• Lionel Pannunzio PT / SCS

Patellofemoral Syndrome: Do you have a Kneecap pain that doesn't want to go away... ?



Introduction


Kneecap pain, also known as anterior knee pain or patellofemoral pain, is the most common injury seen in sports medicine clinics.


Expert clinicians and researchers reviewed about 4500 scientific articles about kneecap pain published between 1960 and May 2018. They chose the best research for the guidelines (271 articles) about the risk factors, diagnosis, examination, outcome measures, and nonsurgical treatment options for kneecap pain.

Here you have the conclusions and guidelines about Kneecap Pain





What is Patellofemoral syndrome?


Presence of Pain Around or Behind the Kneecap pain with squatting, stair climbing, prolonged sitting, running and jumping and change of directions

People with patellofemoral pain describe a gradual onset that typically occurs after a sudden increase in strenuous activities often involving running, jumping, or repetitive squatting.

Once a person begins experiencing symptoms, even simple activities, such as prolonged sitting or descending stairs, can be difficult.



Do I need a MRI for my knee pain ?

Imaging, such as knee magnetic resonance imaging, is not helpful in identifying patellofemoral pain.


How Physical Therapists can diagnose Patellofemoral Pain ?

Physical Therapist will  diagnose patellofemoral pain by assessing movements that are painful, such as squatting, and after ruling out other possible conditions, including iliotibial band pain and patellar tendinopathy.

Reproduction of pain with squatting and other functional activities that load the PFJ in a flexed position (eg, stair climbing or descent).

Patellar tilt test with presence of hypomobility





Classification of Patellofemoral Pain


Current recommendations on PF pain are to classify this condition in 4 categories

1. Overuse/Overload Without Other Impairment

History of an increase in magnitude and/or frequency of PFJ loading at a rate that surpasses PFJ recovery. This is a rapid increase in Activity ( pre-season training , Hill Running, Repetitive Jumping or Squatting) .


2. Muscle Performance Deficits

Lower extremity (LE) muscle performance deficits in the hip and quadriceps


3. Movement Coordination Deficits

Excessive/poorly controlled knee valgus during dynamic task not due to weakness


4. Mobility Impairment

Foot hypermobility and/or flexibility deficits of at least 1 of hamstrings, quadriceps, gastrocnemius, soleus, lateral retinaculum, or iliotibial band








Facts, what we know about PFPS...


1. More common in Females than men

Physically active women are more likely to develop patellofemoral pain compared with physically active men.


2. Single Sport = ↑ risk x 2

Specializing in a single sport may double the risk of experiencing patellofemoral pain.


3. Quadriceps Weakness

↑ risk Thigh muscle weakness may also increase the risk of patellofemoral pain.


4. Height, body weight, and foot posture

No ↑ risk Height, body weight, and foot posture do not predict who will develop this pain.


5. Physical Therapy best Option for PF pain

Because patellofemoral pain typically does not resolve without appropriate treatment, people with this pain should seek appropriate care.




Treatment



The best treatment is a combined program of hip- and knee-strengthening exercises.

The combined strengthening exercises were better for reducing pain and helping people return to their normal activities than strengthening the knee muscles alone.



1 - Hip-Targeted Strengthening

Strengthening exercises that focus on your hip muscles, are more likely to get you back to feeling like yourself.

Hip-Targeted exercises will focus on the posterolateal hip muscles such as your Glutes , hip abductors and external rotators.

Video: Clamshells, Bridges and Deadlifts .





2 - Knee Targeted Exercises




Knee-Targeted Strengthening refers mainly to improve Quadriceps volume and strength

Video: Spanish Squats and Squats. Tip: When doing these exercises be sure they don’t cause any pain under your kneecaps. Spanish Squats are great for creating Quadriceps gains with minimal patello-femoral irritation reason why is one the first Knee Targeted exercises I choose with this type of patients . Back Squats are necessary at a later stage to restore size and volume in the Quadriceps .



3- Combined interventions




In the previous post, we stated that a combination of Hip and knee strengthening was the main treatment for PF pain .

In some cases exercise therapy alone will not be enough and it has to be combined with other interventions such as

  • Foot orthoses,

  • Patellar taping,

  • Running gait retraining

  • Patient education

Foot orthoses The new guidelines for PF pain recommended the use of Prefabricated foot orthoses for those patients that have greater-than-normal foot pronation with the goal to reduce pain in the short term (6 weeks). This intervention showed to be effective only when used in combination with exercise therapy. In this case the insoles are used at the beginning of the treatment to modify the pain and allow the patient to perform the exercises with no pain or less pain. Once pain improves it is recommended to discontinue using them .

Patellar taping and what about Knee Braces for patellar pain ? When Patellar taping was combined with exercise therapy for pain reduction , it showed enhanced exercise therapy outcomes in the short term (4 weeks). Same as with the Inesols , the taping is used at the beginning of the therapy session to modify the pain and allow the patient to perform the exercises with no pain or less pain. Some patients like to use taping or braces for sport activities with the intention of aligning the kneecap and preventing from hurting but research could NOT probe the benefit of this intervention.

Running gait retraining This study showed “weak evidence “ for Running retraining. Even though this weak evidence sometimes cuing for forefoot strike, increase in running cadence, or reduction in peak hip adduction may help to manage pain in the short term .

Patient education Patient education may include load management, body-weight management, adherence to active treatments, biomechanics contributing to overload, evidence for treatment options, and kinesiophobia. From all this options I found that Load management is a very important component when patients are returning to their sports by guiding them to slowly increase the frequency, intensity





Conclusion:


  • Patellofemoral pain is a complex condition.

  • Solving this condition requires a comprehensive approach to correct all deficits that can be causing the anterior knee pain .

  • Research shows that a combination of Hip and Knee Strengthening exercises is the best approach to PFPS

  • Taping and Orthotics are secondary tools that can be using in the treatment of PFPS.



Also be sure you review our previous post on this topic



Lionel Pannunzio is a Physical Therapist Certified in Sports Injuries. With more than 20 years of experience helping athletes return to their sports after an injury. He is the Owner of White Bay Sports Physical Therapy and Fitness, conveniently located in the beautiful City of Weston, where he treats Soccer Player, Runners and Athletes of all ages

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Lionel Pannunzio

Physical Therapist

Board-Certified Sports Specialist

Owner of White Bay Physical Therapy

“Keeping Athletes in the game”



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