Pain Behind Your Kneecap
This is a common sensation, particularly if you like sports that involve activities such as running, squatting or jumping. Sports injuries are really only injuries of tissues in your body that happen to occur or to have been caused by doing the repeated activity that your favourite sport may involve.
You may also feel pain behind your kneecap (patella) when you go upstairs.
You may feel a vague pain in the region somewhere at the back of your patella but you can’t actually put your finger on it. You might feel the pain in both legs and the pain usually builds up slowly along with the fact that the knee feels stiff and sounds “crunchy”. There is usually no inflammation to be seen.
This set of sensations is called Patellofemoral Pain Syndrome (PFPS) and is quite common. It is thought by some sources to represent 25 – 40% of reported pain in the field of sports medicine.
How Does It Occur?
It is thought to be caused by forces that control how your kneecap moves in the groove of your lower leg (tibia) and upper leg (femur) becoming changed. Muscles surround your patella from the front of your femur and pelvis down to your tibia and these muscles control the smooth movement of your patella as you bend your knee. You can imagine that if some of the muscles are not functioning optimally then you may develop aberrant patella movement which can give rise to pain as you put pressure on tissues that are not made to cope with it. Thus every time you use the knee you cause the abnormal pressure and the pain comes on.
You could have anatomical issues that predispose you to developing this pain. For example you might have knees that bend backwards (remember how Christopher Robin stands when talking to Winnie the Pooh?) or knock knees or your lower leg may be twisted inwards or outwards or you may have weakness of the large muscle at the front of your thigh – the ‘quads’ which is actually four muscles making up one muscle ‘group’.
You could of course, have foot problems – high arch or flat feet and these can contribute to the way you move your knees and hips.
When you consult with one of us, we will check all aspects that we think may be causing your PFPS so we treat the right areas.
If you have any of these abnormalities and then you decide to become a long jumper or a marathon runner and you are not aware of the way you stand because it never hurt, by doing these activities which cause you to bend and flex your knees a lot and to the extreme, you can develop this condition. It has also been discovered that anxiety or other psychological factors eg fear avoidance beliefs (I think I have backward bending knees therefore I will get pain if I take up running) may play a role in the development of PFPS.
A study for example in 2007 by Robinson and Nee in the Journal of Orthpaedic Sports Physical Therapy May; 37 (5): 232 – 8 showed that females aged 12 to 35 presenting with unilateral PFPS demonstrate significant impairments in hip strength compared to control subjects in the painful knee.
How Can We Help You?
Even if you are born with a slightly twisted tibia, which we cannot, obviously, change, we can help you to improve the function and mobility of the patellofemoral joint (where the kneecap moves as you bend and straighten your knee). We can manipulate or mobilise the joints of the knee, give you exercises to strengthen weak muscles or stretch over tight muscles and watch how you do what you do and correct any ‘odd’ ways of moving that you were not aware of.
Conservative management is the mainstay of treatment for patellofemoral pain. Even patients with significant malalignment or other pathology often respond to conservative treatment. According to research published in the Current Rev Musculoskeletal Med 2013 Jun; 6(2):188-194 by McCarthy and Strickland, rest, activity modification, and ice are essential components of the initial treatment.
They say that anti-inflammatory medication is often helpful at the beginning for a few weeks to decrease inflammation, pain, and improve the patient’s ability to comply with physical therapy. If you have flat feet, off the shelf orthotics , can be extremely helpful.
McConnell advocated a patellar taping technique to control subluxation and patellar tilt in an effort to reduce anterior knee pain. This technique is learned such that patients can apply the tape themselves. This and a variety of other taping techniques can be beneficial.
However, a recent randomized trial evaluating the use of bracing for patellofemoral pain associated with arthritis found no clinical benefit for bracing.
Physical therapy and strengthening are essential components of the non-operative management.
One researcher, Crossley performed a randomized trial evaluating physical therapy for the treatment of patellofemoral pain and noted that a short course of physical therapy was “an effective treatment for patellofemoral pain”.
Specific exercises aimed at the knee such as quadriceps strengthening, quadriceps, and hamstring flexibility, manual stretching in the case of patellar tilt, or tight tissues around the patella are all appropriate.
Hip stability and hip strengthening are important parts of the physical therapy program. The hip extensors contribute 25 % of energy absorption during landing and if the hip musculature is not strong enough to absorb the appropriate load, that load is transmitted to other joints of the lower extremity, particularly the knee.
Fukuda evaluated patients with patellofemoral pain who underwent a rehabilitation program focusing on knee strengthening exercises with or without hip strengthening exercises and noted that both groups had improvements in pain and function but those that received hip strengthening had significantly improved outcomes for pain relief while descending stairs.
Earl found that an 8-week rehabilitation program with emphasis on strengthening and neuromuscular control of the hip and core musculature reduces the knee abduction moment, improves core and hip strength, and results in improvements in pain and functional ability.
Localized medication therapy to the knee is also an option. Corticosteroid injections are reserved for patients who have significant inflammation that has not responded well to oral anti-inflammatories, ice, and rest.
Their advice is that nonoperative management should be pursued for at least 3 months until both clinician and patient feel that pain and function have reached a plateau. Although surgery is rarely utilized for treatment of patellofemoral pain, it should be considered in a compliant patient who has not responded well to rehabilitation.
When conservative management fails, surgical treatment in the form of realignment of the lower end of the patella femoral tendon and unloading procedures are effective but like all surgery, this should be a ‘last resort’ and the best thing you could do is to work hard with us to try to rectify the problem!