KNEE PAIN

Several bursae — fluid-filled sacs that reduce friction between structures — surround the knee joint and can become inflamed through direct trauma, repetitive pressure or overuse. The three most commonly affected at Dingley Health Hub are: prepatellar bursitis ("housemaid's knee"), which develops from prolonged or repetitive direct pressure on the front of the kneecap (common in carpet layers, tilers, gardeners and plumbers); infrapatellar bursitis, which affects the bursa just below the kneecap; and pes anserine bursitis, which affects the medial (inner) knee below the joint line and is common in patients with knee osteoarthritis, overweight individuals and swimmers. As with elbow bursitis, septic (infected) bursitis — characterised by rapid-onset severe pain, significant warmth, erythema and systemic symptoms — requires urgent medical review and should not be treated with manual therapy.

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Symptoms include:
Prepatellar bursitis: visible, fluctuant swelling directly over the front of the kneecap, localised tenderness on pressure, pain with full knee flexion as the bursa is compressed, but often surprisingly little pain with walking or standing. Pes anserine bursitis: pain and tenderness on the inner side of the knee approximately 5 cm below the joint line, worsening with prolonged sitting, walking upstairs and after exercise — commonly mistaken for medial compartment OA pain. Infrapatellar bursitis: tenderness and swelling just below the patella, provoked by kneeling and repetitive stair climbing.

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How we treat it:
Non-septic knee bursitis is managed conservatively with compression bandaging to control fluid accumulation, ice therapy to reduce acute inflammation, and activity modification to avoid the specific loading pattern that is provoking the bursa. Protective knee padding recommendations are provided for patients whose occupation requires prolonged kneeling. Addressing the underlying driver of the bursitis is essential to prevent recurrence — for pes anserine bursitis this typically means treating the associated knee OA and correcting lower limb biomechanics (particularly excessive tibial valgus and tight hamstrings); for prepatellar bursitis this means occupational padding and kneeling technique modification. GP co-management for aspiration and corticosteroid injection into the bursa is coordinated when the collection is large, causing significant functional limitation, or failing to respond to conservative management within 4–6 weeks.

Patellar tendinopathy — commonly known as jumper's knee — involves degenerative structural change in the patellar tendon, most commonly at its proximal insertion on the inferior pole of the patella. It is one of the most prevalent overuse injuries in sports that involve repeated high-load jumping, landing and sprinting — including basketball, volleyball, athletics (high jump, triple jump, sprinting), AFL and netball. Like all tendinopathies, it represents a failure of tendon adaptation to the cumulative mechanical demand being placed on it, resulting in progressive tendon degeneration rather than an inflammatory process. This distinction is clinically important: rest and anti-inflammatory medications will not drive tendon remodelling and are therefore insufficient as standalone treatments.

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Symptoms include:
Anterior knee pain that is precisely and consistently localised to the inferior patellar pole — the bony point at the bottom of the kneecap — distinguishing it from the more diffuse peripatellar pain of PFPS. A characteristic "warm-up effect" where pain is present at the start of a training session, decreases or disappears once the tendon has warmed up, and then returns after the session — particularly the morning after a heavy loading day. Pain with jumping, landing, deep squatting and rapid deceleration. Tenderness on direct palpation of the inferior patellar pole. In the reactive (acute overload) phase, the tendon may appear visibly thickened on ultrasound.

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How we treat it:
Heavy slow resistance (HSR) training is the best-evidenced rehabilitation approach for patellar tendinopathy and forms the backbone of our treatment program. In the early reactive phase, isometric quadriceps exercises — sustained knee extension holds at 60–70 degrees of flexion — provide reliable pain relief through cortical inhibition and maintain tendon stimulus without provocative dynamic loading. As tendon tolerance improves, we progressively advance to isotonic exercises including decline squats (a gold standard exercise for patellar tendinopathy that maximally loads the tendon in a controlled manner) and leg press. Shockwave therapy is incorporated for chronic or recalcitrant patellar tendinopathy where the tendon has lost its capacity for spontaneous remodelling — it is highly effective at stimulating repair in degenerative tendon tissue. Training load management is a parallel and essential component, identifying and modifying the volume and intensity of jumping and sprinting that are overloading the tendon. We use the VISA-P questionnaire (a validated patellar tendinopathy severity score) to track progress objectively and guide return-to-sport decisions based on functional capacity rather than time alone.

Iliotibial band syndrome (ITBS) is one of the most common running injuries, accounting for up to 12% of all running-related complaints. Contemporary research has clarified that the mechanism involves compression of the highly innervated fat pad that lies deep to the IT band against the lateral femoral epicondyle at approximately 30 degrees of knee flexion during the stance phase of running — not friction from the IT band rubbing over the epicondyle as was historically described. This distinction matters because it changes how treatment is directed. ITBS is strongly associated with weekly running mileage increases, downhill running, hip abductor weakness leading to excessive hip adduction during stance, and a crossover running gait where the foot lands across the body's midline — all of which increase the compressive force on the lateral knee fat pad.

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Symptoms include:
A sharp, burning or stinging pain on the outer side of the knee — over the lateral femoral epicondyle — that is characteristically absent at rest and at the start of a run, but develops consistently at the same distance or time point into a run and escalates rapidly, often forcing the runner to stop completely. Tenderness on palpation over the lateral femoral epicondyle. Pain that is reproducible with the Noble compression test — pressing on the lateral femoral epicondyle at 30 degrees of knee flexion. Unlike most knee pain presentations, ITBS is very specifically a running-related condition — activities such as cycling, swimming and walking typically do not provoke it.

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How we treat it:
Hip abductor and external rotator strengthening is the most important and impactful rehabilitation component, addressing the proximal cause of increased hip adduction and internal rotation during running that drives lateral knee compression. Gluteus medius and minimus strengthening — progressed from side-lying abduction exercises to standing and single-leg functional tasks — produces reliable and lasting improvement. Running gait retraining is equally important: increasing running cadence by 5–10% reduces peak hip adduction, while cueing the runner to avoid the crossover gait pattern (landing the foot across the midline) directly reduces lateral knee compression. TFL and hip flexor soft tissue therapy and foam rolling addresses local tightness contributing to lateral tension. A structured running load reduction — temporarily reducing weekly mileage and avoiding hill running and interval sessions — allows the lateral knee fat pad to settle during the acute phase. The majority of runners with ITBS achieve full, symptom-free return to running within 4–8 weeks with this approach.
 

Osgood-Schlatter disease (OSD) is an apophysitis — a traction injury to a growth plate — at the tibial tubercle, the bony prominence on the front of the upper shin where the patellar tendon inserts. During periods of rapid adolescent skeletal growth, the tibial tubercle apophysis is significantly weaker and more vulnerable than the mature bone it will eventually become. The powerful quadriceps muscle, contracting forcefully during running and jumping, pulls on the patellar tendon which in turn applies traction stress to the apophysis — causing pain, local inflammation and, in some cases, a visible and persistent bony enlargement at the tubercle. OSD is the most common cause of anterior knee pain in active adolescents aged 10–15, is more common in boys than girls, and affects both knees in approximately 30% of cases. It is a self-limiting condition that fully resolves with skeletal maturity when the apophysis fuses to the underlying tibia — though the bony enlargement at the tubercle may remain permanently.

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Symptoms include:
Anterior knee pain localised to the tibial tubercle — the bony bump just below the kneecap — that is tender to direct touch and characteristically worsened by running, jumping, kneeling and any activity requiring powerful quadriceps contraction. A progressively enlarging bony prominence below the kneecap that becomes visible and palpable. Pain that builds with activity and eases with rest. In severe cases, pain severe enough to cause a limp after sport. Symptoms are typically more pronounced during growth spurts and during periods of increased sporting activity. The condition may affect one or both knees.

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How we treat it:
Osgood-Schlatter disease is managed with intelligent load management — not complete rest. Complete cessation of all sport is rarely necessary or beneficial and produces significant negative effects on a young person's physical, social and psychological development. Instead, we work with the athlete and their family to identify a tolerable level of activity that keeps symptoms manageable while maintaining participation, and build from there. Load management during acute flares involves reducing the volume and intensity of jumping and high-speed running — the most provocative activities — while maintaining lower-intensity training. Quadriceps and hamstring flexibility is systematically addressed, as tightness in these muscle groups directly increases the traction force on the tibial tubercle apophysis. A patellar tendon strap (worn just below the kneecap) disperses the patellar tendon's traction force before it reaches the apophysis, providing valuable symptom relief during sport participation. Ice applied to the tibial tubercle after activity reduces post-exercise soreness. We provide thorough, age-appropriate education to the athlete and their parents about the self-limiting nature of the condition — it will fully resolve — which significantly reduces the anxiety and overcautious activity restriction that can develop when the diagnosis is not clearly explained.