Patellofemoral pain syndrome

Patellofemoral pain syndrome is pain at the front of your knee, around your kneecap (patella). Sometimes called “runner’s knee,” it’s more common in people who participate in sports.

It’s usually non-traumatic with diffuse pain gradually presenting around the patella with squatting, jumping, running, or going up and downstairs. Symptoms may also present with kneeling or prolonged periods of sitting.

Crepitus:

A clinical sign in medicine that is characterized by a peculiar crackling, crinkly, or grating feeling. People describe it sometimes as a bone-on-bone sound.

A study conducted by de Oliveira Silva et al in 2018 investigated the relationship between function and crepitus, physical activity level, and pain in women with and without patellofemoral pain.

Although the participants with patellofemoral pain were more likely to present with crepitus, the authors concluded that “knee crepitus has no negative impact on function, physical activity level, and pain of women with patellofemoral pain.” Crepitus was also present in 33% of the asymptomatic group.

Chondromalacia Patellae

Another common concern is chondromalacia patellae. “Chondro” refers to cartilage, while “malacia” means softening. Therefore, chondromalacia patellae refers to a softening or breakdown of the cartilage on the backside of the patella.

However, a paper by van der Heijden et al in 2016 found no significant difference in the cartilage of the patella between subjects that have patellofemoral pain and healthy subjects. A 2016 consensus statement by Crossley et al suggested that we shouldn’t even use that terminology.

Things that have to be clear about chondromalacia:

In 2016, Willet et al found that the Ober’s Test, which has historically been used to assess the “tightness” of the IT band, doesn’t assess the length of the IT band.

With regards to the VMO, a systematic review by Smith et al in 2009 recommended that “clinicians not focus on VMO strengthening.” Atrophy of the quadriceps in individuals with patellofemoral pain isn’t unique to the VMO, and trying to do specific VMO retraining versus general quadriceps strengthening doesn’t make a difference in the long run. Most of the exercises that we give in our sessions aim aimed at targeting the VMO are extremely light.

And while taping may contribute to a reduction in symptoms, Ho et al in 2017 found that it has nothing to do with changing the alignment of the patella.

Exercises:

Similarly, there are no good or bad exercises for your knees. For weight-bearing exercises, there are generally three things that increase the stress at the patellofemoral joint: more knee flexion, higher loads, and a greater distance between your knee and the center of mass behind it.

With regards to exercise prescription, we usually incorporate knee and hip strengthening exercises. What we are going to address can be adjustable, you can certainly add exercises for the same aim, but completing many exercises, 2 to 3 times a week is fine for most people

1 – Bodyweight Squat

Place your feet hip level, move in a downward motion moving from a standing to a sitting like position simultaneously moving your arms up (shoulder level) as you move down. Draw your hips back and downward keeping your chest up

2 -Split Squat:

Place a step or a box behind you and stand up tall. Position your right foot on top of the box and the left one remaining on the floor, bend your knees and lower your hips until your left thigh is parallel to the floor. Return to the starting position and repeat.

3- Lunges:

• Stand straight with your feet shoulder-width apart.
• Step forward with either leg in a long stride. Keep your other foot in place behind you.
• Bend your knees as you do this, so your body is lowered towards the ground. Keep your back straight throughout the movement.
• Continue down until your front knee is just above the ground (your front leg should be bent 90 degrees at the knee). Hold for a count of one.
• Push down through your front heel and extend both knees to return to the standing position.

5- Single leg RDL

• Start in a standing position with both legs on the floor.
• Elevate one leg behind you and flex the other slightly as you bend over keeping your back straight and chest up.
• Carry a dumbbell in your hand to add resistance.
• Return to starting position.

6- Side plank knee variation:

• Lay down inside lying position on your forearm and place a resistance band above your knees.
• Proceed to push with your upper leg towards the ceiling.

7- Side plank with resistance band:  

• Side lying on the floor with the upper body supported on the forearm.
• Place a resistance band around the ankles and move your leg towards the ceiling.

8- Hip thrust body weight:

• Place the upper part of your back below the scapula on the bench with your legs separated hip level
• Elevate your hips and squeeze your glutes

9- Weighted hip thrust:

• Place the upper part of your back below the scapula on the bench with your legs separated hip level
• Elevate your hips and squeeze your glutes
• Apply weights on your hips for more resistance

These are simple ones, that can be done at the gym. Bear in mind that sometimes these exercises need a follow-up with your therapist especially when the pain is unbearable, or you are going through an acute inflammation. listen to your body, don’t push if any of the exercises given are triggering your pain.

References:

–Danilo de Oliveira Silva.  Knee crepitus is prevalent in women with patellofemoral pain but is not related to function, physical activity, and pain. 2018 Sep

-Br j Sports med 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. 2016 Jul

-Am J Sports Med. No Difference on Quantitative Magnetic Resonance Imaging in Patellofemoral Cartilage Composition Between Patients with Patellofemoral Pain and Healthy Controls. 2016 May

– Am J Sports Med. Vastus medialis obliquus atrophy: does it exist in patellofemoral pain syndrome?  2011 July.

-Med Sci Sports Exerc. Effects of vastus medialis oblique retraining versus general quadriceps strengthening on vasti onset.  2010 May.

-Physiother Theory Pract. Can vastus medialis oblique be preferentially activated? A systematic review of electromyographic studies. 2009 February.

-Am J Sports Med. No Difference on Quantitative Magnetic Resonance Imaging in Patellofemoral Cartilage Composition Between Patients with Patellofemoral Pain and Healthy Controls. 2016 May

-J Orthop Sports Phys Ther. Effects of Patellofemoral Taping on Patellofemoral Joint Alignment and Contact Area During Weight Bearing. 2017 February