three things to expect during knee physical therapy

6. January 2020

3 things to expect during knee physical therapy near ealing

Introduction: Understanding Your Path to Recovery

Physiotherapy is a cornerstone of effective treatment for knee pain, offering a structured path from diagnosis to recovery and long-term health. The experience of knee pain is profoundly disruptive. It can transform simple daily tasks, such as climbing stairs or kneeling, into painful challenges.¹ It can force an active individual to give up cherished hobbies like running or football, and for others, it can mean sleepless nights due to a persistent, throbbing ache.² The uncertainty surrounding the cause of the pain, coupled with the fear of a long-term condition or the prospect of surgery, can be a significant source of anxiety.

This report serves as an authoritative guide to demystify the complexities of the knee joint, illuminate the common causes of pain, and provide a clear, evidence-based overview of what to expect from a modern physiotherapy treatment plan in the UK. The aim is to empower individuals with the knowledge required to understand their condition and take an active, confident role in their recovery.

Your Knee’s Anatomy and How You Can Injure It

A fundamental understanding of the knee's structure is the first step toward appreciating why it is so susceptible to injury and how targeted treatment can be so effective. The knee is more than just a simple hinge; it is a complex and sophisticated joint that must withstand immense forces while providing a wide range of motion.

A Look Inside the Knee Joint

knee joint The knee is the largest joint in the body and is primarily a hinge joint, allowing for bending (flexion) and straightening (extension), with a small degree of rotation.¹ It is where three main bones meet: the thigh bone (femur), the shin bone (tibia), and the kneecap (patella).⁴ The integrity and function of this joint depend on a network of specialised soft tissues, each with a distinct role:

Menisci: These are two C-shaped pieces of tough, rubbery cartilage that sit between the femur and tibia, one on the inside (medial) and one on the outside (lateral) of the knee. They act as the knee's primary "shock absorbers" or "washers," cushioning the joint, distributing weight evenly, and providing stability.⁵
Ligaments: These are strong, fibrous bands of tissue that connect bone to bone, acting like robust "ropes" to stabilise the joint. The four main ligaments are the Anterior Cruciate Ligament (ACL) and Posterior Cruciate Ligament (PCL), which cross inside the joint to control forward and backward movement, and the Medial Collateral Ligament (MCL) and Lateral Collateral Ligament (LCL), which provide stability to the inner and outer sides of the knee, respectively.⁵
Tendons: These are tough cords that connect muscle to bone. The quadriceps tendon connects the large thigh muscles to the patella, while the patellar tendon connects the patella to the tibia. Together, they work as powerful "anchors" that allow the muscles to straighten the knee.¹
Articular Cartilage: This is the smooth, shiny, white tissue that covers the ends of the femur and tibia and the back of the patella. It provides a low-friction surface that allows the bones to glide smoothly over one another during movement.⁵

Common Causes of Knee Pain in the UK

Knee pain can arise from an acute injury, such as a sudden twist during sport, or develop gradually over time due to overuse or underlying degenerative changes.¹ Physiotherapists in the UK regularly diagnose and treat a wide spectrum of conditions affecting the knee's intricate structures. The following table summarises some of the most common causes, their typical symptoms, and the populations they frequently affect, helping to provide clarity on the potential source of discomfort.

Condition	Common Symptoms	Who It Typically Affects
Osteoarthritis (OA)	Pain and stiffness that is often worse in the morning or after periods of rest, mild swelling, grating or popping sensations, and difficulty with activities like climbing stairs.¹	More common in older individuals, but risk is increased by previous injury, genetics, and being overweight. It is a form of "wear and tear" on the joint cartilage.⁹
Patellofemoral Pain Syndrome (PFPS) / "Runner's Knee"	A dull ache at the front of the knee, often behind or around the kneecap. Pain is aggravated by prolonged sitting (the "cinema sign"), squatting, or using stairs.¹	Very common in runners, cyclists, and other athletes, but also frequently affects sedentary individuals and office workers due to muscle imbalances or poor biomechanics.⁵
Ligament Sprains (e.g., ACL, MCL)	Often accompanied by a "popping" sound or sensation at the time of injury, followed by immediate swelling, significant pain, and a feeling of instability or the knee "giving way".⁶	Common in sports that involve sudden stops, changes in direction, and pivoting, such as football, skiing, and basketball.⁵
Meniscal Tear	Symptoms can include the knee locking, catching, or giving way. Pain is often felt with twisting movements, and there may be swelling and an inability to fully straighten the knee.¹	Can result from an acute twisting trauma in athletes or occur as part of the degenerative "wear and tear" process in older adults, sometimes with minimal or no specific injury.⁵
Patellar Tendinopathy / "Jumper's Knee"	Pain is localised to the tendon just below the kneecap. It often begins as a dull ache that worsens with high-intensity activities like jumping, running, or squatting.¹	Common in athletes who participate in jumping sports such as volleyball, basketball, and athletics, where the patellar tendon is repeatedly overloaded.⁵
Iliotibial (IT) Band Syndrome	Characterised by a sharp or burning pain on the outside of the knee. Symptoms are often aggravated by activities like distance running, cycling, or repetitive squatting and lunging.¹	Common in endurance athletes, particularly runners and cyclists, where friction of the IT band over the outer part of the femur can cause irritation.⁵

The Hidden Culprit: Understanding Referred Pain

A crucial aspect of diagnosing knee pain, and one that highlights the necessity of a professional assessment, is the concept of referred pain. In some cases, the pain felt in the knee does not originate from any of the knee's structures. Instead, the problem may lie in the lower back or the hip.¹ Conditions such as sciatica, where a nerve in the lower back is irritated, can send pain signals down the leg that the brain interprets as knee pain.⁴ Similarly, weakness or dysfunction in the muscles around the hip can alter the biomechanics of the entire lower limb, placing abnormal stress on the knee joint and leading to pain.

This phenomenon explains why self-diagnosis and treatment based solely on online searches for "knee exercises" can be ineffective or even counterproductive. Without a comprehensive physical examination that assesses the entire kinetic chain—from the lumbar spine through the hip and down to the ankle—the true root cause of the pain may be missed. An experienced physiotherapist is trained to perform this holistic assessment, differentiating between local knee pathology and referred pain to ensure that the physiotherapy is directed at the correct source of the problem.

The Role of Exercise in Knee Rehabilitation

When faced with a painful knee, the natural instinct is often to rest it completely. While a short period of relative rest is important in the immediate aftermath of an acute injury, prolonged inactivity can be detrimental, leading to muscle weakness, joint stiffness, and a delayed recovery.¹ The cornerstone of modern knee rehabilitation is a carefully prescribed and progressive exercise programme.

Why Movement is Medicine: The Principles of Therapeutic Exercise

Therapeutic exercise is not simply about "working through the pain." It is a targeted intervention designed to address the specific deficits contributing to the knee problem. The principles behind this approach are well-established:

Strengthening for Stability: The muscles surrounding the knee, particularly the quadriceps (front of the thigh), hamstrings (back of the thigh), and gluteals (buttocks), are the joint's primary active support system. When these muscles are strong, they absorb shock and control movement, effectively taking the load off passive structures like ligaments and cartilage. A structured strengthening programme is essential for restoring this muscular support and protecting the joint from further injury.⁸
Restoring Range of Motion: Following an injury or surgery, or with conditions like osteoarthritis, the knee can become stiff, limiting its ability to bend and straighten fully. Specific exercises are designed to gently and progressively restore this range of motion, which is crucial for normal function, including walking, climbing stairs, and getting up from a chair.¹⁷
Pain Modulation: Gentle, controlled movement can help to reduce pain. This occurs through several mechanisms, including increasing blood flow to the area, reducing swelling, and stimulating nerve fibres that can block the transmission of pain signals to the brain.¹⁸
Improving Proprioception and Balance: Proprioception is the body's ability to sense its position in space. After a knee injury, this "joint position sense" can be impaired, increasing the risk of re-injury. Balance and control exercises are used to retrain the neural pathways between the knee and the brain, improving stability and coordination.²⁰

Foundational Exercises for Knee Pain

The following exercises represent a foundational programme for improving knee health. They are derived from guidance provided by the NHS and UK physiotherapy clinics.²² It is important to perform them with correct form and to stop if they cause sharp or significant pain. A physiotherapist can tailor the selection, frequency, and intensity of these exercises to an individual's specific condition.

Strengthening Exercises

Straight Leg Raises:

Action: Lie on your back with one leg bent and the foot flat on the floor. Keep the other leg straight. Tighten the thigh muscle of the straight leg and slowly lift it about 20 cm off the floor, keeping it straight. Hold for five seconds, then slowly lower it.²⁴
Purpose: Strengthens the quadriceps muscles without bending the knee.
Repetitions: Aim for 3 sets of 10-15 repetitions on each leg.

Hamstring Curls:

Action: Lie on your stomach with your legs straight. Slowly bend one knee, bringing your heel towards your buttock. Go as far as is comfortable without pain. Hold for a few seconds, then slowly lower the leg.²²
Purpose: Strengthens the hamstring muscles at the back of the thigh.
Repetitions: Aim for 3 sets of 15 repetitions on each leg.

Glute Bridges:

Action: Lie on your back with both knees bent and feet flat on the floor, hip-width apart. Squeeze your buttock muscles and lift your hips off the floor until your body forms a straight line from your shoulders to your knees. Hold for five seconds, then slowly lower.²¹
Purpose: Strengthens the gluteal and hamstring muscles, which are crucial for hip and knee stability.
Repetitions: Aim for 3 sets of 10-15 repetitions.

Wall Squats (Wall Slides):

Action: Stand with your back against a wall, feet shoulder-width apart and about 20 cm away from the wall. Slowly slide your back down the wall by bending your knees, as if sitting in a chair. Go down until your thighs are nearly parallel to the floor, ensuring your knees do not go past your toes. Hold for 7-15 seconds, then slowly slide back up.²³
Purpose: Strengthens the quadriceps, hamstrings, and glutes in a supported position.
Repetitions: Aim for 3 sets of 5-10 repetitions.

Side Leg Raises:

Action: Lie on your side with your legs stacked and straight. Keeping your top leg straight, slowly lift it towards the ceiling as far as is comfortable without rocking your torso. Hold for a second, then slowly lower it.²²
Purpose: Strengthens the hip abductor muscles, which help to stabilise the pelvis and control knee alignment.
Repetitions: Aim for 3 sets of 10 repetitions on each side.

Stretching and Mobility Exercises

Quadriceps Stretch:

Action: Stand holding onto a wall or chair for balance. Grasp the ankle of one foot and gently pull your heel towards your buttock, feeling a stretch in the front of your thigh. Keep your knees together and your back straight. Hold for 30 seconds.²³
Purpose: Improves flexibility of the quadriceps muscles.
Repetitions: Repeat 3 times on each leg.

Hamstring Stretch:

Action: Sit on the floor with one leg straight out in front of you and the other leg bent with the sole of your foot against your inner thigh. Gently lean forward from your hips towards the foot of your straight leg until you feel a stretch in the back of your thigh. Keep your back straight. Hold for 30 seconds.²⁶
Purpose: Improves flexibility of the hamstring muscles.
Repetitions: Repeat 3 times on each leg.

Calf Stretch:

Action: Stand facing a wall with your hands on it for support. Step one foot back, keeping that leg straight and the heel on the floor. Gently lean forward by bending your front knee until you feel a stretch in the calf of your back leg. Hold for 30 seconds.²³
Purpose: Improves flexibility of the calf muscles, which can affect knee mechanics.
Repetitions: Repeat 3 times on each leg.

Three Essential Exercises to Begin Your Knee Injury Recovery

While the library of exercises above is comprehensive, starting a new programme can feel overwhelming. For those in the early stages of recovery from a knee injury or flare-up, focusing on a few key exercises can provide a safe and effective starting point. The following three exercises are foundational because they target the most critical muscle groups with minimal stress on the knee joint itself.

Exercise 1: Static Quadriceps Contraction (Quad Set)

Description: Sit or lie on the floor with your affected leg straight out in front of you. You can place a small, rolled-up towel under your knee. Without moving your leg, tighten the muscle on the front of your thigh (the quadriceps) as if trying to press the back of your knee down into the floor or towel. You should see your kneecap move slightly upwards.¹⁶
Why This Helps: This is often the very first exercise prescribed after a knee injury or surgery. Its primary benefit is that it allows for the safe activation and strengthening of the quadriceps muscle without any movement or loading of the knee joint. This is crucial for preventing muscle atrophy (wasting), which can happen very quickly when a knee is painful or immobilised. Maintaining quadriceps function is the first step to regaining control and stability of the knee.
Protocol: Hold the contraction for 5-10 seconds, then relax completely. Repeat 10-15 times, several times throughout the day.

Exercise 2: Seated Knee Extension

Description: Sit upright in a sturdy chair with your feet flat on the floor. Slowly straighten your affected knee by lifting your foot until your leg is parallel to the floor, or as high as you can comfortably go. Squeeze the thigh muscle at the top of the movement. Hold for 5-10 seconds, and then slowly and controllably lower your foot back to the starting position.¹⁷
Why This Helps: This exercise builds on the static quad set by strengthening the quadriceps through a controlled range of motion. It specifically targets "terminal knee extension"—the final few degrees of straightening the leg. This ability is often lost after an injury and is vital for a normal, efficient walking pattern. By performing this exercise slowly, it builds both strength and muscular control.
Protocol: Repeat 10 times for 3 sets on each leg. As it becomes easier, a light ankle weight can be added to increase the challenge.

Exercise 3: Glute Bridge

Description: Lie on your back with your knees bent, feet flat on the floor about hip-width apart, and your arms resting by your sides. Engage your core muscles, then squeeze your buttock (gluteal) muscles and lift your hips off the floor. Create a straight line from your shoulders to your knees. Avoid arching your lower back. Hold the position at the top for 5 seconds.²¹
Why This Helps: This exercise shifts the focus away from the knee itself and onto the powerhouse muscles of the hips—the glutes. Strong gluteal muscles are essential for controlling the position of the thigh bone (femur). Weakness in these muscles can allow the knee to collapse inwards during activities like walking, running, or squatting (a movement pattern known as knee valgus). This poor alignment is a common underlying cause of patellofemoral pain and a significant risk factor for more serious injuries like ACL tears. By strengthening the glutes, this exercise helps to correct these biomechanical faults at their source.
Protocol: Repeat 10-15 times for 3 sets.

Three Things to Expect: The Benefits of Professional Physiotherapy Treatment

While the exercises outlined provide a valuable foundation for self-management, engaging with a chartered physiotherapist offers a level of care that is comprehensive, personalised, and adaptive. A professional physiotherapy treatment plan goes far beyond a generic list of exercises. It is a dynamic process tailored to an individual's unique condition, lifestyle, and recovery goals. The following three expectations detail the significant benefits of seeking expert guidance.

Expectation 1: A Thorough Assessment and a Clear Diagnosis

The single most important step in resolving knee pain is achieving an accurate diagnosis. A physiotherapist's initial consultation is a detailed investigation designed to uncover the precise cause of the symptoms. This process is typically divided into two key parts ³¹:

The Subjective Assessment ("Listening to Your Story"): This is a structured conversation where the physiotherapist gathers crucial information. They will ask about the nature of the pain, how the injury occurred, what activities make it better or worse, any previous injuries, general health, and, most importantly, what the individual hopes to achieve through treatment.¹⁸ This patient-centred approach ensures that the subsequent treatment plan is aligned with personal goals, whether that is returning to competitive sport or simply being able to walk the dog without pain.
The Physical Assessment ("Finding the Cause"): Following the discussion, the physiotherapist will conduct a hands-on examination. This involves observing posture and walking patterns, assessing the knee's range of motion, testing the strength of key muscle groups, and palpating the joint to identify tender structures. They will also perform a series of special clinical tests designed to assess the integrity of specific ligaments, menisci, and other tissues to confirm or rule out potential diagnoses.¹⁸

The value of this comprehensive approach cannot be overstated, as it allows the physiotherapist to identify underlying factors that a self-assessment would likely miss. Consider the real-world case of a 26-year-old female who presented to a physiotherapy clinic with several months of worsening right knee pain.³³

A superficial examination might have simply labelled it as "anterior knee pain." However, the physiotherapist's thorough assessment revealed a more complex picture. They noted her complaints of pain in other joints, observed significant hyperextension (over-straightening) in her standing posture, and conducted a specific test for joint laxity (the Beighton score), which was highly positive. This led to a much more nuanced diagnosis: Infrapatellar Fat Pad Syndrome (irritation of the fatty tissue below the kneecap) secondary to a pre-existing, underlying condition of Benign Joint Hypermobility.³³ This accurate diagnosis was critical, as it meant the treatment plan needed to address not just the localised knee pain but also the systemic joint laxity that was the root cause of the problem.

Expectation 2: A Personalised, Hands-On Treatment Plan

With a clear diagnosis established, the physiotherapist will develop a multi-faceted and personalised treatment plan. This plan is not static; it evolves as the patient progresses through their recovery. A key component of this is manual, or "hands-on," therapy. These techniques are used to modulate pain, improve mobility, and create a better environment for healing and exercise.¹⁸ Manual therapy can include:

Soft Tissue Massage: To release tension in tight muscles and improve circulation.
Joint Mobilisation: Gentle, passive movements applied to the knee or surrounding joints (like the patellofemoral joint or tibiofibular joint) to reduce stiffness and restore normal joint mechanics.
Myofascial Release: Techniques aimed at releasing restrictions in the connective tissue surrounding the muscles.

Beyond hands-on treatment, a significant benefit of professional physiotherapy is the tailored advice and education provided. The physiotherapist acts as a health coach, empowering the patient with the knowledge to manage their condition effectively. This can involve specific, practical advice on activity modification. For the 26-year-old patient with hypermobility, this included providing a fitness-to-work form recommending more desk-based duties to reduce prolonged standing, advising on appropriate footwear with a slight heel raise to offload the irritated fat pad, and teaching her to avoid locking her knees into hyperextension.³³ This level of personalised guidance is instrumental in breaking the cycle of pain and preventing flare-ups.

Expectation 3: Access to Advanced and Modern Therapies

In addition to manual therapy and exercise prescription, modern physiotherapy clinics often utilise advanced therapeutic modalities to support the recovery process. These technologies are not a replacement for active rehabilitation but serve as valuable adjuncts that can accelerate healing and improve outcomes. An expert physiotherapist understands when and how to integrate these tools to create a window of opportunity for the patient to engage more effectively with their crucial exercise programme.

Electrotherapy for Pain Management: One of the most common forms of electro therapy is Transcutaneous Electrical Nerve Stimulation (TENS). A TENS machine is a small, portable device that delivers a low-voltage electrical current to the skin via sticky electrode pads.³⁵ This therapy works in two primary ways: it can stimulate sensory nerves to block pain signals from reaching the brain (the "gate control theory" of pain), and it can trigger the body's release of its own natural painkillers, called endorphins.¹⁹ For a patient with significant
knee pain, TENS can be an effective, non-pharmacological tool to reduce discomfort, thereby making it easier and more tolerable to perform their essential strengthening and mobility exercises.
Shockwave Therapy for Chronic Tendon Issues: Extracorporeal Shockwave Therapy (ESWT), or shockwave therapy, is a non-invasive treatment that is particularly effective for chronic tendon problems that have failed to respond to other treatments.³⁷ Conditions like patellar tendinopathy ("jumper's knee") are well-suited for this modality.³⁷ The treatment involves a handheld device that delivers high-energy acoustic sound waves to the injured tendon.⁴⁰ These waves create a controlled micro-trauma, which stimulates a new healing response in the tissue, increasing blood flow and promoting cell regeneration.³⁷ A typical session lasts only a few minutes, during which the patient may feel a tapping or pulsating sensation.³⁹ A course of treatment usually involves a minimum of three sessions. By restarting the healing process in a stubborn, chronic injury, shockwave therapy can help patients break through a recovery plateau and achieve long-term pain relief.

Conclusion: Taking the Next Step Towards a Pain-Free Knee

The knee is a complex joint, and the pain it can produce has a multitude of causes, from acute sporting injuries to chronic degenerative conditions and issues referred from other parts of the body. Recovery is an active process, heavily reliant on a targeted programme of strengthening, mobility, and biomechanical correction.

While self-management strategies and foundational exercises are beneficial first steps, their effectiveness is maximised when they are part of a professionally guided plan. The expertise of a chartered physiotherapist provides an accurate diagnosis, a personalised, hands-on treatment plan, and access to modern therapies that can significantly enhance recovery. Enduring knee pain is not a necessity; a clear path to improved function and reduced pain is available. A consultation with a qualified professional is the most important first step in your journey, as a personalised physiotherapy plan is key to achieving your goals.

Frequently Asked Questions About Knee Physiotherapy in the UK

How long does knee physiotherapy treatment typically take?

The duration varies depending on the condition's severity, but most patients see significant improvement within 6-12 weeks of consistent treatment and exercise adherence. Chronic conditions like osteoarthritis or severe ligament injuries may require longer-term management.

Do I need a GP referral to see a physiotherapist in the UK?

No referral is necessary for private physiotherapy, and many NHS services now offer self-referral for musculoskeletal conditions including knee pain. Contact your local NHS physiotherapy service or private clinic directly to book an assessment.

How much does private knee physiotherapy cost in the UK?

Private physiotherapy sessions typically range from £40-£80 per session depending on location and clinic, with initial assessments sometimes costing slightly more. Many private health insurance plans cover physiotherapy treatment for knee injuries.

Can I continue exercising or playing sports during physiotherapy treatment?

Your physiotherapist will provide specific activity modification advice based on your diagnosis, often recommending low-impact activities like swimming or cycling while avoiding high-impact movements that aggravate your knee. Complete rest is rarely recommended, as appropriate movement aids recovery.

When should I see a doctor instead of going directly to physiotherapy?

Seek immediate medical attention if your knee shows signs of infection (hot, red, swollen with fever), cannot bear weight, has severe swelling within hours of injury, or if the pain is accompanied by unexplained weight loss or night pain that disrupts sleep.

Will I need an MRI or X-ray before starting physiotherapy?

Imaging is not always necessary, as physiotherapists can diagnose most knee conditions through clinical examination alone. Your physiotherapist will refer you for scans if they suspect fractures, significant ligament tears, or other conditions requiring imaging confirmation.

Is physiotherapy treatment painful?

Some initial discomfort during assessment or hands-on treatment is normal, but physiotherapy should never cause sharp or severe pain. Your physiotherapist will work within your pain tolerance and adjust treatment intensity to ensure your comfort and safety.

Can physiotherapy help me avoid knee surgery?

Research shows that physiotherapy can effectively manage many knee conditions and may help you avoid or delay surgery, particularly for meniscal tears, mild to moderate osteoarthritis, and patellofemoral pain syndrome. In cases where surgery is necessary, pre-operative physiotherapy ("prehab") significantly improves post-surgical outcomes.

How often will I need to attend physiotherapy sessions?

Most patients attend weekly or fortnightly sessions initially, reducing frequency as they progress and become more independent with their home exercise programme. Acute injuries may require more frequent visits, while chronic conditions often need less frequent monitoring.

What should I bring to my first physiotherapy appointment?

Wear comfortable, loose-fitting clothing that allows access to your knee, bring any relevant medical letters or scan results, a list of current medications, and details of your symptoms and goals. Athletic shorts or tracksuit bottoms are ideal for knee assessments.

Will my knee pain come back after physiotherapy treatment ends?

While physiotherapy aims for long-term resolution, some conditions like osteoarthritis require ongoing management through regular exercise and lifestyle modifications. Your physiotherapist will provide a maintenance exercise programme and strategies to prevent recurrence or manage flare-ups independently.

What's the difference between a physiotherapist and a chiropractor or osteopath for knee pain?

Chartered physiotherapists are healthcare professionals regulated by the HCPC with specialist training in exercise prescription, rehabilitation, and evidence-based treatment for musculoskeletal injuries. While chiropractors and osteopaths may also treat knee pain, physiotherapists typically focus more extensively on active rehabilitation and therapeutic exercise programmes.