The pain paradox
Why we stopped operating on knees — and what that means for your next injury.
By Professor Alister Hart
Fifteen years ago, if you came to my clinic with knee pain there was a good chance you’d leave with a date for keyhole surgery. Today, the odds are five times lower.
A fivefold national decline in knee arthroscopy is one of the most dramatic shifts I’ve seen in my 25 years treating joint injuries. For arthritic knees, the drop is even more extraordinary: a twentyfold fall.
This isn’t because knee problems have disappeared. It’s because our understanding of pain — and what to do about it — has undergone a complete rethink. And it raises two questions I now hear every week: “When should I stop?” and “How worried should I be about the pain?”
People want certainty. Pain rarely offers it. It exaggerates some signals, hides others — and often tells us more about sensitivity than damage. And for decades, clinicians struggled to interpret it too. What looks like the same injury can behave differently in different people. What looks alarming on a scan can be irrelevant. What feels severe can turn out to be benign. How can we make sense of that confusion? How do doctors now decide what pain really means, and what to do next.
Why pain became the centre of this story
Let me share a pattern every orthopaedic surgeon quietly memorises over years:
A runner with a grumbling kneecap. A tennis player with an Achilles that tightens every morning. A cyclist with a hip that “just doesn’t feel right.” A walker whose calf keeps seizing halfway up a hill.
Different sports, different ages, same puzzle: Pain arrives before damage does.
And sometimes damage appears on MRI with no pain at all. This is the part the public never sees — the mismatch between symptoms and scans, between how a joint feels and how it actually is.
Pain doesn’t behave like a car dashboard warning light. It can be a sign of overload, under-load, weakness, poor biomechanics... or nothing serious whatsoever.
Or, of course, it can be the rare but important warning signal that no patient or doctor can afford to ignore.
So how do we tell the difference?
To answer that, I turned to two of the UK’s most experienced sports medicine minds: Doctors Phil Batty and Mark Gillet.
Both have spent decades treating some of the world’s most finely tuned athletes. Both understand pain not as an abstract idea, but as something they’ve chased, questioned, decoded and negotiated inside elite dressing rooms, physio departments, ballet companies, rugby pitches and Premier League stadiums. Their insights reshaped the way I think about injuries — and I suspect they may reshape yours too.
The most common sports injury you’ve never heard of
When I asked Phil Batty what he sees most often, he answered without hesitation: “Tendinopathies — Achilles and patella. By far the commonest.”
And yet most recreational athletes have never heard the term. A tendinopathy is not a tear. It’s not inflammation. It’s a slow, structural change: a tendon that has adapted badly to new load. Why does it happen? Because the cardiovascular system adapts in weeks — but tendons need months.
This is why so many people feel ready to push harder before their body is truly prepared. It’s also why the 10% rule exists — increasing training volume by no more than 10% per week gives tendons time to adapt slowly enough to stay healthy. As one of my physio colleagues puts it: “Tendons hate surprises.”
“Strengthening accounts for 90% of the benefit”
MRI: brilliant, confusing, overused — and still essential
Mark estimates he uses MRI in more than 90% of his patients. Availability has improved, elite athletes expect imaging, and MRI has become the fastest way to rule out the serious, rare problems you never want to miss. Phil’s usage has risen too — from around 25% to roughly 60% over the past fifteen years.
But there’s a trade-off: the more you scan the more you find — and MRI is so sensitive it reveals changes that don’t matter. So higher use means more incidental findings — more reports full of terms that sound concerning, more confusion, and more people worrying about something that isn’t the cause of their pain.
Phil sees plenty of patients whose scans are “normal” despite pain. Mark goes further: “A normal MRI for a Premier League player looks very different from a normal MRI for an office worker.” In other words, MRI informs the diagnosis — but rarely defines it. Context, mechanics and symptoms tell the real story. The scan is a tool — not a verdict.
“MRI informs the diagnosis, but it rarely makes it.”
Time to rethink pain?
When I pushed Mark on whether he thinks most pain is muscular, he said something quietly profound: “I never use that word. Pain from poor movement patterns is far more prevalent.”
This is a huge shift in thinking. Pain isn’t simply located in the tissue that hurts. It comes from the system — strength, balance, technique, load, recovery, expectation, and confidence. This is why two people with identical MRI findings can have completely different experiences: one runs happily, one can barely climb stairs. This is not willpower — it’s biomechanics.
Phil sees the same picture. Many of his patients who present with pain and a normal MRI are dealing with underlying weakness — especially in the quadriceps, glutes, or calf complex. “The best mix of exercise involves both aerobic work and strength,” he told me. “Most people lean too far one way.”
The best treatment almost everyone ignores
When I asked Phil Batty which treatment helps the most people, he didn’t pause: “Strengthening — ninety percent benefit.”
Strength. Not stretching or gadgets or foam rollers. Not injections, orthotics or tape.
He uses isometric holds for severe flares, slow eccentric work for tendons, and resistance bands or body-weight exercises for patients who need to start small and stay consistent. Mark sees the same trend: about 70% of his patients respond to isometrics, 70% to resistance bands, and 90% to weight-based work — what he calls “appropriate lifting.”
Both doctors use injections — steroid for joint flares, PRP rarely and only for specific cases — but always as an adjunct, never the main course. “Steroid turns a painful, weak joint into a weak joint,” Mark said. “Rehab is what makes it strong.”
Shockwave therapy has a role for some tendons. Orthotics or taping can help temporarily — but neither doctor believes they can substitute for improved strength and better mechanics.
This shift alone explains a large part of the fivefold drop in knee surgery. We now know that most injuries don’t need removing, trimming, or repairing. They need retraining.
The hardest part: doing the work
Every clinician can prescribe exercises. The real challenge is helping people stick to them. Both doctors stressed the importance of compliance, motivation and habit-building. The science of behaviour change matters as much as the science of tissue healing.
Make it doable. Make it regular. Make it social if possible. Tie it to something that matters — picking up grandchildren, returning to a favourite sport, or simply feeling more independent.
Mark reframes the goal entirely: don’t chase the long-term health benefits; focus on the immediate reward — better mood, more energy, less stress. “When you push the limits, it’s uncomfortable. Nobody enjoys that,” he told me. “But building the habit is everything.”
Phil takes a broader view: the benefits of exercise go far beyond the joint in question — lowering the risk of heart disease, cancer, dementia and depression. Strength is not just treatment. It is prevention.
When should I stop, really?
Here are the patterns that consistently help us decide when to stop — and when to keep going:
The RED FLAGS: stop immediately if...
pain is sharp and escalating
you’re limping
the joint swells
pain wakes you at night
something “feels wrong” in a deep, instinctive way
impact causes sudden, localised pain
there’s any suspicion of stress fracture
Keep going (carefully) if…
pain warms up then improves
discomfort is predictable and mild
symptoms plateau rather than worsen
strengthening reduces the issue
biomechanics improve with practice
you can move normally without compensating
