Pain in the kneecaps: causes, signs and treatment

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Allow me to introduce myself. I’m Ty, a sports physiotherapist at PhysioTec, recently recovered from my own pain in the kneecaps. I’m thirty-five years old, I’m six feet, four inches tall and I weigh roughly two hundred twenty-five pounds. I enjoy training for and competing in triathlons and have since learned that I qualify for the McClydesdale category when registering for races. A humbling category title for those of us over a certain weight.

Being heavier and adding increased activity felt like it brought some aches and pains with it during my training so, it’s for this reason I would like to discuss pain in the kneecaps; specifically Patellofemoral Pain Syndrome. I will also try to answer a question I have been pondering for a long time, "Does being heavier mean running pain-free is impossible?"

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Pain in the kneecaps is called Patellofemoral Pain Syndrome

Patellofemoral pain (pain in the kneecaps) is one of the most common knee complaints in individuals between the ages of 10-50 years. Sometimes it may also be referred to as Runner's Knee or Chondromalacia Patellae. It is a clinical diagnosis made when patients present with pain around or behind the patella (kneecap) during daily activities, stair climbing, walking, squatting, or running. 

Patellofemoral pain can be a persistent pain in the kneecaps, and commonly reoccurs with nearly 40% of individuals still experiencing symptoms after two years (Winters et al, 2020). Pain in the kneecaps can begin due to an increase in training load but can also arise gradually due to repetitive movement habits (usually walking, running or jumping) - moving in walking that irritates the kneecaps. In my case it was all of the above; an increase in running demand and poor hip and ankle control, resulting in more load on the kneecaps.

The anatomy of the patellofemoral joint

The patella or kneecap lies in a groove of the femur or thighbone, this is called the patellofemoral joint. As the knee bends and straightens, the patella slides up or down this groove.

However, for someone with patellofemoral pain, the patella is drawn toward the edge of the femoral groove and this sliding action can then become irritating causing pain in the kneecaps during knee bending or straightening.

Anatomy-knee-cap-and-femur

What are the causes of pain in the kneecaps? 

Briefly touched on above, patellofemoral pain can happen for multiple reasons.

  1. Biomechanical factors: muscle weakness at the hip and/or thigh, poor ability to control position and movement of the pelvis or ankle - resulting in higher loads transferred to the kneecaps.
  2. An increase in training load or activity e.g., increasing running distance or intensity too quickly.
  3. Repetitive trauma to the knee can lead to loss of patellofemoral joint space and mal tracking of the patella
Causes-of-patellofemoral-pain-syndrome

How do I know if my kneecap pain is Patellofemoral Pain Syndrome?

People with patellofemoral pain demonstrate some common clinical characteristics. Often, patients report pain in the kneecaps with palpation of the distal pole or medial aspect of the patella, the medial plica, and the medial femoral condyle - tenderness to pressure at the bottom tip of the kneecap and/or around the inner side of the kneecap.

There may be pain with grinding or compressing of the patella (Willy et al. 2019) - pain if pressure is applied to the kneecap, and especially if it is moved side to side with that pressure down on the kneecap.

Patellofemoral pain typically presents with weight-bearing activities (activities where you are standing on your feet) or loading of the knee while bending. Pain in the kneecaps commonly occurs with walking, running, climbing up and down stairs, hopping, and walking on slopes.

The kneecap may also become painful if you are sitting for a long time with your knees bent, such as during a longer drive. Kneecap pain usually increases with activity and is slow to settle with rest.

When my own kneecap pain was at its worst, I would feel great discomfort if my knee was bent at 90 degrees (a right angle) for longer than 5 minutes. It also felt hot at night and uncomfortable to put pressure through when laying on my side. This made it hard to relax at times and became frustrating, but I found some gentle thigh muscle exercises and massage did give some relief.

Patellofemoral pain is also common in those with hypermobility due to more flexible ligaments. Working on local muscle control around the patella will be even more important if you are hypermobile.

Cardinal-signs-of-patellofemoral-pain-syndrome

What are the treatment options for Patellofemoral Pain Syndrome?

When you have pain in the kneecaps, you might feel like chopping off your legs! I did! But wait!

Fortunately, multiple effective treatment strategies are available for patellofemoral pain syndrome, including education around the condition, exercise, foot inserts for some people, joint mobilisation, and  taping or bracing of the knee.

Scientists have found that treatments including patellar taping, hands-on treatments like mobilisation of the kneecap, and stretching can have a moderate to large positive effect - good to great improvements in the short term (6-12 weeks). Treatments that made the biggest difference in the long term (1 year) were thigh and gluteal strengthening exercise (Barton et al 2015).

Pain management treatments for pain in the kneecaps

Early pain management strategies we would use in clinic include:

  • Education about the condition - knowledge is power! The more you understand, the better you will become at keeping those kneecaps happy!
  • Load management - this means identifying things that you might be doing to irritate your kneecap pain, and helping you find ways to remove or minimise this irritation
  • Hands-on treatment like massage and joint mobilisation can be really helpful for some people and less useful for others. We'll evaluate your knees and trial some hands-on treatment if it's appropriate for you.
  • Movement training - early advice and training in ways to move to reduce irritating loads on the knee caps.
  • Patellar taping and bracing taping or bracing of the kneecap in the early stages can help reduce irritation during movement and sustained positions.

Building an exercise program for long term relief from pain in the kneecaps

As we mentioned above, the research tells us that the early pain management techniques help get some relief in the short-term, which is great! However, we need to address underlying weaknesses and irritating movement patterns to control the situation for the longer term.

Exercise priorities for long term management of kneecap pain:

  • Buttock strengthening and improving control of the pelvis. Improving gluteal muscle strength and your ability to control your pelvis when standing on one leg is a key priority. The deeper gluteals (gluteus medius and minimus) and the deep rotator muscles at the back of the hip help to provide the needed support to limit side-shifting and dropping of the pelvis, and inward dropping of the knee, all patterns that can have negative effects at the kneecap.
  •  Quadriceps strengthening. Compared with people without kneecap pain, researchers have found people who develop patellofemoral pain have weaker quadriceps - these are the muscles in the front of the thigh. Quadriceps wasting (smaller muscles) is also a common finding in people with pain in the kneecaps (Willy et al. 2019). So, your exercise program should include both gluteal and thigh strengthening.
  •  Foot strengthening and improving mid-foot control. For some people, pain in the kneecaps might be related to how the foot moves, for example too much pronation (rolling in of the foot) can result in irritating loads up at the kneecap. The best way to control this in the longer term will be an exercise program that targets the foot intrinsic muscles - the deep muscles in the feet that control your foot position. At PhysioTec we can use real time ultrasound to assess these deep muscles and help you reconnect with them to get them functioning better.

Foot taping and orthotics - shoe inserts for patellofemoral pain

Where mid-foot control is an important contributor to your knee-cap pain, various methods can be used to support your foot and therefore reduce irritating loads at the knee.

Options for foot support include:

  • Foot taping. Foot taping is often a first option to test the effect of providing support to the foot. it's good to test this before jumping into more expensive orthotics (shoe inserts) that may not help your particular problem.
  • Temporary felt inserts. Particularly if your skin can't tolerate tape or to test some foot support for a little longer, our physiotherapists might try a hand-made felt insert.
  • Foot orthoses (Orthotics or shoe inserts). If the temporary foot support is working for you, then we may recommend orthotics. For most people an off-the shelf orthotics works well. Others may require a custom made orthotic.

But remember - taping and orthotics can never provide the same support for your foot as your muscles that connect directly to your bones! So make sure you pair any foot support device with an exercise program, including both foot and hip exercises. If you have really weak gluteals, there is no way an orthotic is going to control the large forces coming down from the hip!

Research has found that education combined with physical treatment (exercise, orthoses, or patellar taping/mobilisation) is most likely to be effective (Winters et al. 2020)

Running assessment and retraining

For runners, particularly those who are keen to get back running quickly or running longer distances, it can be helpful to have a running assessment. There might be simple things you are doing in your running that are really multiplying those annoying loads at the knee. Once we identify these, often some simple cues can make a big difference in addressing these issues and improving your comfort during and after running.

At PhysioTec we can provide a running assessment with accelerometer (Vi-Move) technology and video assessment.

 

While you may not follow every aspect of these recommendations, combining physical rehab strategies and learning as much as you can about your pain has the best evidence to support favourable outcomes.

Take home message: Doing a combination of these treatments is better than waiting to see if it gets better!

Treatment-options-for-patellofemoral-pain-syndrome

How are my knees now? 

Well thanks for asking! Nearly one year ago, I began increasing my weekly running and cycling from about 1 of each per week to about 3 runs and 2 cycles per week. I was pretty heavy at the time and my gait (running pattern) was heavy too. I had loud footsteps.

I slowly developed patellofemoral pain which steadily got worse. I tried addressing some of my movement mechanics which helped mildly but the pain in the kneecaps didn’t go away. I managed to complete my Tri but with much discomfort and lingering pain well afterward.

Finally, I began a strengthening program of the lower limb. I worked on glute strength, quad strength, calf strength, and foot arch control. I cut out running training but kept walking and cycling twice a week. It took two months to really feel a difference while walking and climbing stairs or steep slopes.

I continued the strength program for another 2 months progressing to more dynamic exercises involving jumping and landing control and finally I was ready to try a run again. Just last week I ran 5km pain-free for the first time in nearly 9 months. I have to say it was a great feeling.

I really just needed the muscle strength and biomechanical control to move a heavier body., and I had to give my body time to adjust to the much higher loads of running.

PS. I still weigh the same and the pain is gone 😉  So yes, it is possible to run painfree even if you are heavier!

If you’re looking for a rehab strengthening program to improve your knee pain, come to PhysioTec and let me or another sports physio design the targeted program you need!

Do you you need help recovering from an injury? Improving your performance? Or just getting back to doing the things that you love? Visit us at PhysioTec, and let one of our physios assess you and provide you with a personalised program to help you get on-top of your condition, and feel at your best.

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Tyler Cultum - Physio at Physiotec, Tarragindi, Brisbane

Author

This blog was written by Tyler Cultum, one of our Sports and Strength & Conditioning Physiotherapists. He has broad interests in sports and musculoskeletal physiotherapy, with special interests in strength and conditioning, the shoulder and hip. You can read more about Tyler here.

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