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Recently I uploaded the video squatting with osteoarthritis which covers exercise progressions and supportive exercises to help those who have osteoarthritis squat. One of the viewers asked a great question in the comments regarding noise coming from her knees when she squats with knee Osteoarthritis. She asked:
"When I do the squat’s I notice when I bend down that there is a click sound from my lower limb but unsure if it is from the ankle or from the knee as there's no pain. The click sound is not just one or twice say if I were to do 3 sets of 10 's there will be 30 times of click sounds" - YouTube viewer.
The problem of noises coming from the knees, whether it be clicking, popping, grating, creaking, cracking, crunching, or grinding, is not uncommon in those with osteoarthritis. And, it is common not just during squats but also with activities like walking, getting up from a chair, getting in and out bed, or really any movement that involves bending and straightening the knee.
While there may be more than one reason for this clicking for this viewer, for those with osteoarthritis, the most common is the classification of crepitus. A definition of crepitus from arthritis-health.com is: "any grinding, creaking, cracking, grating, crunching, or popping that occurs when moving a joint." These noises can be quite concerning when experiencing them, especially because it can be difficult to know where the noise is coming from or to know the cause of the noise. One differentiation and explanation I have seen was by Physiotherapist Claire Robertson. Claire described the following noises that may come from the knee classified as crepitus. 1. Isolated pops or cracks. For instance, the noise of knuckles cracking. These pops or cracks are generally attributed to the physiological process of cavitation, where small air bubbles that develop with the movement of the synovial or joint fluid collapse again. These pops or cracks are usually not associated with pain and there is no evidence to suggest that these pops or cracks cause osteoarthritis.
2. Clunking noise. This can be explained as the patella or knee cap moving into the trochlear groove (knee cap groove) of the femur. This may be a result of incorrect patella tracking, where the patella may not remain completely within the trochlear groove during movement. This noise is associated with a feeling of relief rather than causing pain as the patella re-aligns with the trochlear groove. It is also important to note that this noise is not coming from the tibiofemoral joint which is the weight bearing joint, but rather the patellofemoral joint which is non-weight bearing. This is important because much of the pain and function limitations associated with osteoarthritis come from the tibiofemoral joint during weight bearing activities. 3. Fine, grating sound. This can be attributed to synovial fluid moving behind the cartilage on the back of the patella. Physiologically this is described as the "slip stick" effect. There may be grating at multiple times during movement. This noise is often misinterpreted as bone rubbing on bone or harmful. Again, this noise can often come from the patellofemoral joint which is non-weight bearing.
When understanding what these noises mean, some key points have been found in research.
1. Noise should be disassociated from pain. i.e. noise does not equal pain.
2. Noise should be disassociated from knee function. i.e. noise does not equal harm to the knee joint.
3. Noise should not be the limiting factor for activities. For example, squats, walking up the stairs, and doing exercises.
4. Noise is not associated with the occurrence of knee joint replacement. i.e noise does not mean a knee joint replacement is needed.
5. Noise is associated with lower self-reported function but not objective strength and function. i.e. Those with noise perceived lower function.
It is important to note that these points are regarding more chronic knee joint noises in osteoarthritis. Less frequently, noises from the knee may be attributed to acute damage like an ACL tear, meniscus injury, or post-surgery crepitus. The main differentiating factor is that these noises are from single event or trauma to the knee which a person is likely to remember. The noises we are talking about in this article cannot be attributed to a single event or trauma and are typically ongoing over a prolonged period of time.
So for our viewer, the noise experienced could be attributed to one of these three types of crepitus. While these noises likely won't go away, the noise alone should not be the limiting factor to function and participating in activities such as squats, walking up and down stairs, and doing exercises.
For further information on knee crepitus, here are a few articles.
Physiopedia Knee Crepitus
Pazzinatto et al., 2019. Knee crepitus is not associated with the occurrence of total knee replacement in knee osteoarthritis --- a longitudinal study with data from the Osteoarthritis Initiative.
Pazzinatto et al., 2019 What are the clinical implications of knee crepitus to individuals with knee osteoarthritis? An observational study with data from the Osteoarthritis Initiative
If you have osteoarthritis and are unsure if you have the right exercise program put together, make sure to get your complimentary Fit with Arthritis Self-Assessment to identify if you are meeting 10 key components of a successful exercise program.
For additional support make sure to join the Facebook group, book a consultation, or apply for the Fit with Arthritis program.
Tess Halbauer
Physiotherapist
BHlth&RehabSc, MPhty
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