Chronic Knee Pain
Patellofemoral pain syndrome is the medical term for pain felt behind your kneecap, where you patella (kneecap) articulates with your thigh bone (femur). This joint is known as your patellofemoral joint
Patellofemoral pain syndrome, is mainly due to excessive patellofemoral joint pressure from poor kneecap alignment, which in time, affects the joint surface behind the kneecap (retropatellar joint).What Causes Patellofemoral Pain Syndrome?
Your patella normally glides up and down through the femoral groove. As your knee is bent, pressure between your kneecap and the groove increases.
This retropatellar pressure is further increased if the patella does not ride normally through the groove, but “mistracks”, meaning it travels more to one side, making it rub against the femur.
Repeated trauma causes an increase in your retropatellar joint forces, which can lead to kneecap pain, joint irritation and eventually degeneration of your patella joint surface.
The most common causes of patellar malalignment are an abnormal muscle imbalance and poor biomechanical control.
Aching kneecaps (patellofemoral pain) affect 25% of the population at some time in their lives but it is more common in athletes. The sports where patellofemoral pain syndrome is typically seen are those when running, jumping and landing or the squatting position is required.
Sports include running, tennis, netball, football, volleyball, basketball, skiing and other jumping sports.
Untreated patellofemoral pain syndrome can also predispose you patellar tendinitis.What Causes a Muscle Imbalance?
Your quadriceps (thigh) muscles attach to the patella and through it to the patella tendon, which attaches to the top of your shin.
If there is a muscle imbalance between the quadriceps muscles: vastus lateralis (VL), which pulls your patella up and outwards, and the vastus medialis oblique (VMO), which is the only quadriceps muscle that pulls your kneecap up and slightly in, then your patella will track laterally in the groove.
Common reasons for a weak vastus medialis oblique (VMO) include knee injury, post-surgery, swelling or disuse.
Longstanding tightness of your lateral knee structures (lateral retinaculum, VL, and ITB) will encourage your kneecap to drift sideways over time. Especially, if your VMO is also weak.
Patellofemoral pain syndrome is more common during adolescence, because the long bones are growing faster than the muscles, tendons and ligaments, putting abnormal stresses on the joints. Active children who do not stretch the appropriate muscles are predisposed to patellar malalignment.
What Biomechanical Issues Cause Patellofemoral Pain Syndrome?
Poor foot posture (eg flat feet) and weak hip control muscles can both allow your knee to abnormally twist and result in a lateral deviation of your patella.
When poor biomechanics are repeated with each step of your walking or running pattern that poor habit repeatedly traumatises your patellofemoral pain.
What are the Symptoms of Patellofemoral Pain Syndrome?
The onset of your kneecap pain is normally gradual rather than traumatic.
Patellofemoral pain symptoms are normally noticed during weightbearing or jarring activities that involve knee bending.
Stairs, squatting, kneeling, hopping, running or using stairs are commonly painful. As your patellofemoral pain syndrome progresses your knee will become painful while walking and then ultimately even at rest.
You can also experience kneecap pain when you are in sustained knee bend eg. sitting in a chair. A nickname for this condition is “theatre knee”.
Patellofemoral Pain Syndrome Treatment
Researchers have confirmed that physiotherapy intervention is a very effective short and long-term solution for kneecap pain.
Approximately 90% of patello-femoral syndrome sufferers will be pain-free within six weeks of starting a physiotherapist guided rehabilitation program for patellofemoral pain syndrome.
For those who fail to respond, surgery may be required to repair associated injuries such as severely damaged or arthritic joint surfaces.
The aim of treatment is to reduce your pain and inflammation in the short-term and, then more importantly, correct the cause to prevent it returning in the long-term.
There is no specific time frame for when to progress from each stage to the next. Your injury rehabilitation will be determined by many factors during your physiotherapist’s clinical assessment.
You’ll find that in most cases, your physiotherapist will seamlessly progress between the rehabilitation phases as your clinical assessment and function improves. It is also important to note that each progression must be carefully monitored as attempting to progress too soon to the next level can lead to re-injury and the frustration of a delay in your recovery.
Phase 1 – Injury Protection: Pain Relief & Anti-inflammatory Tips
As with most soft tissue injuries the initial treatment is – Rest, Ice and Protection.
(Active) Rest: In the early phase your best to avoid all activities that induce your kneecap pain.
Ice is a simple and effective modality to reduce your pain and swelling. Please apply for 20-30 minutes each 2 to 4 hours during the initial phase or when you notice that your injury is warm or hot.
Protection: Your physiotherapist will normally apply kinesiology supportive taping or similar to help relieve your pain and commence your patellofemoral joint realignment phase. The patellofemoral taping is normally immediately effective in providing you with pain relief.
Your physiotherapist will utilise a range of helpful tricks including pain relieving techniques, joint mobilisations, massage, strapping and acupuncture to assist you during this painful phase.
Anti-inflammatory medication and natural creams such as arnica may help reduce your pain and swelling. Most people can tolerate paracetamol as a pain reliever.
Phase 2: Regain Full Range of Passive Motion
Your kneecap and knee must be able to glide through its full normal range of motion. Your physiotherapist will assess your motion and apply the necessary techniques to normalise your range of motion.
Phase 3: Restore Full Muscle Length
Your thigh, hamstring and calf muscles will require stretching is they are tight and are causing excessive tension or pressure on your kneecap. It is important to regain normal muscle length to improve your lower limb biomechanics.
Phase 4: Normalise Quadriceps Muscle Balance
n order to prevent a recurrence, your quadriceps muscle balance and its control should be assessed by your physiotherapist. In most instances you will require a specific knee strengthening program.
Your physiotherapist will prescribe the best exercises for you.
Phase 5: Normalise Foot & Hip Biomechanics
Patellofemoral pain syndrome can occur from poor foot biomechanics (eg flat foot) or poor hip control.
In order to prevent a recurrence, your foot and hip control should be assessed by your physiotherapist. In some instances you may require a foot orthotic (shoe insert) or you may be a candidate for the Active Foot Posture Stabilisation program.
Other patient may require a hip stabilisation program. Your physiotherapist will happily discuss what you require.
Phase 6: Normalise Movement Patterns
Kneecap pain commonly occurs from poor habits, whether they be an abnormal gait, jumping, landing, running or squatting technique. In order to prevent a recurrence, your walking pattern, jumping and landing technique, running style or squatting method should all be assessed and corrected as required.
Your physiotherapist will happily discuss what you specifically require.
Phase 7: Restore High Speed, Power, Proprioception and Agility
Most kneecap pain sufferers need to return to high speed or repetition activities, which place enormous forces on your knee. Your physiotherapist will guide you in your return to sport planning.
Balance and proprioception (the sense of the relative position of neighbouring parts of the body) are both known to be adversely affected by patellofemoral pain. To prevent a re-aggravation, both aspects need to be assessed and retrained.
Depending on what your sport or lifestyle entails, a speed, agility, proprioception and power program will be customised to prepare you for light sport-specific training.
Phase 8: Return to Sport
If you play sport, and depending on the demands of your chosen sport, you may require specific sport-specific exercises and a progressed training regime to enable a safe and injury-free return to your chosen sport.
Your physiotherapist will discuss your goals, time frames and training schedules with you to optimise you for a complete and safe return to sport. The perfect outcome will have you performing at full speed, power, agility and function with the added knowledge that a through rehabilitation program has minimised your chance of future injury.
Helpful Products – see our Products section
• Patellofemoral Brace – An effective patellofemoral brace can be useful as an alternative to kneecap taping.
• ITB Roller – Excellent for stretching your tight thigh structures: ITB, quadriceps and hamstrings.
Osgood Schlatter disease is an inflammation of the bone at the top of the tibia (shin bone), where the tendon from the patella (kneecap) attaches. It is an overuse knee injury rather than a traumatic injury.
While Osgood Schlatter disease is a relatively uncommon, it is quite debilitating knee injury that occurs in young active children/adolescents. What are the Symptoms of Osgood-Schlatter Disease?
Osgood Schlatter disease presents in growing boys and girls as:
Local pain, swelling, and tenderness over the tibial tuberosity at the attachment of the patellar tendon.
Pain is experienced during exercise (e.g., running, jumping) or with direct contact, such as in kneeling.
Stairs, squatting and kneeling may be painful.
Quadriceps weakness can be present is chronic cases.
Bilateral symptoms, occur in 20-30% of cases.
The apophysis may be enlarged in later stages, which looks like a lump that is tender in its active phase.What Causes Osgood-Schlatter Disease?
Strong repetitive quadriceps contractions are thought to cause a traction force on the tibial tuberosity, disrupting the immature bone. There is a higher incidence in active children during the adolescent growth spurt.
As a child grows, bones go through different stages of development:
The tibial tuberosity is initially cartilaginous (cartilaginous stage).
It then enters the apophyseal stage when the secondary ossification center (apophysis) appears.
The unity of the proximal tibial epiphysis with the tibial apophysis marks the epiphyseal stage.
Lastly, when the growth plates fuse, the bony stage has been reached.
Children are most susceptible to Osgood-Schlatter disease when their bones are in the (2nd) apophyseal stage.
During this phase the apophysis is unable to withstand high tensile forces. When presented with strong, repetitive muscle contractions, micro-fractures occur at the immature area. The separation results in symptoms typical of Osgood Schlatter disease, as well as irregular bone growth that explains an enlarged tibial tuberosity afterwards.
Another reported cause for Osgood Schlatter disease has been the lack of growth of the quadriceps in comparison to the femur. During a growth spurt in a child, the lengthening of the muscle is unable to keep up with the lengthening of the rapidly lengthening femur, resulting in increased tensile force on the tibial tuberosity.
Who Suffers Osgood Schlatter Disease?
Osgood Schlatter disease usually strikes adolescents who are active during their growth spurts, which is the two year period where they grow most rapidly. Osgood-Schlatter Disease is most common in boys but can affect either gender if the children are active. Tight thigh muscles also predisposes you to Osgood Schlatter disease. (The most prevalent groups are: Boys: ages 11-15 years – Girls: ages 8-13 years.
Activities involving repetitive, strong quadriceps contractions, such as in jumping, running, volleyball, basketball, soccer, gymnastics, dance, netball and ice skating are most at risk.
Osgood Schlatter Disease can normally be diagnosed without the need for further investigation.
Plain X-rays are commonly taken to rule out other conditions such as a tibial tuberosity fracture, malignancy, or infection. MRIs are not commonly used to confirm the diagnosis.
What is the Symptom Progression?
While a mild case of Osgood Schlatter Disease can resolve within days, severe cases must be professionally managed to avoid growth plate damage. The pain and swelling symptoms can potentially last for years. Longstanding Osgood-Schlatter Disease can result in an avulsion fracture of the patella tendon, which can severely affect your ability to walk or run.
Fortunately, Osgood Schlatter disease is very successfully managed via physiotherapy.
Treatment for Osgood-Schlatter Disease
Physiotherapy assessment and treatment is a proven benefit for Osgood Schlatter disease sufferers. About 90% of patients respond well to non-operative physiotherapy treatment, but symptoms may come and go for 12-24 months before complete resolution.
Immediate restriction of high impact activities such as jumping and running.
Use an infrapatella knee strap to dissipate forces away from the site of Osgood Schlatter Disease.
Kinesiology taping may provide both pain relief and load reduction at the site of pain and injury.
Only on rare occasions severe Osgood Schlatter disease may require crutches.
Consult with your physiotherapist for the best advice specific to your knee.
Ice & TENS Machine
A combination of ice treatment and a home tens machine will reduce pain and improve the healing rate. This usually hastens the recovery rate of sufferers. Ice is useful at home or after exercise.
Rest is an important in the management of Osgood Schlatter disease and relief of pain.
Whether or not you should continue playing sport is dependent on symptoms. It is best to discuss your exercise workload with your physiotherapist for advice on how to best manage your return sport while respecting your injury.
Stretching, Massage & Foam Rollers
One of the common reasons for developing Osgood Schlatter disease is excessively tight quadriceps muscles, ITB, hamstrings, hip flexors and calf muscles. Your physiotherapist will prescribe specific stretches for you if they assess that you are tight in these muscle groups.
Massage and Foam rollersare beneficial especially in the early phase when stretches create pain at the Osgood Schlatter disease site.
Your muscle control around the knee will usually need to be addressed to control or maintain your symptoms during the active phase of Osgood Schlatter Disease. Your physiotherapist will commonly prescribe or modify exercises for you.
Foot Arch Control & Orthotics
Your foot biomechanics or arch control may be inadequate for your intensity of sport. Your physiotherapist can assist both the assessment and corrective exercises for your dynamic foot control.
Active Foot Correction Exercises can be beneficial as both a preventative and corrective strategy.
Occasionally, your foot biomechanics may be predisposing you to torsional stresses that can cause abnormal knee forces, which can cause knee injury. In these instances, foot orthotics may need to be prescribed. There are mixed views on how effective these are, since the foot structure is rapidly changing at this age. Ask your physiotherapist or podiatrist for advice.
Prognosis for Osgood Schlatter Disease
Osgood Schlatter disease is a self-limiting syndrome. Complete recovery can be expected with closure of the tibial growth plate. Discomfort in kneeling may occur in the long-term with patients who have enlarged lumps as a result of the apophysitis.
Although symptoms of Osgood Schlatter disease may linger for months, few patients have poor outcomes with conservative treatment, and surgical intervention is seldom necessary. Corticosteroid injections are not recommended due to case reports of subcutaneous atrophy.
For a thorough individualised assessment and professionally guided care for your Osgood Schlatter disease please consult with a CARE Institute/Sabga physiotherapist.
In other words, any sport that involves running, jumping,squatting and landing.Plus, the non-sporting person can even experience kneecap pain when descending or ascending stairs.
The condition usually results from either acute injury to the patella joint surface or from chronic friction between the patella and the groove in the femur (thigh bone) through which it passes as the knee bends.
Potential causes include a tight lateral knee structures such as the ITB, weak medial quadriceps (vastus medialis oblique – VMO), overpronating feet and weak lateral hip rotator muscles. These muscle imbalances result in a rotational instability that causes the patella to be laterally aligned in the femoral groove, which causes pain for the malalignment.
The good news is that patellar maltracking is very quickly fixed with physiotherapy assessment and intervention. Commonly, patients can leave the clinic pain-free after just one treatment session.
As your knee arthritis progresses, bony spurs also develop in and around your knee joint in response to the change in load distribution and biomechanics.
Within your knee there are two joints which can be affected by knee arthritis: the tibiofemoral joint - the joint between your thigh bone (femur) and your lower leg (tibia) and the patellofemoral joint (the joint between the kneecap and the femur itself).What Causes Knee Arthritis?
There are several factors which have been found to predispose people to developing osteoarthritis in the knee joints:
As you age it is normal for joint surfaces to “wear down”, especially the major weight bearing joints of the lower limb. The ability of joint cartilage to repair itself also declines as you grow older.
Your weight will directly affect the amount of load the joints in your lower limb have to support during weight bearing activities.
• Previous Knee Joint Injury
Previous injury to your knee can change the biomechanics of your knee joint. This leads to abnormal distribution of load through the knee in everyday tasks.
The gene that produces your articular knee cartilage is sometimes defective and can lead to either decreased lay down of cartilage, or normal lay down of defective cartilage on the joint surfaces.
• Jobs or Sports that repeatedly load your knee joint
Joint compression is essential for stimulating joint nutrition. Repetition of activities that excessively load the knee joint, such as squatting, lifting heavy objects and running, has been linked to an earlier onset of knee arthritis.
What are the Symptoms of Knee Arthritis?
1 often with a gradual onset and progression
2 often worse first thing in the morning or after periods of inactivity
3 often aggravated with weight bearing activities such as walking, going up or down stairs, kneeling and squatting
Warmth around the knee
Clicking or grating
Decreased strength of the lower limb muscles
How is Knee Arthritis Diagnosed?
Your physiotherapist or doctor will suspect signs of knee arthritis from how you explain your knee symptoms. They will also conduct a series of knee tests which help to identify signs of knee arthritis.
An X-ray may also be used to confirm the diagnosis, as well as establish the location and degree of your knee arthritis.
What is the Treatment for Knee Arthritis?
Knee arthritis is a degenerative condition. Physiotherapy treatment is aimed at improving the symptoms of the disease (i.e. knee pain, swelling, stiffness), and you should begin to notice a positive difference within one or a few physiotherapy sessions.
The main goals of physiotherapy for your knee arthritis are:
• Reduce your knee pain and inflammation.
•Normalise your knee joint range of motion.
•Strengthen your knee: esp quadriceps (esp VMO) and hamstrings.
•Strengthen your lower limb: calves, hip and pelvis muscles.
•Improve your patellofemoral (knee cap) alignment and function.
•Normalise your muscle lengths.
•Improve your proprioception, agility and balance.
•Improve your technique and function eg walking, squatting.
Your physiotherapist may recommend the use of a knee brace to support your knee and help to de-load certain structures. There are many different styles available and it is important to find one that suits your individual needs!
Knee Arthritis Surgery
In some cases, patients with knee arthritis choose to undergo knee surgery to
address the degeneration in the knee. The most common forms of surgery for this condition are arthroscopes, partial or total knee replacements.
If your knee arthritis symptoms are reaching an unmanageable level and treatment results have plateaued, it may be worth talking to your doctor about your surgical options.
Risks of surgery include infection, persistent instability and pain, stiffness, and difficulty returning to your previous level of activity. The good news is that better than 90% of patients have no complications post-surgery.
Post-Surgical Knee Rehabilitation
Post-operative knee rehabilitation is one of the most important, yet too often neglected, aspects of knee surgery. The most successful and quickest outcomes result from the guidance and supervision of a qualified knee physiotherapist.
Your rehabilitation following knee surgery focuses on restoring full knee motion, strength, power and endurance. You will also require balance, proprioception and agility retraining that is individualise towards your specific functional needs.
For any of these knee injuries, contact us for an assessment