Knee Pain

What is Knee Pain?

Knee pain is pain in or around the knee joint, and it is a symptom with many possible causes. About 5% of adult primary care visits involve knee pain, and osteoarthritis, patellofemoral pain and meniscal tears are among the most common causes.^[1]

The evidence for acupuncture, Ayurveda and herbs in this page comes mainly from studies of knee osteoarthritis, so it may not apply to other causes.

Common symptoms

Knee pain can be sharp, dull or aching and often worsens with movement or activity. It may come with stiffness, swelling, clicking or grinding, and a sense of weakness or the knee giving way.^{[1, 2]}

In osteoarthritis the pain usually starts gradually, is worse with activity and may also appear after sitting or resting for a long time. Over time it often becomes more frequent and more limiting.^[2]

Causes and risk factors

Knee osteoarthritis, which comes from gradual wear of the joint cartilage, is the most likely cause in people aged 45 and older with activity-related pain. Patellofemoral pain, felt at the front of the knee, mainly affects younger, active people. Meniscal tears can follow a twisting injury or develop with age.^[1]

Other causes include ligament injuries, tendon or bursa irritation, fractures, gout and other forms of arthritis, and infection of the joint.^{[1, 2]} Older age, past injury and extra body weight raise the risk of knee osteoarthritis.^[2]

How it is diagnosed and treated conventionally

Knee pain is often diagnosed from your history and a physical exam, and imaging is not needed for everyone. X-rays are not recommended for all people with possible knee osteoarthritis. MRI or ultrasound may be used when a tear or soft tissue problem is suspected.^[1]

First-line care is exercise therapy, weight loss if needed, education and self-management. Higher-quality guidelines consistently recommend education, exercise, weight management, anti-inflammatory medicines, and corticosteroid injection into the knee.^{[1, 3]} For patellofemoral pain, hip and knee strengthening are recommended, and exercise therapy is also first-line for most meniscal tears. Knee replacement can be considered for end-stage osteoarthritis after conservative care.^[1]

Why Knee Pain calls for a whole-person approach

Knee pain is not only a worn or injured joint. Inflammation, muscle strength and body weight all play a part in knee pain, so care that covers several of these is a reasonable addition to the treatment your physician or therapist directs.^{[1, 4]}

Inflammation in and around the joint

A systematic review of 37 studies found that signs of inflammation, especially synovitis (inflamed joint lining), were associated with knee pain in osteoarthritis. The link was weak to moderate, and the evidence for other markers was conflicting.^[4] Inflammation is therefore one contributor, not the whole picture.

Muscle strength and movement

Exercise is first-line treatment for the main causes of knee pain, which reflects the role of muscle strength and joint loading.^[1]

Body weight

Weight loss is part of first-line care for knee osteoarthritis when a person is overweight.^{[1, 3]}

Acupuncture for Knee Pain

What the research shows

Research suggests acupuncture may reduce knee pain from osteoarthritis, but trial results disagree and the certainty of the evidence is low.

A 2024 review of 80 trials with 9,933 people found that acupuncture may reduce pain compared with sham acupuncture, NSAIDs, usual care and no treatment, but not compared with injections into the knee. The authors rated the certainty as very low. Electroacupuncture appeared to work better than manual acupuncture.^[5]

A 2017 review of 19 trials of chronic knee pain found that acupuncture was associated with less pain at 12 weeks, but the authors could not draw strong conclusions because of differences between trials and methodological limits.^[6] A 2024 review of 10 trials found that benefits compared with sham acupuncture may last about 4.5 months after treatment, and found no added benefit when acupuncture was added to exercise-based physical therapy.^[7]

Sham-controlled trials are mixed. In a multicenter trial of 480 people, electroacupuncture three times a week for 8 weeks produced more pain and function responders than sham acupuncture, and the effect persisted to 26 weeks. Manual acupuncture did not beat sham at week 8, although it did at later follow-up.^[8] In a trial of 120 people, adding acupuncture to the pain medicine etoricoxib was better than sham acupuncture plus the drug or the drug alone.^[9] In contrast, an 86-person trial of superficial needling found no difference from non-penetrating sham needling.^[10]

A review of clinical guidelines found that recommendations on adjunctive treatments such as acupuncture were less consistent than those for exercise, education and weight management.^[3] A small review found that moxibustion may ease some symptoms of knee osteoarthritis, with limited trials and inconsistent pain and function results.^[11]

How acupuncture may work

Researchers propose that acupuncture influences pain through nerves and immune cells near the needle and through pain pathways in the spinal cord and brain.^[12] This work comes largely from laboratory studies of inflammatory pain, not from studies of knee pain in people, so it is a proposed explanation and not a settled fact.

What treatment involves

Treatment uses fine, sterile, single-use needles placed at points around the knee and on the leg, usually left in place for about 20 to 40 minutes. Mild electrical stimulation or moxibustion may be added. The trials above used 10 to 24 sessions over 4 to 8 weeks, and we reassess after a short course of visits.^{[8, 10]}

Serious problems are rare. In prospective studies, about 9 in 100 patients had a minor reaction such as bleeding, soreness or redness at a needle site, and serious events occurred in about 1 in 10,000 patients.^[13] Tell the practitioner first if you have a bleeding disorder, take blood thinners, are pregnant, have a knee replacement or implant, or have a pacemaker (relevant to electroacupuncture).

Ayurvedic medicine for Knee Pain

The Ayurvedic view

Ayurveda describes knee osteoarthritis as Sandhigata Vata, a Vata disorder of the joint in which dryness and loss of lubrication are said to cause pain and stiffness. This is a traditional framework used to choose treatment, not a biomedical diagnosis.

Therapies that may be used

Care is chosen for the individual and traditionally combines:

• Diet and daily routine intended to calm Vata, such as warm, regular meals and steady sleep
• Warm oil massage and local heat or steam over the knee
• Retaining warm medicated oil on the knee (Janu Basti)
• Herbs such as guggulu-based formulas, Boswellia and turmeric, prescribed individually^{[14, 15]}
• Panchakarma procedures where traditionally appropriate and medically sensible

Panchakarma procedures are not appropriate during pregnancy, acute illness or frailty, or before red-flag symptoms have been medically assessed. A hot, red, swollen knee needs medical assessment first.

What the research shows

The research on Ayurveda for knee pain is limited. It consists of one randomized trial and some uncontrolled studies, all in knee osteoarthritis.

In a German open-label trial of 151 people, a multimodal Ayurvedic treatment, with 15 treatments over 12 weeks, reduced symptoms more than multimodal conventional care, and the effect was sustained at 6 and 12 months. The trial was not blinded and the authors called for confirmation and for work on which components matter and on non-specific effects.^[15]

An uncontrolled study of 142 patients given a guggulu tablet, a decoction and a medicated oil with massage for 12 weeks reported reduced pain and WOMAC scores, but without a comparison group it cannot show cause.^[14]

Herbal medicine for Knee Pain

Herbs and formulas that have been studied

The best-studied herbs for knee osteoarthritis are turmeric (curcumin) and Boswellia (frankincense), both also used in Ayurveda. We did not find systematic reviews of Chinese herbal formulas for knee pain, so we do not discuss them here. Herbal preparations applied to the skin are also part of the clinic's transdermal medication therapy.

What the research shows

Research suggests curcumin and Boswellia may reduce osteoarthritis pain, but the trials are small and of low quality.

A meta-analysis of 11 trials with 1,009 people found curcuminoid and Boswellia products more effective than placebo for pain and function, with study quality low overall. The authors judged the evidence not strong enough for clinical recommendations.^[16] A meta-analysis of 7 trials of Boswellia found less pain and stiffness and better function than controls.^[17]

A network meta-analysis of 23 studies found that curcumin reduced pain scores and rescue medicine use compared with placebo, and that curcumin had fewer adverse reactions than NSAIDs.^[18] The authors say further research is needed to confirm these findings, so results may not apply to any particular preparation.

Safety and herb-drug interactions

Herbs are active substances and can interact with medicines. Case reports describe serious bleeding or clotting events when warfarin was combined with herbs including dang gui (Angelica sinensis), dan shen (Salvia miltiorrhiza), ginger, ginseng and Boswellia.^[19] People who take blood thinners or anti-inflammatory medicines need a practitioner's review before using herbs.

In one study, about one fifth of Ayurvedic products bought online contained detectable lead, mercury or arsenic.^[20] Herbs should come from tested sources and be prescribed individually. Tell us if you are pregnant or breastfeeding, have liver or kidney disease, or have knee surgery planned.

Translating traditional medicine into modern biological language

The links drawn here are interpretation, not equivalence. Chinese medicine often describes knee pain as obstruction of qi and blood by cold, damp or wind, sometimes with weakness of the kidney. Researchers study things that loosely parallel this, such as joint inflammation and the nerve and immune pathways that acupuncture is proposed to act on.^{[4, 12]}

Ayurveda's Sandhigata Vata describes dryness, stiffness and pain in the joint. Researchers describe knee osteoarthritis in terms of cartilage loss and inflammation of the joint.^{[2, 4]} No study has shown that a dosha or a pattern corresponds to a specific biological process.

How this care fits with your medical care

Integrative care for knee pain is complementary. Keep your physician, orthopedist or physical therapist, and do not stop or change prescribed medicines or planned injections or surgery without your prescriber. We do not diagnose the cause of knee pain, so new or unexplained knee pain should be medically evaluated.

Please bring your diagnosis, any imaging reports, a full list of medicines and supplements, and details of any injections, past surgery or a knee replacement. Exercise has the strongest support in conventional care, and acupuncture is best used together with it.^[1]

When to seek urgent medical care

Some knee symptoms need prompt assessment because they can point to infection, fracture or a blood clot.

• A hot, red, swollen knee, especially with fever or chills
• Inability to bear weight, or a knee that is visibly deformed after a fall or injury
• A knee that locks and cannot be straightened
• Calf pain and swelling, or sudden shortness of breath
• New numbness, or a cold or pale foot
• Severe pain at night or at rest with unexplained weight loss or a history of cancer

If any of these occur, call 911 or go to the nearest emergency department.