritis Index. WOMAC, a self-administered questionnaire, is a benchmark for evaluating hip and knee osteoarthritis than those in the controlled group. The questionnaire asked patients about the pain, stiffness and function when performing daily activities.

The study involved 83 patients with knee osteoarthritis at a military hospital in the US with a mean age of 60 – 62 years old.

Gains were sustained over eight weeks when the patients continued the exercise on their own. Manual therapy and exercise also decreased the risk of knee replacement surgery among the patients. When the patients were re-contacted a year later, only 5% of those who received manual therapy and exercise underwent a knee replacement surgery, compared with 20% of those in the controlled group.


Incorporating manual therapy to exercise also makes muscle aches and pain that come with exercise more manageable.

Exercise is the choice of treatment for knee osteoarthritis-related pain and disability in several medical guidelines, according to a 2017 clinical review on the outpatient treatment available for patients in Singapore. Exercise is the “conservative choice” of treatment because exercise is seen as relatively safe, and has proven to improve knee function and quality of life of patients, particularly for overweight patients.


In reality, however, not many patients with osteoarthritis would continue to exercise despite the benefits. Separate research showed one in two patients with knee osteoarthritis dropped out of prescribed home-based exercise within two years. Exercise-induced pain was the most commonly cited reason for the drop-out, a 2015 study in Belgium showed. Patients, who did not continue, reported feeling pain on the hip, lower back and sometimes on the knees from the exercise.

Poor health like presence of cardiovascular diseases, and age of the patient are other factors that determine whether patients continue to exercise. Knee pain patients above 75 years old and/or are in poor health at the start of the exercise program are more likely to drop out than those younger and in better health.


Muscle ache and pain are part-and-parcel of training even for the healthy population,  but the effects are more severe if you have been physically inactive for a while due to a painful knee. The muscle ache and pain may feel worse when the pain is compounded by other joint pain like on the hip and lower back which often accompanied knee pain.

Including manual therapy to exercises for knee care takes away the stings of exercise-induced pain, and any other joint pain that may arise due to an increase in physical activity. It allows patients to stay in an exercise program long enough to reap the benefits of exercise.

The same 2015 study found knee osteoarthritis patients who adhere to the prescribed exercise benefitted from the exercise.


A manual therapy session is like a good massage. But loosening tight muscles that need loosening won’t change faulty movement patterns. Exercise, on the other hand, can correct bad movement pattern like a habit of locking the knee when you stand, or of gliding the knee too far forward when you walk. If we break the bad habit, we remove the source of stress on the knee.

Manual therapy plus exercise work particularly well on gradual-onset knee injury, where poor movement pattern, repeated overtime, is usually the main cause of wear-and-tear at the knee joint. Correcting poor standing or walking habit with exercise such as, not locking our knees when we stand, or strengthening the posterior knee muscles with exercise to prevent an anterior knee glide; can remove the source of pain for gradual-onset injury, and keep the knee joint healthy.

When repairing a door that no longer opens smoothly, we don’t always have to saw off the door or replace it with a new one. Instead, if we can find the cause of the movement restriction and fix it, there is a good chance the door will move like it’s new again.


Michael Boyle. (2008). Functional Strength Coach 3.0: A Joint by Joint Approach to Training. United States.

Medical Disclaimer: Always consult your physician if you have an existing pain or a pre-existing medical condition before beginning any exercise. The above information is not intended to diagnose any medical condition or replace your healthcare professional.

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Knee exercises and activities that I can continue on my own

Working overseas, I came back to Singapore for a short four week holiday and thought I should get some Pilates classes to further strengthen my weak knee due to a meniscus tear. I found Move Therapy by googling and signed up for my 1-to1 trial class. May went through my problem and what the doctors did for me. She then designed a set of exercises and activities which I could continue on my own when I go back to work, overseas. After my first trial lesson, I was just so amazed by the differences in my legs. When I arrived back in Singapore, although I’ve recuperated from the meniscus tear through physiotherapy and physical therapy at the hospital, my legs still felt swollen and stiff. I was not able to bend my knees. My attempts at swimming, which was recommended by the doctor, was hard, as I wasn't sure how to move anymore. After my first session with May, my leg muscles felt more relaxed and subsequent sessions continued to make me feel I’m near full recovery. The exercises and activities May prescribed were easy enough to continue at home and in a gym anywhere I go. Thanks!

I'm running more, have less injury

I am an avid runner. I run 10km a few times a week. I had hurt my ankles, calves just to name a few of the body parts I’d injured from running. Many of times I didn’t wait until I have completely recovered before I resumed running. It had resulted in the injury being prolonged. After attending May’s Pilates classes for about a year, I have gained better awareness of my body and movement. May taught me a lot about core strengthening, maintaining good posture and about movement. I’m more aware of my running posture. I find myself correcting my posture on the go like altering my foot alignment when I encounter discomfort, as well as how to stretch after. I can run more often because I have less injury now. Thank you May.


"I was so worried about climbing Wutai Shan (Shanxi, China) because I'd knee pain. I wanted to  perform the Buddhist rite of walk, pray and kneel on every three steps up the 1,080 stairs of the sacred mountain. It was the main reason for going. It would be very difficult to do with my kneecap problem. My sister recommended Move Therapy to me. After one session, I was so surprised there was no more pain on my kneecap. I felt I was walking with very light steps. The relief was so immediate, it took me by surprise. Of course, I continued to roll after, using the foam roller. It wasn't just from one class at Move Therapy, but the class showed me how to and on which area of my legs I should focus on when I roll. I was able to walk, pray and kneel up Wutai Shan. A wish come true. No knee pain. Thank you."
Beng Lee

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