Physiotherapy management of
Anterior knee pain in runners
Catherine Kwan
M.Sc.(Manip Physio), BSc.(Physio), MCSP, SRP
Clinical Development Lead/Extended Scope
Physiotherapist
Horder Healthcare, The Horder Centre
Overview
• Causes/ associated factors of Patello-femoral pain
syndrome (PFPS)
• Diagnosing PFPS
• Biomechanical analysis
• Physiotherapy management of PFPS
• Recent evidence
• What exercises when
• taping
Anterior knee pain in runners…
• Running is an integral part of life for some
runners
• No matter what distance
• “rest!” doesn’t work for them
• Rehab needs to be gradual but steady,
sufficiently effective to gain results
Anterior Knee pain
• First of the top five running injuries
• Been thought to affect up to 30% of runners
• Too much, too soon, too often, too little rest
Incorporates:
• Patello-femoral pain syndrome (PFPS)
• Patellar tendinopathy
• Infra-patellar fat pad inflammation
• Patello-femoral instability
• Concentrating on Patello-femoral Pain Syndrome
Case Study
• 32 year old female runner
• Antero-lateral knee pain of 5-6 weeks duration, gradual
onset
• Training for 10km run (last weekend) but didn’t do it.
• Is training now for Brighton half marathon on Feb 17th,
and Brighton Marathon in late March
• No history of this pain or any knee pain
• Took up running 2 years ago, this is the furthest she has
run!
• hasn’t done a half or full marathon before
Case study cont
• Shoes – Brooks Adrenaline (neutral to slight
pronation support) 6 months old.
• Runs 4x/week - mainly on the road, also in the
downs (once/week)
• Runs 3 x 5 miles, 1 x 8 miles per week
• No other training, minimal stretching
• Works in an office – mainly sitting
• Wants to continue with her training asap
• How to get her back running asap with minimal
pain?
• What factors are contributing to her condition?
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Effective management and self management
Use of cross training
education
Psychosocial support
WHY DOES PATELLOFEMORAL PAIN OCCUR?
Factors associated with PFPS
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Lankhorst et al 2013
Systematic review to look at factors associated with PFPS
Meta analysis, data from eight variables pooled
Found that the following were found in subjects with PFPS
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Larger Q angle
Larger sulcus angle
More patellar tilt
Less hip abduction strength
Less hip external rotation strength
Reduced peak knee extensor torque
Why does patello-femoral pain happen?
• Aetiology unknown
• Repetitive limb loading
• Generally accepted that
the patella tracks laterally
• Affected by:
– Active and passive factors
– Local and remote
structures
– Neuromotor system
Why does the patella get painful?
Inflammatory reaction due to
• Excessive mechanical
loading of the PFJ
• Causing chemical irritation
to the nerve endings and
synovitis
• Once inflamed, the
synovitis is easily
aggravated
• Influenced by patellofemoral joint force
Underlying factors contributing to increased
PFJ forces
• Dynamic Q angle
– Increased laterally
directed forces
• Quadriceps
dominance/tightness
– Increase compressive
forces across the PFJ
• 10 degree change in Q
angle causes 45%
increase in peak joint
pressure
Q angle
• Dynamic Q angle is
more important than
static
• Internal rotation of
femur, adduction of
femur
• Internal rotation of
tibia,
• Excessive pronation
Patello-femoral pain syndrome
WHAT DO WE LOOK FOR?
Subjective Examination
PFPS
• likely to involve running,
weight bearing sport
• Pain around the patella
• Aggravated by stairs,
hills, sitting prolonged
• More common in female
athletes
Patella Tendinopathy
• Sports involving jumping
and landing
• Pain is usually around
inferior pole of patella,
and in patella tendon
• Aggravated by jumping,
mid to full squat
• More common in males
Objective examination
• Soft tissue tightness – calf, hamstring, quadriceps, ITB
complex, hip flexors, adductors and internal rotators
• Muscle weakness – hip abductors, external rotators,
extensors, Quadriceps especially VMO, calf
• Body structure – eg femoral anteversion, tibial torsion
• foot biomechanics – excessive pronation
• Poor core strength and stability
• Muscle recruitment patterns
Objective
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Posture
Functional tests
Gait analysis
Range of movement
Motor control
Muscle strength
Muscle length
Palpation
Taping offload
Alignment and ground reaction
force
jo martin strideuk.mp4
Courtesy Stride UK
Front on alignment
From behind alignment
Patello-femoral pain syndrome
PHYSIOTHERAPY
MANAGEMENT
Physiotherapy management
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Historically
Multifactorial problem
Individual to each athlete
Many different treatment approaches
Address underlying causes
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Tight muscles
Weakness
Poor alignment
Poor core
Consequences of muscle tightness
• Hamstrings – knee in flexion
longer in early stance phase
• Calf – over-pronation causing
increased tibial rotation
• TFL – increased internal
rotation of femur
• Adductors – increased
adduction of femur,
contributing to increased Q
angle
• Quadriceps and hip flexors –
increased forces on PFJ
stance phase
Lengthening soft tissue
• Massage/soft tissue
techniques
• Stretches
– Hamstring, calf, quads, hip
flexors, TFL/ITB, gluteals
– Need to be held at least 30
seconds, 60 seconds in
middle aged
• Foam rolling
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Quadriceps
ITB
Calf
Gluteal muscles
Adductors
Gluteus medius function (Gmed)
• External rotator of hip
• 3 distinct parts
• Posterior fibres seem
more significant in
PFPS than anterior
fibres
• Its importance in
PFPS is being
recognised recently
(Gottschalk et al 1989)
Gluteus Medius weakness and PFPS
• Boling et al 2009 – increased hip IR is a risk factor for PFPS
• Increased hip IR in female runners with PFPS compared with
control (Noehran et al 2011, Wirtz et al 2011)
• Systematic review: reduced duration of and delay in activation
of Gmed in several tasks in subjects with PFPS. (Barton et al 2013)
• RCT: Hip strengthening exercises + closed kinetic chain
(CKC) quads reduced pain perception and increased knee
strength more than CKC exercises alone (Ismael et al 2013)
• Systematic review showed proximal exercises more effective
than quadriceps exercises only in reducing pain and
improving function in PFPS (Peters et al 2013)
Gluteus Maximus
Gluteus maximus weakness
• Gmax is hip abductor,
external rotator and
extender
• Can present with overactive
TFL
• And weak GMed
• Balance between internal
and external rotation forces
are altered
• If Gmax is weak  greater
quadriceps force needed for
extensor torque
Top 5 exercises that recruit Gluteus Medius
• Side plank abduction
with dominant leg on
bottom
• Side plank abduction
with dominant leg on
top
• Single limb squat
• Clam shell
• Front plank with
extension
(Boren et al, 2013)
Front plank
with extension
The Clam
Top 5 exercises that recruit Gluteus
Maximus
• Front plank with
extension
• Gluteal squeeze
• Side plank abduction with
dominant leg on top
• Side plank abduction with
dominant leg on bottom
• Single limb squat
VMO function and PFPS
• Vastis medialis obliquus – part of vastis
medialis
• Thought to have medial pull on patella
• Historically this was thought to be the
reason PFPS occurs
• Thought there is a delay in onset of VMO
compared to vastis lateralis
Research into VMO activation
• VMO predictive of patella tilt at 0 degrees and 30
degrees cross sectional area of VMO
• VMO activation in squat greater in adduction
than abduction, Gluteus medius activation
greater in hip abduction (Dias et al 2011)
• Specific and general quad strength exercises
both effective in treating PFPS (Hunt et al 2009)
• Addition of adduction results are inconclusive
VMO strengthening exercises
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Isometric quads, good alignment
Wall squats
Plie squats
One leg dips
Step ups/downs
Standing squat
Lunge forwards/backwards
Jump lunge
VMO strengthening
• Inner range exercises
• Emphasising correct
alignment of the lower
limb
• Start with isometric in
standing
• Progress to squats,
one leg dip, squats,
lunges,
• Backwards lunges
Patellar taping
• Underlying principle is
to correct the position
of the patella
(primarily tilt)
• To reduce pressure
on lateral facet of
femur and therefore
correct patellar
alignment
• 50% reduction for it to
be effective
Evidence around taping
• Very variable results through all values assessed
• Taping can reduce perceived pain (Osorio et al 2013, Earl & Hoch, 2011, Aminaka & Gribble,
2008)
• increase peak knee extension force (Handfield& Cramer, 2000, Herrington
2001,Salsich et al 2002, Osario et al 2013)
• However some studies say exactly the opposite (Tunay et al 2008)
• Perhaps due to different taping methods, methodology,
aspects measured, etc.
• There appears to be be enough evidence to suggest that it
may be effective and may be included as treatment of patellofemoral pain, but results are not conclusive
Orthotics
• Moderate evidence to
suggest that orthotics
helpp in patello-femoral
pain
• Off the shelf orthotics can
improve VMO and
gluteus medius function
in controlled movements
but not in vertical jump
(Hertel et al 2005).
Progressing to functional rehabilitation
• Push outwards
against band in
standing
• Sideways steps
• Lunging forward/back
• Jump lunge
• High steps
• 1 leg stand up
Functional rehabilitation
• Progress back into running
• Reduce from 4x/week to
3x/week
• One session in gym –
Pilates/strength&
conditioning
• Intervals to start with –
run/walk
• Increase time
running/distance
• Interval training – fast/slow
• Fartlek training
• Cross training – spin, bike,
cross trainer
Questions ?
References: Available on request