How to reduce your Knee Pain?

Knee pain is a common complaint, specifically amongst runners and running athletes.  Knee pain can be caused by a lot of factors, we will try to unpack some of those factors today.  We are going to look particularly at anterior knee pain commonly known as patellofemoral pain syndrome (PFPS).

As always it is important to understand the anatomy to get a better idea of how the body works, or in this case may not be working, properly. The knee is a fairly simple joint. It is a hinge joint which means it has two main movements, flexion and extension. Flexion is bending your knee, extension is straightening it. The knee does have small amounts of rotation available which plays a vital role in the knee being able to flex and extend properly. Since the knee is a relatively simple joint knee pain can often be a symptom of something happening elsewhere in the leg like the hip or the ankle. The hip is a very mobile joint. It is a ball and socket joint which has a lot of movement available to it. If movement is restricted in the hip or if the hip is not strong enough to stabilise the leg (particularly in a single leg stance) then that could put extra stress on the knee and lead to knee pain. Similarly if the ankle isn’t moving correctly or is not strong enough to support the leg then that could put extra stress on the knee and lead to knee pain.

The normal line of thought is that if there is pain in my knee then there must be something wrong with my quads because they are the big muscles that affect the knee. So I stretch my quads and I foam roll my quads and my knee pain feels a bit better afterwards but it always seems to come back. While the quads may contribute to knee pain in some situations it is more likely to be a symptom rather than the cause of the pain.

There are some structural factors that can cause knee pain.  Damage to the four major ligaments of the knee (ACL, PCL, LCL and MCL) make up a large portion of sporting injuries.  But damaging these ligaments normally requires a forceful impact or twisting of the knee.  Meniscus damage is also a common knee injury.  The meniscus can be damaged through forceful impact or twisting but can also be a wear and tear injury.

Coming back to patellofemoral pain syndrome, PFPS presents as an overuse injury in runners.  Patellofemoral pain is a common, chronic musculoskeletal condition, presenting as pain around or behind the patella during patellofemoral joint loading activities (eg, squatting, stair ambulation and running). Patellofemoral pain has an annual prevalence of approximately 23% of adults and 29% of adolescents in the general population and affects almost 36% of professional cyclists. Patellofemoral pain tends to persist in about 50% of people, in some cases for up to 20 years. Pain and symptoms associated with patellofemoral pain limit participation in daily and occupational tasks and reduce levels of physical activity. 

At the 2018 International Patellofemoral Research Retreat scientists and clinicians who are leading the way in PFPS research and treatment came up with the following recommendations: 

1. Exercise therapy is recommended to reduce pain in the short, medium and long terms and improve function in the medium and long terms.

2. Combining hip and knee exercises is recommended to reduce pain and improve function in the short, medium and long terms, and this combination should be used in preference to knee exercises alone.

3. Combined interventions are recommended to reduce pain in adults with patellofemoral pain in the short and medium terms. Combined interventions as a management programme incorporates exercise therapy as well as one of the following: foot orthoses, patellar taping or manual therapy.

4. Foot orthoses are recommended to reduce pain in the short term.

5. Patellofemoral, knee and lumbar mobilisations are not recommended in isolation.

6. Electrophysical agents are not recommended. 

The overwhelming recommendation in regards to PFPS is that exercise therapy is required targeting the hip and the knee.  My initial exercises for clients with PFPS are the clam, crabwalk, single leg glute bridge and the single leg deadlift.

Clams

Clams are good for lateral hip strength. Your shoulders, back, hips and ankles should be in a straight line. Knees should be bent at 90 degrees with the theraband just above the knees. Make sure that you don’t rock the pelvis back as you complete the movement. The movement should come entirely from the hip.

Crab walks

Clams are good for lateral hip stabilisers. It is the most dynamic exercise in the program. Start with the theraband around your ankles and a soft bend in your knees and hips. The key to the crab walk is maintaining a consistent rhythm. The speed that your leading leg steps out should be the same speed that your trailing leg steps in.

Single leg glute bridges and single leg deadlifts are an excellent exercise for runners.  Running is a single leg exercise you are constantly transferring weight from one leg to the other and you never have both feet on the ground at the same time.  (Check out this blog for more information ‘That’s not running, it’s falling with style’) If you are running regularly then you should be doing single leg training, it’s really that simple.

Single Leg Glute Bridge

This is a progression of the glute bridge. (click here to see a video of how to perform a glute bridge) Performing this exercise on a single leg require activation through the lateral hip stabilises it also challenges the abdominals to keep the pelvis level.  The key is keeping the pelvis parallel with the ground.

Single Leg Deadlift

The single leg deadlift is a progression from the hip hinge. (click here to see a video of how to perform a hip hinge) Again we are challenging the lateral hip stabilises and abdominal muscles.Keeping the trunk straight with the back leg and ensuring the pelvis and shoulders stay parallel to the ground is key.

Exercise is the key to long term recovery from PFPS.  In the short term a combination of exercise and manual therapy can be used so coming for treatment to reduce any tension in surrounding muscles through massage and dry needling can be beneficial.  The other factor that I would like to talk about is the use of orthotics or changing shoes to address PFPS.  The 2018 International Patellofemoral Research Retreat state that foot orthoses can be used to reduce pain in the short term and that there is no evidence supporting the use of custom-fabricated foot orthoses.  Meaning generic orthotics can be used to reduce pain in the short term but they should be used as a pain relieving mechanism while performing the exercises.  Remember the exercise is the best way to reduce pain in the long term.  There is no need to go and get expensive custom made orthotics and generic orthotics should only be used for pain relief in the short term. 

The other consideration is the shoes that you wear.  Lots of people believe that if they are experiencing pain while running they need to go and buy shoes that offer extra support.  This may not be the case.  The underlying fact is that your body should be able to support yourself adequately to run.  You may just need to train a particular part of it that is not doing what it is supposed to.  A 2017 study on the influence of cadence and shoes on patellofemoral joint kinetics in runners with patellofemoral pain looked at two factors that contribute to stress on the patellofemoral joint. These were running cadence (steps per minute) and the type of footwear (traditional cushioned shoes or minimalists shoes).  Increasing running cadence (more steps per minute) can reduce stress on the patellofemoral joint.  Also, contrary to popular belief, running in a minimalist shoe rather than a traditional cushioned shoe can reduce stress on the patellofemoral joint.  Combining increased cadence with a minimalist shoe proved to have the best result in reducing stress on the patellofemoral joint.  So before you run out to buy an expensive pair of shoes with extra cushioning it might be a good idea to have your pain assessed by a qualified health professional (not just a shoe salesperson).

If you are experiencing knee pain and want to start your journey to a pain free life come in and see us. Book now

References:

Bonacci, J., Hall, M., Fox, A., Saunders, N., Shipsides, T. and Vicenzino, B. (2018). The influence of cadence and shoes on patellofemoral joint kinetics in runners with patellofemoral pain. Journal of Science and Medicine in Sport, 21(6), pp.574-578.

Collins, N., Barton, C., van Middelkoop, M., Callaghan, M., Rathleff, M., Vicenzino, B., Davis, I., Powers, C., Macri, E., Hart, H., de Oliveira Silva, D. and Crossley, K. (2018). 2018 Consensus statement on exercise therapy and physical interventions (orthoses, taping and manual therapy) to treat patellofemoral pain: recommendations from the 5th International Patellofemoral Pain Research Retreat, Gold Coast, Australia, 2017. British Journal of Sports Medicine, 52(18), pp.1170-1178.