Kneecaps really aren’t a big deal. They sit there, minding their own business until they start to hurt a little, then a little more, and then… Yeah, it really starts to hurt and they become a big deal.
Patellofemoral Pain Disorder (pain around the kneecap) is one of the most common musculoskeletal problems in young athletes1. Typical signs and symptoms include pain/soreness around the kneecap, pain using stairs, and pain with deep squatting or jumping.
The kneecap sits in a small groove along your femur as pictured to the right. It typically gets irritated on the back side when not tracking properly within its groove or is under excessive compression.
Diagnosis consists of recreating pain at the kneecap, then ruling out similar conditions.
Diagnosing the condition consists of assessing the following:
Why do you get patellofemoral pain?
It was once thought that the inner quadriceps muscle (muscle on the inside front of your thigh) was not working optimally and this was the main reason why the knee cap become irritated. This, along with stretching, seemed the gold standard of treatment. However, patients weren’t getting better consistently2. Other common treatments consisted of ice, rest, ultrasound, and electrical stimulation. Although beneficial in some cases, many patients were still failing to get better.
Recent research has shown that there are other biomechanical influences likely leading to pain in your kneecap. It seems that the biomechanics of your movement mainly cause you to develop patellofemoral pain3-5. A large knee valgus angle (“knock knees”) causes irritation at the joint.
This knee posture can be observed in standing or can happen during a movement. As the femur moves into an inward position below the kneecap, the kneecap cannot maintain its proper position. So, this leads to irritation. Typically, in the clinic I will observe this in patients landing from a jump, during running, or when squatting.
So, how do you fix it?
Initially, placing the kneecap in its proper position (taping it so that it better lines up with the femur) will help with irritation and typically has a drastic reduction in pain with normally painful activities6. Ensuring the joint below the kneecap also has full hyper-extension will help properly seat the kneecap, which is typically accomplished through hands-on mobilizations and follow-up exercises.
After reducing the irritation and regaining full hyper-extension, it’s important to treat the joints above and below the knee including the ankle/foot, hip, and trunk. Improving the arch position of the foot, strengthening the side and back of the hip, and ensuring normal trunk position can all help in decreasing the ‘knock-kneed’ pattern and ensure the kneecap is aligned properly7-11. Very strong, recent research has suggested specific and isolated hip strengthening exercises with excellent results12. These exercises target your hip abductors (muscles that move your leg out to the side from the hip) and external rotators (muscles that rotate the leg in an outward direction). In this particular study, patients went from an average pain of about 8/10 to about 1/10 after simply performing high repetitions of these exercises 3 times per week for 8 weeks.
What do you do if you think you have patellofemoral pain syndrome?
A good place to start would be strengthening your hips and looking at your knee position when performing the activity that is causing you pain. If you have questions, concerns, or would like further guidance if you are dealing with this problem I would be happy to see you in the clinic.
1. DeHaven KE, Lintner DM. Athletic injuries: comparison by age, sport, and gender. Am J Sport Med.1986;14:218–224. [PubMed]
2. Dolak KL, Silkman C, Medina McKeon J, Hosey RG, Lattermann C, Uhl TL. Hip strengthening prior to functional exercises reduces pain sooner than quadriceps strengthening in females with patellofemoral pain syndrome: a randomized clinical trial. J Orthop Sports Phys Ther. 2011; 41: 560– 570.[Medline]
3. Powers CM. The influence of abnormal hip mechanics on knee injury: a biomechanical perspective. J Orthop Sports Phys Ther. 2010; 40: 42– 51. [Medline]
4. Powers CM. The influence of altered lower-extremity kinematics on patellofemoral joint dysfunction: a theoretical perspective. J Orthop Sports Phys Ther. 2003; 33: 639– 646. [Medline]
5. Souza RB, Draper CE, Fredericson M, Powers CM. Femur rotation and patellofemoral joint kinematics: a weight-bearing magnetic resonance imaging analysis. J Orthop Sports Phys Ther. 2010; 40: 277–285. [Medline]
6. Whittingham, M, Palmer, S, Macmillan, F. Effects of Taping on Pain and Function in Patellofemoral Pain Syndrome: A Randomized Controlled Trial. Journal of Orthopaedic & Sports Physical Therapy, 2004 Volume:34 Issue:9 Pages:504–510
7. Eng JJ, Pierrynowski MR. Evaluation of soft foot orthotics in the treatment of patellofemoral pain syndrome. Phys Ther. 1993; 73: 62– 68; discussion 68–70. [Medline]
8. 40: 736– 742. http://dx.doi.org/10.2519/jospt.2010.3246 [Abstract] [Medline]
9. Earl JE, Hoch AZ. A proximal strengthening program improves pain, function, and biomechanics in women with patellofemoral pain syndrome. Am J Sports Med. 2011; 39: 154– 163. [Medline]
10. Mascal CL, Landel R, Powers C. Management of patellofemoral pain targeting hip, pelvis, and trunk muscle function: 2 case reports. J Orthop Sports Phys Ther. 2003; 33: 647– 660. [Medline]
11. Fukuda TY, Rossetto FM, Magalhaes E, Bryk FF, Lucareli PR, de Almeida Aparecida Carvalho N.Short-term effects of hip abductors and lateral rotators strengthening in females with patellofemoral pain syndrome: a randomized controlled clinical trial. J Orthop Sports Phys Ther. 2010;
12. Khayambashi K, Mohammadkhani MS, Ghaznavi, K, Lyle M, Powers C. The Effects of Isolated Hip Abductor and External Rotator Muscle Strengthening on Pain, Health Status, and Hip Strength in Females With Patellofemoral Pain: A Randomized Controlled Trial. Journal of Orthopaedic & Sports Physical Therapy, 2012 Volume:42 Issue:1 Pages:22–29 DOI:10.2519/jospt.2012.3704
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