Knee pain is a very common complaint, and can be due to a number of causes. One of the most common type of knee pain however is patello-femoral syndrome.
Patello femoral syndrome is the term used to describe pain in and around the knee cap (patella), Pain is the result of abnormal position and movement of the patella on the thigh bone (femur) during knee flexion (often referred to as maltracking). This movement can lead to damage of the surrounding tissue and cartilage underneath the kneecap.
Usually the patella sits in the groove between the condyles of the femur, facing straight forwards. In the case of patello-femoral pain, the patella is pulled laterally, sitting out of the normal groove, clicking and grating over the femur and underlying structures causing pain. If it is pulled too far laterally it can even dislocate.
This abnormal position and movement of the patella can be caused by a number of factors.
1. Lower limb structural alignment
The first contributing factor is genetic structural alignment of the legs. If a person has knock knees for example, the knees go inwards and the patella is then more likely to sit laterally. Patello-femoral pain is more common in females as women's hips are wider then men's, meaning the femurs have to travel on an inwards angle, making them more likely to have problems.
Hypermobility in the joints is another contributing factor anyone who stands with their knees locked back is at increased risk. In hypermobile people the knee ligaments are not as taught, so this allows the patella to de drawn laterally more easily as the ligament don't hold it in place as well.
Foot alignment is one of the biggest factors as well. If the foot is pronated (rolls in) or is flat then the whole leg will also medially rotate when walking or standing. As the leg rolls in, the kneecap then sits more laterally.
2. Muscle imbalances and poor stability
The muscles play a huge role in the support and stability of the patella.
Quadriceps: the quadriceps insert onto the patella so have a direct effect on its position. There is a "tug of war" that exists between the medial quadriceps (Vastus Medialis Obliques or VMO) and lateral quadriceps (Vastus Lateralis). The VMO pulls the patella medially, the Iliotibial Band (ITB) and Vastus Lateralis pull it laterally. So if there is an imbalance between these muscles, ie weak VMO and tight ITB and Vastus Lateralis, the patella will be drawn laterally.
Buttock muscles: the Gluteus Medius muscle is the most important buttock muscle as it stops the knee from rolling in and also stabilises the pelvis and knee laterally. If the Gluteus Medius is weak , the knee not only rolls in medially causing strain, but also the Gluteus Maximus and Tensor Fascia Latae muscle (TFL) often become really tight to try to help stabilise the pelvis. They both insert into the ITB, so if they are tight it directly affects the kneecap position this way as well.
Abdominal muscles: these are very important for core strength and pelvic stability, and when weak will contribute to the problem.
***An abnormal patella position and poor stability combined with poor training techniques eg overloading the knee joint with a lot of running and squatting movements with poor technique will cause pain. Patello-femoral pain can occur in anyone, but is most common in females aged 10-30.
Aching pain in knee joint- particularly at the front of the knee
Pain under the patella during knee flexion/ extension
Increased pain walking up/ down hills/stairs
A clicking or cracking sound during knee flexion
RICE Rest from aggravating movements, especially movements involving loaded knee flexion like stairs, running, squats, lunges is important, along with ice
Taping the patella medially to hold it in the correct position
Massage/ stretches for tight muscles ITB, TFL, Lateral Quadriceps, Gluteals. If stretching the quadriceps is too painful on the knee which is often is, then rolling a foam roller or tennis ball up and down the lateral leg or a professional massage should be used instead.
Strengthening exercises for weak muscles (especially VMO, buttock and abdominal muscles) and pelvic stability
Correction of any abnormal biomechanics - orthotics may be prescribed by a podiatrist if the person has flat/pronated feet.
Implications for Exercise:
This can be different in every person with patello-femoral pain and can also depend on the severity. Basically avoid any exercise which causes pain or clicking, weight bearing through the knee joint, kneeling on the kneecap or extreme ranges of motion at the knee. Exercises which are the most likely to cause pain include: running, heavy squats, lunges and stair climbing, especially if performed with poor biomechanics and control.
Ultimately you need to progress to some of these exercises as the inflammation settles down and the strength and control improves, but not until the exercises cause no pain.
Initially, focus on the improving the core with abdominal and buttock exercises as you can safely do these whilst resting the knee, then progress to loaded VMO exercises like squats and light leg press/footwork on the reformer. Just make sure that when you are doing these VMO exercises you check the leg alignment is correct, and feel that the VMO is working, not just the lateral quads, and there is no pain. The VMO can be felt medially just above the kneecap. Pressing through the heels or squeezing a towel, pillow or small ball between the knees when performing squat type exercises can really help the VMO activation.
Some good Pilates Matwork exercises are all of the abdominal exercises, the Side Lying Buttock series. The best Reformer exercises include all of the Supine Abdominal series, Standing Sidesplits, then Footwork as pain allows, progressing onto challenging the stability more with Scooter.
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