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Anterior knee pain or patellofemoral pain syndrome (PFPS) is a common complaint that we see in the clinic. What we are dealing with here is pain located to the front of the knee, usually over or around the kneecap. It can be vague and difficult to say exactly where it is sore. The pain may be constant and made worse by certain activities, otherwise only painful when doing certain things. The pain often starts gradually for no obvious reason and may be aggravated by walking, running, ascending or descending the stairs or prolonged sitting with the knee flexed. You may have severe difficulties continuing the activity that causes you pain and discomfort.
Who is likely to suffer from this condition?
PFPS is more prevalent in females, they are 1.5 to 3 times more likely to develop the condition than males in the athletic population. It can be a significant and debilitating complaint that can affect as many as 1 in 10 active adolescent girls.
What exactly causes PFPS remains a misunderstood and controversial topic. Knee muscle weakness especially of the vastus medialis obliquus (inner thigh muscles which supports the knee cap), abnormal foot biomechanics - in particular abnormal pronation, weakness of the hip stabilising muscles and poor functional control of the femur during weight bearing tasks can be common causes of the syndrome. So in other words if you have weak thighs and hips, wobbly knees, flat feet and generally poor balance you may be at risk.
Treatment options for PFPS
There are a number of different treatment options for PFPS. Exercise therapy seems to be the most valuable technique supported by the current literature. Specific exercises are prescribed depending on what we find on your assessment. If you do these exercises regularly as instructed they can have a dramatic effect in reducing pain and getting back to normal function.
Often in clinical practice, we diagnose the condition and prescribe the appropriate exercises. The patient may return for their follow up appointment and complain that their symptoms are no better. Quite often, it is not the diagnosis or treatment that is inadequate, but the lack of adherence to perform the specific exercises. I often use the following analogy when prescribing exercises – I suggest to the patient that if they have a chest infection their doctor could prescribe an antibiotic that is taken twice per day, they take it, they get better. Likewise if exercises are prescribed, it should be like taking their medicine!
Other forms of treatment include ‘hands on’ manual therapy to the patellofemoral joint/knee cap itself as well as the surrounding knee structures such as the iliotibial band. The application of these manual therapy techniques should be considered on a case by case basis. What can help one patient may not work for another.
There is evidence for Medical Acupuncture - here and here for knee pain. Which points used are unique to the individual patient. The often tight outer thigh and muscles about the hip are targeted for release using gentle needling. Ensuring adequate flexibility in these muscles may improve patella “alignment’’ during movement and therefore reduce strain to the joint. Medical Acupuncture has also been shown to reduce general pain and sensitivity about the knee joint.
Currently a study is being carried out in Denmark run by Michael Rathleff. He has a particular interest in knee pain and his team are investigating whether patient education and multimodal (i.e a combined approach using different techniques) physiotherapy applied at an early stage proves to be effective in the management of PFPS. In the clinic I certainly find this multi-modal approach to be most effective so will be interested to see the results of the study.
Clinically if a patient presents for treatment within a week of the start of pain symptoms, a better outcome is achieved with a multimodal physiotherapy programme. This which usually consists of patient education, manual therapy to the local joints and soft tissue structures as appropriate, therapeutic exercise and Medical Acupuncture. Taping techniques may also be applied.
The research tells us that the longer the patient complains of the problem, the older they are and the more severe the pain is, the less likely they are to have a positive outcome. So don’t sit on the problem if you have knee pain, get it seen to!
In summary
If you suffer with PFPS get it diagnosed and treated as early as possible. We know that PFPS is related to abnormal lower extremity mechanics and this need to be assessed to see where in the system your problem lies and a treatment plan initiated that is specific to you. Ensure that your physiotherapy programme always consists of graded therapeutic exercises and that you are compliant and adhere to this programme. If left untreated patellofemoral pain can rapidly develop into a chronic and debilitating condition.
by Lorraine Carroll
Further references:
Collins NJ, Crossley KM, Darnell R, Vicenzino B: Predictors of short and
long term outcome in patellofemoral pain syndrome: a prospective
longitudinal study. Bmc Musculoskel Dis 2010, 11:11.
Blond L, Hansen L: Patellofemoral pain syndrome in athletes: a 5.7-year
retrospective follow-up study of 250 athletes. Acta Orthop Belg 1998,
64(4):393-400.
Kannus P, Niittymaki S: Which factors predict outcome in the
nonoperative treatment of patellofemoral pain syndrome? A prospective
follow-up study. Med Sci Sport Exer 1994, 26(3):289-296.)
