Patellofemoral joint problems (usually pain at the front of the knee) is a common problem reported by many runners. This often starts gradually with no obvious cause of injury and no direct trauma. Patients with Patellofemoral Joint (PFJ) symptoms can often become very frustrated as their pain often appears to settle down with rest/treatment but can quickly re-occur when they return to running or any activities that place an increased pressure through the front of the knee such as going up and down the stairs (source).
the cause
The reasoning behind the repetitive 're-occurrence' of symptoms lies within the complexity of the condition. Although the discomfort is normally quite specific to the front of the knee, there can be variety of underlying sources as the cause. A selection of these include: the patella femoral joint itself, Ilio-tibial band, synovial plica, patella tendon, quadriceps tendon, fat pad and a number of bursa. Also.... to make things just a little bit more complicated... the problem can often be a combination of these things and not necessarily just one of these alone! (source).
Due to the various sources of symptoms here... it is important in the early stages of rehabilitation to identify the exact cause/causes using a thorough assessment. Once this is established, the following steps can be used in order to get back on the road towards pain free running!
Steps
1. Reduce the pain
2. Address contributing/aggravating factors
3. Gradually increase the patellofemoral joint’s (movement of knee cap with thigh/shin bone) work load (source)
So... How do I reduce the pain??
As a runner myself it’s quite hard to say this but in the initial phases, running may have to be modified/reduced or even stopped in order to temporarily reduce the patellofemoral joints load, this allows the symptoms to settle. After the initial groans of disappointment.... I can hear you asking.... how do I know if what I am doing is still too much?? Unfortunately there is no simple black and white answer to this as it depends on a number of factors. This is unfortunately one aspect that would need thorough discussion with your physiotherapist and ideally one that has an interest and understanding of running injuries management. However.... if running does have to stop or become reduced for a short while, non aggravating cross training activities such as cycling are highly recommended to maintain fitness.
There are a variety of other methods to try and help manage/reduce pain initially.... these often include ice/analgesia, Non-Steroidal Anti-inflammatories, soft tissue massage, joint/patella mobilisations and taping. However .... unfortunately with anterior knee pain using these methods alone will not necessarily get you better. In order to get best use of them you will need to skilfully use them as adjuncts alongside a thorough rehabilitation programme in order to ensure you get long term benefit and not just a temporary short term fix. The key thing here is to make sure the underlying problems are directly addressed (source).
So.. what could the contributing factors be??
A recent review by Lankhorst et al (2013) suggested there could be up to as many as 500 contributing factors to patellofemoral joint pain! Again, this highlights just how complex the nature of this condition can be! However.... with a skilled and thorough initial assessment it is feasible to identify a small number of more likely contributing factors. You can then identify in order of priority which ones will have the most influence on that specific individual’s presentation.
Often the main factors include:
1. Quadriceps, Gluteal, Hamstring, Soleus strength plus timing of contractions
2. Altered movement control e.g. increased hip adduction during running gait
3. Reduced flexibility of Quadriceps/Hamstrings/Gluteal Maximus/Tensor Fascia Lata/Gastroc/Soleus and hip flexors
4. Reduced joint range of movement E.g. Ankle dorsiflexion(Foot pointing upwards)
5. Recent/sudden increase/change in activities/work loads
So what next....
So as long as some attention has been paid to the above factors, a gradual increase of the patellofemoral joints work load and a return to running can begin!
The concept behind a gradual return and 'gradual increase in joint load' can be found in more detail by reading our previous blog on TISSUE REGULATION.
In order to gradually build back up to running, our knees require being able to tolerate from 4.3-7.6 times our body weight! Therefore.... in order to return to injury free running you would need to adopt a gradual phased return that is graded in an appropriate manor towards your goal. So.... one example of this could be by starting loading the patellofemoral joint using a static 45 degree squat. This was suggested by Powers and his team as a good starting point when injured (source) as they found any weight bearing loading of the PFJ between 0-45 degrees placed minimal force through the joint as was likely to be tolerated well. In order to achieve loading of the joint between 45 and 90 degrees they advised avoiding weight bearing and instead using a leg extension machine (or resistance band) to access this range. This is a good example of using specific research that focuses on the amount of force that is put through the PFJ during different joint ranges and also during different activities in order to keep the joint as active as possible (to help it heal) without flaring up symptoms. This is just one example of many clever methods that your physiotherapist can use to get your rehabilitation on track when you are in an injured state. Similar principles also apply throughout every progressive stage of your rehabilitation with the aim of returning to high impact activities/running.
Although problems with the patellofemoral joint can appear to be a very complex problem to manage.... you will be pleased to know that with the right guidance and advice.... a return to normal high level activities and running can realistically be achieved.
If you are currently suffering with this problem and require any help or advice, please get in touch and one of our physiotherapy team will be more than happy to help. Hope you have enjoyed reading our latest blog. Keep a look out for our next instalment!
Best wishes,
The Consortium Team