Anterior knee pain goes by a large number of names but unfortunately seems to have relatively few effective treatments. Chondromalacia Patella, Patella Tendonitis and PatellaFemoral Syndrome are all names used to describe various types of often debilitating\u00a0 anterior knee pain. A large part of the problem in treating anterior knee pain may be that\u00a0 treatment has often focused on the knee joint or, what would be described as the primary\u00a0 pain site. In reality, the knee may be the repository of pain that emanates from issues at the\u00a0 \u00a0hip or the foot. A knee-centered approach to treatment of anterior knee pain becomes a\u00a0 symptom-based approach versus a cause-based approach. In other words treatment often\u00a0 focuses on eliminating a key symptom versus trying to eliminate the cause.<\/p>\n
Interesting enough current research is leading to the conclusion that many of the overuse\u00a0 conditions of the knee are not conditions of the knee at all. Anterior knee pain may in fact
\nbe more of a symptom than a diagnosis. All of the conditions mentioned in the opening\u00a0 sentence may in fact be related to poor stability at the hip but present as knee pain.\u00a0 (Powers, 2003)<\/p>\n
The analogy we have frequently used to describe why this occurs is what I refer to as the “rope analogy”. If I put a noose loosely around your neck, stood in front of you, and pulled\u00a0 on it you would tell me that the back of your neck hurt. If I simply stopped pulling on the\u00a0 rope your neck pain would disappear. The fact of the matter is that nothing was ever really\u00a0 wrong with your neck. The neck was simply the endpoint at which you felt the pull. This is\u00a0 very similar to the effect of the glute medius and glute max pulling on the IT band and\u00a0 resulting in pain at the knee. The IT band transmits forces from the glute medius to the patella tendon. For some reason the patella tendon feels pain much like the back of the\u00a0 neck feels the pull from the rope.<\/p>\n
Another potential cause of anterior knee pain may be an unintentional loss of ankle\u00a0 mobility. The zeal of athletic trainers to stabilize the ankle with shoes, tape and braces has\u00a0 led to many athletes playing with ankle joints that function as if they were fused. The\u00a0 reality is that in the sport of basketball (a leading sport for anterior knee pain) serious ankle sprains are less frequent and patella-femoral pain has reached near epidemic levels.<\/p>\n
The desire to over-stabilize the ankle joint has led to a phenomenon we now call the “high\u00a0 ankle sprain” and to an epidemic of patella tendon issues. The high ankle sprain was virtually unknown twenty years ago and may also be a by-product of over-stabilizing the\u00a0 ankle. Interestingly enough soccer has few ankle or patella-femoral problems yet, soccer players use a low cut, lightweight shoe on grass. Training with less artificial stability at the\u00a0 ankle joint probably protects the ankle and the knee.<\/p>\n
Over the past decade, Anterior Knee Pain has been blamed on poor VMO development,\u00a0 poor “patella tracking” and numerous other causes. Most treatments have centered on\u00a0 trying to reduce the pain at the pain site with various treatments (ice, taping, ultrasound\u00a0 etc.) The reality is that an aggressive strengthening program aimed from the hip down,\u00a0 particularly the eccentric control of knee flexion, adduction and internal rotation may in\u00a0 fact be more effective.<\/p>\n
The Ireland study (Ireland et al. 2003) states clearly that “females presenting with patellafemoral pain demonstrate significant hip abduction and external rotation weakness when compared to non-symptomatic age matched controls”. Lower extremity strengthening\u00a0 done with emphasis on hip control in combination with a program of progressive single leg\u00a0 plyometric training to address the eccentric and neural stability components may allow\u00a0 many trainees to experience long-term relief.<\/p>\n
Recent research has validated what up until now was an empirical feeling. Beginning three\u00a0 years ago all athletes training in our facility would be evaluated for hip pain (palpation of\u00a0 glute medius) when complaining of anterior knee pain. We found nearly a 100%\u00a0 correlation between Anterior Knee Pain and glute medius tenderness. All of our athletes\u00a0 with anterior knee pain had direct point tenderness in the glute medius of the hip on the\u00a0 effected side.<\/p>\n
Further study in the past year (Summer 2006) has caused us to look at the adductors, another hip stabilizer in the lateral sub-system. In 2006 in addition to looking at lateral hip
\nstructures as a potential causative factor in knee pain we also began to look at the strength and over-activity of the adductors. Upon further investigation we found weakness in the
\nadductor muscle group, with a preference to substitute hip flexors for adductors, as well as\u00a0 obvious tender trigger points in the adductors.<\/p>\n
The key from a both a cause and a solution standpoint lie in the sagittal plane dominant\u00a0 strength training so prevalent in the American system. Our American strength training
\nsystem is classically sagittal plane dominant as well as double leg oriented. It seems clear\u00a0 that the key to solving anterior knee pain lies in control of hip, knee and foot movement in
\nthe frontal plane and that single leg exercises must be employed in both strength training\u00a0 and power training to address these issues.<\/p>\n
In addition the single leg strength training must center on what we have termed single leg unsupported exercises like one leg squats and one leg deadlift variations. Knee dominant\u00a0 single leg exercises like split squats and rear-foot elevated split squats (sometimes referred\u00a0 to as Bulgarian squats from Spassov’s work) may provide adequate stress in the sagittal\u00a0 plane but do not provide adequate stress to the hip structures in the frontal or transverse\u00a0 planes.<\/p>\n
The athlete must be standing on one foot with the opposite foot having no contact with either the floor or any other object. In essence the act of standing on one foot and\u00a0 performing a single leg squat becomes a tri-planar exercise even though the athlete is\u00a0 moving in only the sagittal plane. Having only one foot in contact with the ground forces\u00a0 the hip structures (abductors and external rotators) to stabilize against movement into\u00a0 both the frontal and transverse planes. In these single leg unsupported exercises we will\u00a0 allow less than full ROM to develop hip control. This is a major exception in our system of\u00a0 training as we have always used full range of motion exercises. The objective is always to\u00a0 get to a full pain free range (see figure 1) with bodyweight before the addition of any\u00a0 external resistance.<\/p>\n
The exception will be the addition of five-pound dumbbells to allow weight shift toward the\u00a0 heel. We have dubbed this concept progressive range of motion exercise. The progression\u00a0 is in range versus load to cause the progressive control of hip motion.<\/p>\n
The following treatment program is suggested for patella-femoral pain syndromes:<\/p>\n
The term Reactive Neuromuscular Training can be confusing as the same term has been used by two well-respected physical therapists to describe two entirely different thought processes. Mike Clark of the National Academy of Sports Medicine uses the term Reactive Neuromuscular Training for all intents and purposes in place of the term plyometrics. Physical Therapist Gray Cook on the other hand uses the term Reactive Neuromuscular Training to apply to an entirely different thought process. Cook’s concept of Reactive Neuromuscular Training involves applying a stress to a joint in opposition to the action of the muscles. In other words to effectively target the hip abductors a band is placed around the knee and the leg is pulled with an adduction force. The addition of the adduction force will in effect “turn on” the abductors.<\/p>\n
Single Leg Unsupported with Progressive Range of Motion Increases and RNT Emphasis is a mouthful. The key is that the athlete is standing on one foot. In a therapy or personal
\ntraining situation the adduction force can be provided by the therapist or trainer with Theraband etc. In a groups situation the adduction force can be provided by a piece of Theratube as indicated in figure 2. In figure 2 the glute medius fires to counter the adduction force of the tubing (idea of courtesy of Shad Forsythe, Performance Specialist, Athletes Performance-Los Angeles)<\/p>\n
Additional Points of Emphasis<\/strong> Core training should always be included in any sound program but, with patellafemoral\u00a0 pain both quadruped and bridge variations should be used for emphasis on glute max and Conditioning\/ Muscle Endurance<\/strong><\/p>\n Retro walking is another excellent exercise for the athlete or client with patella femoral\u00a0 pain. Backward walking provides less stress to the patella-femoral joint and is in fact a Eccentric Strength<\/strong><\/p>\n Eccentric strength work should focus on single leg plyometrics with emphasis on landing\u00a0 skills, jumps should be forward as well as medial and lateral. In addition the MVP Shuttle
\nCore<\/p>\n
\nglute med function<\/p>\n
\nseries of closed chain terminal knee extensions. Backward walking can begin with a\u00a0 treadmill program of intervals at progressively higher inclines and progress to walking
\nbackward with a weighted sled.<\/p>\n
\ncan be used to develop landing skills for athletes returning from injury or athletes with\u00a0 poor strength to bodyweight ratios.
\nThe key to battling patella femoral pain is adopt a well rounded approach that works on the\u00a0 source of the pain versus the site of the pain and takes into account all of the functions of\u00a0 the lower extremity.
\nFigure 6- Slideboard Leg Curl<\/p>\n