You notice it on the stairs, at the bottom of a squat, or about four miles into a run, and the first thing you do is press around the knee with your thumb to find the spot that hurts. That instinct is a good one, because where your knee hurts narrows down what is going on more than almost anything else you can check at home.
This is the map I use in my clinic in Waukee when someone sits down and points at their knee: what front, inside, outside, and back of the knee pain usually means, which signs mean you should get it looked at before you train on it, and what treatment looks like once we know what we are dealing with.
Pain under or around the kneecap usually comes from the kneecap joint or the tendons just above and below it. Pain on the inside of the knee usually points to the medial meniscus, the MCL, the tendons and bursa just below the joint line, or early arthritis. Pain on the outside of the knee in a runner or cyclist is most often the IT band, and pain behind the knee is usually a hamstring tendon, a Baker's cyst, or the back of the meniscus. A review in American Family Physician puts the location of the pain near the top of the list of things that focus a knee evaluation, right next to how the pain started [1].
Location gives you a short list, and a short list is useful, although it is still a list. Two people can point at the exact same spot and have different problems, which is why the rest of this article covers the clues that separate them and the point where a hands-on exam has to take over from a thumb and a guess.
Front of the knee pain is the most common pattern I see in runners and lifters, and it usually sorts into three areas depending on exactly where you point.
If the front of your knee has a soft, squishy swelling sitting right on top of the kneecap, especially after a lot of kneeling, that is more often the bursa in front of the cap than the joint itself, and you can read how we handle it on our bursitis page.
What these front of the knee problems have in common is that they respond to load, which means the treatment is usually a change in how much and how you load the knee rather than taking everything away. If squats are what set it off, start with knee pain from squatting, where I go through the changes I make to depth, stance, and tempo so you can keep lifting while it settles.
Inside of the knee pain has more possible sources than any other spot, so the details of how it started and what makes it worse matter a lot here.
The meniscus is where people tend to expect surgery. For a degenerative meniscus tear in middle-aged adults, a trial in the BMJ followed 140 patients for two years and found that 12 weeks of supervised exercise gave the same knee outcomes as arthroscopic surgery, with better thigh strength at three months [2]. The physical therapy guideline for meniscus and cartilage injuries also recommends exercise therapy as a core part of care [5]. Your surgeon's opinion still matters, and some tears do need surgery, especially a knee that locks, although strength work is a reasonable first move for most people with a sore inner knee.
Arthritis has its own good news. A Cochrane review of 139 trials with more than 12,000 people found that exercise improved knee arthritis pain and function compared with no treatment [3]. The change is moderate rather than dramatic, which matches what I see in the clinic: arthritic knees tend to feel better as they get stronger and more used to load, and they tend to get worse when they are rested into weakness.
When a runner tells me the outside of their knee starts burning at the same mile every time, and that it gets worse running downhill or going down stairs, I am thinking about iliotibial band syndrome before anything else. The pain usually sits on the bony bump on the outside of the knee, it fades soon after you stop, and it comes right back at the same distance on your next run.
Foam rolling the IT band is what most runners try first, and it can feel good for a few minutes, although the band itself is dense connective tissue that a roller is unlikely to lengthen. A 2024 systematic review of conservative treatment for runners with IT band syndrome found that hip abductor strengthening was the most common treatment across the studies, and that programs built around it reduced pain and improved function within two to eight weeks [4]. In practice that means side planks, banded walks, single-leg work, and a look at your running mechanics and weekly mileage, which is how we approach it in running physical therapy.
Less often, outside of the knee pain comes from the lateral meniscus, especially after a twist with the foot planted, or from the LCL after a hit to the inside of the knee. Those two usually come with a clear moment of injury, swelling, or a knee that feels unstable, which is a very different story from the predictable, mileage-based burn of the IT band.
Back of the knee pain is the one people tend to ignore the longest, because it often feels like tightness rather than pain, and the usual causes are different from the front and the sides.
There is one back of the knee pattern you should never treat yourself: swelling, warmth, and tenderness in the calf below the knee, especially after a long flight, a surgery, or a stretch of time when you were not moving much. That can be a blood clot, and it needs a same-day medical visit rather than a physical therapy appointment.
Most knee pain is safe to keep moving with while you sort it out, although a few signs mean you should get a medical evaluation before you train on it. These are the warning signs I screen for in every first visit, and they line up with the ones in the American Family Physician review above:
If none of those apply, you are in the large group of people whose knee pain usually responds to the right kind of training, and the next step is figuring out exactly what is irritated so the plan matches the problem.
This article is general education, not personal medical advice. Consult a healthcare provider about your own knee.
The first thing I do in an eval is the same thing you did with your thumb, only more thoroughly: I find exactly where it hurts, then I test the meniscus, the ligaments, the tendons, and the kneecap, and I watch you squat, step down, lunge, and hop if you can. I also check your hip and ankle, because a knee that hurts is often a knee that is absorbing work that the joints above and below it are not doing.
Then we load it in the gym. A front of the knee problem usually gets a squat or split squat variation at a depth and tempo the tendon tolerates, an inside of the knee problem gets strength work for the quads and hips with the twisting kept out at first, and an IT band problem gets hip strength plus changes to your mileage. If a tender spot is holding things up, dry needling for knee pain can calm it down enough to train. You keep training through the process at a dose your knee can handle, and the dose goes up as your knee proves it is ready for more.
We're a hybrid practice, so we take insurance and cash pay. You can see more about how we approach hip and knee pain and sports physical therapy on the site.
Where your knee hurts gives you a short list: the front points to the kneecap and its tendons, the inside points to the meniscus, the MCL, the pes anserine, or early arthritis, the outside in a runner points to the IT band, and the back points to a hamstring tendon, a Baker's cyst, or the back of the meniscus. Most of these improve with the right strength work, and a few warning signs mean you get checked before you train.
If you have been pressing on the same spot for weeks and it keeps coming back, that tells us the plan needs to change. Book a free discovery call and let's find out what your knee is actually telling you, so you can get back to running, lifting, and taking the stairs without thinking about it.
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This content is for general education and is not medical advice. It does not replace an evaluation by a licensed clinician, and reading it does not create a patient relationship. Talk to a qualified health professional about your own symptoms before you act on anything here. If you have severe, sudden, or worsening symptoms, seek medical care right away.
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