Last updated September 20, 2019

What Type of Knee Pain Do You Have?

Knee pain can be caused by an injury like a fall, or a sudden force to the knee when playing a contact sport like soccer or rugby, or from an awkward step which caused a sudden twist between the thigh and leg at the knee joint.

But knee injury can also happen gradually rather than from an accident. Overuse of the thigh muscles, poor posture and weak muscles are some common causes of progressive knee pain. Unlike a trauma-caused injury, the injury worsens overtime. When left untreated, walking, climbing up or down stairs, squatting and kneeling would become painful.

Most type of knee pain are progressive in nature rather than due to a trauma. So why do progressive knee pain occur? Is your knee pain located mostly on the anterior, posterior, lateral or medial knee? Why is it so and what can you do?


To understand why progressive knee pain occur is to first understand the purpose of the knee. A joint basically describes the space between any two bones. So the knee joint is the space between the thigh and leg bones. If we don’t have a knee joint, and the thigh and leg were of the same entity. we would have walked like toy soldiers, or guard men’s in a ceremonial march: straight and stiff. We would have to lift the leg high to avoid hitting the floor.

Figure 1: A ceremonial march without knee flexion. An example of how we would walk if we don’t have a knee joint.

Having a knee joint makes walking easier, and also more efficient. Bending the leg at the knee joint let us pick up the leg when we walk, as well as cushion the impact of the landing when our foot hits the ground. If we were to land our foot on a straight leg, the impact would have hurt the foot, and reverberate up the thigh to the spine. The ability to bend the thigh at the knee joint absorbs the shock when we walk.

The knee joint also allows for knee extension, the opposite of knee flexion. Extending the leg at the knee joint increases our stride length when we walk, and when our feet is on the ground, knee extension helps us stand tall.


The thigh and leg can move in relation to each other because of the existence of the knee joint. To keep the thigh and leg stacked and in place when we move, we have the knee ligaments. Imagine the knee joint like a space, and the anterior, posterior, lateral, medial and cruciate ligaments of the knees like strong ropes that bound the thigh and leg to each other at the knee joint. Collectively, the knee ligaments keep the thigh and leg in place.

However, neither the knee joint or the ligaments are responsible for moving the thigh or leg. They don’t flex or extend the thigh or leg at the knee joint when we walk, or squat or run. The task falls on muscles in the body. Muscles attached to the thigh and leg, particularly the quadriceps and hamstrings are responsible for knee extension and flexion at the knee joint.

Figure 2A: A medial view of the knee joint. 2B: The muscles attached to the thigh and leg which create movement at the knee joint. 2C: The knee joint without the muscle attachments. The knee joint is the space between the distal thigh and proximal leg.


Quadriceps are anterior thigh muscles. Quadriceps are attached from the anterior thigh to the anterior leg. Muscles can be likened to elastic bands because they are stretchable fibres, and they work like elastic strings to connect two bones together at a joint. In order to move any two bones, a muscle needs to have at least two attachments, one each on the bones they are supposed to move.

So when the quadriceps contract, they pull the leg closer to the thigh anteriorly because of the attachments to the two bones. The action creates knee extension at the knee joint. Imagine having many pieces of elastic bands pulling the leg to the thigh. It is how the quadriceps work when they contract. 

When you tie knots on the elastic bands, the knots shorten the length of the bands. Similarly, when the quadriceps are shortened by the knots or tension in the muscle fibre, they pull the anterior leg and anterior thigh too close together. The constant grinding of bone-to-bone can cause pain and premature wear-and-tear on the anterior knee.

Hence, the rule of the thumb — though there are exceptions —  is when you have anterior knee pain, quadriceps, the anterior thigh muscles, are likely to be knotted and tight. 


Conversely, hamstrings are posterior thigh muscles, antagonists to the quadriceps which are anterior thigh muscles. When the hamstrings contract, they pull like elastic bands but this time, on the posterior leg. The action brings the posterior leg closer to the posterior thigh, which causes the leg to flex or bend backwards at the knee joint. It is similar to the action of kicking the leg back.

When the hamstrings are knotted and tight, they shortened the distance between the thigh and leg posteriorly when they contract. There is too much bone-to-bone rubbing which can cause discomfort and injury on the posterior knee. Hence, the rule of the thumb when you have posterior knee pain is, the hamstrings are likely to be tight.


The anterior and posterior thigh muscles are big muscles. They are build large to carry the weight of the upper body when we move from knee flexion to extension, every time we transit from a seated to a standing body. Imagine carrying a heavy box from the floor to a standing position. The effort to lift the box is similar to the effort needed to lift the upper body from seated to standing. The thigh muscles have to be large for the task.

Figure 3: Place your hand on your thigh to feel for the contraction of the muscles at the knee joint. 3A: Knee extension. 3B: Knee flexion.

As the thigh muscles are big muscles of the body, you can easily feel the contraction of the quadriceps and hamstrings on the thigh. To feel the contraction of the quadriceps, sit on a chair:

  1. Place your right palm on your thigh (See Figure 3A.)
  2. Extend the leg at the knee joint and hold. Feel the hardening of the quadriceps in your palm
  3. If  you can’t feel the contraction, lift the leg slightly away from the floor and straightened the leg some more. You would feel an even bigger contraction on your palm. 

To feel the contraction of the hamstrings: 

  1. Place your right hand this time, at the back of your thigh (See Figure 3B.)
  2. Flex the leg at the knee joint by bringing the leg behind the chair. Feel the hamstrings hardened in your hand. 
  3. If you can’t feel the contraction, draw your leg further behind the chair. You would feel an even bigger contraction on your palm.


Figure 3C: Medial and lateral knee rotation.

We are also able to rotate the knee medially and laterally:

  1. Sit on the chair. Keep the right knee bend and the right foot on the ground. 
  2. Lift the right toes slightly off the floor. Keep the thigh unchanged pointed forward, but turn the right foot and leg into the body (medial rotation.)
  3. Bring the foot and leg back to the centre then turn the foot and leg away from the body (lateral rotation.)

You can repeat the exercise on your left leg. 

The thigh and leg are able to perform medial and lateral rotation at the knee joint when the knee are bend. Medial and lateral knee rotation allow us to change direction when we walk. We can turn to right, or left or turn around 180 degrees to head back. Being able to rotate the thigh and leg at the knee joint also let us play sports that require frequent directional shifts like tennis, badminton, basketball and soccer. We can cut in and out as we dribble a ball in a game of soccer because of the presence of the lateral and medial thigh muscles. 


If the pain is on the medial knee when you walk, it is likely the medial thigh muscles are knotted and tight. Conversely, if the pain is on the lateral knee, then the lateral thigh muscles are likely to be tight.

Hence, the direction of the pull of the tight muscles at the knee joint often determines the type of knee pain you are experiencing. So if you have anterior knee pain, loosening the anterior muscles of the knee with manual or physical therapy will bring relief. Similarly if you have medial knee pain, removing the knots and tension from the medial thigh muscles will reduce the medial pull on the knee joint.

There are, however, exceptions to the rule since we walk and stand differently. Sometimes, the cause of the knee pain is not due to tight muscles at the knee joint, but at the hip and/or ankles which can affect how the knee moves. For example, a tight hip or a stiff ankle may cause the knee joint,  which lies between the two joints, to move more to make up for the limited range of motion at the hips or ankle when we walk. Too much movement at the knee joint makes the knee unstable and vulnerable to injury.


What causes certain muscles of the knee joint to be tighter than the other muscles? Overuse of the thigh muscles, poor posture and a lack of stretching are common causes of muscle imbalance at the knee joint.

However, long hours of sitting can also cause muscle imbalance to occur at the knee joint as it weakens and tightens certain thigh muscles. Sitting for too long, where there is a lack of full knee flexion for example, can cause the quadriceps, the anterior thigh muscles to become weaker and tighter, compared to the hamstrings, the posterior thigh muscles.

When you try to recruit the quadriceps in physical activity like join an aerobic class, or pick up walking as an exercise, the quadriceps are unable to cope with the increased physical activity. The result is anterior knee pain. The pain is a setback if you have just started on your goal to exercise more regularly. 


What can you do? A combination of manual therapy and exercise for the knee have shown to relieve progressive knee pain. The reason manual therapy with exercise is effective is that it addresses the muscle imbalance at the knee joint.

Figure 4: Manual therapy with exercise offer a functional treatment for knee pain, and have shown to help progressive knee pain.

The conventional treatment is to treat knee pain as a structural problem, a degeneration of the bones at the knee joint and to treat the bones. However, you can also treat the pain functionally with manual therapy and exercise.  When we address the muscle imbalance at the knee joint, we remove the source of stress on the knee.

A functional treatment is less invasive, does not have a long recovery period, and does not require medication or injection. Why not give manual therapy and exercise a try today? Sign up for a session.

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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  1. October 10, 2019

    hi, do you treat scoliosis

    • October 11, 2019

      Hi Aive, yes. You can either call us, or fill in the online form and we will contact you.

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