Anterior knee pain and Runner’s knee are the common terms used to describe Patellofemoral Pain Syndrome. This is the most common cause of knee pain in runners and cyclists. There are a few structures which are the pain generator in this problem. There are many contributing factors ranging from biomechanical alignment issues, repetitive strain and poor health of the tissues. Treating needs to address alignment, improve tissue mobility, break down scar tissue and adhesions, improve circulation, improve strength and internal health.
For runners this is a great video to learn about runners knee pain, since this problem affects a large number of runners.
Hey guys, this is Manu Kalia, physical therapist and Ayurveda herbalist. So in this video I’m going to talk to you guys about patellofemoral pain syndrome. A lot of you guys have asked me questions about this problem and how to treat it, and I’ve posted a bunch of videos in the past on treatment, but I wanted to give you a little bit more detail regarding this problem. So I’ll go over some of the anatomy behind it and what are some of the contributing factors as well as what are the pain generators, so what structures or what are the sources causing the pain. And as I mentioned in some of the other videos, this is one of the most common anterior or front knee pain problems in runners. Of course, it affects cyclists and other athletes, and even people in the sedentary population get affected by this problem, and I’ve treated a lot of patients with this issue.
So anytime something has a syndrome at the end of it, it usually implies that there’s not one cause, one contributing factor. So there might be a host of things that are causing this issue. So that’s why they call it patellofemoral pain syndrome. And there are biomechanical issues, anatomical issues as well as training and internally what’s going on within the person. So all these things can be contributing to the problem also. So why don’t we go over a little bit of the anatomy, and then we can go into more some of the pain generators and some of the causes?
By the way, before I go into more detail, I just want to give you guys an update and let you know that our program that we’re putting together on knee injuries will be coming up soon, and so stay tuned and keep checking the channel. Go check out the website and I’m going to be posting more details on when the program launches. If you guys want to be added to the list, to be one of the first to find out about the program, make sure you get to the website and sign up for that and I’ll be issuing a bunch of free copies initially, too. So if you guys are interested, make sure you get in there and check it out.
Alright, so regarding patellofemoral pain, so first of all, looking at the knee here to give a little bit of anatomy, the patellofemoral joint is the joint that the kneecap makes with your femur, which is your thigh bone. It is the kneecap sitting in the trochlear groove, which is that groove at the bottom that’s created by the bottom part of your femur or your thigh bone, and it works by gliding back and forth. And to the top of the kneecap, you have your quadriceps tendon, which is part of your quadriceps muscle, your thigh muscle, and the bottom part is your patellar tendon, which comes in attached below the kneecap. So the kneecap, the bone itself, is helping transfer all this force that’s generated by your big muscles or quadriceps to extend or strengthen out that leg.
Now, this problem is commonly known as runner’s knee. That’s one of the common terms that’s used for it, but the correct term is runner’s knee or anterior knee pain, which is basically front knee pain. So any kind of pain that’s generated around this area is called runner’s knee pain or anterior knee pain. There could be some other causes too, but we’re going to be discussing more the patellofemoral issues. So anything that’s going to be essentially along this region, front of the knee, even down through here, is related to patellofemoral pain. Occasionally you will have patellofemoral joint referring pain to the back of the knee also, but most common is anterior knee pain.
So some of the structures that can be causing the pain are medial and lateral retinaculum, which is basically your fibers that are coming from your vastus medialis, which is your inner quad muscle, vastus lateralis, the outer quad muscles, fibers coming off of that and attaching on the border of the kneecap, on the outside border here and the inside border. So a lot of those, if they’re irritated, they can refer pain or cause pain. The synovial tissue, the tissue that covers the joint itself, if it’s irritated it can cause pain too. So any of the tissues that are surrounding this area or sitting underneath the kneecap, could be cartilage here too, synovial tissue which is the covering around the joint. You also have the subchondral bone, which is underneath the cartilage you have bone, if that’s irritated, so that can also refer pain. So any of these structures, if they’re irritated due to compression or repetitive strain, or an injury for that matter, can cause pain.
Now, this is a repetitive strain injury, so poor mechanics, too much loading of that joint. Repetitive strain, so constant movement of that joint whether I’m running or cycling, can cause that area to get irritated and set up a process where it’s so irritated that you can have pain with even day-to-day activities, and one of the classic signs is the movie goers sign. So when you sit for a while you start having pain in that front of that knee, and when you go to get up and it’s irritated it can be patellofemoral pain. And other activities like squatting, going up and down stairs sometimes, definitely kneeling, can cause pain too. Running, jumping, any of these things can cause pain as well.
So what are some of the reasons that cause these problems? So as I mentioned, biomechanical things are some of the things you’ve got to consider, which basically means that, what is the alignment of the patellofemoral joint? Is the kneecap tilted to the outside? Is the alignment off the kneecap? Is it too hot? Is it not only just tilted to the outside, is it gliding to the outside? Or, is it that because of the anatomy of your tibiofemoral joint, tibia and femur, it throws off the anatomy of the kneecap? Maybe the groove is too shallow where the kneecap sits in. Maybe the hip is too tight further up in the chain. For women, a lot of times it’s cited that there’s a larger Q-angle, which is the width, so wider hips, which cause the alignment to be off between the thigh bone and the pelvis and which results in the kneecap’s alignment being off. Flatfoot or excessive pronation at the foot has also been cited as one of the reasons.
So I don’t think one specific thing is the cause of the problem. Now, all these things combined can, yes, set up an environment which mechanically the kneecap is off alignment and cause more problems. So the flatfeet combined with possibly excessive valgus or medial drift of the knee where the knee is drifting inwards can change the alignment of the kneecap, can contribute to that problem. So, as I said, not one thing, multiple things combined with repetitive strain will cause this problem to come up.
Now, regarding treatment, you have to address all of those factors. I might have to address the foot mechanics. Am I missing my ankle range of motion? Am I missing my big toe range of motion, which is causing my foot to go more into a flatfoot position or the foot to drift out more, which is mechanically changing what’s happening up the chain? For that matter, is my hip too tight or my glutes too weak, which is again causing my knee to drift in more, my thigh to drift in, which is resulting in a change in mechanics? And this might not happen necessarily when you’re just walking, but once you’re starting a higher-level activity like running or other athletic activities, once that muscle fatigues or some of the other muscles fatigue and you don’t have enough stability in that pelvis and the leg starts to drift in, that’s when you start having those problems coming about.
So think about it from a much broader perspective. What’s happening up the chain? Is my core strong enough? Am I able to maintain a good solid position? Are my hips strong enough? Same with your foot. Are my foot stabilizers, foot muscles, strong enough for not only shock absorption but controlling the foot motion and mechanics? So all these things can contribute to the issue. So it requires a bit more in terms of management, and management will be addressing those things by joint mobilization techniques, by strengthening, mobility exercises; also by hands-on cross friction massage techniques should break down that scar tissue, improve the mobility of that kneecap. It’s too stiff on the outside direction, I’ve got to make sure that kneecap’s working better; maybe making sure the joint mechanics, you have full extension in that knee joint, you have good range of motion in the tibiofemoral joint, the main knee joint so that there’s less load on that kneecap too. So you have to consider all of those factors when you’re looking to address this problem.
So I hope this gives you a better understanding of what’s happening at this joint, some of the pain generators we discussed such as the medial and lateral retinaculum fibers that are catching on the inside and outside, the cartilage underneath it, the subchondral bone – bone underneath the cartilage. The cartilage is worn out, there’s more irritation. So try to consider all of those variables when you’re thinking about treatment, and I will be posting more videos on treatment but I wanted to give you a much better understanding of what’s really going on and what we’re talking about in terms of the problem. This gives you a global and better understanding of the issue, and then we’ll do specific treatments to address the problem.