Knee Pain: Patellofemoral Pain Syndrome

Patellofemoral pain syndrome is one of the most common knee complaints of both the young active sportsperson and the elderly.

Patellofemoral pain syndrome is the medical term for pain felt behind your kneecap, where your patella (kneecap) articulates with your thigh bone (femur). This joint is known as your patellofemoral joint

Patellofemoral pain syndrome, is mainly due to excessive patellofemoral joint pressure from poor kneecap alignment, which in time, affects the joint surface behind the kneecap (retropatellar joint).

What Causes Patellofemoral Pain Syndrome?

Your patella normally glides up and down through the femoral groove. As your knee is bent, pressure between your kneecap and the groove increases. 

This retropatellar pressure is further increased if the patella does not ride normally through the groove, but “mistracks”, meaning it travels more to one side, making it rub against the femur. 

Repeated trauma causes an increase in your retro patellar joint forces, which can lead to kneecap pain, joint irritation and eventually degeneration of your patella joint surface.

The most common causes of patellar malalignment are an abnormal muscle imbalance and poor biomechanical control.

Aching kneecaps (patellofemoral pain) affect 25% of the population at some time in their lives but it is more common in athletes. The sports where patellofemoral pain syndrome is typically seen are those when running, jumping and landing or the squatting position is required. 

Sports include running, tennis, netball, football, volleyball, basketball, skiing and other jumping sports. 

Untreated patellofemoral pain syndrome can also predispose you to patellar tendonitis.

What Causes a Muscle Imbalance?

Your quadriceps (thigh) muscles attach to the patella and through it to the patella tendon, which attaches to the top of your shin. 

If there is a muscle imbalance between the quadriceps muscles: vastus lateralis (VL), which pulls your patella up and outwards, and the vastus medialis oblique (VMO), which is the only quadriceps muscle that pulls your kneecap up and slightly in, then your patella will track laterally in the groove.

Common reasons for a weak vastus medialis oblique (VMO) include knee injury, post-surgery, swelling or disuse.

The longstanding tightness of your lateral knee structures (lateral retinaculum, VL, and ITB) will encourage your kneecap to drift sideways over time. Especially, if your VMO is also weak.

Hip muscles have been shown in the research to be very important in the control of your thigh. Poor buttock muscle control allows your knee to roll in and apply a relative lateral displacement of the the patella. Most successful rehabilitation programs require assessment and correction of your hip and buttock muscle control.

Patellofemoral pain syndrome is more common during adolescence, because the long bones are growing faster than the muscles, tendons and ligaments, putting abnormal stresses on the joints. Active children who do not stretch the appropriate muscles are predisposed to patellar malalignment.

What Biomechanical Issues Cause Patellofemoral Pain Syndrome?

Poor foot posture (eg flat feet) and weak hip control muscles can both allow your knee to abnormally twist and result in a lateral deviation of your patella.

When poor biomechanics are repeated with each step of your walking or running pattern that poor habit repeatedly traumatises your patellofemoral pain.

What are the Symptoms of Patellofemoral Pain Syndrome?

The onset of your kneecap pain is normally gradual rather than traumatic.

Patellofemoral pain symptoms are normally noticed during weight bearing or jarring activities that involve knee bending. 

Stairs, squatting, kneeling, hopping, running or using stairs are commonly painful. As your patellofemoral pain syndrome progresses your knee will become painful while walking and then ultimately even at rest. 

You can also experience kneecap pain when you are in sustained knee bend eg. sitting in a chair. A nickname for this condition is “theatre knee”. 

Patellofemoral Pain Syndrome Treatment

Researchers have confirmed that physiotherapy intervention is a very effective short and long-term solution for kneecap pain.

Approximately 90% of patellofemoral syndrome sufferers will be pain-free within six weeks of starting a physiotherapist guided rehabilitation program for patellofemoral pain syndrome.

For those who fail to respond, surgery may be required to repair associated injuries such as severely damaged or arthritic joint surfaces.

The aim of treatment is to reduce your pain and inflammation in the short-term and then, more importantly, correct the cause to prevent it returning in the long-term.

There is no specific time frame for when to progress from each stage to the next. Your injury rehabilitation will be determined by many factors during your physiotherapist’s clinical assessment.

You’ll find that in most cases, your physiotherapist will seamlessly progress between the rehabilitation phases as your clinical assessment and function improves. It is also important to note that each progression must be carefully monitored as attempting to progress too soon to the next level can lead to re-injury and the frustration of a delay in your recovery.

Phase 1 - Injury Protection: Pain Relief & Anti-inflammatory Tips

As with most soft tissue injuries the initial treatment is - Rest, Ice and Protection.

(Active) Rest: In the early phase your best to avoid all activities that induce your kneecap pain.

Ice is a simple and effective modality to reduce your pain and swelling. Please apply for 20-30 minutes each 2 to 4 hours during the initial phase or when you notice that your injury is warm or hot.

Protection: Your physiotherapist will normally apply kinesiology supportive taping or similar to help relieve your pain and commence your patellofemoral joint realignment phase. The patellofemoral taping is normally immediately effective in providing you with pain relief.

Your physiotherapist will utilise a range of helpful tricks including pain relieving techniques, joint mobilisations, massage, strapping and acupuncture to assist you during this painful phase.

Anti-inflammatory medication and natural creams such as arnica may help reduce your pain and swelling. Most people can tolerate paracetamol as a pain reliever.

Phase 2: Regain Full Range of Passive Motion

Your kneecap and knee must be able to glide through its full normal range of motion. Your physiotherapist will assess your motion and apply the necessary techniques to normalise your range of motion.

Phase 3: Restore Full Muscle Length

Your thigh, hamstring and calf muscles will require stretching as they are tight and are causing excessive tension or pressure on your kneecap. It is important to regain normal muscle length to improve your lower limb biomechanics.

Phase 4: Normalise Quadriceps Muscle Balance

In order to prevent a recurrence, your quadriceps muscle balance and its control should be assessed by your physiotherapist. In most instances, you will require a specific knee strengthening program.

Your physiotherapist will prescribe the best exercises for you.

Phase 5: Normalise Foot & Hip Biomechanics

Patellofemoral pain syndrome can occur from poor foot biomechanics (eg flat foot) or poor hip control.

In order to prevent a recurrence, your foot and hip control should be assessed by your physiotherapist. In some instances, you may require a foot orthotic (shoe insert) or you may be a candidate for the Active Foot Posture Stabilisation program.

Other patients may require a hip stabilisation program. Your physiotherapist will happily discuss what you require.

Phase 6: Normalise Movement Patterns

Kneecap pain commonly occurs from poor habits, whether they be an abnormal gait, jumping, landing, running or squatting technique. In order to prevent a recurrence, your walking pattern, jumping and landing technique, running style or squatting method should all be assessed and corrected as required.

Your physiotherapist will happily discuss what you specifically require.

Phase 7: Restore High Speed, Power, Proprioception and Agility

Most kneecap pain sufferers need to return to high speed or repetition activities, which place enormous forces on your knee. Your physiotherapist will guide you in your return to sports planning.

Balance and proprioception (the sense of the relative position of neighbouring parts of the body) are both known to be adversely affected by patellofemoral pain. To prevent a re-aggravation, both aspects need to be assessed and retrained.

Depending on what your sport or lifestyle entails, a speed, agility, proprioception and power program will be customised to prepare you for light sport-specific training.

Phase 8: Return to Sport

If you play sport and depending on the demands of your chosen sport, you may require specific sport-specific exercises and a progressed training regime to enable a safe and injury-free return to your chosen sport.

This article originally appeared on physioworks.com.au and was written by John Miller

Overuse injury: How to prevent training injuries

Thinking of starting a new physical activity program or ramping up your current training routine? If so, you may be at risk of an overuse injury — which could ultimately prevent you from being active. Find out what can cause an overuse injury and how to safely increase your activity level.

Common causes of overuse injury

An overuse injury is any type of muscle or joint injury, such as tendinitis or a stress fracture, that's caused by repetitive trauma. An overuse injury typically stems from:

• Training errors. Training errors can occur when you enthusiastically take on too much physical activity too quickly. Going too fast, exercising for too long or simply doing too much of one type of activity can strain your muscles and lead to an overuse injury.
• Technique errors. Improper technique can also take its toll on your body. If you use poor form as you do a set of strength training exercises, swing a golf club or throw a baseball, for example, you may overload certain muscles and cause an overuse injury.

Risk factors for overuse injury

Although an overuse injury can happen to anyone, you may be more prone to this type of injury if you have certain medical conditions. Overuse injuries are also more likely to occur as you get older — especially if you don't recognize the impact aging can have on your body and modify your routine accordingly.

For these reasons, it's a good idea to talk to your doctor ((*and health care team)) before starting a new activity or ramping up your current routine. Your doctor may offer tips to help make physical activity safer for you. If you have a muscle weakness in your hip, for example, your doctor may show you exercises to address the problem and prevent knee pain.

Avoiding overuse injury

Most overuse injuries are avoidable. To prevent an overuse injury:

• Use proper form and gear. Whether you're starting a new activity or you've been playing a sport for a long time, consider taking lessons. Using the correct technique is crucial to preventing overuse injuries. Also make sure you wear proper shoes for the activity. Consider replacing your shoes for every 300 miles you walk or run — or at least twice a year if you regularly exercise.
• Pace yourself. If you're starting a new fitness program, avoid becoming a weekend warrior. Compressing your physical activity for the week into two days can lead to an overuse injury. Instead, aim for at least 150 minutes of moderate aerobic activity or 75 minutes of vigorous aerobic activity — preferably spread throughout the week. It's also a good idea to take time to warm up before physical activity and cool down afterward.
• Gradually increase your activity level. When changing the intensity or duration of a physical activity, do so gradually. For example, if you want to increase the amount of weight you're using while strength training, increase it by no more than 10 percent each week until you reach your new goal.
• Mix up your routine. Instead of focusing on one type of exercise, build variety into your fitness program. Doing a variety of low-impact activities — such as walking, biking, swimming and water jogging — in moderation can help prevent overuse injuries by allowing your body to use different muscle groups. And be sure to do some type of strength training at least twice a week.

Recovering from overuse injury

If you suspect that you have an overuse injury, consult your doctor. He or she will likely ask you to take a break from the activity that caused the injury and recommend medication for any pain and inflammation.

Be sure to tell your doctor if you've recently made changes in your workout technique, intensity, duration, frequency or types of exercises. Identifying the cause of your overuse injury will help you correct the problem and avoid repeating it.

When you think the overuse injury has healed, ask your doctor to check that you've completely regained strength, motion, flexibility and balance before beginning the activity again. When you return to your activity, pay special attention to proper technique to avoid future injuries.

Playing it safe

Don't allow an overuse injury to prevent you from being physically active. By working with your doctor, listening to your body and pacing yourself, you can avoid this common setback and safely increase your activity level.


This article originally appeared on Drugs.com