Chronic vs. acute is the first fork in the road
When someone comes in with knee pain that’s been lingering for months, that timeline is already part of the differential diagnostic process. If it’s been lingering for months, it’s more likely to be chronic in nature. It’s more likely to not have as much structural tissue damage or injury associated with it. And if there was some tissue damage or injury associated with it in the beginning, after a few months, it’s likely to have started to structurally heal.
So the first differentiating factor is determining whether it’s acute, subacute, or chronic in nature, and then going more specific into the anatomical differential from there.
The questions that narrow the anatomy
Once we know it’s chronic, we start asking about the specific activities where the pain shows up. From those specific activities, we get a better understanding of what biomechanical or anatomical positions are associated with the pain.
Someone feeling it after prolonged sitting versus going up or down stairs versus changing directions in an athletic activity versus kneeling down and bringing their heels to their butt versus keeping their legs straight — all of these positions or activities have a different anatomical position associated with them. That leads us to be thinking more or less likely that certain tissues surrounding the knee may or may not be involved in generating the symptoms.
A recent case: pain on the inside of the knee going downstairs
We had a patient with chronic knee pain for a few months. They didn’t feel it with walking, sitting, or standing, but they did feel it going down stairs. Next question: where exactly is the pain? The knee is a general area. It could be the front of the knee, the outside, behind the kneecap, on the back of the leg, or the inside. This patient said they felt pain on the inside front aspect of their right knee.
From there, the assessment breaks into two pieces. The orthopedic assessment tries to figure out what tissues or structures are likely involved in generating the pain. The functional assessment looks at movement patterns and asks, especially in a chronic context, what movement behavior is creating a pattern that consistently strains or irritates the area.
For the inside front of the knee, the likely candidates were the medial quadricep tendon (vastus medialis), the pes anserine tendon, the medial meniscus, and the MCL. We started with palpation. Joint line palpation ruled out the medial meniscus. Palpation of the pes anserine didn’t reproduce it. The medial quad insertion didn’t reproduce it. But palpating the MCL recreated familiar symptoms, and pairing that with a valgus stress test also recreated the pain. That confirmed the MCL was most likely what was biomechanically involved.
Why we show patients the anatomy
When we walk a patient through what we found, we bring up an anatomy app on the phone. We say: I palpated your quad, that wasn’t it. I palpated your medial meniscus, that wasn’t it. I palpated the pes anserine tendon, that wasn’t it. But when I palpated the MCL, your medial collateral ligament, that was recreating your pain. Because pressing on that specific ligament brings up familiar symptoms, that’s confirming to me that that’s most likely what’s causing your pain.
If they don’t track with it, we simplify: there are multiple muscles and ligaments on the inside of the knee. There’s a specific ligament in there that was tender when I touched it, and that’s making me think that’s the structure creating your discomfort.
The movement behavior behind the pain
With any new patient, we bring them through our movement paradigm: breathing first, then bracing and the ability to maintain intra-abdominal pressure, then the ability to stabilize lower extremity function starting at the hip.
With an MCL sprain, we tend to see compromised intra-abdominal pressure and pelvic stabilization issues. This patient had sufficient pressure at baseline but couldn’t maintain it once the hips started moving. With braced hip flexion, we saw significant pelvic instability, more prevalent on the right (symptomatic) side. They also had a positional bias to pull the right hip inward into adduction when initiating hip flexion.
Then in the hinge, another common pattern with knee pain: knee-dominant stabilization. Instead of initiating the hinge at the hips, they were bending the knee first, then following with a hip hinge, with the right knee drifting into valgus (inward). In a chronic MCL context, that stabilization pattern is drawing the knee toward the inside, which imposes exactly the strain on the MCL you don’t want.
Explaining the pattern to the patient
Here’s how we say it in the room: when you go to initiate movement of your hip, I’m seeing excessive movement of your pelvis. I want you to focus on stabilizing your spine and midline so we can get more controlled movement at the hip. What often happens with knee pain is the knee is compensating for a lack of stability higher up the chain, and that creates excessive strain to the knee.
With you specifically, you have relative instability in the right hip, difficulty maintaining midline stability with hip movement, and a tendency to draw your leg toward the inside both with hip flexion and with hinging. When the knee tracks inward, more force accumulates on the inside of the knee. If you have a ligament irritation there, that repetitive stress makes it hard for the area to heal.
So we want two things: keep the pelvis more stable as you move your leg through range of motion, and keep neutral knee tracking through your hinges so the knee stops drifting in.
The first drill: banded knee-out against a squat or deadlift
A simple starting drill is placing a band on the knee that pulls it further into that inward position, so the patient can very clearly and visibly appreciate what’s happening. Then we cue them to use their glute muscles to push outward against the band and maintain that outward pressure through a squat or deadlift. That re-teaches them that the outside of the hip has to stabilize to keep the knee in a neutral position under load.
The first marker we look for is pain. If squatting with the knee tracking in reproduces the inside-knee pain, that behavioral pattern is confirmed as a driver. Then with the band cue and active glute engagement, we want the patient to feel a decrease in pain, and we want them to feel more work on the outside of the hip, which confirms the gluteus medius is doing its job resisting that inward pull. This patient confirmed both.
Progression is about load, not about a new movement
Once pain drops and tracking cleans up, we’re not changing the underlying intervention. We’re progressively overloading the stress, weight, volume, or complexity that the patient can reliably handle without symptoms.
If the patient is relatively sedentary and just wants to walk a mile without pain, the basic progression is probably enough. If we’re working with a soccer player who has to absorb impact, change directions, and handle high-velocity forces through the knee, the same positional intervention has to be applied to jumping off a box, lateral jumps, single-leg hops with a 180-degree turn in the air, and loading that matches what their sport actually demands. Same movement principle, progressively harder context.
What progress actually looks like day to day
If we can get the patient’s symptoms to decrease in real time with a movement change, that’s already strong evidence that they could potentially not experience knee pain moving forward, with the caveat that they maintain the awareness of stabilizing and positioning the knee that way in their actual life.
More important than the exercise creating an adaptation is the exercise being a learning tool. Progressing, in the real sense, is the patient integrating and applying the awareness they’re gaining through the drill into the moments in their day when they aren’t doing the drill.
Why we’re not worried when the pain is a switch
If a worried patient can completely eliminate the knee pain by interacting with the knee differently through a movement, that is not the picture of someone with a fully ruptured ligament who needs surgery or a higher level of intervention. Being able to turn the pain off with a movement change reduces our suspicion of significant underlying tissue damage.
That’s the reassurance we give: the fact that you can create this much change in your pain through a movement that was previously painful and now isn’t, is not only great because you’re not feeling the pain anymore, it’s also telling us the severity of the underlying injury is not something to be too concerned about.
If you’ve had knee pain nagging for months and no one has walked you through what’s actually driving it, that’s the conversation to come have. Book a first visit here.