Knee Pain

Anterior knee pain is pain around the front of the knee or patella (kneecap). We often see people with patellofemoral pain syndrome (PFPS) at Kingsland Physiotherapy. It is common in females and young adults, who are usually active. However, it can occur in less active people (Hettrich, Liechti, 2015).

What are the symptoms?

• Pain is usually around the kneecap area
• Knee pain going up or down stairs
• Knee pain squatting (going down or up)
• Pain with prolonged sitting with flexed knees
• The sensation that your knee will give way (this is different to true giving way, when your knee gives way to the point you fall over) (Physiopedia, 2019)
• Pain kneeling
• Pain when wearing high heels
• Pain when wearing tight compressive clothing (Physiopedia, 2019)
• It can occur without any injury

What causes it?

• Muscular imbalances – muscular tightness or weakness
• Patella alignment issues on flexion and extension
• Overuse injuries – tendinopathy
• Patellar instability
• Patella abnormalities (Physiopedia, 2019)
• Pain is a multidimensional experience. Factors such as stress, worry about the condition and beliefs can influence the pain you experience (Physiopedia, 2019)

There can be several underlying causes for this pain, which include (Physiopedia, 2019):

• Patellofemoral pain syndrome
• Chondromalacia patellae
• Osgood-Schlatter’s disease
• Knee bursitis/Hoffa’s fat pad
• Patellofemoral instability
• Patellar tendinopathy
• Patellofemoral osteoarthritis

What can I do?

• Rest from aggravating For example, if you flare up with running, try cycling, walking or cross training temporarily to allow the symptoms to settle
• If you are struggling with pain, it may be worth speaking to a GP or pharmacist about pain relief
• If your symptoms flare up with prolonged sitting, bend and straighten the knee a few times to loosen it off before moving, or every 15-20 minutes when sitting
• It can take time for the symptoms to settle, and usually involves a period of regular rehabilitation programme to help the symptoms in the long term
• Hip and Knee strengthening exercises (Collins et al, 2017)
• If you are overweight, losing weight can help reduce the strain on the knees, especially in loading positions e.g. going downstairs (Mayo Clinic, 2018)
• Exercise combined with foot orthoses only if indicated (Collins et al, 2017). A physiotherapist or podiatrist would assess you for this
• A physiotherapy assessment can guide your rehabilitation. They may consider taping, bracing, acupuncture, dry needling, manual therapy, blood flow restriction training, gait re-education, although there is uncertainty on their effectiveness and evidence in rehabilitation of PFPS (Collins et al, 2017)
• Knee, patellofemoral mobilisations in isolation, electrotherapy is not recommended (Collins et al, 2017)
• Activity adaptation, improving range of movement, strengthening and a gradual return to sport programme is the main rehabilitation for this problem

Exercises

You can try these exercises. However, it is worth seeing a Physiotherapist to rule out other injuries or causes of the pain. They should not worsen your pain:

Single Leg Stand – have something near your hand to correct your balance if you need e.g. wall/kitchen worktop. Stand on one leg and hold for 30 seconds. 5 repetitions.

Wall sit – leaning against a wall, bend your knees in to a squat. Keep your knees behind your toes. Try and reach a 90 degree knee bend, but only go as far as comfortable. Hold for 5-10 seconds. Repeat 10 times.

Hip abduction side lying – lying on your side with one hip directly on top of the other one. You can bend your bottom leg to keep your balance. Lie on one pillow or head resting on bottom arm. Leading with your heel, raise the top leg up, not too high, hold for a few seconds, and lower down. Repeat 3×8 repetitions. You should feel this working the outside of the hip (glutes).

Calf stretch – lean on a wall if you need to. Keep your toes pointing forwards, step one leg back. Bend the front knee, keep both heels on the ground and feel a stretch up the back leg in the calf. Take a bigger step back to increase the stretch. Repeat 2 repetitions, 30 second hold pain free range.

Quadriceps stretch – have something near you to hold on to for balance if you need. If you have the range, grasp your foot behind you with your hand, and feel the stretch down the front of the thigh. Hold for 30 seconds, 2 repetitions, and pain free range.

Hamstring stretch – you can also do this sitting. Put one heel out in front of you, bend the other knee and keeping the back straight hinge forwards to feel a stretch up the back of the leg. Hold for 30 seconds, repeat 2 times.

References:

Collins, N; Barton, C; Middelkoop, M; Callaghan, M; Rathleff, M; Vicenzino, B; Davis, I; Powers, C; Macri, E; Hart, H; de Oliveira Silva, D; Crossley, K. 2017. Consensus Statement on Exercise Therapy and Physical Interventions (Orthoses, taping and manual therapy) to treat patellofemoral pain: recommendations from the 5^th International Patellofemoral Pain Research Retreat, Gold Coast, Australia. British Journal of Sports Medicine. [online]. [Accessed 10^th July 2019]. Available from: http://www.bjsm.bmj.com

Hettrich, C; Liechti, D. 2015. Patellofemoral Pain Syndrome. [online]. Ortho Info. [Accessed 10^th July 2019]. Available from: http://www.orthoinfo.aaos.org

Mayo Clinic. 2018. Patellofemoral Pain Syndrome. [online]. [Accessed 23^rd July 2019]. Available from: http://www.mayoclinic.org

Physiopedia. 2019. Anterior Knee Pain. [online]. [Accessed 10^th July 2019]. Available from: http://www.physio-pedia.com

Physiopedia. 2019. Biopsychosocial Model. [online]. [Accessed 10^th July 2019]. Available from: http://www.physio-pedia.com

Physiopedia. 2019. Patellofemoral Pain. [online]. [Accessed 10^th July]. Available from: http://www.physio-pedia.com

Images from Syme, K. Kingsland Physiotherapy. 2019.