Knee

What It Is

Osteonecrosis means death of bone tissue. It happens when part of a bone loses its blood supply, and because bone cells need a steady supply of blood to stay healthy, that part of the bone starts to die (NIAMS, 2021a). It can occur in almost any major joint, and the knee is one of the more common joints affected.

In the knee, osteonecrosis affects a section of bone in the femur (thighbone) or tibia (shinbone). It is a cause of knee pain in older adults: it is more common in people over the age of 60, and women are three times more likely than men to develop it (AAOS, n.d.).

It is not always known what causes the loss of blood supply, but doctors have identified a number of risk factors (AAOS, n.d.):

An injury to the knee, such as a stress fracture or dislocation, combined with some kind of trauma, which can damage blood vessels.
Long-term use of oral corticosteroid (steroid) tablets. Steroid-related osteonecrosis often affects several joints in the body.
Medical conditions such as obesity, sickle cell disease and lupus, and some medicines used to treat HIV.
Organ transplants, especially kidney transplants.
Drinking too much alcohol over a long time.

In cases that do not follow an injury, the reasons for the loss of blood supply are less clear, but it may be due to blood clots blocking the circulation or increased pressure inside the bone squeezing the blood vessels (NIAMS, 2021a).

Osteonecrosis is not caused by osteoarthritis. It works the other way round: if osteonecrosis is not picked up and treated early, the bone can collapse and the knee can develop severe osteoarthritis (AAOS, n.d.).

Osteonecrosis of the Knee Anatomy

Osteonecrosis of the knee affects the end of the thighbone or the top of the shinbone, just under the smooth cartilage that covers the joint surfaces. If the affected bone collapses, the cartilage covering it can collapse too (AAOS, n.d.).

How to Treat Osteonecrosis of the Knee:

A good conditioning programme with exercises to strengthen the muscles in the thigh and keep the knee moving is beneficial, and in some cases exercise in water may be recommended to avoid stress on the knee joint (AAOS, n.d.). Physical therapy can work on strengthening the muscles around the joint and improving the range of movement of the knee (NIAMS, 2021b). I can guide you on what you can and can't do with exercise and sport, and build strength and movement around your knee with exercises and hands-on work. See the My Approach tab for how I work.

In the early stages, or if only a small area of the knee is affected, non-surgical treatment may be all that is needed (AAOS, n.d.).

1. Medication

In the early stages, medicine can help to relieve some of the pain and swelling. AAOS says that non-steroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen and naproxen, can help reduce pain and swelling in the knee (AAOS, n.d.). (This medicine information comes from the American Academy of Orthopaedic Surgeons (AAOS), not from me. Always check with a pharmacist or your family doctor or nurse practitioner before taking any medicine.) Being able to reduce the pain in the knee means you will be able to get out and move around more.

2. Reducing Weight on the Knee

For some people, taking weight off the affected knee can slow the damage and allow healing, and your doctor may recommend using crutches for a period of time. In some cases, an "unloader" brace can help relieve pressure on the joint surface by shifting weight away from the affected part of the knee (AAOS, n.d.). Your doctor can advise whether a brace is right for you. I can help you work out what you need and how to get it, and point you to the right specialist if you need a custom brace.

3. Modification of Activities

To help minimise the pain in the knee, you might want to avoid or change activities that bring on your symptoms (AAOS, n.d.).

Not a diagnosis — for more information, contact me or another trusted healthcare provider.

Symptoms

How It Feels

Symptoms

The first symptom is usually pain on the inside of the knee, which may come on suddenly and be triggered by a particular activity or a minor injury. As the condition progresses, it becomes harder to stand and put weight on the knee, and moving the knee is painful. There may also be swelling over the front and inside of the knee, tenderness around the knee and a reduced range of movement (AAOS, n.d.). It is important to diagnose osteonecrosis early, so see your family doctor or nurse practitioner if you have knee pain like this.

Treatment

Self-Care & Treatment

Treatments you may want to discuss with your family doctor or nurse practitioner

Your family doctor or nurse practitioner can refer you to a specialist if needed.

Options outside my scope

Bisphosphonates: prescription medicines that a doctor may discuss with you, especially if you are diagnosed at a younger age (AAOS, n.d.). (This medicine information comes from the American Academy of Orthopaedic Surgeons (AAOS), not from me. Always check with a pharmacist or your family doctor or nurse practitioner before taking any medicine.)
Surgery: if a large part of the bone is affected, or the pain does not improve with non-surgical treatment, surgery may be recommended. More advanced osteonecrosis often needs surgery (NIAMS, 2021b).
Core decompression: an operation in which narrow channels are drilled into the bone to lower the pressure inside it, often combined with a bone graft (AAOS, n.d.; NIAMS, 2021b).
Osteotomy: an operation in which the shinbone or thighbone is cut and reshaped to shift weight away from the damaged area of the knee (AAOS, n.d.).
Knee replacement: if the bone has already collapsed, the damaged parts of the knee may need to be replaced with a total or partial knee replacement (AAOS, n.d.).

How I can help (see the My Approach tab)

Strengthening and movement exercises for the knee, thigh and hip
Hands-on work for stiffness and tight, overworked muscles
Advice on activity, sport, crutches and braces
Support with recovery after surgery, once your surgeon clears you

Tips

Osteonecrosis of the knee is linked with obesity (AAOS, n.d.). If you are overweight, losing the excess pounds can help to reduce the load on your knee joints.
Drinking too much alcohol over a long time is a risk factor for osteonecrosis (AAOS, n.d.). If you drink a lot of alcohol, you might want to consider cutting back.
Conditions such as sickle cell disease and lupus are linked with osteonecrosis of the knee (AAOS, n.d.), so it is important to keep any such condition under the care of your doctor.
If you have recently injured your knee, for example with a stress fracture or dislocation, your chance of developing osteonecrosis is increased (AAOS, n.d.).
People who take steroid tablets long term are at increased risk, and the condition can affect several joints (AAOS, n.d.). Do not stop any prescribed steroid without talking to your doctor.

Treatment

My Approach

Your medical team manages osteonecrosis of the knee and decides how much weight the knee can take and whether you need surgery. I work within their plan to ease pain and stiffness, look after overworked muscles, and build strength around the knee. After surgery, I need your surgeon's okay before any hands-on treatment.

Please bring any X-ray or scan reports and notes from your medical team to your first visit. They're an important part of planning safe treatment for you.

I assess how your knee moves, how you walk and your leg strength.

Easing Pain and Stiffness

Massage for the thigh, calf and hip, with light pressure over the painful area
Gentle knee movement within comfort, never forced
Warm or cool applications in the clinic, and safe use of ice and heat at home
Crutch set-up, and easing the other leg, back and shoulders
Working out whether a brace would help and how to get one

Building Strength

Thigh-tightening exercises, building to sit-to-stands and step-ups as the knee allows, with a home programme
Guidance on exercise and sport, including cycling or exercise in water
After surgery, once you're cleared: lymphatic drainage for swelling, scar work once healed, and a gradual return to strength

If the pain worsens or weight-bearing gets harder, tell your doctor.

What to Expect

Typical Course

Typical course: Most people come once or twice a week at first, then weekly, with a reassessment at about 4 to 6 weeks, then less often, all fitted around your medical team's plan. In the early stages, expect gradual gains in comfort, strength and movement over a few weeks; after surgery, timing follows your surgeon's plan.

What I Focus On

Working Within Your Team's Plan

Compensation Relief

Gentle Knee Mobility

Thigh & Hip Strength

Activity Guidance

Sources

References

American Academy of Orthopaedic Surgeons (AAOS) (n.d.) Osteonecrosis of the knee. OrthoInfo. Available at: https://orthoinfo.aaos.org/en/diseases--conditions/osteonecrosis-of-the-knee/ (Accessed: 7 October 2026).
National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS) (2021a) Osteonecrosis (avascular necrosis): symptoms and causes. Available at: https://www.niams.nih.gov/health-topics/osteonecrosis (Accessed: 7 October 2026).
National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS) (2021b) Osteonecrosis: diagnosis, treatment, and steps to take. Available at: https://www.niams.nih.gov/health-topics/osteonecrosis/diagnosis-treatment-and-steps-to-take (Accessed: 7 October 2026).

Massage therapy · Kitchener–WaterlooOsteonecrosis of the Knee

What It Is

Osteonecrosis of the Knee Anatomy

1. Medication

2. Reducing Weight on the Knee

3. Modification of Activities

How It Feels

Symptoms

Self-Care & Treatment

Treatments you may want to discuss with your family doctor or nurse practitioner

Tips

My Approach

Easing Pain and Stiffness

Building Strength

Typical Course

References

Related Conditions

Book a session

Massage therapy · Kitchener–WaterlooOsteonecrosis of the Knee

What It Is

Osteonecrosis of the Knee Anatomy

1. Medication

2. Reducing Weight on the Knee

3. Modification of Activities

How It Feels

Symptoms

Self-Care & Treatment

Treatments you may want to discuss with your family doctor or nurse practitioner

Tips

My Approach

Easing Pain and Stiffness

Building Strength

Typical Course

References

Related Conditions

Osteonecrosis

Anterior Cruciate Ligament Rupture and Reconstruction

Baker's Cyst

Blount's Disease

Book a session