Back of Knee Pain: Causes, Symptoms & Physiotherapy Treatment

Written by Dr Ajay Shakya | BPT, MPT (Neurology), Certified Manual Therapist

Published: June 2026 | Reading Time: 15 minutes

Back of knee pain is one of the most common musculoskeletal complaints seen in physiotherapy clinics today. Whether you are a runner, an office worker, or an older adult, pain in the back of the knee can make everyday activities like walking, climbing stairs, and sitting for long periods genuinely difficult. The back of the knee — medically known as the popliteal region — contains muscles, tendons, ligaments, nerves, and fluid-filled sacs called bursae. Because so many structures are packed into this small area, posterior knee pain can have many different causes, ranging from a Baker's cyst or hamstring strain to a meniscus tear or, in rare cases, a deep vein thrombosis requiring urgent medical attention. In this article, Dr Ajay Shakya explains the causes, symptoms, diagnosis, and physiotherapy treatment of back of knee pain in simple, evidence-based language.

1. INTRODUCTION

Pain at the back of the knee — medically known as posterior knee pain — is one of the most frequently encountered musculoskeletal complaints in physiotherapy clinics across India and worldwide. Whether you are a recreational runner, a sedentary office worker, a competitive athlete, or an older adult managing a chronic condition, back of knee pain can significantly interfere with your daily activities, sleep, and overall quality of life.

The back of the knee, also called the popliteal region, is anatomically complex. It contains muscles, tendons, ligaments, blood vessels, nerves, and fluid-filled sacs called bursae — all packed into a relatively small space. This complexity means that pain arising from this region can have many different causes, ranging from a simple muscle tightness or overuse injury to a potentially serious condition like a deep vein thrombosis (DVT) that requires immediate medical attention.

Understanding the exact cause of your back-of-knee pain is the most important first step toward effective treatment and full recovery. This guide by Dr Shakya explains everything you need to know about posterior knee pain — from anatomy and causes to diagnosis, physiotherapy treatment, and rehabilitation exercises.

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2. ANATOMY OF THE POSTERIOR KNEE

To understand why back of knee pain occurs and why it can feel so different in different people, it helps to know what structures are present in the popliteal region.

The popliteal fossa is the diamond-shaped hollow at the back of the knee, bordered above and laterally by the biceps femoris muscle, and above and medially by the semimembranosus and semitendinosus muscles. Below, the fossa is bounded by the two heads of the gastrocnemius muscle — the medial and lateral heads — which arise from the posterior surface of the femoral condyles.

Within this fossa lie the popliteal artery and vein, which are the major blood vessels supplying the lower leg. The tibial nerve and the common peroneal nerve also pass through this region on their way down the leg. Damage or compression of these neurovascular structures can produce unusual symptoms such as calf numbness, tingling, or weakness in addition to local knee pain.

The posterior cruciate ligament (PCL) sits inside the knee joint and prevents the tibia from sliding backwards on the femur. The popliteus muscle — a small, triangular muscle — originates at the lateral femoral condyle and inserts on the posterior tibia. It plays a vital role in "unlocking" the knee from full extension at the start of knee flexion. A popliteal bursa sits in the posteromedial corner and, when distended with excess synovial fluid, becomes what is commonly known as a Baker's cyst.

Understanding which of these structures is the source of pain requires a thorough clinical assessment by a trained physiotherapist.

3. COMMON CAUSES OF BACK OF KNEE PAIN

There are many possible causes of back of knee pain. The following are the most common conditions seen in clinical practice, along with their key features.

Baker's Cyst (Popliteal Cyst)

A Baker's cyst is the most common cause of a swelling or lump at the back of the knee. It develops when excess synovial fluid — the natural lubricant inside the knee joint — accumulates in the popliteal bursa and causes it to bulge out as a cyst. Baker's cysts are usually secondary to an underlying knee problem, such as osteoarthritis, a meniscus tear, or rheumatoid arthritis, all of which cause the knee to produce more fluid than normal.

The typical presentation is a soft, fluctuant swelling behind the knee that produces a feeling of tightness or fullness, particularly after prolonged standing, walking, or exercise. In some cases, the cyst can rupture, causing sudden, sharp pain that spreads down the inner calf and mimics a deep vein thrombosis. Baker's cysts are more common in middle-aged and older adults, though they can occur at any age.

Hamstring Muscle Strain or Tear

The hamstring muscle group — comprising the biceps femoris, semimembranosus, and semitendinosus — is one of the most commonly injured muscle groups in sport. A hamstring strain or tear at the distal end of the muscle near the knee is a frequent cause of posterior knee pain, particularly in runners, footballers, cricket players, and sprinters.

Hamstring strains are classified by severity: a Grade I strain involves mild overstretching with microscopic damage, a Grade II strain is a partial tear, and a Grade III strain is a complete rupture. The typical mechanism involves a sudden eccentric load — such as sprinting at full speed or a sudden change of direction — causing the muscle to tear under tension. Symptoms include sudden sharp pain at the back of the knee or posterior thigh, bruising, swelling, weakness in knee flexion, and difficulty walking or running normally.

Posterior Cruciate Ligament (PCL) Injury

The posterior cruciate ligament is the strongest in the knee, and PCL injuries, while less common than ACL injuries, are an important cause of posterior knee pain and instability. The PCL is most commonly injured by a direct force to the front of the tibia with the knee in a flexed position — as seen in dashboard injuries during road traffic accidents, falls on a bent knee, or contact sports collisions.

Clinically, PCL injuries present with posterior knee pain, swelling, and a feeling of instability, particularly when descending stairs or walking on uneven ground. On physiotherapy examination, the posterior drawer test will be positive, indicating laxity of the posterior cruciate ligament. MRI is required to confirm the diagnosis and grade the injury.

Posterior Horn Meniscus Tear

The menisci are C-shaped fibrocartilage pads inside the knee joint that act as shock absorbers and load distributors. The posterior horn of the medial meniscus is the most commonly torn portion of the meniscus, and a posterior horn tear is an important and often underrecognised cause of back of knee pain.

Meniscal tears can be traumatic — occurring in young athletes following a twisting injury — or degenerative, developing gradually in middle-aged and older adults as the cartilage becomes more brittle with age. The typical symptoms of a posterior horn meniscus tear include pain along the back of the knee at the joint line, clicking or catching sensations, a tendency for the knee to lock or give way, and swelling that develops some hours after activity. MRI is the investigation of choice for meniscal pathology.

Gastrocnemius Muscle Strain (Tennis Leg)

The medial head of the gastrocnemius, which originates from the posteromedial femoral condyle, is a frequent site of muscle strain or partial tear. This injury is most commonly seen in middle-aged recreational athletes participating in racket sports, squash, or badminton — and is sometimes called "tennis leg." The mechanism is typically a sudden push-off with the knee extended and the ankle simultaneously dorsiflexed, placing maximal eccentric load on the gastrocnemius at its origin.

The presentation is a sudden, often dramatic onset of pain at the back of the knee and upper calf, which the patient may describe as being hit or kicked from behind. Bruising subsequently tracks down the calf over 24 to 48 hours, and there is significant pain on tip-toe walking and going up stairs. Because calf swelling may be prominent, it is important to clinically exclude a DVT in all cases.

Hamstring Tendinopathy (Distal)

Tendinopathy of the distal hamstring tendons — particularly the semimembranosus tendon at its insertion on the posteromedial tibia — is a chronic overuse condition commonly seen in runners and cyclists who undertake high training volumes. Unlike an acute muscle strain, tendinopathy develops gradually over weeks to months as a result of repetitive microtrauma exceeding the tendon's capacity to repair itself.

The hallmark of hamstring tendinopathy is a gradual onset of deep aching pain at the back of the knee that is stiff and painful after rest, warms up somewhat during exercise, and then worsens again with prolonged or higher-intensity loading. Morning stiffness lasting a few minutes after getting out of bed is a common feature. Tenderness is localised to the tendon insertion rather than the muscle belly.

Popliteus Muscle Strain or Tendinopathy

The popliteus is a small but clinically important muscle that originates at the lateral femoral condyle and inserts on the posterior surface of the proximal tibia. Its primary function is to internally rotate the tibia and unlock the knee from full extension at the beginning of knee flexion. Popliteus tendinopathy is an underdiagnosed condition that produces pain at the posterolateral aspect of the knee, most commonly in downhill runners.

The classic presentation is lateral or posterolateral knee pain that develops during and after downhill running, with tenderness on deep palpation just below and behind the lateral femoral condyle. Popliteus strain is also seen after sudden pivoting injuries and is sometimes associated with lateral meniscus tears or posterolateral corner injuries.

Posterior Knee Osteoarthritis

Osteoarthritis of the knee is the most common joint condition in adults over 50, and while it most frequently presents with medial joint line pain and anterior knee symptoms, advanced osteoarthritis commonly affects the posterior joint compartment as well. Posterior knee pain in the context of osteoarthritis is typically accompanied by other classic features of the condition — morning stiffness that resolves within 30 minutes, crepitus (a grinding or crackling sensation during movement), progressive loss of range of motion, and bony enlargement or deformity.

Pain tends to worsen with prolonged weight-bearing activity and by the end of the day, and is typically relieved by rest. Osteoarthritis-related Baker's cysts are common, as the inflamed joint produces excess synovial fluid that accumulates in the popliteal bursa.

Biceps Femoris Tendinopathy

The biceps femoris tendon inserts at the fibular head on the posterolateral aspect of the knee, and tendinopathy at this insertion is a recognised but frequently missed cause of posterolateral knee pain in cyclists, runners, and football players. It is commonly misdiagnosed as iliotibial band syndrome because both conditions produce lateral knee pain in athletes.

The distinguishing feature is that biceps femoris tendinopathy produces localised tenderness directly at the fibular head insertion, with pain that is present at the start of exercise, partially warms up, and then returns at higher intensities or after the session. Imaging with ultrasound or MRI can confirm the diagnosis.

IMPORTANT — Deep Vein Thrombosis (DVT): A Medical Emergency

Deep vein thrombosis is a blood clot that forms within the deep veins of the calf, popliteal region, or thigh. It is not a musculoskeletal condition, but it must always be considered in any patient presenting with posterior knee pain and calf swelling because it is a potentially life-threatening emergency. If a DVT is not treated promptly, the clot can break off and travel to the lungs, causing a pulmonary embolism, which can be fatal.

The symptoms of DVT include persistent, constant pain at the back of the knee or calf, significant swelling of the lower leg, warmth, redness or discolouration of the skin, and a heavy or tight sensation in the leg. Risk factors include prolonged immobility (long-haul flights or bed rest), recent surgery, pregnancy, obesity, use of oral contraceptives, a personal or family history of blood clots, and certain medical conditions affecting blood clotting.

If you have back of knee pain and calf swelling — particularly following recent surgery, a long journey, or a period of immobility — seek emergency medical attention immediately. Do not attempt to massage the leg, as this can dislodge the clot.

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4. SYMPTOMS — WHEN SHOULD YOU SEE A PHYSIOTHERAPIST?

Most back of knee pain responds well to physiotherapy, but it is important to know when to seek professional assessment and when to seek emergency care.

You should consult a physiotherapist if you experience back of knee pain that persists for more than two weeks without improvement, if there is swelling, warmth, or redness in the area, if the knee is locking or giving way, if you are unable to fully bend or straighten the knee, if the pain is waking you at night, or if the pain started after a fall, collision, or sports injury.

Seek emergency medical attention immediately if you suspect a DVT (back of knee pain with calf swelling, warmth, and redness), if you have sustained a high-energy injury such as a road traffic accident or a fall from height, if you have back of knee pain accompanied by chest pain or shortness of breath (which may suggest a pulmonary embolism), or if you notice neurovascular signs such as coldness, pallor, loss of sensation, or weakness in the foot or ankle.

5. HOW IS BACK OF KNEE PAIN DIAGNOSED?

Accurate diagnosis is the cornerstone of effective physiotherapy. A rushed or incomplete assessment is one of the most common reasons why back of knee pain fails to improve with treatment.

The assessment begins with a detailed clinical history. Your physiotherapist will ask about when the pain started, what you were doing at the time, how the pain has progressed since, what makes it better or worse, whether you have had any previous knee injuries, and what your occupation, sport, and activity level are.

This is followed by a physical examination including observation of swelling, bruising, limb alignment, and gait; palpation of the specific anatomical structures at the back of the knee to localise the site of maximum tenderness; and active and passive range of motion testing to assess how much pain-free movement is available.

A series of special clinical tests will then be performed depending on the suspected diagnosis. These may include the posterior drawer test and reverse Lachman test to assess the posterior cruciate ligament; McMurray's test and the Thessaly test to assess for meniscal pathology; the dial test to evaluate the posterolateral corner; and a thorough assessment of the lumbar spine and hip to screen for referred pain, which can easily masquerade as local knee pain.

When imaging is required, MRI is the gold standard investigation for soft tissue pathology at the back of the knee, providing excellent visualisation of the ligaments, menisci, tendons, muscles, and bursae. Plain X-ray is used to assess for bony changes, osteoarthritis, and fractures. Musculoskeletal ultrasound is highly useful for the dynamic assessment of tendons and bursae and is the first-choice imaging modality for Baker's cysts. If DVT is clinically suspected, a Doppler ultrasound of the lower limb venous system should be arranged as an urgent investigation.

6. PHYSIOTHERAPY TREATMENT FOR THE BACK OF THE KNEE PAIN

Physiotherapy is the first-line treatment for the vast majority of back of knee pain conditions. Treatment is always individualised based on the specific diagnosis, severity, the patient's age and general health, and their activity goals. A well-structured rehabilitation programme is divided into three progressive phases.

Phase One — Acute Management (Days 1 to 7)

The primary goals in the first phase are to reduce pain and inflammation, protect the injured tissue from further damage, and maintain as much mobility and muscle activity as safely possible. The PRICE protocol — Protection, Rest, Ice, Compression, and Elevation — remains the standard first-aid approach for acute posterior knee injuries. Ice applied for 15 to 20 minutes, three to four times daily, helps reduce localised swelling and pain. Activity modification is important during this phase: the patient is advised to avoid activities that significantly aggravate the pain while maintaining gentle movement and walking as tolerated.

During this phase, the physiotherapist may use electrotherapy such as TENS (transcutaneous electrical nerve stimulation) or therapeutic ultrasound for pain relief, gentle soft tissue massage to the surrounding musculature (avoiding direct massage if a DVT is suspected), and knee taping to offload the painful structures and provide proprioceptive feedback.

Phase Two — Active Rehabilitation (Weeks 2 to 6)

Once the acute pain has settled, the focus shifts to active rehabilitation — restoring a full range of motion, rebuilding muscle strength, and re-educating neuromuscular control. Progressive loading of the hamstrings and calf muscles is introduced using a structured isometric, isotonic, and then plyometric progression, based on the evidence for tendinopathy and muscle rehabilitation. Hip and gluteal strengthening is always included, as weakness in the hip stabilisers is a common contributing factor to knee overload.

Manual therapy techniques, including joint mobilisation, soft tissue release, and myofascial therapy, are used to restore normal tissue mobility and joint mechanics. Dry needling of myofascial trigger points in the hamstrings and gastrocnemius is an effective adjunct for pain modulation in this phase. Proprioception and balance training — beginning with double-leg balance and progressing to single-leg and unstable surface training — is an essential component of rehabilitation that is often overlooked.

Phase Three — Return to Activity (Weeks 6 to 12 and Beyond)

The final phase prepares the patient for a full return to their specific sport or daily activities. Sport-specific drills, running gait retraining, plyometric progressions, and a graduated return-to-sport programme are used to ensure the patient can tolerate the full demands of their activity before being fully discharged. Ergonomic advice for occupational or recreational activities is provided, along with a long-term maintenance exercise programme to prevent recurrence.

7. EXERCISES FOR BACK OF KNEE PAIN

The following exercises are general guidelines for posterior knee rehabilitation. They should be performed only within a pain-free range and after consulting your physiotherapist. Stop any exercise that causes sharp or worsening pain.

Standing Hamstring Stretch

Stand tall next to a wall or chair for balance. Place the heel of the affected leg on a step, low stool, or the second stair with the knee straight. Keep your back straight and gently lean forward at the hip until you feel a comfortable stretch at the back of the thigh. Avoid rounding the back. Hold the stretch for 30 seconds, relax, and repeat three times. Perform this exercise twice daily. This is an essential stretch for hamstring tightness contributing to posterior knee pain.

Standing Calf Stretch

Stand facing a wall with both hands placed flat against it at shoulder height. Take a step back with the affected leg, placing the heel flat on the floor. Lean gently into the wall, keeping the back knee straight, until you feel a comfortable stretch through the calf. Hold for 30 seconds and repeat three times. This stretch is particularly important following gastrocnemius strains and for patients with posterior knee pain associated with calf tightness.

Prone Hamstring Curls

Lie face down on a mat with both legs straight. Slowly bend the knee of the affected leg to approximately 90 degrees, pause briefly at the top, and then slowly lower the leg back to the floor over three to four seconds. This controlled lowering — the eccentric component — is the most important part of the exercise for tendon rehabilitation. Perform three sets of 15 repetitions. As strength improves, progress by placing a resistance band around the ankle to increase the load.

Terminal Knee Extension with Resistance Band

Loop a resistance band around a fixed object at knee height and step into the band so it sits behind your affected knee. Stand with your back to the anchor point and take a step forward to create tension in the band. Start with a slight knee bend, then straighten the knee fully against the resistance of the band and slowly bend it back. This exercise is excellent for activating the popliteus muscle, improving VMO function, and restoring normal terminal knee extension mechanics. Perform three sets of 15 repetitions.

Single-Leg Balance

Stand on the affected leg with a slight knee bend to keep the quadriceps active. Focus on a fixed point in front of you and maintain your balance for 30 seconds. Repeat three times. As this becomes easier, progress to standing on a folded yoga mat or wobble board to challenge the proprioceptive system further. Single-leg balance training is a critical and often underemphasised component of posterior knee rehabilitation.

Nordic Hamstring Curl (Advanced)

This exercise is reserved for the advanced stage of rehabilitation. Kneel on a padded surface with your feet firmly anchored by a partner or wedged under a fixed object. Keeping your body in a straight line from knee to shoulder, slowly lower your body forward toward the floor by allowing the knees to extend, controlling the descent entirely with the hamstrings. Lower as far as you can control, then use your hands to push back up to the start position. Begin with three sets of five repetitions and build gradually over weeks. The Nordic hamstring curl has the strongest evidence base of any exercise for both hamstring injury rehabilitation and prevention.

8. PREVENTION TIPS

The most effective approach to back of knee pain is preventing it from occurring in the first place. The following strategies are evidence-based and practical for both athletes and non-athletes.

Always warm up properly before exercise with five to ten minutes of light cardiovascular activity followed by dynamic stretching of the hamstrings, quadriceps, calves, and hip flexors. A proper warm-up increases muscle temperature, improves tissue extensibility, and activates the neuromuscular system before high-intensity loading.

Strengthen the hamstrings and quadriceps regularly throughout the year, not just during an injury episode. Muscle strength imbalances — particularly a relatively weak hamstring compared to the quadriceps — are a well-established risk factor for posterior knee injuries. Include eccentric hamstring exercises such as the Nordic curl in your regular training programme.

Follow the 10% rule when increasing your training load: never increase your weekly mileage, training volume, or intensity by more than 10% from one week to the next. The majority of overuse injuries at the back of the knee — including hamstring tendinopathy and popliteus tendinopathy — occur when training load increases too rapidly for the tissues to adapt.

Use appropriate footwear for your specific sport or activity, and consider a biomechanical gait analysis if you are a runner, as abnormal running mechanics are a common contributing factor to posterior knee injuries. Maintain a healthy body weight to reduce the compressive and shear forces transmitted through the knee joint during weight-bearing activities. Finally, listen to your body: pain is a warning signal, and training through significant pain consistently accelerates tissue damage and delays recovery.

9. WHEN IS SURGERY OR FURTHER INVESTIGATION NEEDED?

The great majority of back-of-knee pain conditions respond fully to conservative physiotherapy management, and surgery is rarely required. However, there are specific circumstances in which referral for further investigation or surgical assessment is appropriate.

A complete posterior cruciate ligament rupture with significant posterior instability, particularly in a young active patient, may require surgical reconstruction if the instability cannot be managed conservatively. Complex posterolateral corner injuries involving the PCL, LCL, and popliteus tendon together almost always require surgical repair, as these structures do not heal reliably on their own.

A large, locked meniscus tear that causes the knee to be mechanically blocked from full extension requires arthroscopic surgery to remove or repair the torn fragment. Significant loose bodies within the knee, causing recurrent locking and giving way, may similarly require arthroscopic removal. Baker's cysts secondary to severe osteoarthritis that do not respond to conservative management — including aspiration and corticosteroid injection — may eventually require surgical treatment of the underlying joint disease.

As always, a suspected DVT is a medical emergency requiring immediate referral to an emergency department, and failure to respond to a well-structured physiotherapy programme over three to six months warrants re-investigation to ensure the diagnosis is correct.

10. CLINICAL PEARL — DR. AJAY SHAKYA

Not all pain in the back of the knee originates from the knee itself. In my clinical experience at Physio Health & Wellness, a significant number of patients referred for posterior knee pain actually have referred pain from the lumbar spine — specifically from the L3, L4, L5, or S1 nerve roots — or from the hip joint. Trigger points in the hamstring or gastrocnemius muscles can also refer pain to the popliteal region without there being any local pathology.

This is why a thorough physiotherapy assessment must always include a screening examination of the lumbar spine and hip, even when the patient's pain appears entirely localised to the back of the knee. Treating the knee when the true source of the problem is the lumbar spine or hip is one of the most common reasons that posterior knee pain fails to respond to treatment. Always assess the joint above and the joint below before concluding that the pain is coming from the knee.

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11. CONTINUE READING

1. Lateral Knee Pain Exercises & Treatment
2. Physical Exercise in ACL Injury for Rehabilitation
3. Is Osteoarthritis a Disability? Exploring the Impact & Facts
4. What is the home remedy for knee pain?
5. Immediate Relief for Sciatica Pain
6. Early Warning Signs of Osteoporosis: Don't Wait for the Fall
7. Exercises for Sacroiliac Joint Pain

12. CONCLUSION

Back of knee pain is a common, often distressing condition that can arise from a wide range of causes — from simple muscle tightness and overuse injuries to significant ligament and cartilage pathology. In rare but important cases, it can also signal a medical emergency such as a deep vein thrombosis.

Accurate diagnosis by a qualified physiotherapist is the single most important step in the management of posterior knee pain. Without knowing exactly which structure is responsible for the pain, treatment will be guesswork at best. With the correct diagnosis, a personalised physiotherapy rehabilitation programme — combining manual therapy, targeted exercises, and patient education — gives the vast majority of patients an excellent chance of making a full recovery and returning to all the activities they enjoy.

If you are experiencing back-of-knee pain that is not improving, do not wait. Early physiotherapy assessment consistently leads to faster recovery, better functional outcomes, and a lower risk of the problem becoming chronic. The longer posterior knee pain is left unaddressed, the more it can affect your movement patterns, muscle strength, and confidence in using your leg.

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Dr. Ajay Shakya BPT, MPT (Neurological Conditions) · 10+ years experience Certified physiotherapist and manual therapist with over 10 years of clinical experience. Specialises in neurological rehabilitation, back pain, neck pain, and sports injuries. Runs Physio Health and Wellness clinic in Jaipur, Rajasthan. BPT Graduate   MPT Neurological   Certified Manual Therapist

Medical Disclaimer: This article is written for educational and informational purposes only. It does not replace professional medical advice, diagnosis, or treatment. Always consult a qualified physiotherapist or doctor for your specific condition before beginning any treatment or exercise programme.