What causes knee clicking and how is it treated?

Knee Clicking: Causes and Treatment

Knee clicking is most commonly a benign symptom associated with degenerative knee disease and early osteoarthritis, not an isolated meniscal problem requiring surgery, and should be managed conservatively with exercise therapy, education, and analgesics rather than arthroscopic intervention. 1

Understanding the Cause

Knee clicking represents a symptom commonly reported by middle-aged patients with degenerative knee changes, and its causes are multifactorial:

• Clicking is frequently associated with early osteoarthritis rather than isolated meniscal pathology, even in patients with MRI-verified meniscal tears 2
• The symptom can arise from multiple sources including chondral lesions, meniscal tears, and loose bodies—not just one specific structure 3
• Middle-aged patients (35-65 years) with degenerative meniscal tears report clicking as a common symptom, with median severity rated as at least moderate, but this does not distinguish those with meniscal tears alone from those with early radiographic knee osteoarthritis 2
• Less common causes include snapping pes syndrome (painful clicking at the posteromedial corner when moving from flexion to extension) 4 and fabella syndrome (posterolateral clicking with knee flexion) 5

Diagnostic Approach

Start with plain radiographs (AP, lateral, Merchant/sunrise, and tunnel views) to evaluate for osteoarthritis and structural abnormalities 6:

• Radiographs are appropriate initial imaging for patients presenting with clicking, pain, edema, and crepitus 6
• MRI without contrast should be considered only if radiographs are normal or non-diagnostic and symptoms persist, to evaluate meniscal pathology, cartilage lesions, and bone marrow edema 1, 6
• Clinical examination combined with real-time ultrasound can be useful for specific conditions like snapping pes syndrome 4

Treatment Recommendations

Conservative Management is First-Line

The cornerstone of treatment is non-operative management, which should include 1:

• Exercise therapy (joint-specific strengthening and range of motion exercises, plus general aerobic conditioning) 1
• Patient education about the degenerative nature of the condition 1
• Weight reduction if obesity is present, as this is a modifiable risk factor 1
• Paracetamol (acetaminophen) up to 4g/day as the first-line oral analgesic 1, 6

Pharmacological Options

If paracetamol is insufficient 1:

• Topical NSAIDs have clinical efficacy with favorable safety profiles 1
• Oral NSAIDs for patients unresponsive to paracetamol, with gastroprotective agents in those at increased GI risk (age ≥60, history of peptic ulcer disease, concurrent corticosteroid use) 1
• Intra-articular corticosteroid injections for short-term pain relief, particularly if accompanied by effusion or inflammatory flare 1

Surgery is NOT Recommended for Clicking Alone

Arthroscopic surgery should be avoided in patients with degenerative knee disease presenting with clicking or other mechanical symptoms 1:

• Strong guideline evidence recommends against arthroscopic knee surgery in patients with degenerative knee disease, including those with clicking, locking, or other mechanical symptoms (except persistent objective locked knee) 1
• Mechanical symptoms, particularly catching/locking and clicking, are multifactorial in their causes and less responsive to arthroscopic meniscectomy 3
• While 65.6% of patients experience resolution of grinding/clicking after arthroscopy, this does not justify surgery given that conservative management is equally effective without surgical risks 7
• Predictors of symptom persistence after surgery include smoking, overweight/obesity, absence of meniscal tear, and multiple compartments with cartilage lesions 7

Important Caveats

Do not interpret clicking as an automatic indication for MRI or surgery 1, 2:

• Clicking does not distinguish between isolated meniscal pathology and early osteoarthritis 2
• The presence of clicking, even with an MRI-verified meniscal tear, represents early signs of knee osteoarthritis rather than a surgically correctable mechanical problem 2
• Rare exceptions requiring surgical consideration include persistent objective locked knee (not just clicking), snapping pes syndrome unresponsive to 8 months of conservative therapy 4, or fabella syndrome after total knee arthroplasty 5