Knee pain and especially anterior knee pain can be a debilitating and annoying issue for anyone whether they are sedentary office workers or high level athletes. Anterior knee pain or patellofemoral pain (a pain around, behind or under the knee cap) is very common, affecting both males and females of all activity levels; often resulting in pain during simple daily activities such as walking, running, sitting, squatting and walking up and down stairs. Anterior knee pain or Patellofemoral pain has many causes and as a result a number of treatment methods are available to improve the sufferers discomfort. The information held in this piece will hopefully give you an insight into the condition and its rehabilitation, as well as helping to highlight how a physiotherapist can help you recover.
How common is it?
Anterior knee pain is reported in the literature to have a prevalence of 16.5% in the general population and up to 3-20% in active individuals, novice runners and military recruits (Lack et al, 2015) The condition is also two times more prevalent in females, something which has been linked to anatomical differences in pelvic structure and hip / knee angle.
The impact of patellofemoral pain is huge with between 36-52% of people reducing their physical activity level as a result, whilst 23% end up quitting exercise altogether (Stathopulu, 2013). Patellofemoral pain also has a high recurrence rate with around 71 -91% of individuals experiencing pain up to 20 years later (Rathleff, 2014).
What might cause your pain?
As mentioned above there are multiple reasons behind someone developing anterior knee pain and in particular patellofemoral pain. Some of the main causes highlighted in the literature include,
- Excessive loading or varied and rapid increases to your physical activity levels for example large changes in distance, speed and / or the intensity of training sessions can cause the onset of pain. Whilst hill or stair work is a common cause due to a higher levels of patellofemoral load.
- A traumatic injury (where you get kicked or have a bang to your knee) which causes swelling or irritation to the area.
- An inadequate level of strength around your hip, knee and/or foot, Specifically in the quads and glutes musculature.
- Poor biomechanics (movement patterns) which contribute to the knee cap moving toward the outer part of the knee stopping it from tracking normally in its groove. These biomechanical issues concern movement and control issues at the hip, knee and ankle which cause adaptations to the position and increased force (Load) being placed through the patellofemoral joint itself. (Figures 2,3)
Figure 3: Biomechanical factors which can contribute to patellofemoral joint overload
- Pelvis drops on opposite side, placing increased tension on the outside of the leg and pulling the knee cap outward.
- Hip collapses inward and rolls under the knee cap due to poor function and weakness of the hip muscles.
- Thigh muscles are weak or function poorly, meaning there is inadequate support for the knee and knee cap.
- Foot rolls in too much, causing the shin and knee to collapse inward under the knee cap.
Overall they are the main key identified reasons for developing this issue however there are numerous other potential contributing factors to patellofemoral pain. These include the structure of your knee, previous trauma, surgery and systemic disease, which you may wish to speak to a physiotherapist about
What are your treatment options?
A vast number of studies within the academic literature have identified that the key to improvement from this issue is a physiotherapist prescribed exercise rehabilitation program completed alongside manual therapy and education regarding the condition.
What are the key factors / treatment options to address?
- Weakness and poor function of the hip and thigh musculature is common, so the completion of exercises to improve these are key.
- With some people the foot or back are also involved and exercises or treatment is required in these areas.
- Your physiotherapist may highlight a need to stretch your calf, hamstring or thighs musculature due to shortening of the muscles.
- With your desire to return to normal activities exercises should be progressed to mimic or match activities you previously had pain with i.e. squatting, stairs, running, ensuring that good movement patterns are maintained during their completion and you return to normal pain free function.
How can a physio help?
- Guide you on your most appropriate exercises and other helpful treatments.
- Answer questions related to your knee pain, and explain in greater detail the contents of this blog where necessary.
- Help you understand why you have knee pain, what factors have most likely caused your pain and how to modify your activity to improve your pain and recovery.
- Provide taping or manual therapy which may be important to improve pain and flexibility.
What exercise principles are important?
- “Rest”. This is done to allow your acute symptoms to settle down
- Exercises designed to activate and improve the endurance and function of weak muscles. These are done in sitting or lying at the beginning which help to get your hip and thigh muscles functioning without exacerbating your knee pain.
- As soon as your pain starts to improve exercises can be performed in standing postures which mimic daily activities.
- Using a mirror and phone video functions to complete correct exercise techniques at home.
- Exercises will not help unless you perform them with the correct technique and on a regular basis. *Compliance*
- Compliance with your exercise program – A recent study from Rathleff et al, (2014) found that those who completed their exercises 3-5 times per week as directed or 70% of their total recommended rehabilitation, had 4.4 times the reduction in their symptoms to those only completing their exercises 0-2 times a week or below 40% of their total sessions (Figure 4).
If you think you have patellofemoral pain, you should seek help from a physiotherapist as early as possible as this will improve your chances of a successful recovery. There are many effective treatment options available to you, all of which you can discuss with your treating physiotherapist. Whilst it is important to make that first step in your recovery by seeking advice from a physiotherapist you will be best served by actively participating in your rehabilitation.
Thanks for reading
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