Patellofemoral Pain Syndrome (PFPS) also known as runner's knee, chondromalacia patellae, anterior knee pain, and patellofemoral joint syndrome is a generic term used to describe patella pain at the front of the knee. Here we explain the symptoms, common causes, treatment and exercises.
On this page:
- Symptoms & diagnosis
- Causes & anatomy
- Self help treatment
- What can a professional do?
Patellofemoral pain syndrome symptoms
Symptoms include an aching pain in the knee joint, particularly at the front of the knee around and under the patella.
There is often tenderness along the inside border of the kneecap and swelling will sometimes occur after exercise. Patellofemoral pain is often worse when walking up and down hills or sitting for long periods of time.
Other signs a sports medical practitioner may pick up include a click or cracking sound when bending the knee, wasting of the quadriceps muscles if the injury is an old one and tight muscles around the knee joint.
The Q angle of the knee is a measurement of the angle between the quadriceps muscles and the patella tendon and provides useful information about the alignment of the knee joint.
Other tests include the Apprehension test, Patella compression test, and the Patella grind test.
Patellofemoral pain syndrome causes & anatomy
PFPS occurs when the patella (kneecap) rubs on the femur bone underneath. It is often thought that incorrect tracking or rubbing of the patella over the femur bone is a significant factor and results in damage or irritation of the articular cartilage underneath the patella.
Patellofemoral pain is common in people who do a lot of sport and, in particular, adolescent girls. It can have a number of causes but damage to the cartilage itself cannot directly cause pain because there are no blood vessels or nerves involved. However, it can lead to other problems which in turn result in pain. These include synovitis (inflammation of the synovial membrane or joint lining in the knee), erosion of the cartilage and bone, soft tissues injury or irritation such as to the lateral retinaculum, and the infra patella fat pad.
The initial cause of patellofemoral pain syndrome is likely to be overuse. This may be from external factors, for example, a sudden increase in training, or performing high-intensity jumping and knee bending, or it can be from internal factors such as poor patella tracking. Identifying the cause is an important part of treatment.
There are a number of factors which can increase the risk of suffering patellofemoral pain including:
Incorrect running shoes for your running style can contribute to poor foot biomechanics. Some shoes are designed to resist pronation inwards by having a firmer block on the inside of the mid-sole. Looking at the wear pattern on a shoe can give an indication as to whether they are appropriate. Also the age of a running shoe is important. Most runners will replace them after 500 miles or 6 months. Some will have two or three pairs on the go at once which can extend the life of the shoe.
Increased training loads can be from increased volume for example increasing the number of miles run or days trained. This increases the overall load from repetitive strain on the patellofemoral joint. Increasing intensity such as through bounding or jumping exercises can also increase the load on the joint.
Training surfaces can increase the load through the joint. Hard surfaces such as roads or concrete floors will increase the load on the joint compared to grass or artificial 3G type training areas.
Increased internal rotation of the femur or thigh bone may contribute to the development of patellofemoral pain. The therapist will assess the patient in a standing position and will observe the patella facing inwards towards each other. This may be more prominent during running or walking or performing a single leg squat and could be due to weak hip muscles, particularly the gluteus medius.
Increase knee valgus is also known as genu valgum or an increased Q angle. Simply put, the knee bends inwards increasing the angle between the quadriceps and the patella tendon. This can be seen with the patient in a standing position or during a single leg squat exercise. A Q-angle greater than 18 to 20 degrees could indicate patella tracking problems.
Increased tibia rotation is where the tibia or shin bone rotates inwards too much. This can cause the femur to rotate inwards and the patella to track incorrectly. Rotation of the tibia is often due to an over pronated foot.
Over pronation of the foot is where the foot rolls in too much and flattening. This has a knock on effect of causing the tibia to rotate.
Poor flexibility of any of the muscles surrounding the knee joint can be a contributing factor, in particular, tight muscles on the outside of the knee and hip such as the tensor fascia lata and iliotibial band.
Position of the kneecap can assessed through both active movements which the patient initiates and passive movements which are facilitated by the therapist. The patella may be rotated, tilted forwards or backwards or displaced sideways, any of which can be a contributing factor. Taping the patella back into place may also be used to determine the cause of pain.
Soft tissue surrounding the patella such as the lateral retinaculum and iliotibial band could be too tight whilst the vastus medialis muscle on the inside of the knee could be too weak. This could be obvious from assessing the patella position or through feeling or palpating the tissues.
Neuromuscular control of the vastus medialis is assessed to identify if the muscles are contracting at the right time. Just because there is plenty of muscle bulk does not mean the muscles are working properly. If the vastus medialis on the inside of the knee contracts slightly later than the rest of the quadriceps muscles then this could be a contributing factor. The therapist should assess this in a number of positions, particularly those which closely relate to the patients normal sporting activities.
Patellofemoral pain syndrome treatment
Patella pain treatment and rehabilitation are based on reducing symptoms, identifying the causes and strengthening or re-training muscles which may have contributed to the injury. The aims of a patelliofemoral pain rehab program are to:
- Decrease pain and inflammation
- Strengthen the weakened muscles of the knee and hip
- Increase flexibility of the tight muscles
- Address any biomechanical issues
- Gradually returning to full fitness
What can the athlete do?
Apply PRICE principles of protection, rest, ice, compression, and elevation after activity to help reduce pain and swelling. Rest completely from aggravating activities until there is no pain.
Wear a patella tracking knee brace or support. These usually have a hole in the middle of the kneecap and straps which are pulled across the knee applying support to the patella.
What can a professional do?
A professional practitioner can confirm the diagnosis and rule out other conditions which may have similar symptoms such as a synovial plica. A doctor may prescribe anti-inflammatory medication such as ibuprofen which should not be taken if you have asthma.
A patella taping technique (play video) can have an instant effect in relieving pain as the kneecap is pulled away from the site causing pain. The purpose of taping is to reduce pain and allow muscle strengthening exercises to be done correctly. If the athlete has pain on normal daily activities then taping should be applied all day until there is no pain. If there is patella pain only on sports specific activities or muscle strengthening exercises then patella taping should only be done for those exercises.
Sports massage (play video) can help loosen tight structures and muscles which may be contributing. Gait analysis can also be done to determine if the athlete overpronates and orthotic inserts can correct poor foot biomechanics. In chronic cases, a surgeon may operate to release the tight lateral (outside) structures of the knee although there is little evidence as to the success of the surgery.
Patellofemoral pain syndrome exercises
Depending on what is causing the patella pain, exercises to strengthen the muscles on the inside of the thigh are usually recommended. In particular, heel drop exercises can strengthen the vastus medialis muscle on the inside of the thigh. This is an important muscle for controlling patella tracking and is often weak in athletes with patellofemoral pain. Thigh stretching exercises are also important as the muscles on the outside of the thigh (vastus lateralis muscle) is often tight.
The aim of exercises is usually to strengthen the vastus medialis muscle on the inside of the knee and ensure it contracts at the same time as the other quadriceps muscles. This should help pull the kneecap inwards (medially) and allow it to track normally on the tibia bone. Isometric or static exercises should be done first progressing to weight bearing exercises with the foot in contact with the ground, which are thought to be most beneficial.
Patella taping can be done to prevent exercises being painful and assist with correct tracking of the patella. It is important that the athlete can feel the vastus medialis muscle contacting during strength exercises and beginners may need to actually feel the muscle with their hand as it contracts.
Exercises to stretch the structures on the outside of the knee as well as the hamstrings and calf muscles should be done. This is just as important as strengthening the inside. Tight lateral structures will not allow the kneecap to track naturally on the Tibia.
Read more on patella pain exercises.
Return to fitness and prevention
Return to full fitness should be gradual and sports specific training should only begin when there is no pain. Full strengthening exercises should have been done to restore the muscles to full and balanced strength.
It may be necessary to tape the knee or wear a support whilst returning to sport, but do not get to rely on it long-term unless specified by your therapist. Any biomechanical abnormalities (e.g. pronation) should be corrected to prevent the injury returning.