Friday, January 23, 2009

Patellar Pain: Part 1 - The Problem

Everyone would probably agree with me that knee pain is one of the more common orthopaedic problems in our society today. One of the more common diagnoses for knee pain is termed patellofemoral pain syndrome (PFPS). In my mind PFPS is an epidemic. Of the 11 people who saw me in therapy this week, 9 of them came in with some type of patellofemoral pain.

A description of PFPS is that it is sort of a "catch all term" for pain around the "patella" or kneecap (kind of like how shin splints is termed for shin pain). The culprit is usually blamed on improper patellar tracking where the patella/kneecap is not staying properly within the femoral groove where it is suppose to. This can lead to many different type of knee problems (chondromalacia, cartilage damage, acute and chronic patellar dislocations). All of these and more can lead to problems and issues requiring surgery.

Image of a Right Knee

For the longest time, the problem was blamed on the inner part of the quadriceps muscle (the vastus medialis or VMO) and that it wasn't strong enough to hold the patella in its groove and the outer quadriceps (vastus lateralis or VLO) was "pulling" the patella outward and hense causing Patellofemoral Pain.

So as rehabilitation specialists we all spent all this time trying to strengthen the quadriceps muscle with leg extensions, quad sets, & short arc quads. The problem we had with rehabiliting PFPS this way was is that it did not help the problem. Looking back on it now we were actually making the problem worse.

The actual problem with PFPS wasn't the knee at all, the knee pain was just a symptom of a bigger problem. The main problem was not at all with the quadriceps musculature but with the muscles associated with the hip. There was an imbalance present in the hip musculature that caused the thigh to move inward, while the patella would then rub or track to the outside of its intended groove.

A study published in the Journal of Orthopedic and Sports Physical Therapy performed MRI studies of 6 female patients who had laterally subluxing patellas (this is what causes patellofemoral pain) in an open chain (non-weight bearing) and closed chain (weight bearing) positions. They had this to say:

"In addition, the results of this investigation suggest that the patellofemoral joint kinematics during non–weight-bearing could be characterized as the patella rotating on the femur, while the patellofemoral joint kinematics during the weight-bearing condition could be characterized as the femur rotating underneath the patella." J Orthop Sports Phys Ther 2003;33:677-685.

It wasn't until I learned this that I began treating my athletes/patients/clients by working on their muscular imbalances at the trunk & hip that they started to become pain free and able to resume their regular activities.

Next blog, I will talk about the process you should take to bring your body back into balance and become pain free in your knee.

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