Patellofemoral pain syndrome is one of the most common knee injuries seen clinically and often challenging to treat. The following exercises and advice are aligned with current best practice guidelines(1) and treatment so that you have the best chance to become pain-free and fully active again!
Common names for Patellofemoral Pain Syndrome (PFPS) are: Chondromalacia patella, anterior knee pain, runners knee, patellofemoral tracking disorder.
*Now just a quick clarification: Chondromalacia Patella is not PFPS. Chondromalacia Patella is commonly over diagnosed and is when the articular cartilage on the under-surface of your knee cap is damaged. The prevalence of this is far less than Patellofemoral pain syndrome but generally occurs if PFPS is left too long as the cartilage gradually softens and degenerates. This can be confirmed with a MRI. The below rehab exercises and advice for Patellofemoral pain WILL HELP this also, it will just be a longer recovery period.
What: Patellofemoral pain is felt at the front of the knee and typically comes on gradually typically comes on gradually . Normally the patella (your knee cap) glides in a groove in your femur when bending your knee. It is believed PFPS results from abnormal Patella tracking (not gliding smoothly in the groove) causing excessive compression on the under surface.
This mal-tracking can be caused by:
- Quadriceps weakness (particularly poor activation of your VMO/inside quads) causing an imbalance.
- Excessive knee soft tissue tightness
- Tight Quads and Iliotibial band
- An increased quadriceps angle (Q-angle)
- Hip weakness (particularly Hip abductors and external rotators)
- Altered foot biomechanics eg. over-pronation
Generally there is always a combination of these factors causing a significant imbalance of forces on the knee cap, leading it to be pulled to one side (like a tug of war!). It is generally pulled laterally.
Symptoms and signs
- Anterior knee pain
- Knee stiffness with prolonged knee flexion eg. sitting in movie or driving.
- Activity-related pain: Running, squatting, stair climbing (especially going down), kneeling, cycling, swimming breaststroke.
- Tenderness/pain on compression if the knee cap
- Crepitations or Grating sensation
- Giving way
- Swelling around the knee cap
- Female gender
- Iliotibial band syndrome (ITB syndrome)
- Training: Long distance running, training on hard surfaces, hills, stairs
Note: it is important to remember that muscle dysfunction and repetitive loading of the Patellofemoral joint rather than fixed biomechanical factors and the major contributors to PFPS(Baker and Juhn 2000) and so there is a lot that can be done to help.
Prognosis: Depends on co-existing conditions, but poor if causative/aggravating factors and not addressed. If symptoms have been there for over 12 months you will have a poorer prognosis but do lose heart, it can get a lot better, you just need to persevere and stick at it 🙂
Test yourself! To see how stable your hips are.
1. Single leg bridges:
Action: 10 x 3-5 second holds on each leg.
Tip: alternate legs and switch your core on.
2. Decline mini squats:
This squat is great for VMO (your inner quad) activation but it also increase glute activation. I have used a phone book here just to show that you can use anything at all that is 1-2 inches.
Action: Do not push into pain (if it is sore, don’t go as low), you do not need to go below parallel. Squat like you are going to sit down in a chair and do not let your knees go past your toes.
Perform 3 sets of 12, nice, slow and controlled.
Tip: look up to the top of the wall to help your balance.
3. Foam roller: These are great. If you haven’t got one, get one! (A reasonably dense Foam Roller preferably)
Roll all the way from the knee to the hip, making sure you do it slowly.
Spend 2 minutes on the side as shown and then 2 minutes on the front/quads.
Tip: try to keep your feet off the ground and DO NOT LET PAIN PUT YOU OFF, it will get easier.
Lying on your side as shown. keeping your ankles together, lift your top knee 20cm, then lower down again (don’t drop it!)
Goal = 1 set of 50, if you are doing them right, you will need to build up to this.
Tip: Keep your top elbow down on the ground and hips rolled forward.
5. Quads stretch:
Hold this stretch for 1 minute.
You may need to put a cushion or towel under the planted knee!
Tip: you do not need to lunge forward, to add more stretch, tuck your bum in under you or put back foot up on something (eg. wall or foam roller).
Note: if this hurts the knee (even with padding) then stop doing it and wait a couple of weeks before building it in.
Do these exercises two times daily.
Other things that may help:
- Brace: while rehabbing your knee, a brace can help keep you moving, such as a Patella Tracker
- Orthotics: the use of Orthotics reduces PFPS in the short to medium term and addresses bio-mechanic deficiencies on the foot.
- Ice: after exercise, after a long day or when there is any pain ice minutes for 10 -15 at a time (no longer).
- Rest, give it a couple of weeks rest. this gives you a great time to get a head start on the exercises and really start the rehab off well.
- Altering training: shorter distance, get off hard surfaces, cross-train.
- footwear: throw out old shoes, stay away from shoes with poor support eg: Flip-Flops, jandals, sandals, slippers.
Often it is not the knees fault all this pain and discomfort happens, so to treat this condition it is important to look above (quads, ITB, hip) and below (foot, calf).
Follow this advice for at least 12 weeks (yes three months, you NEED to be serious about this to decrease the risk of early knee arthritis and ongoing pain.)
If you have any questions feel free to comment below.
Please share, comment, follow and let me know how you get on!
You may also like:
Lower Limb rehab
Glute activation, the missing link
Quick stability and balance test
A good research paper if you want more info on PFPS research