I recently had a patient who had come in for a consultation with minimal knee pain. When he came to me, he was worried, distressed and anxious.
Because his doctor had told him that he might need a total knee replacement, as the cracking in his knees “…didn’t sound good”. However, this is an absurd notion, and this blog post is here to help you understand why. Fortunately, knee cracking, popping and snapping sounds in the knee are a common and completely normal process in the knees.
Physiological vs pathological sounds
The vital differentiation in knee sounds is the presence of ‘painful sounds’ versus ‘non-painful sounds’. In more formal terms, physiological (normal knee sounds) versus pathological knee noises (Song et al., 2018). In most cases, many individuals have normal physiological knee noises, which are associated with:
No worsening of sounds or increased symptoms (such as loss of ROM, increases in pain, decreases in functional ability)
No association with a history of injury
Sporadic or inconsistent noise characteristics (e.g. Usually the most common way to describe this is: “It sometimes cracks, but other times doesn’t.”)
Pathological noise is often associated with symptoms such as:
Swelling and effusion in and around the joint
On injury, a loud “POP” sound with pain was noticed
Consistent cracking with careful examination
A proper assessment and diagnosis will need to be completed by your physiotherapist to create an accurate diagnosis of your knee pain. In this situation, a trip to the doctor is not always necessary, as physiotherapists can assess and diagnose your knee pain and other surrounding tissues.
What EXACTLY causes noises in the knees?
Physiological Knee Noise
The exact origin of normal, physiological knee noises is variable. Some proposed mechanisms include:
Buildup or bursting of tiny bubbles in the synovial fluid
Ligaments and tendons may stretch as over a small bony lump and then snap back into place – causing the clicking sound
Catching of the synovium or physiological plica
(Song et al., 2018)
The buildup of cavitation bubbles in the synovial fluid of the knee joint is the commonly circulated explanation for knee joint noises. The sudden collapse of the bubble during regular joint movements can create the “popping” sound. The nature of this sound is sporadic due to the air buildup, which means that immediately after cracking your knee, it’s often hard to reproduce the same sounds again.
Pathological Knee Noise
There are many causes of pathological noise, which include degenerative changes (i.e. osteoarthritis), pathological plica, patellofemoral instability, pathological snapping knee syndrome and post-surgical crepitus (Song et al., 2018).
The Osteoarthritic Knee
The general characteristics of osteoarthritis may cause crepitus in the knee secondary to osteoarthritis—namely, gradual loss of cartilage, development of bony spurs and cysts. Crepitus in the knee can be synonymous with symptoms of patellofemoral osteoarthritis.
It comes at no surprise that greater severity of knee osteoarthritis is highly correlated with more significant pain levels and decreased functional abilities (Neogi et al., 2009; Sowers et al., 2011). Those with the highest pain had a higher likelihood and severity of pathological abnormalities such as:
Full thickness cartilage defects
Complex or mascerated meniscus tears
(Neogi et al., 2009; Sowers et al., 2011)
However, exercise can slow the progression and development of knee osteoarthritis (Bosomworth, 2009). In some cases, there is an associated improvement in pain and function in those who perform regular moderate exercise compared to those who engage in sedentary lifestyles (Bosomworth, 2009).
So what is the management of knee noises and/or osteoarthritis?
Managing ‘noisy knees’ really does depend on the underlying reason and the presence of physiological knee noise vs pathological knee noise. Like many other joints or spine-related pathology/pain, the most significant factor for knee noise may be the psychological factors associated with the sound or feeling. For those who don’t understand the fundamental reasoning behind knee noise, they may have anxious and negative thoughts, which can lead to decreased self-confidence, avoidance of movement/exercise and just general heightened sensitivity to any stimulus around the knee. Unfortunately, many times this may be compounded by your surrounding family and friends (unintentionally) when they make comments such as:
Those knees make you sound 20 years older
You have old people’s knees
Your knees sound arthritic
That doesn’t sound good for your knees
It is important to remember that knee noise isn’t something we need to worry about unless there are painful or functional changes to your knee. However, you should attend an appointment with your local physiotherapist if you have ongoing concerns.
Knee noises are scary if you don’t know what causes them. Most noise in your knee is generally non-painful physiological noises, which are naturally occurring sounds that happen in almost every person’s knees. If you have ongoing pain or functional limitations associated with the noise, then the recommendation would be to seek out your local health practitioner to get it checked.
In the meantime, it’s important to keep moving and keep exercising as you can! As this has the best chance of delaying chronic conditions like osteoarthritis of the knees.
Do you have noises in your knee?
Bosomworth N. J. (2009). Exercise and knee osteoarthritis: benefit or hazard?. Canadian family physician Medecin de famille canadien, 55(9), 871–878.
Neogi, T., Felson, D., Niu, J., Nevitt, M., Lewis, C. E., Aliabadi, P., Sack, B., Torner, J., Bradley, L., & Zhang, Y. (2009). Association between radiographic features of knee osteoarthritis and pain: results from two cohort studies. BMJ (Clinical research ed.), 339, b2844. https://doi.org/10.1136/bmj.b2844
Song, S. J., Park, C. H., Liang, H., & Kim, S. J. (2018). Noise around the knee. Clinics in Orthopedic Surgery, 10, 1 – 8.
Sowers, M., Karvonen-Gutierrez, C. A., Jacobson, J. A., Jiang, Y., & Yosef, M. (2011). Associations of anatomical measures from MRI with radiographically defined knee osteoarthritis score, pain, and physical functioning. The Journal of bone and joint surgery. American volume, 93(3), 241–251. https://doi.org/10.2106/JBJS.I.00667
Knee pain is annoying, and can often impact almost everything in your daily life. Whether that be walking to and from work, squatting down to get or getting in and out of your car. Unfortunately, there isn’t a band-aid solution that can solve your particular knee pain. Knee pain is multifaceted and requires a proper diagnosis of what particular structure might be causing the discomfort or pain.
However, for a specific type of knee pain – or even for any knee pain – taping can be an effective way to get some quick pain relief and help you get through your day. The purpose of this post is an informative guide on a specific taping technique called: “Modified McConnell Taping“. This is not encouraging the use of knee taping without proper rehabilitation advice from your healthcare professional.
Before We Begin: Contact Dermatitis
Before application of tape, you must test if you are allergic or have a reaction to the tape itself. Some individuals may have a reaction to certain components of the tape which may results in symptoms such as:
Tender to touch
Occasionally, specific brands of tape can cause allergic reactions, so you may have to ask your pharmacist on recommendations and to trial different types. This usually involves getting a small piece of tape placed on your hand or wrist, then seeing if there’s a reaction.
Diagnosis of knee pain
The diagnosis of knee pain is quite difficult as there are a multitude of structures that surround the knee. The particular structure this taping works well for is something colloquially coined: “Fat pad impingement“. Unfortunately, with the huge amount of variability within the physiotherapy profession, there is a large amount of variation behind the diagnosis and treatment behind this specific pathology.
The following signs and symptoms may indicate you have “fat pad impingement”. However, many of these symptoms are all common knee pain symptoms for any pathology.
Knee pain signs and symptoms:
Pain directly under the knee cap
Generally achy but sometimes sharp depending on movements
Sometimes may radiate to the sides of the knee cap
Pain with putting weight in a bent position (e.g. up and down stairs, lunging / squatting)
Usually settles with rest and not moving it
Returns after resuming activities, especially high impact exercise such as running or jumping
I must reiterate. Each of these symptoms individually will not mean anything, but collectively when combined with physical tests from a physiotherapist may reveal evidence of “fat pad impingement.”
The Taping Technique
General guidelines after the application of tape are:
Check for any adverse reactions, such as those mentioned in the Before We Begin: Contact Dermatitis section.
Tape can be kept on for 3 – 5 days, so long as you haven’t been sweating excessively
Tape can get wet, and just needs to be pat dried after showering
If the tape begins to come off, it is recommended to reapply as opposed to trying to fix it
Removing the tape: Roll the tape, do not rip the tape off. This can help with reducing skin irritation after taking off tape. (Hint: Don’t just rip it like a band-aid).
Let’s get one thing straight… Taping of the knee is not a long-lasting solution and will not be useful in the prevention of further knee pain. If the underlying reason behind the knee pain is not resolved, then recurrence of knee pain is common. However, this knee taping technique can still be useful in providing some pain relief with general knee pain.
A recommendation would be to follow this knee pain guideline as well as trial the application of this taping technique.
To summarise the knee pain guideline, knee pain can be improved by:
Short-term pain relief strategies, such as massaging, myofascial release and trigger point therapy
Education on pain management and understanding the pain cycle
Long-term management through a structured exercise programme
How many of us have heard about or felt the dread and fear that comes with a diagnosis of “knee arthritis.”
What do we do?
Can we fix it?
Will my pain ever go away?
Unfortunately, sometimes we feel like we’re hitting our head against the wall when trying to answer these questions.
Each one of these questions are so important, and for some, this might seem like a life sentence. But… What if I told you knee arthritis isn’t bad? Arthritis is a normal part of life, and an ageing process that each and every one of us have to go through as we age.
There are so many uncontrollable factors that influence the onset of arthritis, from:
Fitness level, and
Previous injury (Gly-Jones et al., 2015)
It doesn’t seem so bad now does it?
We’ve all heard that arthritis is bad. That it’s this disastrous diagnosis spelling the end of our youth and that we have old and painful, arthritic joints. But the thing is, arthritis and pain are not mutually exclusive. What I mean is that: You can have a diagnosis of knee arthritis, and have pain… But you can also have a diagnosis of knee arthritis, and have no pain!
The fact is that research supports the notion that osteoarthritic changes occurs in everyone. However, there are also individuals that have severe levels of joint arthritis, but are completely asymptomatic and have no pain (Dieppe & Lohmander, 2005).
Which means that arthritis DOES NOT equal pain. Please repeat that after me – Arthritis DOES NOT equal pain.
The good thing is, while we cannot fix your knee arthritis (because our medical and technological advancements aren’t at this stage), we can perform some simple actions and steps to relieve your pain. These are split into two main categories.
These techniques involve massaging or ‘trigger point release’ of the ‘tight’ musculature around the hip and knee joint, which may be involved in the tight sensation and painful feelings in these muscles. Fundamentally, massage does not change the underlying structures or physiology of muscles, nor does it make you any stronger, or place you in any position to decrease long-term outcomes by any means.
Regardless, they are still fantastic for pain relief. Trigger points and massaging of the common sensitive areas including: glute medius (side of your hip), glute max (your buttocks), your hamstring origin into the ischial tuberosity (the bony part of your bum) as well as the quadriceps (your thigh muscles).
As for duration and prescription – there are no strict guidelines as to how long you should spend on one specific area. The easiest way to approach this is:
Find a sore spot
Keep moving around on the sore spot until the tenderness decreases or disappears
Rinse and repeat
Be cautious of being over eager with massage, as you may find a bit more bruising the next day!
Part 2: Short-term pain relief – Passive stretching
Passive stretching is also a fantastic way to create some quick pain relief for tight structures and painful areas. However, while a long term stretching program may be able to increase flexibility or range, it does not increase the strength or stiffness of your muscles and tendons (Marshall, Cashman & Cheema, 2011). This may predispose the muscle or the individual to recurrent injury and may not provide any long term benefits.
Again, stretching is a fantastic adjunct or add-on to the next few steps, but should never be on its own. Some example stretches for the knee may include general quadriceps and hamstring stretches, glute med stretch (newspaper stretch), and calf stretching.
General prescriptions for stretching exercises generally vary around 20 – 30 second holds, for 2 – 3 sets of each stretch. I wouldn’t spend a lot of time stretching as there are other strategies and movements that can provide much greater benefits than stretching alone.
Part 3: Long-term pain management – Education
Understand that your pain is a multifaceted, complex machine. Simply attributing pain to the results shown on a scan is vastly underestimating the complexity of pain. Instead, we should be learning how to manage and understand the difference between “good” and “bad” pain.
We must understand that pain does not necessarily equate to structural damage within the knee. This is especially important as many are worried about further long-term damage when there is any onset of pain, especially with a diagnosis of knee arthritis. This can lead into negative habits and beliefs, and can have long-term consequences as a result.
A simple and easy way to understand this would be using “the pain cycle. “The cycle is destructive, and usually starts with pain, then immobility (decreased movement), atrophy (loss of muscle), decreased function which creates a predisposition for pain and the cycle starts again (Figure 1).
Figure 1: The pain-function cycle
Ultimately, our aim is to be able to intercept this pain cycle at one or multiple parts. Either through strengthening, encouraging movement and healthy practices, or – in extreme circumstances – the use of pain medication to offset the pain just enough that we can engage in exercises.
Part 4: Long-term pain management – Structured exercise program
Long-term improvement and prevention requires a structured exercise program aimed at targeting the specifically weak muscles of your lower limb. These exercise programs include strengthening of the glutes, quadriceps, hamstrings, calves and even your feet.
Exercise prescription is in itself a huge topic and one that I will save for a later blog post. However, general suggestions to improve lower limb strength and provide some basic strengthening for the lower limbs include: glute bridges, elevated glute bridges, calf raises as well as step ups.
Prescription for these can vary from 10 – 20 reps, 2 – 3 sets depending on your current fitness activity levels as well as your pain levels. If you are worried about rising or fluctuating pain levels, a set of rules that you can follow is, if your pain:
gets significantly worse during the activity
doesn’t settle after 10 minutes following stopping the exercise, or
is significantly worse the next day
Then STOP. You may have done too much, and will need to ramp it down and monitor your situation. Exercise prescription is a delicate balance between finding just enough exercise to help stimulate strengthening while also not performing too much that it stirs it up and makes it annoying unbearable to walk or move on.
Many individuals will have been plagued by knee pain or fear of knee osteoarthritis for years and years. Worse still, some individuals have been given the diagnosis of “knee arthritis” and were never given any actionable steps or solutions to easing pain and improving movement. The aim of this post is to highlight the fact that knee osteoarthritis is not a ‘death sentence,’ and we should not be overly worried about the ramifications brought about by scans and investigations and by even the words of some medical professionals.
Short-term treatments for pain may include massage, ‘self-myofascial release’, trigger points and stretches. However, if we are aiming for long-term improvement and prevention of pain in the knee, then understanding your pain is paramount and being able to provide a structured exercise program is key.
For more information, keep following our blogs for weekly posts.
Don’t hesitate, book in a consultation and talk to us!
If you could start moving again and get rid of your knee pain, how would that affect your life?
Dieppe, P. A., & Lohmander, L. S. (2005). Pathogenesis and management of pain in osteoarthritis. Lancet, 365, 965 – 73.
Glyn-Jones, S. Palmer, A. J. R., Agricola, R., Price, A. J., Vincent, T. L., Weinans, H., & Carr, A. J. (2015). Osteoarthritis. The Lancet, 386(9991),376 – 387.
Marshall, P. W. M., Cashman, A., & Cheema, B. S. (2011). A randomized controlled trial for the effect of passive stretching on measures of hamstrings extensibility, passive stiffness, strength, and stretch tolerance. Journal of Science and Medicine in Sport, 14(6), 535 – 540.