Patellofemoral Syndrome

Patellofemoral Syndrome treatment and information

Your knee is the largest joint in your body and one of the most complex. It is made up of the lower end of the femur (thighbone), the upper end of the tibia (shinbone), and the patella (kneecap). Ligaments and tendons connect the femur to the bones of the lower leg. The four main ligaments in the knee attach to the bones and act like strong ropes to hold the bones together. Muscles are connected to bones by tendons. The quadriceps tendon connects the muscles in the front of the thigh to the patella.

Patellofemoral syndrome is a condition that describes pain in the front of the knee and around the kneecap, known as the patella. Specialists may also call patellofemoral syndrome “jumper’s knee” or “runner’s knee.”

The main symptom associated with patellofemoral syndrome is a dull, aching pain that usually occurs on the front of the knee. The pain may be in one or both knees. It often worsens with activity.

Other symptoms can include:

• Pain during exercise and activities that repeatedly bend the knee, such as climbing stairs, running, jumping, or squatting.
• Pain on the front of the knee after sitting for a prolonged period of time with your knees bent, such as one does in a movie theater or when riding on an airplane.
• Pain related to a change in activity level or intensity, playing surface, or equipment.
• Popping or crackling sounds in your knee when climbing stairs or when standing up after prolonged sitting.

The causes leading to this syndrome are still unclear in some cases, but a few possibilities are mentioned below:

Over use of the quadriceps muscles – The overuse of the quadriceps is the most common cause leading to patellofemoral syndrome. Repetitive activities such as running or jumping, can put an increased impact and tension through the knee. This can lead to an irritation of the patellar tendon, resulting in patellofemoral syndrome.

Direct injury or trauma on the knee – can create a fragility of the area, predisposing to patellofemoral syndrome.

Patellar Malalignment Some people have a kneecap that abnormally tracks in the groove at the end of the femur. This can cause extra pressure on the cartilage covering the kneecap or on the femur where it rubs, called the trochlear surface.

Factors that can contribute to the maltracking of the knee cap include:

Weakness or muscle imbalances of the quadriceps muscles – Muscle imbalances in the quadriceps can cause poor tracking of the kneecap as it articulates through the trochlear.

Instability or imbalance in the lower extremity – can also lead to an irritation of the tendon. The nature of the imbalance can vary from an unstable ankle on running/jumping activities for example to a domination of the inner thigh muscles in opposition to the muscles on its external border which leads to a maltracking of the kneecap. also responsible for a similar irritation.

A patellofemoral syndrome is usually diagnosed through a physical examination and can be suggested by the case history taken by your consultant. During your consult, your practitioner will ask you a series of questions including:

• Questions about the history of the injury (traumatic or not)
• Aggravating or relieving factors?
• The onset of the symptoms?
• Have there been any recent changes to your training intensity?

In some cases further imaging may be requested to further diagnose or rule out any other condition. This may include an x-ray or MRI.

You don’t need to visit a local hospital for such symptoms as knee pain located under the kneecap, as it is very likely this can be managed by your GP or a specialist consultant. An osteopath for example can see you in a consultation and with their anatomical knowledge and experience can appropriately answer your questions.

There are two different categories of treatment recommended for a patellofemoral syndrome: conservative intervention or surgical intervention.

Conservative treatment can consist of a selection of different self help remedies along with exercises, prescription and physical therapy. Below is a non-exhaustive list of conservative treatment options for the management of patellofemoral syndrome.

RICE – Reducing pain and inflammation around the knee. RICE stands for rest, ice, compression and elevation.

Medication – your GP may suggest taking non-steroidal anti-inflammatory (NSAIDs) medication to help with reducing pain levels and inflammation. Examples of NSAIDs include ibuprofen.

Activity Change – altering or reducing exercise that aggravates your knee will reduce pain and enhance recovery time. Opting for lower impact activities such as swimming or stationary bike is ideal. As your knee pain improves higher impact exercise can be reintroduced.

Exercise prescription – A personalised exercise designed by a registered physiotherapist or osteopath can be used to help strengthen the patella tendon and stabilise both the knee and ankle of the affected side.

Osteopathy and Physiotherapy – Hands on physical therapy can be used to help assess and treat areas of weakness and instability within the knee joint complex. A treatment plan can then be put in place to help restore strength, mobility and function helping with pain reduction. Many different techniques may be used to do this,including: joint mobilisation and articulation, soft tissue release and guided exercise prescription.

Surgical intervention
Surgical intervention is very rarely needed and only recommended in cases where conservative treatment has not been successful. Some of the surgical options available include:

• Arthroscopy – this type of surgery consists of the “cleaning” and decompression of the affected knee, using small incisions and cameras for guidance.
• Tibial tubercle transfer – this type of surgery consists of the alignment of the kneecap moving the patellar tendon along with a portion of the tibial tubercle.

As for every tendon irritation or inflammation syndrome, a patellofemoral syndrome will only be resolved once the tendon is fully healed and stronger. This can take a few weeks, up to 6, but can usually be well managed and shortened with manual therapy, appropriate self management and rest.

With the appropriate work done to stabilise the ankle, pelvis, and the prevention of any muscle imbalance in the lower extremity muscles (anterior or posterior chains), a patellofemoral syndrome may be prevented. A stress of the tendon can still be created due to a repetitive high impact based activity, but the input of a stability and conditioning program can help reduce the intensity and severity of the symptoms.

The exercises below are designed to help with the recovery from patellofemoral syndrome. The aim of the exercises are to stabilise the affected limb, strengthen the patellar tendon and help staying active even during the acute phase of the symptom presentation. Here are 3 example exercises:

Wall sits isometrics. A basic exercise but used for many knee injury rehab programs. Place your whole back against the wall, with a mild flexion of both hips and knees, averaging 120 degrees. Lift one leg up off the floor, so your bodyweight is only resting on one leg. Hold this position for 15 to 20 seconds depending on the difficulty of doing the exercise and/or your pain level. This exercise can be repeated 3 times for each leg.

Wobble board stability. A basic exercise consisting of standing, one leg at a time, on a wobble board (can easily be found online or in sports shops), with a mild knee bend (to unlock the knee joint and make the muscles work more efficiently). Ensure to find your stability, resisting the collapsing of the ankle inwards, or the body weight shift towards the outside. Can be done every 2 days, aiming to work on each leg for approximately 10 mins in total, with an extra 5 mins focus on the “weaker”, affected leg.

Cycling (during recovery phase). Cycling (either on a moving bicycle or on an indoors static one) is a very good exercise to maintain a level of activity and movement in the affected knee during the acute (most painful) phase of the symptoms presentation. Ideally, the activity session on the bike shouldn’t be longer than 30-45 mins at a time, in order to ensure the knee and mainly the quadriceps muscles are active and loaded, without stressing the patellar tendon.

*It is recommended to get the go ahead from your physical therapist or GP before carrying out any of these exercises.