TEN WORK-RELATED ACTIVITIES AND KNEE PAIN

The knee is made flexible by which the offence of the Lord is mitigated, wrath appeased, grace called forth

 - St Ambrose

In Australia, during the 2023-2024 reporting period, traumatic joint, ligament and muscle or tendon injuries, as well as musculoskeletal and connective tissue diseases totalled more than seventy-thousand serious claims, making up just over 58% of the total number of serious claims in that period (Safe Work Australia, 2025). 22.3% of those injuries or diseases were found to affect the lower limbs, which include the hips, the knees, the ankles, and the feet, as well as the muscles and nerves that traverse through those regions. Within that same report, the mechanisms of injury of those work-related illnesses were primarily body stressing (34.5%), and falls, trips and slips (21.8%). Body stressing is the most commonly reported mechanism of injury for serious work-related musculoskeletal disorder claims, consistent with historical and other reporting periods (Safe Work Australia, 2022, 2024b). Body stressing arises from muscular exertion while handling objects, stress while lifting, carrying, or putting down objects, tone that arises when no objects are being handled, and from repetitive movement (Oakman et al., 2019). Lower limb injuries and disorders are common occurrences that arise from occupational exposures, with bursitis, meniscal lesions, osteoarthritis, patellofemoral pain, and stress fractures as well as muscular and ligamentous tears, nerve entrapments, and general strain being typical injuries that workers experience as a consequence of engaging with physical or posturally awkward work (Okunribido & Lewis, 2009). Occupational knee injuries, specifically, are common in physical job roles, where discomfort may arise owing to poor control of modifiable risk factors (Fransen et al., 2011). A person’s risk of experiencing an occupational knee injury that arises quickly or slowly has more to do than with whether they kneel or squat – research suggests that there are as many as 14 broad contributing factors to the ecosystem of aetiology of occupational knee injuries and structural change of the knee (Dulay et al., 2015; Palmer, 2012; Reid, Bush, et al., 2010) and which may be influenced by recreational activities outside of work as well (Baker et al., 2003). The knees are inherently unstable joints, where the ends of the long bones of the thigh articulate with the tops of the shinbones, and over which the kneecap is held between the tendons which connect the muscles of the front of the thigh with the front of the shin, and behind which the muscles of the hamstring and calf form an interwoven net of tissue which stabilises the knee in coordination with cartilage inside the knee such as the meniscus, and ligaments such as the internal cruciate and external collateral ligaments (Teichtahl et al., 2010). The knee is prone to locking, grinding, dislocation, and trauma from occupational and sporting contexts. With this in mind, here is a brief exploration of ten common causes of occupational knee discomfort, as identified by research and similar to those we have seen in the clinic, at Atlas Physio, handled as no-gap WorkSafe Physio, or on an OHS consulting basis.

Kneeling

There are several definitions of kneeling, where kneeling is best defined as a position where at least one knee is in contact with some part of the environment, usually the ground, and in this situation the weight of the body is supported predominantly through that knee or both knees when both knees are in contact with the environment (Benfayed et al., 2017). Frequent or sustained kneeling increases compression forces on the patellofemoral joint and surrounding soft tissues (Pollard et al., 2011). Kneeling increases the tension of the knee tendons as well as exposes the knee to force which may be profound or more tolerable depending on the deformability of the ground – kneeling on grass may be more manageable than kneeling on concrete or steel, but owing to the nature of the task the worker might not be able to control these circumstances. In these activities, kneepads may assist workers in easing the strain imposed on the knee from contact between the knee and the environment (Xu et al., 2017), which can not only redistribute the loading on the knee joint but can allow small controlled movements of the joint to move slightly under load. However, regardless of whether kneepads are used, the contraction of muscles when descending into and rising from kneeling positions are significant, and only slightly attenuated when using the arms to assist in liftoff (Hirokawa & Fukunaga, 2013). Sustained, repetitive, and loaded kneeling and squatting is strongly evinced to be a contributing factor in the development of strain in the short term and knee osteoarthritis in the long term, especially in those whose body habitus affects their mobility (Coggon et al., 2000). Safe Work Australia’s guidance (Safe Work Australia, 2024a) and Model Code of Practice for Hazardous Manual Tasks (Safe Work Australia, 2018) instruct workplaces to eliminate risks arising from hazardous manual tasks, or if that is not reasonably practicable, minimise the risks so far as is reasonably practicable. Kneeling is undertaken when tasks are lower than a certain point. To this end, raising the height of tasks or pre-performing those tasks may act as engineering controls. Instituting breaks and task rotation are administrative controls that may break up periods of sustained awkward postures as well. WorkSafe Victoria recognises kneeling as an awkward posture (WorkSafe Victoria, 2019), and recommends providing supports such as workstation and workplace layout changes, addressing the height of the task, and minimising the need to adopt one-off or sustained kneeling postures.

Squatting and Crouching

Squatting and crouching, hereafter referred to as squatting for convenience, is a pattern of movement where by keeping the feet on the ground and bending the ankles, knees, and hips, the center of mass and the trunk may be lowered from normal height (Kritz et al., 2009). People may squat to different depths depending on the degree to which the knees bend, where squats to lower heights require more joint flexibility to accommodate the posture and more muscular strength to maintain position (Cook, 2003). As in kneeling, squatting postures put load on the muscles of the thigh and lower limbs, the joints of the leg, and the back when balancing (Gallagher et al., 2011), and movement from and between both kneeling and squatting can result in changes to walking patterns (Tennant et al., 2018). Sustained squatting, repetitive squatting, or even one-off squatting when squatting to any depth is not required in working tasks, may give rise to discomfort, soreness, stiffness, and residual ache (Reid, McCauley Bush, et al., 2010), in the legs as well as the back (Roffey et al., 2010). Sustained and repetitive squatting, kneeling, and heavy lifting lone and in combination increases the risk of cartilage irritation and accelerated degenerative change, within the knee generally and within the patellofemoral join specifically (Amin et al., 2008). The combination of mechanical load from occupational lifting as well as the range of motion needed to be undertaken during work-related lifting may predispose workers exposed to these factors to knee osteoarthritis (Berryman et al., 2009; Verbeek et al., 2017). In contrast to the range- and weight-controlled movements undertaken in recreational and competitive weightlifting which are undertaken in bouts of exertion interspersed with recovery periods, occupational squatting and postural change is driven by task demands which give rise to repetitive, sustained, loaded, and awkward squatting which places high load on knee cartilage, tendons, and ligaments, contributing to overuse injuries. A lesson may be taken from weightlifting and weight training generally, by interspersing break periods between bouts of sustained squatting when needed, or by providing the means to relax the legs with a stool or adjustable seating. In these conditions, while the knees are unloaded in terms of muscular relaxation, joint flexion may still need to be eased with stretching or some other appropriate recovery strategy. WorkSafe Victoria recognises kneeling as an awkward posture (WorkSafe Victoria, 2019), and recommends adjusting the work to avoid the need to squat, by providing lifting aids and mechanisation when handling loads, or by redesigning work to eliminate the need to handle loads altogether.

Heavy Lifting

Body stressing has already been defined in terms of mechanism of injury for musculoskeletal structures. Body stressing is commonly experienced during manual handling tasks, which are defined by Work Safe Victoria as work requiring the use of force exerted by a person to lift, lower, push, pull, carry or otherwise move, hold or restrain loads (WorkSafe Victoria, 2019). The knees and legs generally are used in nearly all those manual tasks that are not undertaken when a person is sitting down. Work activities like kneeling, squatting, and heavy lifting are associated with the onset and severity of discomfort (Jones et al., 2007). Occupations involving knee bending and lifting in combination are suspected to most significantly increase the risk of knee pain, where the range of motion of the knee under load, the lifting being undertaken, as well as the weight of the load may all interact to cause discomfort (O'Reilly et al., 2000). Heavy mechanical loading may increase the risk of changes within the knee that may cause immediate irritation or long-term discomfort if the bending of the knees is repetitive as well (Coggon et al., 2000; Cooper et al., 1994). Under load-bearing conditions that are greater than those imposed by the body’s own weight, the load borne by the cartilage may reach or exceed its loading capacity (Thambyah et al., 2005). These high loads can cause degenerative changes in the joint especially if other degenerative change or damage to the knee is already present that affects the joint biomechanics or the health of tissues bearing weight (Nagura et al., 2002). All tissues of the knee are affected by loading (Logerstedt et al., 2022), and a person’s ability to handle the physical effect of heavy loads changes over their lives. Load is also borne by the knees and legs when pushing, pulling, and carrying across distance. When pushing a trolley, for example, the trolley is pushed but also steered by force exerted from the body of the person using the trolley which may be more intense or more brisk depending on the load of the trolley and the manner in which it is arranged. When not pushing, loads carried in baskets or bags exert a downward pull on the shoulders and increase the load on the knees when bearing weight through stride and when walking. The load profile experienced by the knee may be influenced by the flooring, the shoes the person is wearing, and the characteristics of their stride, all of which may require consideration when managing risk.  WorkSafe Victoria does not support “How to Lift” training as a suitable risk control for hazardous manual handling (WorkSafe Victoria, 2026a), and instead recommends that duty holders consult with employees to examine the environment, work composition, and systems of work that give rise to these exposures and control them appropriately (WorkSafe Victoria, 2023).

Carrying Uneven and Awkward Loads

Loads carried or managed throughout the working day are rarely ever uniform. This is another reason why the strain experienced during weightlifting and exercise is different to the strain experienced when undertaking occupational tasks. Weights available in commercial gyms are symmetrical, with a consistent and unchanging centre of mass and balance, and are moved in controlled ranges in controlled environments. In working environments, even sealed boxes might have asymmetrical centres of mass, or because of the physical properties of objects like preassembled framework, piping, toner racks, furniture, buckets, sanitation equipment or other loads, their uneven weight might cause issues. Because of the uneven and asymmetrical characteristics of objects , they may change the biomechanics of walking and standing in addition to imposing load on one knee more than the other or awkwardly through one knee (DeVita et al., 1991). Carrying loads at the waist, chest, and shoulder using the hands or by changing the position of the torso can increase the extent to which a person sways when standing and walking (Rafi, 2026), where the extent of asymmetrical positioning of the trunk may influence the significance of knee movements in terms of bend and excursion in order to compensate for increased upper body instability with lower body adaptations (Gagnon et al., 1996), where prolonged walking with heavy loads has been found to magnify the effect of biomechanical factors associated with knee osteoarthritis (Drew et al., 2021; Ezzat et al., 2013; Manninen et al., 2002). Awkward and unevenly weighted loads affect all characteristics of gait such as stride length, width, step cadence and foot placement, all of which represent adjustments to optimal or otherwise normal loading of the lower limbs (Thakurta et al., 2015), which can in turn increase the risk of trips, slips, and falls depending on the interaction between the worker and the environment they are navigating. Suboptimal loads and awkward manual handling are identified ergonomic risk factors for the development of musculoskeletal strain, and thus are the remit of the workplace or work director to manage risk and control exposure from hazardous manual tasks. Where uneven and awkward loads impose a risk to workers, WorkSafe Victoria recommends managing identified risks in line with the measures specified within the Hierarchy of Control (WorkSafe Victoria, 2022), where elimination of the hazard or exposure to the hazard is the most effective means of control. Where elimination of the hazard is not possible, delegation of risk through engineering or isolation serves to transform the risk vector to the worker, and thus may transform the risk profile positively or negatively. A comprehensive consultative and reviewed process of control is necessary to minimise harmful exposures and promote sustainable participation at work.

Repetitive Climbing

Climbing, or changing elevation using stairs and ladders, is common in workplaces, construction sites, and in daily life. When negotiating stairs, the knees and legs move through ranges of motion that are more dramatic in comparison with walking on flat ground. In addition to this, moving the body against gravity means that in addition to the increased bend, the force exerted through loaded joints is greater as well. The magnification of this force increases with the steepness of the gradient being negotiated. Stairs in residential and commercial settings are constructed to comply with codes which allow them to provide safe means of traversal for most able-bodied people, and these considerations are also applied to ramps. Hills, berms, ditchsides and other natural landforms may impose more load on the knees. Ladders are basically just vertical stairs that allow a person to move straight up or down. Excessive bending and loading increases stress on the patellar tendon and joint surfaces (Fransen et al., 2011), which can result in pain. There is some evidence supporting an association between degenerative changes in the knee and climbing ladders or stairs, and that the effect may be seen when low loads are handled over extended working durations (Jensen, 2008). The effect of this may again be magnified for persons who are overweight or obese (Coggon et al., 2000), and in industries where dynamic postural activities are common like mining, construction, warehousing, and in services (Reid, Bush, et al., 2010). Climbing up and down ladders requires strength in the legs, the hips, and the back, sufficient to overcome the body’s own weight and the weight of any worn or held tools or materials for the duration of the climb (Bloswick & Chaffin, 1990). While most laddering undertaken is over short distances and heights, repeated ascending and descending has the potential to increase load on the knees as a function of repetition, where long climbs up individual ladders can be managed by using lifts if possible or using engineered solutions like working platforms if working at heights introduces fall and risk mitigation obligations. WorkSafe Victoria’s Compliance Code for Hazardous Manual Handling (WorkSafe Victoria, 2019) suggest examining repetitive, sustained, and awkward movements that may require high force or be conducted across different levels as a point of intervention. Where work can be done on one level, or where workers can move between levels without needing to use stairs or ladders, accessibility means should be provided. However, in dynamic or construction environments, such controls may not be practicable or within the scope of works, and so adjustments should be made that are appropriate to the circumstances.  

Twisting, Turning, and Rotating

The primary weightbearing articulation of the knee joint is where the end of the thighbone (femur) meets the top of the shinbone (tibia). The end of the femur is rounded, and the top of the tibia is largely flat. Stability at the knee joint is supported by the strength of the muscles crossing the knee like the latticed stays of a sailing ship, as well as the strength of connective tissues like ligaments inside and outside the knee, and lastly by the cartilaginous surfaces of the bones above and below the knee as well as within the knee provided by the meniscus. Turning, twisting, and rotating through the knee joint impose variable, repetitive, and compressive strain on the knee joint and its components (Innocenti, 2022), which can result in wear depending on how the knee moves during daily activities and weightbearing (Senter & Hame, 2006). Turning, twisting, and rotating are common in activities like pick-packing, the preparation of food in small workspaces, and in workstation-based work. These movements can occur under loadbearing conditions as well. The effect of turning, twisting, and rotating on the load of the knee and consequent likelihood of injury can be affected by the repetition of the movement as well as the physical loads being carried (Kirkhorn & Earle-Richardson, 2006; Maetzel et al., 1997) which itself may be influenced by the design of work. Subtle turning, twisting, and rotation through the knee may occur when walking over uneven or dynamic terrain like mud, gravel, or unshod spaces, and may also occur when using plant. Forklifts, dozers, grades, trucks, and cars all have control elements that are manipulated by the feet and which require rotation of the lower limbs to engage pedals, gears, and shifters. Repetitive and sustained twisting, turning, and rotation of the knee even in non-weight-bearing contexts imposes the knee joint to some degree of strain and load, and should be considered when managing the total ecosystem of strain.

Prolonged Standing

The knees are part of the legs, and the legs are responsible for supporting the weight of the trunk and upper limbs in addition to the weight of any loads that might be borne or carried by the upper body, by transferring that load through the thighs, the knees, the lower limbs, and the feet, into the floor. Weightbearing of any loads imposes compressive force on the knee (Nisell, 2009) and while some loading of the knee is necessary to promote the health of the joint and of the structures within and around it, excessive, sustained, or poorly directed loads can cause discomfort, particularly in prolonged standing. Prolonged standing and static postures of any kind are understood to have adverse health effects such as atherosclerosis, oedema, and venous insufficiency in addition to musculoskeletal pain (Halim & Rahman, 2011; Waters & Dick, 2015). Standing is understood to be associated with lower back and lower limb symptoms and pain, where standing more than forty minutes may be enough to give rise to this discomfort (Coenen et al., 2017). While this exposure may be attenuated somewhat by examining environmental ergonomics through the use of fatigue mats, appropriately soled shoes, and using administrative controls such as walking meetings, stand time, and the provision of sitting and standing desks, uncontrolled standing for long periods, especially on hard surfaces, contributes to joint fatigue, swelling, and muscular strain in environments from industrial enterprises to schools (Afreen et al., 2024). The effect of these exposures may be magnified in older workers who, owing to age-related physical and physiological changes, may have poorer bone density, poorer venous return, and poorer muscular strength, all of which may synergise to increase the risk to which these workers are exposed as a combination of their own biomechanics, their occupational, and their physical exposures.

Slips, Trips and Falls

In the 2020-2021 reporting period, falls, trips, and slips of a person were the second-most common mechanism of injury or disease that resulted in a serious claim (Safe Work Australia, 2022). In the decomposition off these claims, environmental causes outnumbered non-powered handtools, mobile plant, and materials as the mechanism of injury, suggesting that the primary reason for which people experience falls is owing to environmental disturbance. Falls, slips and trips all refer to circumstances where part or all of a person’s body comes to rest on the ground inadvertently (Monash University Accident Research Centre, 2008). This can be due to a loss of balance from tripping, may be because of a change in the standing surface, may be the result of another medical event like a fall happening after fainting, or may be due to some other circumstance. Falls, slips, and trips impose mechanical load on the body as a consequence of the contact force applied when that body meets the ground. The rate of deceleration of the body when in contact with a surface affects the likelihood of injury – a person of constant mass falling at constant speed may experience less discomfort if landing on soft carpeting or grass in contrast to if the same person landed at the same speed on concrete or tile. The injuries sustained also depend on the part of the body coming in contact with the ground – muscular tissue is more deformable than bone (just try massaging your bicep and then try massaging the pointy bit of your elbow) and so landing on muscles may produce nasty bruises while landing on bone may produce a fracture. Sudden knee twisting or impact during a fall can cause ligament sprains or tears, meniscal jarring or tearing, or contusions. The knee has a large amount of potential space in which inflammatory fluid can pool as a consequence of the deformability of the skin and of the number of structures moving in and around the knee, and so can also become quite profoundly swollen as a consequence of direct trauma.  WorkSafe Victoria provides resources for employers to protect their workers from slips, trips, and falls (Work Safe Victoria, 2026; WorkSafe Victoria, 2025b, 2026b), where work design and circumstances may necessitate working at heights or in uncontrolled environments. Nevertheless, awareness, cleanliness, and surveillance of the space in which work is done combined with mindfulness of movement at the task at hand are all preparatory and protective means to minimise the risk of injury from slips, trips, and falls. For those with injuries, Atlas Physio, in Preston delivers personalised, no-gap, detailed assessment and targeted rehabilitation for occupational knee injuries, supporting safe and sustainable return to work.

Vibration

Vibration is the mechanical oscillation of an object around a central point, called the equilibrium, which is most often caused by an external force. Vibration is typically the result of a mechanical disturbance to an object, which can be the result of normal or abnormal use or engagement of that object (Shabana, 2012). Vibration can affect the whole body, or body segments. Vibration that affects the legs can again cause tingling and numbness in the feet and toes, as well as discomfort in the knees, hips, and back, which can give rise to symptoms comparable to those of mechanically aggravated lower back pain. In occupational contexts, the feet are typically shod in shoes or protective footwear, which controls the dose of vibration received through the lower limbs. However, where a worker is driving plant like a tractor or dozer, where a worker needs to keep a pedal engaged like the dead-man's switch of a locomotive, or where the worker is firmly held in place by locking systems, the continuous contact of the lower limbs with vibrating surfaces results in a dose of vibration whose concentration is increased owing to muscular action of contact, transmitting this dose through the legs and into the thighs. There, the joints of the knee and hip can receive vibration doses that can cause numbness, trembling, and weakness, or the dose can be perceived in the back as back pain (Eger et al., 2014). WorkSafe Victoria discusses the control of vibration in the context of noise control (WorkSafe Victoria, 2025a), and Safe Work Australia provides guidance regarding segmental (hand-arm) vibration as well as whole-body vibration and generally recommends that factors that can increase health effects such as frequent lifting, cold work temperatures, prolonged postures and poor ergonomics are addressed through appropriate controls and management of risk (Safe Work Australia, 2016a, 2016b, 2016c).

Walking

Typically, most people walk from the time at which they get out of bed and until the tie they go to sleep, where breaks are added for travel by car or other transport, and when no movement is being done when sitting, standing, or at other rest. Walking is a cyclical, repetitive movement wherein the legs are used to balance, move, and direct the body from one point to another. Balanced upright walking is one of the first complex motor activities that humans learn as infants alongside hand-eye coordination and the ability to identify African savannah animals. Walking loads the feet, ankles, shins, knees, thighs, and hips, coordinating the action of muscles on and around those sections in order to bear the weight of the body. This repetitive loading, even though it is controlled and largely benign, can cause discomfort when undertaken over long periods of time such as in long walks, when wearing inappropriate footwear such as unsupportive footwear on dynamic surfacing or restrictive footwear that constricts the feet, if loaded when carrying, and for other factors. Even jobs that do not require walking may load the knees through walking, where people need to traverse office spaces, campuses, building floors, and other environments. While the most benign, it is also the most important to consider how workers are protected not just at their work, but when getting to and from as well.

Occupational knee discomfort arises from a complex interaction of physical demands, environmental conditions, and individual factors. As highlighted throughout this article, everyday workplace activities can impose cumulative strain on the knee joint and surrounding tissues. These exposures, especially when repetitive, sustained, or performed under load, contribute to both short‑term symptoms and long‑term degenerative changes. Reducing the burden of knee-related injuries requires a proactive, systems‑based approach that prioritises risk elimination, thoughtful job and task design, and supportive administrative controls. Engineering solutions, ergonomic adjustments, and collaborative consultation between employers and workers all play essential roles in creating safer, more sustainable work environments. By recognising the diverse mechanisms through which knee strain develops and addressing them comprehensively, workplaces can better protect workers’ long‑term musculoskeletal health and support continued participation across all stages of working life. Atlas Physio Preston 3072 offers skilled, personalised consultation grounded in comprehensive assessment, supporting fast and effective recovery from occupational knee discomfort and promoting long‑term musculoskeletal health. Contact us today if any of this has seemed familiar to you or has affected you.

Alex Phillipos

B-Sci, B-HSci, GD-OHS, M-PHTY, M-ESH, M-OHT

Atlas Physio 2 Bruce Street, Preston

Melbourne, VIC, 3072

None of this information constitutes medical, legal, occupational health and safety, best guidance, standard, or other guidance, instruction, or prescription.

No artificial intelligence or assistive intelligence was used in the creation of this work.

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