Do you have Patellofemoral (knee) pain syndrome?

Patellofemoral pain syndrome or PFPS is a common cause of knee pain, especially among women. Usually the pain is focused around the front of the knee and/or around the knee cap. There’s usually increased pain with descending stairs, walking downhill or sitting for long periods of time. Rest or straightening the knee will usually feel relieving. Want to know more? Read on for common causes and latest research on how to most effectively remedy PFPS.

What’s causing the pain?

The most widely accepted theory in regards to the cause of the pain in PFPS is an increased pressure of the kneecap on the underlying bones. This could be either at rest or when doing activity and is referred to as patellofemoral malalignment or maltracking. (4) Sometimes this is from the knee joint itself causing the malalignment, sometimes it’s from muscles around the knee pulling at the knee cap. In the later case it can even be a ankle, hip or back issue making the knee joint and muscles compensate. That’s why if you have unfamiliar pain, it’s always good to get a proper assessment to check the underlying cause. How frustrating to do a months worth of knee exercises, when all you need is a weeks worth of hip exercises!

What exercises are effective according to the research?

• Knee and knee cap in alignment while performing functional exercises can be helpful. For example, here at the clinic we use the McKenzie method to assess which movement is going to align the knee the best to create pain free movement. We then teach you exercises to continue with or use tape to help hold it the correct alignment while you exercise. This is useful for the short term until your body gets stronger. (2)
• Strengthen your quad, especially the VMO (vastus medialis obliquus) muscles. Depending on your fitness and current strength this could be a straight leg raise or squats just to name a few. Squats performed with feet slightly wider than hip width apart active the VMO better. This muscle is shown to be weak in people with PFPS. (1, 2)
• Active stretching for the hamstrings, quads, calf and front of the hip. Check out helpful videos and pics on our youtube channel or social media account on instagram and facebook @myothrive. (2) This is something we can help with via video consultation very effectively if you’d like something tailored to you!
• A more recent 2018 meta analysis where they reviewed a number of recent good quality studies found that strengthening multiple joints was more effective than strengthening the knee alone. (11) Therefore make sure you look to strengthen your glutes, back, ankles and knees. Sometimes the shoulders need strength to assist with the lower body, or the core, so again, it’s important to get a proper analysis done to save you time in your approach to recovery!

What exercises are not effective, according to the research?

• As mentioned previously, it’s ideal to strengthen multiple areas of the body in helping your knee, however, strengthening those areas in isolation is no better than strengthening the knee only. The research showed that hip strengthening should not be your primary exercise focus.(2, 11) Some examples of hip strengthening exercises are clams or side lying leg work where the knee is not engaging.
• Exercise under supervision is no more beneficial than doing the exercises on your own.(2) However there are a few note worthy points around this. Firstly, the assessment is still really important. Once you know what to do, if you’re self motivated, you can likely do the exercises on your own. Secondly, if you know you’re someone who is not self-motivated or needs regular check ins and progressions to keep it interesting then enlisting the help of a trainer is probably best.
• Only focusing on the VMO strengthening is shown to be less effective as the evidence is pointing towards multiple factors being involved in PFPS. (3, 4, 11)

What do I need to be careful with?

• Doing too many knee flexion and extension exercises as this may aggravate your pain. Keep the reps and weight low when doing things like a squat or lunge and slowly build up to higher amounts and more weight. All exercises should be pain free and other than workout muscle soreness you should not feel increased pain the following day or after your workout. Some low to moderate pain that lasts less than 10 minutes is acceptable.
• Going too deep in knee flexion as this may aggravate your symptoms. Start with shallow squats and lunges and as your strength builds and pain is reducing you can slowly bring yourself into a deeper posture.
• Sitting for too long as this may aggravate your PFPS. The amount of time tolerable can be different for everyone and you probably already know how long you can tolerate. If you happen to sit for too long, come up slowly and carefully. Also try not to tuck your legs under the chair or sit on your foot with the knee maximally bent.
• Put yourself in an unstable position or on an unstable surface until you are well on your way to recovery. There is an increased chance that you may fall with PFPS because the muscles around the knee aren’t getting proper nerve signals. This will improve with the exercises but you need to be careful in the initial rehabilitation phase. (2)
• Kneeling as this may aggravate your symptoms. Putting something soft down can help relieve this problem such as a Pilates mat, a cushion or some foam.

What non-exercise treatments are shown to be effective?

Unfortunately good quality PFPS research is lacking when it comes to non-exercise treatments. The below treatments may be advantageous for some people with PFPS.

• Kinesio Tape can be beneficial in the initial stages to help with knee proprioception (the connection between the brain and the knee) when combined with low impact rehabilitation exercises. It is not appropriate to use with high impact exercises such as running. (5)
• Myofascial release and self myofascial release to reduce general musculoskeletal pain.(6) This may involve trigger point therapy, dry needling or massage in a clinic setting or a foam roller or spiky ball at home. Again check out our YouTube, instagram or facebook accounts for videos and pics or join us for a video consultation and we can go through it with you.
• Ice, ultrasound, biofeedback, neuromuscular electrical stimulation and laser may be beneficial in combination with exercises however alone they showed no improvement.(7)
• Taping specific to your needs (i.e for lateral glide, rotation etc…) can be beneficial in early stages but loses effectiveness at 4 weeks and research showed no changes at 3-12 months.(8)
• Orthotics can be beneficial over no treatment at all.(9) However this could be a simple arch support from the chemist, you don’t necessarily need an expensive moulded orthotic.
• Surgery can be considered after failure of a comprehensive rehabilitation program.(10)

Hopefully you’ve got some good ideas on how to help your knee pain move forward to increasing function and decreasing pain. Have a question for us? Click on the help button (bottom left) to chat with us!

Resources

1. Eun-Mi Jang et al. Journal of Physical Therapy Science 2013. Activation of VMO and VL in squat exercises for women with different hip adduction loads.
2. Demetris Stasinopoulos et al. The Open Sports Medicine Journal 2015. A systematic Review of Reviews in Patellofemoral Pain Syndrome. Exploring the Risk Factors, Diagnostic Tests, Outcome Measurements and Exercise Treatment.
3. Els pattyn, PT et al. American Journal of Sports Medicine 2011. Vastus Medialis Obliquus Atrophy Does it Exist in Patellofemoral Pain Syndrome?
4. Frances T. Sheehan (PhD) et al. Clinical Biomechanics (Online) 2012. Alterations in vivo Knee Joint Kinematics Following a Femoral Nerve Branch Block of the Vastus Medialis: Implications for Patellofemoral Pain Syndrome.
5. Freedman (PT) et al. Sports Health 2014. Short-Term Effects of Patella Kinesio Taping on Pain and Hop Function in Patients With Patellofemoral Pain Syndrome.
6. Adelaida Maria Castro-Sanchez et al. Clinical Rehabilitation 2011. Effects of myofascial release techniques on pain, physical function, and postural stability in patients with fibromyalgia: a randomized controlled trial.
7. David A. Lake et al. Sports Health 2011. Effect of Therapeutic Modalities on Patients with Patellofemoral Pain Syndrome: A systematic Review.
8. Christian Barton et al. British Journal of Sports Medicine 2013. Patellar taping for patellofemoral pain: a systematic review and meta-analysis to evaluate clinical outcomes and biomechanical mechanisms.
9. April D. Jessee (MS) et al. Journal of Athletic Training 2012. Bracing and Taping Technques and Patellofemoral Pain Syndrome.
10. Sameer Dixit et al. American Family Physician 2007. Management of patellofemoral pain syndrome.
11. Kristen Scali et al. Is multi-joint or single joint strengthening more effective in reducing pain and improving function in women with patellofemoral pain syndrome? A systematic review and meta-anaylsis. International Journal of Sports Physical Therapy. June 2018.