There are many potential causes for knee pain without a specific injury that causes it, but today I would like to narrow my discussion to persistent pain in the front of the knee, aka patellofemoral pain syndrome. In the absence an underlying issue such as osteoarthritis, ligamentous injury, tendinopathy, Osgood-Schlater disease, or bursitis among other issues, patellofemoral pain may be a diagnosis that your physiotherapist may make for the pain in the front of your knee. This can be caused by slight differences in your anatomy, muscular imbalance that can create tracking issues for your kneecap or physical over activity (1).
Let’s talk a little bit about knee anatomy associated with the patellofemoral joint, or the joint between the kneecap and femur, which is the long bone in your thigh. The kneecap has a groove in the femur that it tracks along as you bend and straighten your knee. The kneecap movement is created by surrounding muscles and is stabilized by ligaments and other connective tissue that attach to bone and to those muscular structures. The kneecap actually serves as a part of a pulley system for our quadriceps muscle, and the quads blend into a common tendon and attach to the shin bone below the kneecap. Therefore, if there are issues with any of the stabilizing structures or the moving structures, frontal knee pain can occur!
For example, weakness or issues for contracting the quad muscles and hip muscles that help with hip rotation and stabilization can create issues and pain in the front of the knee. These muscles are active A LOT! They are active with every step that we take, and pretty much every time we are on our feet. Therefore, frontal knee pain can be experienced with many forms of physical activity which can include running, walking, squatting, climbing stairs and even sitting with a bent knee due to tension in the pulley system or inflammation. On top of pain, knees may also make more popping or crackling sounds with the above-mentioned activities. If frontal knee issues get really cranky, inflammation can even wake a person up at night (been there)!
What should you do if you are having pain with your activities but you still need to do them? If it is a more strenuous activity like running or participating in sports, try to reduce the intensity once pain is present or becomes higher than your average pain. Continuing to “push through the pain” will not help you in this situation. Your body is trying to tell you that it is not liking what is happening and it is asking for a change to be made. Although there are some situations where pain may be present as a baseline and learning to function with that pain is important without ramping it up and creating a new injury on top of a present pathology (i.e., in some cases of knee arthritis), this is pain that can be modified in the long run and structural issues can be improved. That is where your physiotherapist comes in.
We know that exercise is an important part of the recovery of frontal knee pain and helps to reduce pain levels and improve function for the short and long-term (2). I like to use a combination of therapy tools including hands-on techniques to reduce muscular tension or over-activity, instructing on specific strengthening and lengthening exercises for the hips and knees where these things are lacking to promote balance and coordination in muscular structures, and getting joints, ligaments and other passive structures moving well around the knee. Consideration of the way that the core, the back, the feet and the ankles are moving is also important because everything is connected! All of these things can improve a person’s ability to do the physical activities that they enjoy with good knee form, and then I can help a person return to doing what they love. This is the best part of the therapy process <3
On a personal note, I can relate closely to those who experience frontal knee pain. I have intermittently had this type of pain in my life since 7th grade, and it often flares with changing or increasing and sometimes decreasing my physical activity. For example, I maintain single leg squat and calf strength while staying loose with foam rolling, quad and gluteal stretches while I run. With having two kids under the age of 4, I have also had periods with decreased activity (haven’t we all?), and have noticed increased knee pain with normal life activities like walking up and down stairs. Slowly getting moving and strengthening more always helps this.
As you can tell I could talk about this subject at length, but if you have questions about your frontal knee pain and you are wondering if physiotherapy may help, please feel free to give me a call or you can call the clinic and set up an appointment with one of our excellent therapists. Here’s to helping everyone get happier knees!
~ Kristyn Froc, PT
1. Thomee R, Augustsson J, Karlsson J. Patellofemoral Pain Syndrome: A Review of Current Issues. Sports Med. 1999 Oct: 28(4):245-62.
2. van der Heijden RA, Lankhorst NE, van Linschoten R, Bierma-Zeinstra SMA, van Middelkoop M. Exercise therapy for adolescents and adults with pain behind or around the kneecap (patellofemoral pain). 20 January 2015. https://www.cochrane.org/CD010387/MUSKINJ_exercise-therapy-for-adolescents-and-adults-with-pain-behind-or-around-the-kneecap-patellofemoral-pain.