What are the treatment options for a knee that feels loose and clicks?

Treatment for a Knee That Feels Loose and Clicks

Conservative management with exercise therapy is the first-line treatment for a knee that feels loose and clicks, as mechanical symptoms like clicking and catching are often multifactorial and do not reliably respond to surgical intervention. 1, 2, 3

Initial Diagnostic Approach

Obtain standard knee radiographs (AP, lateral, sunrise/Merchant, and tunnel views) when evaluating knee symptoms including clicking, looseness, pain, swelling, or mechanical symptoms. 1 These imaging studies help identify:

• Osteoarthritis changes 3
• Loose bodies 1
• Osteochondritis dissecans lesions 1
• Joint space narrowing 3

MRI is reserved for specific indications, not routine use:

• When concomitant pathology is suspected (meniscal tears, ligament injury, articular cartilage damage) 1
• To characterize known lesions 1
• When diagnosis remains unclear after radiographs and clinical examination 3

First-Line Conservative Treatment

Exercise Therapy (Strongest Evidence)

Implement a structured exercise program as the primary treatment, regardless of whether imaging shows meniscal tears or early osteoarthritis: 1, 4, 3

• Quadriceps strengthening exercises (quad sets, short-arc and long-arc quad sets) performed 3-5 times per week 4, 5
• Aerobic exercises including walking, cycling, swimming, or low-impact aerobics for 20-60 minutes per session 4
• Progressive resistance training with gradual increases in difficulty as tolerated 4

Patient Education and Self-Management

Provide education on joint protection techniques and proper body mechanics during daily activities. 4, 5 This approach has strong evidence for improving pain outcomes and should not be delayed. 5

Weight reduction for overweight patients significantly improves knee symptoms and reduces disease progression. 5

When Surgery Should Be Avoided

Do NOT perform arthroscopy with debridement or lavage for patients with:

• Primary diagnosis of symptomatic osteoarthritis 1
• Degenerative meniscal tears with mechanical symptoms (clicking, catching, locking) 1, 3
• Clicking or catching symptoms alone, as these are multifactorial and poorly responsive to arthroscopic meniscectomy 2

The BMJ clinical practice guideline provides a strong recommendation against arthroscopic knee surgery in patients with degenerative knee disease, even when mechanical symptoms are present. 1 Recent evidence demonstrates that mechanical symptoms, particularly catching and locking, may arise from multiple causes (chondral lesions, meniscal tears, loose bodies) and do not reliably improve with surgery. 2

Surgical Indications (Limited Scenarios)

Arthroscopic partial meniscectomy or loose body removal is an option ONLY when:

• A true loose body is identified on imaging causing mechanical symptoms 1
• Severe traumatic tears (bucket-handle tears) with displaced meniscal tissue are present 3
• Persistent objective locked knee (not just clicking or catching sensations) occurs 1

This represents expert consensus (Grade C recommendation) as high-quality evidence is lacking for surgical intervention in patients with concomitant osteoarthritis. 1

Common Pitfalls to Avoid

Do not assume clicking or looseness requires surgery. These mechanical symptoms are often present in degenerative knee disease and do not predict surgical success. 1, 2 The McMurray test (61% sensitivity, 84% specificity) and joint line tenderness (83% sensitivity, 83% specificity) assist in diagnosing meniscal tears, but even confirmed tears should be managed conservatively first. 3

Do not delay physical therapy referral. Early exercise intervention is crucial, and delaying this worsens outcomes. 5 Supervised exercise programs show significant improvements in pain (Effect Size 1.05). 5

Do not order MRI routinely. Clinical diagnosis based on history, physical examination, and standard radiographs is sufficient for most patients with clicking and looseness. 1, 3 MRI should be reserved for cases where diagnosis remains unclear or when planning surgical intervention for specific indications.

Adjunctive Treatments

Manual therapy (joint mobilization, soft tissue mobilization) is conditionally recommended in combination with supervised exercise. 4

Topical NSAIDs or capsaicin provide localized pain relief with minimal systemic absorption. 5

Intra-articular corticosteroid injections should be considered for acute pain exacerbations, especially when accompanied by effusion. 5

Heat and cold therapy can be used for pain management before or after exercise sessions. 4