The Most Common Causes of Knee Pain: A Physical Therapist’s View

When it comes to knee pain, many people believe it’s caused by arthritis, a torn meniscus or other damage seen on an X-ray or MRI. But from a physical therapist’s perspective, the most common causes of knee pain are often movement problems and muscle imbalances that make the knee move too much, in ways it shouldn’t.

These faulty movement patterns create uneven wear and tear on the knee joint, leading to pain, inflammation and a higher risk of long-term joint damage. Here are three of the most common knee dysfunctions we see in the clinic, how they cause pain, and how to fix them.

1. Tibiofemoral Rotation Syndrome: The Twisting Knee

What it is: tibiofemoral rotation syndrome happens when the tibia (shinbone) and femur (thighbone) rotate too much in opposite directions during movement. This rotation puts uneven stress on the knee joint, especially the ligaments, cartilage and meniscus.

It’s often caused by muscle imbalances between the quads, hamstrings and glutes, along with poor foot and hip mechanics.

Common Causes

• Weak gluteus medius: leads to poor hip stability
• Overactive hamstrings: pull the shin into rotation
• Overpronation of the foot: the foot rolls in, which rotates the knee inward

How It Causes Pain

• Ligament stress: extra strain on the ACL and other knee ligaments
• Meniscus wear: twisting forces wear on the meniscus
• Kneecap pain: it can lead to patellofemoral pain syndrome (pain around the kneecap)

How to Fix It

• Hip strength: strengthen the glutes and hip stabilizers to improve knee alignment
• Foot mechanics: improve how the foot works to limit overpronation and knee rotation
• Movement retraining: correct squat and lunge patterns to reduce twisting forces on the knee

2. Hip Knee Hyperextension Syndrome (HKE): When the Knee Straightens Too Far

What it is: HKE happens when the knee straightens beyond its normal range, often before the hip extends properly during walking, running or squatting.

It’s driven by overactive hamstrings taking over from the quads and glutes, so the knee locks out too early. The result is too much knee extension and instability, which can cause pain and add to knee hypermobility.

Common Causes

• Weak quads and glutes: they don’t control the knee as it straightens
• Overactive hamstrings: they take over the work
• Stiff ankles: limited ankle dorsiflexion (bending the shin forward over the foot)
• Poor control: weak coordination through the hip-knee-ankle chain

How It Causes Pain

• Joint stress: more stress on the knee joint and ligaments
• Instability: it can lead to chronic knee instability
• Cartilage wear: extra wear on the cartilage, which raises the risk of osteoarthritis

How to Fix It

• Quad and glute strength: build the muscles that control the knee as it straightens
• Ankle mobility: restore dorsiflexion so the knee doesn’t have to lock back to compensate
• Movement retraining: practice walking, running and squatting without snapping the knee into lockout

3. Lack of Inferior Glide of the Patella: The Stiff Kneecap

What it is: this happens when the patella (kneecap) doesn’t glide downward properly as the knee bends. Instead, it stays stuck in an upward position because the quadriceps are tight.

The quadriceps tendon pulls the kneecap upward, and when it can’t glide down as it should, the result is friction, irritation and pain in the knee. It’s often seen in people with tight quads and poor knee mobility.

Common Causes

• Tight quadriceps: hold the kneecap high
• Weak hamstrings and glutes: leave the forces around the knee out of balance
• Poor patellar mobility: the kneecap itself doesn’t move freely

How It Causes Pain

• Kneecap pain: patellofemoral pain syndrome (pain around or behind the kneecap)
• Tendon irritation: inflammation in the patellar tendon (patellar tendinitis)
• Cartilage damage: a higher risk of chondromalacia patella (cartilage damage behind the kneecap)

How to Fix It

• Quad release: stretch and release the quadriceps to improve kneecap mobility
• Balance the forces: strengthen the hamstrings and glutes
• Hands-on care: improve knee bending with manual therapy and kneecap mobilization techniques

What Do These Knee Problems Have in Common?

All three come from muscle imbalances and movement impairments that make the knee joint hypermobile. The knee becomes the “victim joint”: it moves too much to make up for poor movement at the hips, ankles or feet. Over time, those compensations cause pain, inflammation and long-term joint damage.

That’s also why an X-ray or MRI rarely tells the whole story. Read more in why your X-ray or MRI for knee pain can be misleading, and see how these patterns show up in the gym in 3 reasons why squatting hurts your knees.

When to Get Your Knee Checked Right Away

• Swelling: a knee that swells quickly after an injury or keeps swelling after activity
• Locking or giving way: the knee catches, locks or buckles
• After an injury: pain that started with a twist, pop or fall
• Can’t bear weight: you can’t walk normally on the leg
• Fever or redness: a hot, red knee, especially with a fever

Why This Approach Works (and Why Most Traditional Treatments Don’t)

Traditional treatments for knee pain, like painkillers, injections or even surgery, often focus on managing symptoms rather than fixing the root cause. At Back In Motion Physical Therapy & Performance, we use The Gray Method™ to:

• Find the cause: detect what’s behind your knee pain with a movement assessment
• Fix the dysfunction: with targeted exercise, manual therapy and movement correction
• Get you back to life: active and pain-free, without relying on surgery or medication

Stop Treating the Symptom and Fix the Cause

If you’re struggling with knee pain that just won’t go away, whether it’s tibiofemoral rotation syndrome, hip knee hyperextension syndrome or a stiff kneecap, our knee pain treatment in Fort Myers can find and correct the movement problems behind it. You’ll work one-on-one with a Doctor of Physical Therapy at our clinics in Fort Myers, Cape Coral and Estero.

Start with our Fixing the Cause & Not Just the Symptoms Assessment, or Inquire About an Appointment →

Call our office at (239) 223-0484 to schedule your appointment.