Patella Femoral Knee Pain - Ask An Expert - with Alex Nicholson, APA Sports and Exercise Physiotherapist

What is patellofemoral pain?

Patellofemoral pain syndrome (PFP)  refers to pain in and around the knee cap. Sufferers usually report pain in the front of the knee with activities such as squatting and stairs. Generally walking downstairs is more painful than upstairs. PFP is a common affliction of the knee, particularly in active adolescents, with an incidence of up to 9.2% (Crossley et al., 2016).  Furthermore, females are 2.23 times more likely to develop PFP than for their male counterparts (Boling et al., 2010). A study of adolescents with knee pain found that 56% of subjects still reported knee pain at two-year follow up, and that PFP sufferers had a higher relative risk of reporting knee pain, and a higher incidence of decreased sporting participation, compared to other types of knee pain (Rathleff, Rathleff, Olsen, Rasmussen & Roos, 2016). Thus, for many adolescents, PFP is not self-limiting and if not properly rehabilitated may impact their future sporting pursuits.

What are the causes?

There are many potential causes but the most common cause that I see is a change in activity. That could be either an increase or a decrease in activity, but more commonly an increase. For example, a runner or walker who increases their weekly mileage rapidly. Muscle imbalances/tightness and weakness are also thought to contribute. Other common possible causes include weight gain, and increased foot pronation (your foot rolling inward excessively when walking/running).

How do you treat patellofemoral pain?

The best way to treat PFP is to first assess the individual and identify any muscle weaknesses or flexibility issues in the body. Once identified, exercises should be prescribed to address these deficits. Common findings include gluteal weakness, and tightness of the calf and quadriceps muscles.  Taping techniques for the kneecap or the fat pad (underside of the knee cap) can be helpful in providing pain relief with activities such as squatting, stairs and running. A walking or running assessment may also beneficial where appropriate. Discussing training programs and modifying any errors within them, such as a sudden increase in exercise volume or intensity, may also be necessary. 

What exercises are good for patellofemoral pain?

Early exercises for PFP often include stretches for muscle identified as being tight or short in length (e.g., quadriceps, hamstrings, calf muscles) and strengthening for the hip muscles. In the first stage of rehab, heavy quadriceps strengthening exercises may not be included as they may be irritating, and need be introduced in the next stage.

What exercises are bad for exercises?

When the patellofemoral joint is flared up, activities such as lunging and squats are often quite poorly tolerated as they do place high levels of force on this joint in particular.

How long does it take to heal?

PFP can be a very stubborn condition, particularly if left untreated. How long you have had PFP for may also influence the recovery period as muscle weakness and unhelpful movement patterns may have set in, which will need to be corrected. If any significant weakness is identified, then I would anticipate a 12 week rehabilitation program. This is because you cannot suddenly strengthen up a muscle. It takes time and progressive exercises to achieve it.

Is patellofemoral pain a form of arthritis?

Strictly speaking, no. However, you may have some underlying patellofemoral joint arthritis. This is unlikely to change the treatment approach unless it is very severe.

Is it ok to exercise with patellofemoral pain?

My general guideline for exercising with pain is that if that pain is low level, not changing the way you move (e.g. you are not limping), not causing your knee to swell or to have night pain, then it is ok to continue to exercise. Whilst it is not ideal, exercising with a low level of pain can actually be helpful by helping to make you stronger and gradually making your knee more robust. However, I recommend that you seek the experience of a professional to assess your knee and provide you with clear advice and a rehabilitation program tailored to you rather than Googling your way through rehab!

 If you would like someone to help make sense of your pain, please call us at (02) 8411 2050. At Thornleigh Performance Physiotherapy, we can give you an accurate diagnosis and treatment, to help you get back in action as soon as possible. We are conveniently located near Beecroft, Cherrybrook, Hornsby, Normanhurst, Pennant Hills, Waitara, Wahroonga, Westleigh, West Pennant Hills, and West Pymble.

References

Boling, M., Padua, D., Marshall, S., Guskiewicz, K., Pyne, S. & Beutler, (2010). Gender difference in the incidence and prevalence of patellofemoral pain syndrome. Scandanavian Journal of Medicine and Science in Sports, 20, 722-730. doi: 10.1111/j.1600-083832009.00996.x

Crossley, K.M., Stefanik, J.J., Slefe, J., Collings, N.J., Davis, I.S., Powers, C.M.,  ... Callaghan, M.J. (2016). 2016 Patellofemoral pain consensus statement from the 4th international patellofemoral pain research retreat, Manchester. Part 1: Terminology, definitions, clinical examination, natural history, patellofemoral osteoarthritis and patient-reported outcome measures. British Journal of Sports Medicine, 50. 839-843. doi: 10.1136/bjsports-2016-096384

Rathleff, M.S., Rathleff, C.R., Olesen, J.L., Rasmussen, S., & Roos, E.M. (2016). Is patellofemoral pain a self-limiting condition? Prognosis of patellofemoral pain and other types of knee pain. American Journal of Sports Medicine, 44(5), 1165-1171. doi: 10.11770363546515622456