Knee pain in adults over 50 is often attributed to arthritis and treated with a combination of pain medication and advice to manage it. This approach is inadequate for the majority of cases, which have specific mechanical drivers that are identifiable and treatable. Arthritis, even where present, is rarely the primary driver of pain and functional limitation.
The Most Common Mechanical Drivers
- Patellofemoral pain: compression and maltracking of the kneecap against the femur, typically driven by quadriceps weakness and hip abductor weakness rather than the knee itself
- Medial compartment loading: driven by valgus collapse of the knee during loading activities, itself a consequence of weak gluteals and poor foot mechanics
- Pes anserine bursitis: inflammation of the bursa on the inner aspect of the knee, common in overweight adults and those with medial compartment arthritis
- Iliotibial band syndrome: lateral knee pain driven by hip abductor weakness and altered running or gait mechanics
The Arthritis Diagnosis Problem
Radiographic changes consistent with osteoarthritis are present in the majority of adults over 60, regardless of whether they have pain. Conversely, not all adults with knee pain have significant arthritic changes. Using arthritis as an explanation for knee pain without identifying the specific mechanical factors is clinically insufficient. The presence of arthritic changes on an X-ray does not determine the treatment. The mechanical assessment does.
The Treatment Priority
Progressive resistance training targeting the quadriceps, gluteals, and hip abductors is the highest-evidence intervention for knee pain in adults, including those with osteoarthritis. It reduces pain, improves function, and reduces the need for surgical intervention. It is routinely underused because it requires effort and produces results over weeks rather than minutes.