Well what better way to start a bit of clinical education that with one of the most common, and one of my favourite conditions, anterior knee pain (pain at the front of your knee), or otherwise known as Patellofemoral dysfunction.
I enjoy assessing and treating this sort of problem because it requires a lot of understanding of a patient’s problem and contributing factors, so that means lots of questions. As well as the fact that once you get to the bottom of it all, this is an issue with which people can get fantastic results and relief by managing the problem the right way.
As I said, anterior knee pain is one of the most common issues in the community when it comes to musculoskeletal complaints. In fact, you have probably experienced it yourself at some stage, or otherwise, I would bet my bottom dollar that one of your friends has. So what does it look like?
The most common things I get told in my clinic when I’m meeting someone with this issue for the first time are
– pain at the front of the knee that is sharp and achey and sometimes feels like its deep inside the knee
– pain going up and down stairs
– pain sitting with bent knees for prolonged periods of time
– painful clicking in the kneecap
– swelling around the knee
– a feeling of weakness around the knee
Clinicians out there will hear any number of different descriptions from their patients, but I think it will be agreed that these are quite common descriptors of what the patient is experiencing.
I was always taught, and thoroughly believe that a good clinician will be able to diagnose an issue before even looking at the patient, by listening to the way somebody describes their pain or dysfunction. Patellofemoral pain is one of the most recognisable because of the consistency of the symptoms and the aggravating factors.
Sometimes the onset is insidious, meaning there is no specific incident recalled, but has progressively appeared, and sometimes the complaint can be related to a specific incident of trauma to the knee or an activity like repeated stair climbing or a long run, that might be out of the ordinary routine for someone.
So, how do I assess the problem?
Generally, by the time it comes to the hands on and eyes on assessment of a knee like this, I have a good idea that based on what the patient has told me, the problem is Patellofemoral in origin. That means a good amount of questioning about how and when it started, what the symptoms feel like and when they are felt, where the symptoms are and what aggravates or relieves the symptoms. It is generally a good estimate that if the person is having pain in the front of the knee with aggravations such as what I have already described, that the symptoms are coming from the Patellofemoral joint.
I think it is useful for the patient to have a good idea of why the Patellofemoral joint causes pain. So once I am convinced that is the problem, I will spend time going through the anatomy and function of this particular part of the knee so that the patient can have a better awareness of why the things that hurt do and why it is important to modify particular activities to reduce the aggravation.
If the reader wants to get a better idea, I would recommend quickly pulling up a picture of the knee on another internet tab and have a quick look at the structures involved while you read through this blog entry.
The Patellofemoral Joint is not a joint like most people would imagine, because the kneecap (Patella) doesn’t physically articulate with the bone underneath it (Femur). They certainly contact each other, but the Patella is a floating bone (sesamoid) held in location by tendons and by ligaments (retinaculum). The undersurface of the kneecap is shaped kind of like a triangle if you look from the top or bottom and this is designed to fit within the groove of your Femur’s condyles, the big bumps at the far end of the Femur (the Trochlear Groove). The idea being that the Patellar slides up and down the groove as your knee bends and doesn’t dislocate all over the place.
Therefore, although contact between the bones is pretty normal, sometimes excessive or traumatic contact can irritate the surfaces of the bones and this becomes inflamed, symptomatic and voila! you have Patellofemoral pain. It can often be transient and recover spontaneously, or relatively quickly with a bit of rest from the aggravation, but for some people it can be a very, very uncomfortable and painfully stubborn problem.
What I am going to talk about now are the things that I look for in terms of biomechanical contributing factors, when I am assessing one of my patients with Patellofemoral pain. Because, even in a traumatic obvious injury, the pre existing, or even compensating biomechanics after the injury, can be a big reason why the knee doesn’t get better. Just the same as a less obvious, insidious onset, whereby biomechanical influences are almost entirely to blame in a lot of cases.
Unfortunately for a lot of folks, the knee itself is considered in isolation and treatment methods are directed entirely at the locality of the knee. This approach can often reduce symptoms to a degree with the help of time and natural recovery, however it is not uncommon that either the symptoms soon return, or otherwise don’t change at all. The vast majority of the time, the knee is the source of symptoms, whilst the problem exists elsewhere along the biomechanical chain. So that means to really solve the problem, the remote factors need to be considered in a wholistic approach. Tape and an aggressive foam roller down the ITB will more often than not leave you disappointed that your knee is still sore and stopping you from doing what you want.
That means the objective assessment needs to be thorough and broad to ensure all contributing factors are taken into account. As with all objective assessments, it is generally necessary to provoke the soreness a little bit to get a good impression of how irritable it is, this is normal, so don’t be alarmed if your Physio is making you do things that are making you sore. Of course, if irritability is very high, it would be irresponsible to push it too hard, so the objective assessment can be tailored accordingly.
Therefore, for those of you attending the Physio to get a better idea of what’s going on, you should expect that the clinician will observe the way your feet move and support you when you walk, and if appropriate, when you run or even hop. They will observe how well your leg supports your body when you move through dynamic positions. There is often a tell tale sign when a single leg squat is performed, whereby if the hip rotates inwards because the muscle groups in the pelvis are inefficiently working, the knee will be placed into a loaded position, adding unnecessary compressive force to the Patellofemoral joint. If this is noticeable, it should firstly be assessed if the patient can correct this, and then a thorough assessment of the gluteals and other appropriate muscle groups should be undertaken.
Have you ever considered how much sitting down all day can effect your knee? Perhaps not. But if you can consider the effect that having hip flexors at the front of the pelvis in a shortened position all day as well as having the gluteals and other posterior muscles inhibited through compression on you seat, you can start to see how muscle imbalance can start to play a negative role in loading up your knee.
So, what I look for in my assessment is:
– Muscle length around the hip , knee and ankle
– Joint range of motion in the hip, knee and ankle joints
– Muscle tone and strength in those same groups
– Foot shape, posture and control with dynamic activities
– Biomechanical control and alignment of the lower limb in static and dynamic activities
– Active trigger points in muscles that can contribute to symptoms and altered forces around the knee
– Sensitivity of the patellofemoral joint under different degrees of compression
– The effectiveness of footwear in the control of your feet
– Strength and endurance in abdominal and trunk muscles if necessary
– Importantly, whether the alteration of any, or multiple of these factors, changes symptoms.
So consider whether or not all these things are being looked at when you visit your clinician. And if not, ask why not? The more you know about your problem the more you can help yourself. Don’t think that all conditions need lots of intervention from your clinician, some issues are better managed by yourself, with the right understanding.
In my next post, I will talk about what can be done to actively and positively impact your issue. Remember there is no recipe and everyone is different!
Was this helpful? Let me know with feedback if you think what I’m saying doesn’t make sense or if you think I have missed something.
Communication makes the world go round.
James. In Clinic Physiotherapy.