top of page




This is partly due to the number of individual structures that can contribute to knee pain and partly due to descending factors from the hip and ascending influence from the ankle. Like so many things in corrective manual therapy, there is a complex underpinning theory and a relatively simple therapeutic application. Over the course of this article we are going to demystify the complexities and lay out a simple treatment approach!

The clearest way to a deeper understanding of your client’s knee pain is a list of potential pain generating structures and a reliable assessment for each one (see Table 1 and Figure 4).

Most of the time muscles and ligaments are uninjured. They become painful because of sustained load or stress. This is known as simple ligament or muscle/tendon pain. Here are 15 of the most common chronic pain contributors and the assessments I most commonly use. There are many more assessments and you should definitely include your own.

Most of these structures become painful when the joint is compromised. Why? Because a joint capsule is densely populated with nociceptors. These sensory nerve endings are specialist ‘threat’ receptors 1 . When the joint function or position is compromised, the perceived threat sensitises the nervous system. This in turn causes an increase in tissue tension through protective guarding and an increased tendency to perceive any stimulus as pain. To reverse this process we need to down regulate the nervous systems response, unload any over stressed structures and restore joint movement.


  1. Normalize tissue texture

  2. Restore joint space and optimal position. Tissue texture.

Normalizing tissue texture simply means restore glide to any adhered tissues, extensibility to habitually short, tight muscles and improve tone in weak and inhibited muscles. Most therapists have their preferred techniques for this soft tissue work, but here is a suggested guide to treatment progression.

General Guide To Progression Through Treatment:

  1. Test the area – Active, Passive, Resisted Tests and Special Tests (Figure 1)

  2. Palpate

  3. Connective Tissue Massage

  4. Prepare/warm up with Effleurage and Petrissage

  5. Myofascial Spreading

  6. Soft Tissue Release (Figure 2)

  7. Trigger Point Therapy.

  8. Treat any strain/sprain – multi- directional friction, pain free movement and eccentric loading

  9. M.E.T. or P.N.F. for tight muscles / Spindle stim techniques for weak hypotonic muscles

  10. Home care – stretch tight muscles and strength train weak muscles.

Remember to look at the client’s posture to determine which muscles are short and tight and which are weak and inhibited. Regardless of where the client feels pain, you should treat the short, tight muscles first. In the vast majority of cases the flexors need treatment first.

Joint space and optimal positioning

There are two primary dysfunctions that contribute considerably to knee issues. The first is lateral rotation of the Tibia. This rotation tensions the Patellar retinaculum, the collateral and Patellofemoral ligaments.

It disrupts patellar tracking, contributing to Patellofemoral pain and places uneven load on the Meniscus leading to meniscal tears. The additional muscle guarding stresses tendons and can irritate local bursa.

It is typically a loss of extensibility in the short head of Bicep femoris that causes lateral rotation of the tibia. The IT band can also contribute to a lesser extend due to the influence of dysfunction in TFL and Vastus lateralis. Once the texture of these muscles i s normalized it is a simple process to de-rotate the Tibia (Figure 3)

Restoring joint space is almost as quick and easy as correcting tibial rotation. All synovial joints should be capable of joint play 2 and approximately 3mm (an eighth of an inch) of distraction. The knee can be assessed for joint space and treated simultaneously. First, the joint is placed under distraction by gripping the lower leg between the therapists legs and the therapist then leans back (Figure 5). The knee is now moved in an alternating Valgus / Varus direction. It there is joint space on both sides the bones will be felt to tap on either side. Commonly this is only felt on one side or occasionally not at all.

To correct this dysfunction and restore space the joint is mobilized in an Anterior / Posterior direction (Figure 6) then in a Valgus / Varus direction once again, all while under distraction. This can be repeated several times. Typically joint space will be restored and bone tap will be felt on both sides in under a minute.

Arguably one of the most effective home retraining exercises for reducing knee pain is a stretch for the short head of bicep femoris (Figure 7). This will have the added benefit of de-rotating the Tibia on a regular basis.

Additional home retraining can certainly include stretching of each of the Quadriceps with particular emphasis on Rectus femoris and Vastus lateralis. As Gastrocnemius also crosses the knee in is prone to tightness stretching of this important calf muscle can also be considered for long term maintenance.

Strength training the proximal portion of the hamstrings with Glute thrusts, squats and deadlifts can be added once knee pain is eliminated and the shortened muscles have regained their extensibility. Adductor strength training is also useful at this stage if these muscles have tested as weak.

Key takeaway points

  • There are many structures that can contribute to knee pain

  • Each structure should be assessed

  • Treat tight muscles before weak and work to restore optimal tissue texture

  • De-rotate the Tibia and restore extensibility to the short head of Bicep femoris.

  • Mobilise the knee to restore joint space

  • Home care exercises can maintain optimal bicep femoris length and prevent a re-occurrence of chronic Tibial rotation.

Having thought seminars on four continents, Aubrey is a highly regarded international presenter with over three decades of clinical experience. Together with his sister he runs a successful massage school in their home city of Dublin, Ireland.

He is also the author of ‘Myoskeletal and sports therapy’, ‘Kinesiology Taping Strategies and Assessment’ online course and former President of the Irish Massage Therapists Association.

Further resources

The micro module ‘Tibial Trouble’ demonstrates some of the relevant assessment, treatment and home care discussed in this article. Visit Holistic College Dublin’s website to purchase:

Books and videos are available on store/

A full range of Myoskeletal seminars, online courses and text books can be found on and


1. Messlinger K. Was ist ein Nozizeptor? [What is a nociceptor?]. Anaesthesist. 1997 Feb;46(2):142-53. German. doi: 10.1007/s001010050384. PMID: 9133176

2. John M. Mennell, M.D., Rationale of Joint Manipulation, Physical Therapy, Volume 50, Issue 2, February 1970, Pages 181–186, 10.1093/ptj/50.2.181


bottom of page