Patellofemoral Syndrome

Having done your annual Memorial Day Murph, you might have woken up the next day with sore knees and returned to the daily grind behind a desk. Everything feels fine…until you stand up. Come to think of it, every time you extend your leg it hurts and stairs are no joke. You may be experiencing patellofemoral pain.

patellofemoral-pain

Your knee joint is made up of the femur (thigh bone) and tibia (shin bone), but a lesser known joint that can become problematic is the patellofemoral joint; the junction between your knee cap and femur.

The end of the femur has two protrusions called condyles with a groove between them. Remember how you used to draw bones as a kid? It’s just like that. That groove acts like a trough that keeps the patella in line when you squat and stand. And the patella is smack in the middle of where the quadriceps muscle transitions to the patellar ligament (better known as patellar tendon). When you’re at the bottom of an ass to grass squat your patella should be nice and congruent with that groove. When you stand up, the tension releases and the patella glides within the groove until you’re at full extension. Kind of like this. Patellofemoral pain occurs when the patella just doesn’t want to slide in that groove.

What seems like a minor biomechanical issue can get pretty nasty. The femoral groove has raised edges and the patella rounded on both sides, like a fat almond. If the patella is grinding on that edge, it damages the cartilage covering both the back of the patella and the surface of the femoral condyle. Double duty cartilage damage = no fun. Plus, the cartilage on the surface of both the bones is not thick like the meniscus, it’s thin; just enough to keep everything slippery and sliding smoothly. Keep grinding and it can wear right through the protective covering. Now we’re talking bone on bone and tons of friction.

patellofemoral-syndromepatellofemoral-syndrome

Patellofemoral pain occurs for a number of different reasons, both structurally and functionally. Structurally, your bony geometry might set you up for failure if you have wide hips, or femurs that are rotated. Functionally, musculature pulling or giving slack on the knee cap can mess with its ability to stay in the groove. Over time, even the joint capsule and ligaments on either side of the patella can become tight, leading to subpar movement.

If your problem is structural, there’s not a lot you can do, conservatively, to change the way your body is put together. Patellofemoral pain syndrome can lead to more serious issues like arthritis or subluxing/dislocating patella that could lead to surgical intervention. BUT there are a number of things you can try to manage the functional causes of your pain. Mobility is always a great place to start. Ask yourself these questions:

Am I acutely inflamed or is this an ongoing issue?
If you’re going on your third day of knee pain, applying some heat before mobility can help to make the tissues more pliable before doing any dedicated mobility work. Before that? Ice, NSAIDs , and compression. There are braces designed to control patellar motion and a taping technique called McConnell taping. It’s not as sexy as ROCKTAPE, but holds for days….literally.

Do I have full mobility?
Consider the hip and ankle too, not just the knee. A lot of times, hip and ankle dysfunction cause knee problems just because it’s stuck in the middle. If you’re not already in tune with your trouble areas, there are a number of resources out there to assess your functional mobility.
  Here’s one of them.

What is the quality of my movement? Do my knees feel creaky, achey, crunchy?
These are signs of poor tissue quality. If you’ve got a foam roller or lacrosse ball lying around, dig in to EVERY muscle in your lower extremity that lights you up. This below video demonstrates a pretty comprehensive foam rolling routine, pay particular attention to 5:10 on for the lower extremity. Remember, just because your knee is in pain, doesn’t mean that that’s the root of the issue. Self myofascial release can be eye opening, so take note to where your trigger points are.

Am I holding the standards and proper alignment for all the motions that have knee flexion/extension?
This can be a tough one to evaluate, so get some extra eyes on you. Developing good movement patterns before adding weight is essential to developing strength in all the muscles that help establish and maintain proper alignment. Some movements you may want to examine are squats, cleans, and that quick dip drive into your split jerk. Don’t forget about running and jumping…double unders, box jumps….Clovis. Yikes.

 

Written by Liz Caruso‏

5 Comments

  1. Ali, I agree with your PT it sounds like you started out with a mild tendonitis that got worse because of pushing through pain, your story is common. I would see an MD just to confirm, but often times these can take months to completely go away. read the tendonitis post on 321GOMD. Good luck

  2. Hi there,
    I have been expereicning knee problems and am very bothered about it. If you could give me some advice or share some knowledge I would really appreciate it. Thanks for reading…
    I am a 16 year old female who has been doing crossfit for just over a year now. I am 5’9″ and around 120lbs, so I am relatively tall and slim, with very long legs. In April I was doing an Easter WOD with a lot of burpee box jumps, as well as back squats, wall balls, double unders, etc. and I felt completely fine during the workout. After I didn’t notice anything, but that night my right knee felt a little “off”. The next day it was still there, and I didn’t really know what it was. I never once remember hurting my knee, or jumping funny or anything. However I went to the gym the next day and the workout was back squats. My right knee seemed to bother me when I squated, but thinking not much of it, I kept on through the workout. It didn’t get worse, but it didn’t get better. I told my parents and we decided to go to the physiotherapist that works at our crossfit gym to see what he thinks. I am a very active person, who plays volleyball, runs track, crossfits about 5x per week, etc. The physiotherapist examined my knee and thought that I had tendinitis, caused by many things. These, he thought, include that I am growing, very active (maybe too active), tall with long limbs, and it is likely an overuse injury, that has not had much time to recover. I went to physio, did exercies to strengthen my glutes, quads and hamstrings (am still doing them today) and the problem seemed to persist, and the pain did worsen to some extent because I know how it feels now was not as bad as it was when I first notice it. The pain did not subside, however I also did not give me knee much rest; I kept working out, playing volleyball, etc. along with physio, hoping it would get better. It is now the end of June, and the problem is still there. The knee pain is quite bad and my physiotherapist still believes there is nothing seriously wrong, other than overuse, I am growing, my legs are so long, things are still adjusting, haven’t grown into my body, etc. The last 2 weeks I have taken completely off, doing nothing but walking, (no crossfit, it’s also summer vacation so volleyball, track, etc. aren’t in season) to try and heal. It doesn’t seem to have made it better. I have also been doing acupuncture, which seemed to help the first time, but now I am not sure. The pain is present when I squat, and it’s quite bad at times. It is not like an achey pain below the knee cap from squatting, but rather something deeper in the knee, like something is rubbing, or out of place or something, I am not too sure. I feel it just about my knee cap, surrounding my knee and any pressure on my right side iritates it and cuases the pain. This includes getting out of chairs, which is a big one since I notice it all day. I just know it hurts a lot to squat, and never used to. It also clicks when I walk. Any pressure on the bottom of my right foot (putting a shoe on, squatting, getting up from the couch, etc.) causes pain. If I do some air squats, the pain seems to go away somehwat, after about 4 squats or so. It doesn’t go away completely, but it goes away a little bit. I have continually done my exercises, rolling out all the muscles in around my knee, stretching, etc. but it doesn’t seem to be getting much better. I have not squatted or done any exercises since April that have bothered it, which is basically anything invloving squats (olympic lifting, wall balls, back squats, etc.) I haven’t really even done air squats. Now my physiotherapist says to try and do thsese movements (nothing heavy of course) as long as the pain is no greater than a 3 on a scale of 1 to 10. I am hoping to go back to the gym this week (Wednesday or so) and see how this is. I have also ordered rehband knee sleeves to see if that helps. I ice it every night. I also ran into a metal post while toboganning a few years ago, and put a dent in my quadricep muscle. It was a very painful accident that left me with a large dent in my right quad, almost like the muscle was cut or something. I did physio for that, but eventually the pain went away, and I was just left with a nice dent! He thinks this could be minorly contributing to my knee troubles. When he does the accupuncture, there is a lot of scar tissue around my quad where the dent is that could be a contributing facotr. It also hurts my knee to flex my quad or extend it fully (like in a locked position). My right ankle is also seeming to be very stiff and less mobile. My right leg does not fully extend as far as my left when I sit down and put both legs out. The pain doesn’t seem to go away in my knee, and I keep hoping that I will wake up one day and it will be much better or gone, but no such thing is happening. It doesn’t bother me to sit still, but as soon as I get up, the pain is very present and just a reminder to me that something is clearly wrong. I am beside myself and don’t know what to do because being active is basiaclly my life, and this injury has been extremely hard for me. I want to get back to my normal ways, but I can’t help wonder if that will ever happen. I wodner if I am screwed up my knee for life, adn peopole keep reassuring me I haven’t but how do I know? I have made a doctors appt. to see what my doc thinks about it, if I should see a specialist, or what. That is not until July 11th. Although my physiotherapist thinks there is nothing “serious” wrong with it, I can’t help but wonder if there is. I just want it to feel normal again, but it seems like its far from that. Some people I have talked to say they had knee trouble and their’s got better but just took a really long time, but in my mind it has been a really long time. I run quite a bit (or I was before injury) and have had the achey pains before, but this is different. I can’t quite describe it, but it definitly stops me from doing things that I once did not problem, and I am not exactly a baby when it comes to injuries! (I don’t think!) I have been very lucky in the past to stay healthy and my parents and I just think this is a lesson. I was not giving my body enough time to recover, and was overworking/overdoing it by going to the gym, sports practices, running onmy own, and virtually taking hardly any days or time off. I have definilty learned my lesson, and plan to take more days off, and just appreciate my health and wellbeign if I get back to squatting and functioning “normally” with no pain again. But now I just want to heal and get back to myself, prior to the injury. I am not sure what to do, if I should seek further medical attention or just give it more time. Perhaps there is more than just tendinitis wrong with it and I can’t handle it and would appreciate any thoughts you have! Thanks so much, Ali

  3. Great Blogging Styles.. In the last Australian Open tennis Tournament it has been seen that Serena William was wearing a Tape in her left leg to get rid off from pain and injury. As I am therapist, I know well what it was. Some of my fellow asked what it was? I am going to explain… Rocktape a special medical tape that is mostly used by the athletes and injured people. It contains special medicine that can reduce severe pain and injury within a few seconds. Now RockTape is also used by the general by following instruction with it.

  4. Sorry for the delay. We had a software glitch. Hope it is feeling better by now. But as I tell people that is the beauty of crossfit there are so many other things that you can do upper body wise and fitness wise that don’t irritate the patellofemoral joint. Push-ups planks modified pull-ups kettle bells you name it. Do what doesn’t hurt.

  5. Liz – very helpful stuff here. Just got diagnosed with this today after almost 3 weeks of pain and my specialist’s recommendation was to simply avoid activities that irritate the knee: running, jumping, squatting, lunges…Crossfit, essentially. Thanks for giving some how-to’s on how to effectively manage the pain and prevent recurrence without needing to completely abandon what I view as essential fitness movements.

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About Me

Dr. Sean Rockett is an Orthopedic Surgeon specializing in Sports Medicine. His group is Orthopedics New England with offices in Dedham, Natick and Newton, Massachusetts. Dr. Rockett is a CrossFit Level 1 Trainer and has been a CrossFitter at CrossFit New England since 2007. Dr. Rockett is on the Medical Team for the CrossFit Games and the Northeast Regionals.

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