One of the most common problems for female trainers, particularly younger female trainers, is a loosely named constellation of symptoms known as patellofemoral pain syndrome or PF. PF should not to be confused with chondromalacia patella, which refers to a wearing of the cartilage under the kneecap. The “patella” part of PF is the kneecap, and “femoral” refers to the femur, or thighbone. Essentially, PF refers somewhat nonspecifically to pain experienced in the knee around the area where the patella contacts the end of the femur.
Symptoms of PF typically include pain at the front of the knee while performing certain activities such as descending stairs or hills, running, or after prolonged periods of sitting. Crackling or grinding in the knee may also be experienced, although this is more likely to indicate chondromalacia.
The kneecap, or patella, is a roughly oval piece of bone, held in place by connective tissue, that sits in a little groove on the femur, and slides up and down as the knee bends or straightens. One of the most likely culprits behind PF is improper patellar tracking, or movement in its groove, and this can be caused by a number of things. Bear in mind that not all explanations are equally accepted by all members of the medical establishment. Also, some things are a bit chicken-and-egg. Which came first, bad structure or bad movement patterns?
1. Women tend to have wider hips than men, and as a result, their femurs must swoop down to the kneecap at a greater angle. This is known as the Q-angle. This increased Q-angle can increase the likelihood that the patella will not be properly aligned.
2. Pronation (inward lean) or supination (outward lean) of the foot can also exacerbate PF syndrome. Pronated feet require the ankle and consequently the femur to compensate, and supinated feet provide decreased shock absorption when the foot hits the ground. Both of these conditions can be alleviated by purchasing good shoes, and using orthotic inserts. Check the bottoms of your shoes to see if you have this problem. Pronators will have the worn spot of the sole on the inside of the ball of the foot, while supinators will show wear along the outside of the sole.
3. Muscular weaknesses in the thigh muscle (quadriceps). Some suggest that a weakness in the vastus medalis (inner quad muscle above the knee) is the problem (see below for more of a discussion about this). Others add that weak hip muscles play a part, especially weak external rotators. We see this problem with trainees who let their knees cave together when squatting.
4. Inflexibility in some areas, particularly the iliotibial band (a piece of connective tissue running from the hip to the knee along the thigh), hamstrings (back of thigh), calves or lower back. Again, folks are divided on this. PTs argue that the IT band can’t be stretched. On the other hand, stretching of the aforementioned muscles can do little harm and is quite likely helpful. Hamstrings are involved in bending the knee, and inflexible hamstrings can cause pressure to increase between the patella and femur.
5. Poor running mechanics. If you run, you should probably be striking the ground with the forefoot (ie the ball of the foot) rather than the heel. For more on the biomechanics and proper technique of running, see Ozzie Gontang’s page on mindful runnng and Michael Yessis’ excellent book Explosive Running.
so, your knee is screwed. what to do?
1. Rest. Quit doing whatever you’re doing that causes pain, if possible. That means jogging, skiing, high-impact aerobics, allowing your two-year-old to whack your knee with her Pokemon doll, whatever. Chronic overloading is one of the most significant causes of PF pain.
2. Ice. Wrap some crushed ice in a ziploc bag, or a bag of frozen peas in a dishtowel and sit with it on your knee for 10-15 minutes (no longer). Do not allow ice to touch skin directly, if possible. Do this 1-3 times daily, especially after activity if you’re able.
3. Pain relief. Now, I stay away from anti-inflammatories because they upset my tummy. That means ibuprofen, naproxen drugs like Anaprox, and so forth. You are welcome to try them over the short term, since they do help reduce some of the underlying cause of pain, which is the inflammation. Dietary supplementation with things like bromelain (pineapple enzyme) and fish oil are a better choice for long term anti-inflammatory, as they does not have many of the negative effects of OTC anti-inflams. If you just want some short-term pain relief, acetaminophen (Tylenol) is fine.
4. Accurate diagnosis. See a doctor and make sure what you have is really PF. One quick test you can do at home (but I warn you, this is painful) is to sit with leg out straight in front of you. Relax your leg. Then have someone put their hand on your thigh, just above your kneecap, and exert a gentle but firm pressure downwards, towards the floor (not down your leg towards your foot). Flex your thigh. If you feel a sharp pain, it likely means you’re having kneecap tracking problems. When I read about this, I tried it on myself, and I can attest that it does hurt. I then tried it on my somewhat unwilling but PF-free husband, and he had no problems with it. However, this test has a few problems. First of all it hurts like hell, and second it is likely to return a lot of false positives (in other words, it can cause pain for people who don’t have PF).
long term treatment
1. Quadriceps strengthening. It used to be that PTs would try to strengthen the vastus medialis, believing that its weakness relative to the other quad muscles allowed the patella to be pulled out of the groove. More recent studies agree that since the quads are designed to work in concert, you can’t really isolate a single one. So, attention is now focused on having people do compound exercises that strengthen the entire thigh muscle group.
Despite all that stuff about squats supposedly being bad for your knees, full depth squats are actually great for knee rehab. They strengthen all the leg muscles with a compound, natural movement. If you can squat without pain, then by all means do so, even if you can’t use any weight. If you can’t squat the full range, squat in the range of motion that is pain-free for you, and gradually try to increase the range. Front squats are an ideal exercise, both because they put more emphasis on the quads, and because they seem to put pressure differently on the knee joint. When I was having real PF problems, I could do full depth front squats with no difficulty whatsoever.
Some folks recommend leg extensions, but I am very hesitant to recommend these. Putting frontal/lateral as opposed to downward force along the shin (tibia) can actually worsen knee problems with the shearing force that is created in the joint. If you choose to do leg extensions, do them with very light weight, and only the top 1/3 of the movement (like from nearly straight leg to straight leg) and don’t lock your knee.
Other exercises to do if you cannot do squats at all without pain, try these:
-Step up onto a step or block with one leg, then step back off (land gently, and don’t lock knees). Over time, increase the height of the step. Focus on driving through the heel of the foot on the step rather than pushing off with the back leg.
-Step down from a step with one leg, then back up
-Sitting on the floor with legs outstretched in front of you, slowly raise one leg, keeping it straight, as high as you can go; hold it in the air for 10 seconds, then lower slowly. This can be done with ankle weights.
2. Hamstring, hip, and calf stretching.
One good stretch given to me by my PT is this. Stand with right side facing a wall, feet together about 6 inches away from the wall. Take your right foot and cross it over your left leg, placing it on the floor. Stick your hip out to the left like Mae West workin’ it, and turn your upper body to face the wall, placing hands on wall. Push outward on hip to the left. You should feel a stretch along your left hip and down the outside of your left thigh. Hold for 30 seconds, then repeat for other side.
For lots of folks, though, this stretch doesn’t do much. So I came up with a better one. It’s like a standing hamstring stretch with a twist — literally. Stand facing a staircase. You can do this on any elevated surface, but a staircase works best, because you can wedge your foot into the corner so that it doesn’t turn. Lift the right leg and place the right foot on the second or third step. Keep your leg straight. That’s step 1. Step 2: turn your entire body except for the elevated leg (especially your hips) slightly to the right. You want to turn towards your elevated leg, but leave the leg where it is. Now the elevated leg is slightly across your body at a diagonal rather than straight out in front. Step 3: Just like a regular hamstring stretch, bend forward from the hips (not the waist). You should feel this down the outside of your hip, thigh, or even the side of your calf. You won’t be able to go down very far. Repeat on other side.
To stretch hamstrings and calves: stand, cross one leg over the other, then bend at hips as far down as you can go. You should feel a pull along the back of the rear leg. Repeat for other leg.
Other stretches can be found here – click on the body part you want to stretch.
3. Hamstring strengthening. Again, full squatting is useful here, so do it if you can. Also, you can do stiff legged deadlifts and hamstring curls.
4. Shoe orthotics. If you do indeed pronate or supinate, orthotics will help. Also, folks in athletic shoe stores are often very knowledgeable about which brands of shoe are better for which problems.
5. Checking exercise form. Many people allow their knees to cave in while squatting or leg pressing. Bad!! When ascending from a squat, focus on pushing knees outwards. You won’t really push them out much, but it will feel like you are. When going up stairs, shift your weight back onto your heels as much as possible. Same goes for the stairmaster.
6. Supplementation. Supplementing with glucosamine and chondroitin sulfate may help. Other supplements such as bromelain, fish oil, and MSM will help reduce inflammation.
7. Soft tissue therapy such as Active Release Technique and self-massage of the soft tissue of the thigh with a rolling pin.
8. Surgery. This should be a final, final, final option, after all other non-invasive avenues of treatment have been tried.