There is an indisputable amount of evidence now that when it comes to anterior knee pain exercises… we can’t just treat the knee.
Here is a short and sharp explanation of why and what we should be doing:
Often people are told to strengthen up their quads and get their legs strong to help knee pain but really is this the best way to do it?
The answer is no. There is a lot of evidence when it comes to anterior knee pain (also known as patellofemoral pain) that rehabbing proximally is much more effective the strengthening the knee and quads alone. Proximally means working on the muscles further up the chain, closer to your spine, such as your:
Hip external rotators
In fact, a thorough systematic review was published recently which showed that compared to quads strengthening:
There is strong evidence that proximal rehab, combined with quads strengthening had better pain reduction
Proximal rehab alone and combined with quads strengthening results in better functional gains
Proximal rehab, was better in the short and long-term.
This basically shows us that when it comes to knee pain, it isn’t often the knees fault. We need to look up the chain at what controls the knee – The hip. Including rehab exercises that improve him strength and neuromuscular control has much better effects in outcome in both the short and long-term and cannot be ignored.
So what exercises should you be doing?
Type of exercise: This should be a combination of closed chain (feet/foot in contact with the ground) and open chain exercises in a comprehensive rehab program.
Frequency of exercise: Exercises that aim at neuromuscular training and stretching/foam rolling can be performed daily, whereas strength training should be aimed for 3 x weekly.
What knee pain exercises work well?
Follow this link for a great post for the rehab exercises to get you started, or go the whole hog and download our knee pain rehab guide HERE
Conclusion: Proximal rehab should be included in all rehab programs for anterior knee pain and if in doubt, go and see your local physio for best results.
The approach to treatment and rehabilitation is changing and for the better. Gone are the days (going anyway) of just treating the pain and symptoms. This approach lead to :
Short term outcomes: Pain relief, symptom relief (muscle spasm etc) and you feeling better.
Flare ups and frustration: But the pain kept coming back after these quick fixes.
Meaning more money spent in the long-term, more frustration and decreased quality of life.
The reason the quick fix approach doesn’t work for a lot of people is because the cause is not being addressed – The reason behind the pain and injury isn’t being rehabilitated.
When an injury, pain or niggles occurs you need to look above and below the area to find the contributing and causative factors.
Some examples? Here is a couple of common examples:
1. An office worker gets regular headaches that stops them doing what they love, playing on their mind and being very, very frustrating. They have had their neck treated in various ways – acupuncture, massage, trigger point release, joint mobilizations etc. All of these offer release – but they keep coming back!
Often the reason behind this is a rounded thoracic spine (upper back). This rounded spine pushes the head forward in a less than ideal position as you can see in the image to the right. This forward head position, one closes down the joint at the base of the skull and also every centimeter that the head is forward makes the neck muscles work four times harder! This will definitely cause muscle knots and stiff joints at the base of your skull AND headaches. So no matter how much you pull your head back, have the neck treated etc – If you do not treat your spine below the neck – You are going to keep getting headaches.
2. Another common example that will ring true with a lot of people, particularly runners, is anterior knee pain (Patello-femoral pain). Anterior knee pain is one of the most common running injuries and the pain happens because the knee cap doe not glide in its grove correctly. This is due to increased tension in your quads (particularly the outer quads) – pulling the knee cap laterally (to the outside) causing pain, inflammation and further muscle tension to due it grinding in the wrong place. Studies have shown that runners with PFPS have weak hip abductors and external rotators – This is a huge contributing factor as if these muscle are weak the knee is not controlled, in turns inwards, changing the tracking and position of the knee. So the knee can be treated, taped, dry-needled and exercises etc as much as you like but of hip strength and endurance isn’t improved then this will hang around and really frustrate.
It is amazing how the body is connected, with no muscles and joints working in isolation. The body is full of synergies, with different muscles and tissues working together to move everything in unison, it really is an awesome machine.
But this is why when one thing goes wrong – multiple other areas can be affected. Other areas help out and work hard to compensate, some parts get more stress through them, leading to pain and niggles, that may bot be where the problem is!
This is why you need to rehab with your eyes open. If you have:
Shoulder pain – Check your thoracic spine and shoulder-blade position.
Look at your body holistically – Don’t just focus on the pain and getting a quick fix. Health care is changing; less pills, less anti-inflammatories, healthy food and less steroid injections – Become aware of your body and improve it for the long-term and Physioprescription is here to help you do that, giving you the tools, info and exercises to live better!
Please share, like and let me know how you get on!
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 undersurface 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 an 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.
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.
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 🙂