Now Revealed: The Most Common Reason For Knee Pain - And How It Is Treated

Posted on May 22, 2007 and filed under Hip and Knee

Jennifer is a 35-year old runner. She’s in top condition and jogs an average 35 miles per week. Lately, however, something has been bothering her. About a week ago, she noticed a vague soreness and a bit of pain on the inside of her left knee. Figuring it was just “an overstretched tendon”, she continued her normal regimen and decided she’d “push through it”. Although her knee continued to bother her during her morning runs, the pain was especially bad after she had been sitting and driving for a while. But this morning Jennifer awoke to the same pain as before, only this time much worse. A little more concerned, she stretched longer than normal, put on her beat-up running shoes and set out on the road. Five minutes into the run Jennifer thought to herself, “Something is definitely wrong. This is not a normal pulled tendon or muscle. And the pain’s getting worse”. Discouraged, she turned around and walked back home. Back in her kitchen, she grabbed her cell phone, called her doctor, who referred her to her physical therapist. Later that afternoon at the clinic (and after the diagnostic exam) she received the news that she had a condition called “Patello-Femoral Syndrome”. Jennifer wanted to know more: what exactly is this condition and who does it affect?

Patello-Femoral Syndrome is an extremely common condition that affects the knee joints. It’s often seen in active people (such as runners) likeJennifer. It’s also the most common reason for knee complaints and affects people of all ages (Patello-Femoral refers to a specific part of the knee joint itself).

Common symptoms include:

• Vague discomfort in the inner knee area.
• Pain. The pain caused by this condition can be anterior knee pain (at the front of the knee), inside the knee joint or pain underneath the patella (kneecap) itself.
• Mild swelling and a vague sense of tightness or fullness in the knee area.
• Pain with prolonged sitting or pain with any other position in which your knees are bent for an extended period of time (called the “theater” sign of pain).
• Sometimes a “clicking” sound in the knee will be audible.

Like most disorders, if these symptoms are ignored, the condition can get worse. Much worse. You may start to lose muscle strength and mass, especially in the quadriceps (the muscle on the front of the thigh). Going up and down stairs, jumping or climbing can become painful, and in some cases, impossible. And in certain instances when the condition progresses even further, it may cause the leg to give out completely. Patello-Femoral Syndrome is no laughing matter - and nothing to ignore.

What Causes Patello- Femoral Syndrome?

This condition is very common because the vastus medialis (the inner or “teardrop-shaped” part of the quadriceps) is greatly underdeveloped in the majority of the population. This is true even of runners and other athletes. The quadriceps supports the knee joint. And the medialis serves to prevent the capsule around the knee from being impinged underneath the patella. In a nutshell, Patello- Femoral Syndrome is a muscle imbalance between the vastus medialis and the vastus lateralis (the muscle on the outside of your leg), along with a tight iliotibial band. This is a band of tissue that extends from your hip down to the outer part of your knee. Because of this imbalance, the patella tracks to the side - or it is pulled out of its natural “groove”. In laypersons language, the patella starts to migrate – or move - to the side of the knee. Ouch! If not corrected, the patella is pulled out of its normal groove and starts rub against the femur (big thigh bone) itself. Can you imagine the pain and inflammation when this happens? Bone is NOT supposed to rub against bone. That’s why improper loading of the patella — or any joint for that matter — will cause pain. Like arthritis, bone against bone creates inflammation and pain. Plus, if the joint is not properly aligned, parts of the joint degenerate because the joint is not getting enough compressive forces. Or it’s getting too much in the way of compressive forces and the joint gets overloaded. Too much in either direction - too much compression or too little – can cause problems. Remember: the body needs to be in balance at all times.

Who Is Affected?

Females are pre-disposed to this condition more than males, due to the way the hip and femur are aligned in women. Also knock kneed people, flat-footed runners, and people who have poor arch support also suffer from Patella- Femoral Syndrome in greater numbers. Finally, people who pronate a lot when walking (which means they turn their foot when they walk and it kind of collapses) are also at risk for Patella-Femoral Syndrome. The types of people I see here at Physical Therapy Specialists who have symptoms of Patello-Femoral Syndrome are a lot like Jennifer: runners, skiers and other athletes. Anyone who has a lot of high compressive forces in the Patello- Femoral joint are likely candidates for this disorder.

How To Prevent It

1. Listen to your body. As I’ve said in previous editions of this newsletter, don’t ignore your pain. This is especially directed at all the guys reading this article! If you noticed, one of the things Jennifer did right was that she called and got professional help right away. She didn’t wait for months and months. Which brings me to…
2. See your doctor and physical therapist. If you suspect something is wrong - or experience any of the symptoms I mentioned a moment ago, make an appointment to see your doctor or your physical therapist. Don’t wait for the pain and the condition to worsen. With any illness or ailment, catching things early makes for more successful outcomes.
3. Wear the right shoes for your activity. Read last month’s newsletter to discover how to choose the right type of shoe.
4. Avoid high compressive forces on your knees. Avoid any
   activity which causes high compressive forces in knee joint, such as squatting, kneeling or stair climbing.
5. Strengthen your quadriceps. Since Patello-Femoral is caused by weak quadriceps muscle, strengthening that muscle helps. Weight training, martial arts, and other isometric exercises are perfect. Remember: most people in the have underdeveloped quadriceps muscles!

How It Is Treated

I treat this syndrome (or disorder) a lot, since it’s so common. In any treatment regimen, the primary goal is to create a straighter pathway for the patella to follow. Initially, we want to work on avoiding motions that irritate the kneecap, such as: going into squats, climbing up and down stairs, and any other compressive forces such as skiing and high impact aerobics. And you should avoid running while you’re being treated.

Treatment #1: Icing

Icing is a common remedy for many types of joint disorders. It’s also effective with Patello-Femoral Syndrome. Typically, icing is applied for 15 minutes two or three times a day after activity. In other cases, it’s applied once per day. In most cases, the icing regiment will continue for a period of two weeks; however, in more extreme cases, it can continue for a longer period of time.

Treatment #2. Pain Relief

The main pain-relievers used with Patello-Femoral Syndrome are Ibuprofen, Advil and Motrin. There is quite a bit of inflammation associated with this condition, normally seen along the sides of the knees. Anti-inflammatory medications are sometimes given in conjunction with pain relievers.

Treatment #3: Surgery

In very severe cases, a patient may need surgery. The surgical technique to reverse the effects of Patello- Femoral Syndrome is called a “lateral release technique”. This reduces the influence of the vastus lateralis and the IT band on the lateral tracking of the patella. In other words, things really need to be rearranged inside there! How often does it get to this point? Without early treatment, almost all cases will end up in this severe situation. However, physical therapy is very effective in helping people avoid surgery and treat this syndrome.

Treatment #4: Strength Training

The primary focus here is to selectively strengthen the inner portion of the quadriceps muscle. Remember, this syndrome is partially caused by a weak vastus medialis (in layman’s terms, the muscle on the inner part of your thigh). Strengthening this muscle can help. Some examples of exercises that strengthen the quadriceps are: leg extensions, leg curls, leg presses and mini wall squats (this is a type of “partial squat” that puts less pressure on the knee joint). In addition, here at Physical Therapy Specialists, we also do eccentric leg work, eccentric extensions as well as stationary bicycling. In other words, low resistance but high RPM exercises. Stretching is also very helpful in treating this condition. Since a tight IT band contributes to this condition, anything that releases the pressure caused by this tight IT band helps. In addition to stretching, we also perform soft tissue work and myofascial release techniques. These techniques loosen up the IT band and soft tissues around the knee. And, as always: stretches like these should only be performed under the supervision of a physical therapist.

Treatment #5: Bracing

Bracing techniques and centering devices serve to keep the patella centered and in its proper place. Taping can also serve to stabilize the patella and keep it centered. Both of these techniques help improve the “recruitment” of the quadriceps muscle and stretches out some of the muscles and soft tissues that have tightened up. Plus, bracing and taping helps unload the patella, which helps relieve some of the compressive forces.

The good news is that most treatments take about six to eight weeks to correct. Not too bad, considering this condition takes years to develop! Yes, Patello-Femoral Syndrome is the most common problem associated with the knee joint. If you are experiencing pain around your knees, make sure you get it properly diagnosed. Do not put it off – call me and I’ll be happy to set a time for a consultation.