Are you experiencing nagging knee pain in your barbell squats or even just simply climbing stairs? No matter how many massages you go for or how long you spend foam rolling the thigh, it just doesn’t seem to go away. Whichever the reason, let’s go over why you may have knee problems and what are some of the ways you can fix them.
What is it?
Anterior knee pain also known as patellofemoral pain syndrome (PFPS) is a preferred term used to describe pain in and around the kneecap. This front knee pain involves structures such as the thigh bone (femoral or femur) and the kneecap (patella) but is not limited to surrounding soft tissues. Due to the multitude of structures potentially responsible for the source of knee pain, a simple cookie-cutter approach for treatment does not work well i.e. just foam rolling.
Your knee pain can be brought on gradually over time or acutely by an incident. You will usually find activities with a high compressive force quite painful.
Ascending/ descending stairs
Walking up / down hills
Kneeling against the ground
Sitting with knees bent
Wearing tight clothing i.e. skinny jeans
What causes it?
The cause of PFPS is mainly biomechanical and it refers to how your body moves or how your joints are positioned. This means the pain is usually reproduced during physical activity such as climbing stairs or even simply walking on uneven surfaces.
Common biomechanical errors:
Increased femoral internal rotation could be the result of:
Congenital femoral anteversion - Do you in-toe when you stand or walk?
Poor hip control
Increased knee valgus - Does your knee cave in as you squat or lunge?
Genu valgum or increased Q angle
Weak glutes, quadriceps and hamstrings muscles
Poor core and hip control
Increased subtalar pronation - Does the arch of your foot flattens as you squat or climb stairs?
Inadequate flexibility or reduced muscle and tendon compliance can affect knee movement. Common muscles affected by PFPS
TFL or iliotibial band
“Patellofemoral pain syndrome, not so much a cookie-cutter approach…”
An integrated approach to the management of patellofemoral pain should include:
Pain Reduction (week 1-2)
Activation of muscles (week 3-4)
Movement (week 5+)
Strength Building and Sports Performance (week 7+).
This is the approach we've developed here at Breathe Physio and Pilates.
Pain Reduction (weeks 1-2)
The first priority of treatment during the first week or two is to reduce pain as this will allow you to move better and sleep better.
Common methods of pain relief include:
Rest from aggravating factors such as walking up and down the stairs or hills, heavy squats, kneeling against the floor
Physiotherapy including joint mobilisation and taping
Sometimes these pain-relieving methods may not be enough. It is important for you to understand your diagnosis and its pain behavior. It is then you learn self-management strategies knowing what to avoid i.e. stairs.
Activation (weeks 3-4)
After pain and discomfort have subsided or are under more control, it is time to move on to muscle activation. Muscle activation is important to allow better, more efficient body movement and positioning (biomechanics). Activation exercises can come naturally to some but difficult for others, thus, the timeframe can range from 2-3 weeks. Muscle weakness can happen either from past unrelated injuries elsewhere or due to current pain inhibition. Despite the cause, a thorough clinical assessment by your physiotherapist will guide you in the right direction.
Commonly targeted muscles for activation include the abdominal, gluteal, quadriceps, hamstrings, and intrinsic foot muscles to improve the arch of your foot.
Movement (weeks 5+)
Now that you are geared up with better muscle activation, it is time to learn how to integrate it into your day-to-day activities or sports. This stage usually takes the longest (up to 4 weeks) as it requires some level of activation, coordination, body awareness, and proprioception. The main goal is to move well, develop good knee hygiene to eliminate tissue irritation, and prevent re-injury.
Common movement patterns to practice are:
Squat (bilateral or double-legged loading)
Lunge or split squat (unilateral or one-legged loading)
Single leg squat
Strength Building and Sports Performance (week 7+)
The majority of people who reached the Movement phase should be proud as this progress usually suffices to prevent re-injury. However, for those who are exercise-centric or sports-specific, we do encourage you to continue to build strength and conditioning specific to your needs.
The timeframe for the final stage of rehabilitation is not specific as you are likely to commence with the hypertrophy phase (high repetitions and volume) into the strength phase (lower repetitions and volume) and into the power phase (volume remains low but with explosive intent and longer rest). If you are curious about strength training and when to transition into a power program, visit our previous blogs called, “Level Up Your Strength Training” and “Dynamic Strength Index - When to Switch Between Strength and Power Training”.
Patellofemoral pain syndrome can be as simple and as complicated based on your presentation. As the representation varies amongst individuals, there is no cookie-cutter approach toward this condition. If you want further guidance on your management or return to sports, feel free to contact us or book an appointment online.
Brukner & Khan’s (2014) Clinical Sports Medicine (4th Edition), McGraw-Hill Education (Australia)
Powers CM, Witvrouw E, Davis IS, Crossley KM. Evidence-based framework for a pathomechanical model of patellofemoral pain: 2017 patellofemoral pain consensus statement from the 4th International Patellofemoral Pain Research Retreat, Manchester, UK: part 3. Br J Sports Med. 2017 Dec 1;51(24):1713-23