While knee pain can be a result of many causes, this article focuses on muscular related pain, and not menisci or ligament related damage.
Knee Pain is a common and scary type of pain with 5% of primary care visits revolving around it (Duong et al., 2023). The fear of knee pain usually evolves from horror stories going around and the thought the knee is ‘gone’ and will restrict daily life with the potential for a whole replacement.
There are many possible reasons for pain in the knees, with the most common being patellofemoral pain, knee osteoarthritis, and meniscal tears (Duong et al., 2023). But those does not mean muscles do not play a role in pain (D’Ambrosi et al., 2022, Beutler and Fields, 2025).
A quick structural review of the knee: the knee consists of 2 joints. Patellofemoral, and Tibiofemoral. The Patellofemoral joint is create from the Femur (thigh bone) and the Patella (kneecap), while the Tibiofemoral joint consists of the Femur and Tibia (shin bone). The Patella is a sesamoid bone, meaning she is enclosed inside the tendon of the Quadriceps. While not officially part of the knee joints, you may find the Fibula resting besides the Tibia. The Fibula is important for the ankle structure, however, it does provide insertion points for muscles crossing the knee joint, and it is important to know of its location. Our first clue at muscle involvement with knee pain, is the Patella. Since the bone resides inside a tendon, any change to the muscle will affect the location of the bone, which could potentially cause pain.
Muscles and Causes for Knee Pain
Quadriceps
Quadriceps (Quads) are the most common group of muscle that can cause knee pain. The Quads are made of 4 different muscle heads (hence the name Quad = 4, ceps = headed). The Quads insert to the same tendon, which hold the Patella. A change in muscle elasticity or force in any of the 4 heads will directly effect the Patella position and may cause pain with knee movements. A simple way for a therapist to check for tension is a technique called Patella Tracking.
If you recall from the Lower Back Pain (LBP) article, the Rectus Femoris is the connecting link between the Quads and our back, and pain to the back can start from the knee and vise versa.
Hamstrings
The Hamstrings are a group of muscles, just like the Quads, and they perform the opposite movement to the Quads. They are located at the back of your thigh and insert on the lower border of your knee. When looking into knee pain, a tightening of the Hamstrings will pull the lower portion of the knee backwards into flexion. This constant pull will cause the whole musculature structure to adjust activation patterns and positions within the joint through the motion and could cause pain.
Just like the Quads, the Hamstrings are also part of the causes for LBP, and any pain on either one, can be caused due to an issue on the other.
Gastrocnemius
The Gastrocnemius (Gastro) are part of both the ankle and the knee. They assist the Hamstrings with flexing the knee, however, their insertion to the joint is to the upper border, and so any tightness in them may cause instability to the structure of the knee and lead to pain.
Gastro related pain can populate through the Foot and Ankle and affect the knee, and vise versa.
Adductors
Even though the knee’s main function is flexion and extension, there could also be a slight side bend either externally or internally.
The Adductors are a group of muscles consisting of 5 muscles. Those muscles originate from the pelvic bone, and grab a hold of the knee from both the upper and lower borders. As their name suggests, their action is adduction of the leg, and since their pull is through the knee they can populate different types of pain, depending on the injury you had. This group can often be confused with MCL or LCL injuries due to their location.
Iliotibial Band [Tract in some sources] (ITB)
The ITB is controlled by 2 different and opposing muscles originating at the hip. The ITB inserts into the knee on the external part of it, and any movement done with it can affect the knee.
Unlike the muscles discussed so far, reducing the pull of the ITB is not done directly on it, but from the muscles controlling it. Massaging the ITB can be very painful, and is not efficient. In order to reduce the pull on the ITB, you need to address both the Gluteus Maximus and the Tensor Fascia Latae (TFL) which control the ITB.
To Sum It Up
While knee pain is commonly related to structural issues, it is important to remember muscles are playing a crucial role in it. Getting a proper examination will lead to an educated diagnosis, and correct treatment to help you get back on track. A qualified manual therapist (orthopaedic therapist, osteopath, physiotherapist, etc.) will be able to provide a correct assessment of your pain, and treat you accordingly.
Left you with some questions? Feel free to contact me regarding the matter.
Content Last Reviewed & Updated on February 2026 – All statistics, references, and therapy recommendations have been reviewed to ensure current best practices.
References
Beutler, A. and Fields, K.B. (2025). UpToDate. [online] Available at: https://www.uptodate.com/contents/approach-to-the-adult-with-knee-pain-likely-of-musculoskeletal-origin.
D’Ambrosi, R., Meena, A., Raj, A., Ursino, N. and Hewett, T.E. (2022). Anterior Knee Pain: State of the Art. Sports Medicine – Open, 8(1). doi:https://doi.org/10.1186/s40798-022-00488-x.
Duong, V., Oo, W.M., Ding, C., Culvenor, A.G. and Hunter, D.J. (2023). Evaluation and Treatment of Knee Pain: A Review. JAMA, [online] 330(16), pp.1568–1580. doi:https://doi.org/10.1001/jama.2023.19675.
Images taken from Sobotta – Atlas of Human Anatomy, 11th English Edition, Vol. 2