(Last updated May 4, 2020)

What Type of Knee Pain Do You Have?

COMT and Pilates, a Functional Remedy for Knee Pain

Knee pain may occur on the anterior or posterior knee. The location of the knee pain determines where Clinical Orthopedic Manual Therapy would be applied on the knee. COMT is a functional remedy for knee pain. When combined with Pilates, the pain-relieving therapy becomes even more effective.

Knee Pain Remedy
Most knee pain happen gradually rather than due to an accident.


Knee pain can be caused by an injury like a fall or a collision when playing a contact sport like soccer or rugby. Traumatic knee pain is due an event which you can remember. 

But knee pain can also happen gradually, where there is no traumatic event. You could not remember how it started. The pain simply worsened overtime. Gradual-onset knee pain is more common of the two types of knee pain.

The common causes of progressive knee pain are long hours of sitting which weakens the anterior thigh muscles, and poor walking or running posture. Muscle imbalance develops as result. The muscle imbalance — where certain muscles become more active than others at the knee joint — causes tension or knots to build up at the knee. The tension creates pain when walking, running or stair climbing. The pain increases overtime. There is no single event that causes the pain.


To understand what causes gradual-onset knee pain, we have to first understand the purpose of the knee joint.

A joint is basically the space between any two bones. So the knee joint is the space between the thigh and leg bones, which divides the bones.

If we don’t have a knee joint, and the thigh and leg is fused into one entity, we would look like toy soldiers or guard men’s in a ceremonial march when we walk: straight and stiff. We have to lift the entire leg up to avoid hitting the floor if we can’t bend at the knee joint.

Purpose of the knee joint
A ceremonial march without knee flexion. An example of how we would walk if we don’t have a knee joint.


Having a knee joint makes walking easier and more efficient. Knee flexion allows us to pick up the leg when we walk. It also cushions the impact of the landing when the leg hits the ground. If we were to land with a straight leg, the impact would have reverberated up the thigh and to the spine. Not being able to bend at the knee joint could potentially cause low back pain.

The knee joint is capable of knee flexion, as well as knee extension. Being able to extend the leg at the knee joint increases our stride length when we walk. Knee extension also allows us stand tall.

Hence, there are many benefits in having a knee joint. The knee joint makes our gait efficient and absorbs the shock to the body when we walk.


If the knee joint is the space between the thigh and leg bones, what keeps the thigh and leg bones in place at the knee joint? Knee ligaments. Imagine knee ligaments like strong ropes. We have anterior, posterior, lateral, medial and cruciate knee ligaments. Similar to strong ropes, they bind the thigh and leg bone together from all sides. The menisci (a pair of meniscus) provide the cushioning between the two bones at the knee joint.

But neither the knee joint or ligaments are responsible for moving the thigh or leg. They create the structure, but they are not responsible for movement like knee flexion or extension when we walk, run or squat. The task falls on the muscles at the knee joint.


Muscles attached to the thigh and leg, particularly the quadriceps and hamstrings are responsible for knee extension and flexion, respectively.

Muscles are connective tissues like ligaments except they have different fibrous makeup. If ligaments are like ropes, then muscles are more like elastic bands as they are stretchable like bands.

Purpose of knee muscles
Figure A: A medial view of the knee joint. B: The muscles attached to the thigh and leg which create movement at the knee joint. C: The knee joint without the muscle attachments. The knee joint is the space between the distal thigh and proximal leg.


Quadriceps are thigh muscles that cross the knee joint anteriorly. So when the quadriceps contract they pull the leg closer to the thigh to create knee extension at the knee joint (see Figure A.)  Imagine having several pieces of elastic bands pulling the leg to the thigh. If we were to tie knots on the elastic bands, the knots will shorten the length of the bands.

Similarly, when the quadriceps are shortened by knots in the muscle fibres, they could pull the leg and thigh bones too close together for comfort at the knee joint. The rubbing of bone to bone creates friction and anterior knee pain.

Hence, the rule of the thumb — though there are exceptions —  is when you have anterior knee pain, quadriceps (anterior thigh muscles) are likely to be knotted and tight. 

Knee Function
Figure A: Knee Extension. Figure B: Knee Flexion.


In contrast, hamstrings are posterior thigh muscles. When the hamstrings contract, they pull like elastic bands but this time on the posterior leg. The action brings the posterior leg closer to the thigh, which bends the knee.  So the hamstrings are responsible for knee flexion at the knee joint.

When the hamstrings are knotted, they shortened the distance between the thigh and leg posteriorly. This results in posterior knee pain.

The anterior and posterior thigh muscles are big muscles. They are build large to carry the weight of the upper body when we move from knee flexion to extension, every time we transit from a seated to a standing body.


Apart from knee flexion and extension, the knee joint also allows for medial and lateral knee rotation when knee is flexed. The medial knee muscles are responsible for medial rotation, while the lateral knee muscles are tasked with lateral rotation (see Figure C.)

So if you are experiencing pain on the medial knee when you walk, the medial thigh muscles are likely knotted and tight. Conversely, if the pain is on the lateral knee, then the lateral thigh muscles are tight.


Medial and lateral knee rotation allow us to change direction when we walk. We can turn to left to right, or make 180-degrees U-turn to head back, mainly because the knee joint allows for rotation.

Good knee rotation is also important in sports like soccer, basketball, tennis and badminton, which require frequent directional shifts. A good soccer player needs to be able to cut in and out as he dribbles a ball, while a badminton player needs to shift and turn at the knee joint to chase down each shot.

Knee function rotation
Figure C: Medial and Lateral Knee Rotation.


Hence, the direction of the pull of the tight muscles at the knee joint determines the type of knee pain you have. So if you have anterior knee pain, loosening the anterior knee muscles with manual therapy will bring relief and remove the movement restriction at the anterior knee joint. Similarly if you have medial knee pain, removing the knots from the medial thigh muscles reduce the medial pull on the knee joint and relieve pain.


However, there is exceptions to the rule. Sometimes, the cause of the knee pain is not due to tight muscles at the knee joint, but at the hip and/or ankle joint, which can also affect how the knee moves. For example, if the hip joint is tight, the knee has to compensate for the lack of hip movement by moving more when we walk, run or dance. Excessive movement at the knee joint makes the joint unstable, and vulnerable to injury.

So the cause of the knee pain is not always due to muscle tension at the knee joint. It can also be due to tightness at the hip joint. When you know more about how the knee works, it decreases frustration because you know you can play an active role in maintaining your knee health.


Manual therapy like COMT provides relief, particularly from gradual-onset knee pain, where muscle imbalance is the cause of the pain. COMT targets the muscle imbalance. So how does it work?

For example, if you suffer from anterior knee pain, the manual therapist would assess the knee muscles like quadriceps for muscle tone and tension. The assessments will include checking the function of the quadriceps which is responsible for knee extension. Your range of knee extension will be tested at the assessment. If the quadriceps are indeed tight, manual therapy will be applied. Find immediate relief and an improvement in the range of motion.

COMT is a functional remedy for knee pain, compared to knee surgery which is a structural remedy. COMT treats the muscle imbalance, while knee surgery treats the bone structure. Both are remedies for knee pain but the approaches are different.

What is COMT?


COMT becomes even more effective when combined with Pilates, as the exercise further corrects the muscle imbalance. Pilates has a long history as an exercise programme for rehabilitation. Pilates is gentle on the body. For example, if doing standing knee exercises have been  challenging for you, the Pilates reformer replicates the same knee exercises lying down. The position decreases the stress on the knees, and at the same time, improve your knee function and leg strength.

Remedy for knee pain
Pilates for Knee Care: The Pilates reformer allows you to perform knee flexion and extension in a supine position.

Pilates also improves hip movement and core strength, which translate to better balance when you walk and less stress on the knees.

Learn More About Pilates


When we know more about our knee function and muscle imbalance, we are better able to remove the source of pain. Imagine muscles like stretch bands. A tight muscle is like a stretch band with knots. When there are many knots, the knots shorten the range of motion which the thigh and leg bones can move in relation to each other. The action results in knee pain and excessive bone-to-bone rubbing which increases wear and tear at the knee joint.

A combination of COMT and Pilates is a functional remedy. COMT relieves knee pain, while Pilates provides a good exercise programme to improve knee function and leg strength. Give COMT and Pilates a try. Start Today.

Medical Disclaimer: Always consult your physician if you have an existing pain or a pre-existing medical condition before beginning any exercise. The above information is not intended to diagnose any medical condition or replace your healthcare professional.

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    Perceptive & Good

    May is very perceptive and good at picking out which muscles that are not working as they should!

    Better Body Alignment & Awareness

    After a few sessions with May, I realize if I don’t center my body when I walk and stand, all the pains in my right knee and lower back returns. Now I consciously seek to distribute equal weight to both legs and align my body when I walk. Thanks May!

    Given Me Hope That I'll Walk Normally Again

    May has given me hope that I will in the near future, be able to walk normally again with minimal pain in my knees. She is great at getting to the root of the problem, in correcting muscular imbalances through manual therapy, pilates and home exercises. Thank you, May!

    Relieves Knee Pain, Improves Fitness

    I'm glad to have May as my Pilates instructor. May has helped me with my bad knee through exercises and orthopedic manipulation. She is also very patient, and committed to my body's improvement beside my knee.
    Ai Lin

    Knee exercises and activities that I can continue on my own

    Working overseas, I came back to Singapore for a short four week holiday and thought I should get some Pilates classes to further strengthen my weak knee due to a meniscus tear. I found Move Therapy by googling and signed up for my 1-to1 trial class. May went through my problem and what the doctors did for me. She then designed a set of exercises and activities which I could continue on my own when I go back to work, overseas. After my first trial lesson, I was just so amazed by the differences in my legs. When I arrived back in Singapore, although I’ve recuperated from the meniscus tear through physiotherapy and physical therapy at the hospital, my legs still felt swollen and stiff. I was not able to bend my knees. My attempts at swimming, which was recommended by the doctor, was hard, as I wasn't sure how to move anymore. After my first session with May, my leg muscles felt more relaxed and subsequent sessions continued to make me feel I’m near full recovery. The exercises and activities May prescribed were easy enough to continue at home and in a gym anywhere I go. Thanks!

    I'm running more, have less injury

    I am an avid runner. I run 10km a few times a week. I had hurt my ankles, calves just to name a few of the body parts I’d injured from running. Many of times I didn’t wait until I have completely recovered before I resumed running. It had resulted in the injury being prolonged. After attending May’s Pilates classes for about a year, I have gained better awareness of my body and movement. May taught me a lot about core strengthening, maintaining good posture and about movement. I’m more aware of my running posture. I find myself correcting my posture on the go like altering my foot alignment when I encounter discomfort, as well as how to stretch after. I can run more often because I have less injury now. Thank you May.


    "I was so worried about climbing Wutai Shan (Shanxi, China) because I'd knee pain. I wanted to  perform the Buddhist rite of walk, pray and kneel on every three steps up the 1,080 stairs of the sacred mountain. It was the main reason for going. It would be very difficult to do with my kneecap problem. My sister recommended Move Therapy to me. After one session, I was so surprised there was no more pain on my kneecap. I felt I was walking with very light steps. The relief was so immediate, it took me by surprise. Of course, I continued to roll after, using the foam roller. It wasn't just from one class at Move Therapy, but the class showed me how to and on which area of my legs I should focus on when I roll. I was able to walk, pray and kneel up Wutai Shan. A wish come true. No knee pain. Thank you."
    Beng Lee

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