FIG. A: Patellofemoral Pain Syndrome & the Anatomy of the Knee (Frontal View). Copyright Jennifer Lamb Massage. Also known as: Runner's Knee; Patella Tracking Syndrome; Patellar Subluxation; ITB Syndrome
What is it?
Patellofemoral Pain Syndrome (PFPS) is a common pain syndrome that is often experienced by cyclists, runners and people who walk for exercise. PFPS manifests as a minor to severe pain in the front of knee, often experienced as pain originating from the inside aspect of the knee or behind the patella, or kneecap. Sometimes this pain is associated with a "clicking" or "grinding" sound or sensation in the knee, as the knee is straightened or bent. Running, jumping, squatting, twisting or walking down stairs tends to make the pain worse, as does sitting for a long period of time with the knee in a flexed position - for example, at work or at a movie theatre. In severe or prolonged cases, swelling may be noticeable around the patella, and the sufferer may complain that he or she feels as though the knee is going to "give out" entirely.
What causes it?
PFPS is most often caused by an imbalance of muscle strength and soft tissue tension around the patella. Under normal circumstances as the knee is flexed and straightened, the patella glides centrally along the patellar groove - a bony groove located just beneath the patella, on the front (anterior) surface of the femur, or "thigh bone". However, improper running or walking biomechanics may, over time, create too much strength and tension in the Iliotibial Band (ITB), a thick band of fascia that runs along the outside of the thigh, as well as in the Vastus Lateralis, the most lateral (outside) muscle of the Quadriceps muscle group of the anterior thigh [See Fig A, above]. In conjunction with this, the Vastus Medialis (aka, "VMO") - the Quadriceps muscle on the inside (medial) aspect of the thigh - becomes weak. The result is too much lateral pull and not enough medial pull on the patella as the knee is straightened, causing instability in the knee as the patella is pulled up and slightly out of the patellar groove. Over time, this may lead to injury and inflammation of the soft tissue within the knee itself, such as irritation of the cartilage that lies underneath the patella.
What is the treatment protocol?
If the pain in the knee is severe or particularly bothersome, then the most immediate thing to do is rest the injured knee. Avoid cycling or walking for long distances and running for any distance, and seek diagnosis by a physiotherapist, osteopath or other musculo-skeletal specialist. The therapist may decide to temporarily tape the knee, to provide support around the patella and keep it tracking properly. If inflammation is severe, you may notice some swelling in the knee. If this is the case, then application of an ice pack to the knee for 20 minutes several times a day may help to reduce the inflammation. (Always remember to wrap the ice pack in a light towel to avoid ice burns to the skin!) Additionally, application of an over-the-counter anti-inflammatory cream or gel, such as a gel containing ibuprofen, may be helpful, however avoid "warming" or "icy-hot" creams and gels, as these substances may actually increase inflammation. When in doubt, talk to your chemist for more information.
In the medium-term, exercises that specifically address the imbalance of tension around the patella will help to correct the position of this bone as the knee moves. Specifically, exercises that strengthen the VMO, as well as stretching the Quadriceps muscles in general, will assist in creating better muscle balance around the patella itself. Using a Foam Roller to release tension in both the ITB and Vastus Lateralis will help to reduce the lateral pull on the patella. Additionally, regular Hamstring stretches may help reduce the medial Hamstring tension that typically develops as a result of this muscular imbalance.
In the long-term, however, the biomechanical problems that have led to the muscle imbalance around the affected knee must be addressed in order to overcome this injury. Commonly, PFPS is associated with weakness in the Gluteus Maximus - the large muscle of the buttocks that ideally provides the main propulsion forward during a walking or running gait - as well as weakness in the Gluteus Medius - a smaller, deeper and slightly more lateral buttock muscle that is important for pelvic and hip stability. When these muscles are weak or firing out-of-sequence during a run or walk, the Quadriceps muscle will typically become overactive to compensate for this weakness, providing the propulsive movement forward instead of the Gluteal muscles. By strengthening these Gluteal muscles, the hips will be more stable and the Quadriceps will be less likely to be over-used for forward propulsion. Thus, the strain on the patella and knee is reduced. Additionally, addressing any foot biomechanical problems, such as pronating (dropping) arches, by appropriate lower leg and arch strengthening exercises, or by wearing corrective orthotics, will help to create a more efficient and stable gait, with less torsion at the knee.
In the medium-term, exercises that specifically address the imbalance of tension around the patella will help to correct the position of this bone as the knee moves. Specifically, exercises that strengthen the VMO, as well as stretching the Quadriceps muscles in general, will assist in creating better muscle balance around the patella itself. Using a Foam Roller to release tension in both the ITB and Vastus Lateralis will help to reduce the lateral pull on the patella. Additionally, regular Hamstring stretches may help reduce the medial Hamstring tension that typically develops as a result of this muscular imbalance.
In the long-term, however, the biomechanical problems that have led to the muscle imbalance around the affected knee must be addressed in order to overcome this injury. Commonly, PFPS is associated with weakness in the Gluteus Maximus - the large muscle of the buttocks that ideally provides the main propulsion forward during a walking or running gait - as well as weakness in the Gluteus Medius - a smaller, deeper and slightly more lateral buttock muscle that is important for pelvic and hip stability. When these muscles are weak or firing out-of-sequence during a run or walk, the Quadriceps muscle will typically become overactive to compensate for this weakness, providing the propulsive movement forward instead of the Gluteal muscles. By strengthening these Gluteal muscles, the hips will be more stable and the Quadriceps will be less likely to be over-used for forward propulsion. Thus, the strain on the patella and knee is reduced. Additionally, addressing any foot biomechanical problems, such as pronating (dropping) arches, by appropriate lower leg and arch strengthening exercises, or by wearing corrective orthotics, will help to create a more efficient and stable gait, with less torsion at the knee.
How can Remedial Massage help?
Remedial Massage, when applied effectively to the appropriate muscular systems, acts to both treat and prevent occurrences of PFPS. When I do Remedial Massage Therapy for PFPS, I focus on releasing the unequal tension around the knee, thereby relieving the lateral pull on the patella. Typically, I employ Myofascial Release techniques to release the ITB, central and lateral Quadriceps, medial Hamstrings and the retinaculum - the dense band of fascia that wraps around the knee and encapsulates the patella. Deep Tissue Massage techniques may also be employed to these areas, as well as lighter, more stimulating massage to the VMO to encourage blood flow and nerve activation of this weaker Quadriceps muscle. I use Trigger Point Therapy to release any trigger points (small, painful "knots") in the Vastus Lateralis muscle. Additionally, Myofascial Release and Deep Tissue techniques may be used to release tension in the calves, buttocks and lower back to encourage a better, more biomechanically-efficient gait. If the there is a postural rotation in the pelvis, I utilise a special, advanced technique called Muscle Energy Technique to correct for this pelvic rotation, which in turn, helps to reduce the torsion through the knee. At the end of each session, I teach my clients how to strengthen their VMOs and Gluteal muscles, as well as how to stretch and release their ITB and Quadriceps. Ultimately, the effect of the massage treatment and exercise "homework" is to locally release the strain on the affected knee, as well as to treat the ultimate cause of this strain by correcting any problematic posture. This allows for a more efficient gait, and thus reduces the lateral pull on the patella.
For more information...
The websites and video listed below give some general information on the causes and treatment protocols for PFPS:
- "Patellofemoral Pain Syndrome" on the MyDr Website: basic information about this injury.
- "Patellofemoral Pain Syndrome" on the PhysioAdvisor Website: more detailed information about this injury.
- "Patellofemoral Pain Syndrome" on the Sydney Sports Medicine Centre Website: includes some exercises to help treat & avoid this injury.
- "The Best Treatment for Patellofemoral Pain Syndrome" YouTube clip by Lisa Howell of Perfect Form Physio: great explanation of how PFPS is not simply a knee problem, but must include treatment of the underlying factors that are likely causing the muscular imbalance around the knee in the first place.
Exercises
Soon, I hope to upload my own videos to my YouTube Channel, demonstrating the various exercises I advise for treatment and prevention of PFPS. Once I have these up, I will update this blog. Until then, however, check out these videos for some exercise tips:
- "Pilates Foam Roller - Myofascial release of outer thighs/ITB." YouTube video by Martina & Gemma of Perth-based Sense of Space Pilates Studio: demonstrates 3 alternative positions for releasing the ITB using a foam roller.
- "Pilates body - The Clam Exercise." YouTube video by Wayne Gordon of Sports Injury Clinic: demonstrates the basics of how to do the "Clam" exercise for strengthening the Gluteus Medius muscle.
Edited on Fri, 17/10/14: Minor changes to link HTML codes & formatting.
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