Knee pain becomes common from the fifties onwards, and most people assume arthritis. Often that is correct. But several other conditions produce similar pain and are managed very differently, so the distinction is worth making properly rather than assuming.
The most common cause. The smooth cartilage lining the joint wears gradually until the underlying bone surfaces come into contact.
It tends to announce itself with pain that is worse with activity and better with rest, stiffness after sitting or in the morning that eases within half an hour of moving, swelling after a long day, and a walking distance that shortens over months and years rather than days. Many people notice difficulty with stairs — particularly going down — before anything else. Over time the leg may begin to bow.
The menisci are C-shaped cartilage cushions in the knee. In younger people they tear during sport; after fifty they often tear with very little provocation, sometimes just standing up from a squat, because the tissue has weakened with age.
This tends to cause pain localised to one side of the knee, along the joint line, sometimes with catching or a sense that the knee briefly gets stuck. Importantly, degenerative tears frequently coexist with early arthritis — and in that situation, surgery is often not the answer. Many settle with physiotherapy and time.
Pain around or behind the kneecap, worse on stairs, on getting up from a low chair, or after sitting for a long time with the knee bent. This often relates to how the kneecap tracks and to weakness of the muscles controlling it, and it commonly responds well to targeted physiotherapy.
This one is missed regularly. Hip arthritis frequently refers pain to the thigh and knee — some patients are treated for knee pain for months while the problem is the hip. Problems in the lower spine can also refer pain down the leg.
A useful clue: if the knee itself looks and feels normal, moves fully, and the pain is diffuse rather than localised, the source may be elsewhere. This is one reason examination matters more than imaging alone.
Rheumatoid and other inflammatory arthritides behave differently from osteoarthritis: stiffness in the morning lasting well beyond half an hour, several joints involved, often the small joints of the hands, and sometimes fatigue or general unwellness. Gout typically causes a sudden, intensely painful, hot, swollen joint.
These need medical rather than primarily surgical management, and the treatment path is quite different — another reason not to assume.
Less common, but important. Bone can lose its blood supply, or a small stress fracture can occur in weakened bone — either can cause knee pain that comes on relatively suddenly and is often notably worse at night. X-rays may look normal early on; an MRI is usually what identifies it.
A history — where the pain is, what makes it worse, how long it has been going on, how far you can walk — followed by an examination of the knee, and of the hip and spine when referred pain is a possibility. Standing (weight-bearing) X-rays are usually the first imaging, because films taken lying down understate joint space narrowing and can make arthritis look milder than it is. An MRI is added when soft tissue injury or bone changes are suspected.
For most people, not surgery — at least not initially. Strengthening physiotherapy, weight management where relevant, activity modification, and pain relief as advised carry many people a long way. Injections have a role in selected cases.
Surgery enters the conversation when pain persistently limits daily life despite these measures, and when imaging confirms damage that explains the symptoms. The point at which that line is crossed is personal: it depends on what you need to be able to do, not on the X-ray alone.
Knee pain lasting more than a few weeks deserves an assessment rather than a guess. The treatment for early arthritis, a degenerative meniscus tear, referred hip pain and gout are entirely different — and starting the wrong one wastes months.
Consultations at Sahyadri (Deccan), Bharati Vidyapeeth (Katraj) and Apollo (Swargate).
