Anterior knee pain is one of the most common non-traumatic conditions affecting the knee. Pain is felt in or around the kneecap (patella). It is usually insidious in its origin unrelated to any specific injury affecting both males and females regardless of age.
Anterior knee pain may be a limiting factor for our simple daily activities such as walking, prolonged sitting, walking up and down stairs, squatting and running.
There are many potential causes of anterior knee pain, which may include the fat pad, retinaculum, ligamentous structures, abnormal bone loading the most prevalent being patellofemoral pain syndrome (PFP), often called “runner’s knee”, often due to overenthusiastic runners doing too much too soon.
Causes of patellofemoral pain are often multifactorial in origin with interplay of social, neural and numerous anatomical, biomechanical, physiological, intrinsic and extrinsic factors at play.
Common Symptoms of Patellofemoral Pain
• Anterior knee pain while running • Knee flexion or squatting • Pain with prolonged sitting • Walking up or down stairs • Sudden weakness or giving way • Crepitus or grinding of the patella • Painful around the patella borders • Mild swelling
A Multimodal Approach in Managing PFP
PFP treatment is based on assessment outcomes, allowing for a tailored treatment protocol specific for each individual.
• Education understanding exacerbating factors • Pain management • Manual therapy • Taping • Shoe inserts if required • Motor control • Gait analysis/retraining • Proprioception and balance • Exercises targeting weak muscles
A recent study by Bramah et al, investigating (kinetics) or the underlying body alignment and mechanics as a possible cause specific running injuries. Their research group compared the different kinematics between injured and non-injured runners.
The injured runners demonstrated: Greater contralateral hip drop.
Forward trunk-lean at midstance.
An increase in forward extended knee and dorsiflexed ankle on initial contact.
Contralateral hip drop appeared to be the most important identifiable variable associated with running injuries.
Strengthening and Retraining Program
Positive outcomes may be gained by integrating the distal lower limb and the more proximal pelvis of the kinetic chain in a strengthening and endurance program, as the patella floats in the middle may be influenced by either of these sites.
Quadriceps Individuals with PFP appear to have weaker quadriceps. A strong quadriceps plays an important role not only in torque production, but also maintaining the congruence within the patellofemoral joint (PFJ).
Pelvis Training the hip extensors and abductors is essential as these stabilize the lateral pelvis in case of contralateral hip drop. The external rotators control internal rotation of the hip and knee.
Trunk Control The abdominals and muscles of the back are essential for controlling ground reaction forces through the kinetic chain and body lean during activity.
Foot and Lower Limbs Foot position and control are imperative during both static and dynamic loading. Dysfunctions due to fatigue, poor foot control, excessive pronation or lack of mobility may be associated with PFP.
Increase your training levels slowly allowing your body to adapt while increasing its capacity to tolerate speed, time and distance.
Taking part in a new activity, or too much too soon does not allow the body to adequately recover and adapt. Monitor your pain during and after exercise, pain appearing immediately or 24hrs later is a sign you are doing too much too soon.
Be aware of your running time and distance prior to pain. Don’t stop running, but decrease distance or time to a pain free running. Progressively increase it again at about 10% per week.
In some cases forefoot or mid-foot landing with an increase in step rate and forward lean may decrease the loading on the patellofemoral joint.
RDM Blandon, FV Serrāo, SR Scattone, R Silva, SR Piva. 2014. Effects of functional stabilization training on pain, function, and lower extremity biomechanics in women with patellofemoral pain: a randomized clinical trial. J Orthop Sports Phys Ther; 44(4) 240-A8
C Bramah, SJ Preece, N Gill, L Herrington et al. 2018. Is There a Pathological Gait Associated With Common Soft Tissue Running Injuries? The American Journal of Sports Medicine. 46 (12) 3023-3031
NJ Collins, CJ Barton, M Van Middelcoop, MJ Callaghan, et al. 2018, 2018 Consensus statement on exercise therapy and physical interventions (orthoses, taping and manual therapy) to treat patellofemoral pain: recommendations from 5thInternational Patellofemoral Pain Research Retreat, Gold Coast, Australia 2017. BJSM On line first 20 June 2018
JF Escullier, LJ Bouyer, B Dubois, P Fremont, L Moore, B Mc Fayden, JS Roy.2018 Is combining gait retraining or an exercise programme with education better than education alone in treating runners with patellofemoral pain? A randomized clinical trial. BJSM; 52: 659-666
L Herrington. 2001 The effect of patellar taping on quadriceps peak torque and perceived pain: a preliminary study. Physical Therapy in Sports; 2 (1) 23-28.
L Herrington. 2018 Anterior knee pain& impact of load with Dr Lee Herrington. Clinical Edge podcast. June 14, 2018
S Lack. 2018. The interaction of hip and foot biomechanics in the presentation and management of patellofemoral pain. BJSM; 52 (8)
S Lack, C Barton, O Sohan< K Crossley, D Morrissey. 2015 Proximal muscle rehabilitation is effective for patellofemoral pain: a systematic review with meta-analysis. BJSM; 49 (21)
GS Nunes, CJ Barton, FV Serrão. 2018 Hip rate force development and strength are impaired in females with patellofemoral pain without signs of altered gluteus medius and maximus morphology. Journal of Science and Medicine in Sport; 21 (2) 123-128.
AF Santos, TN Nakagawa, FV Serrāo, R Ferber, 2016 Patellofemoral joint stress measured across three different running techniques. BJSM: 50 Suppl1.
Knee treatments are available with Raymond Smith, Chiropractor, 114 Alexander Street, Crows Nest, NSW 2065
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