On Injuries with Ben McCormack, P.T. Patellofemoral Syndrome or Pain under Kneecap by Ben McCormack

Information on this Web page is for educational use only, and is not intended as medical advice.
Every attempt has been made for accuracy, but none is guaranteed.
If you have any serious health concerns, you should always check with your health care practitioner
before treating yourself or others.
Always consult a physician before beginning or changing any fitness program.

If you are experiencing a grinding pain deep under the kneecap, which occurs when walking down the stairs, sitting for prolonged periods, or rising from a chair, you likely have patellofemoral syndrome. The syndrome is caused by lack of smooth tracking between joint surfaces of the thigh bone (femur) and the undersurface of the kneecap (patella)—hence the name: patellofemoral syndrome.

Diagnosis
To confirm that you have a patellofemoral syndrome you may try the following tests. I describe these tests as you would do them on yourself, but on the accompanying videos I show these tests as they are done by a physiotherapist—because that makes it is easier to point out what to look for. 

1. Sit with the legs out straight and lean back on one hand as you use the other hand to glide the kneecap up and down on the leg. Exert light downward pressure on the kneecap as you move it up and down. There may be a crunching feeling under your finger tips, but the symptom you are looking for is pain.

Proximal-distal glide. Click on the picture to see the video (Windows Media Video, 0.7 MB).

2. Glide the kneecap to the inside with one hand, and use the forefinger on the other hand to feel under the inside edge of the kneecap. Then push the kneecap to the outside and push up into the underside of the kneecap with your finger. Tenderness with either of these tests indicates a patellofemoral dysfunction.

Medial-lateral glide. Click on the picture to see the video (Windows Media Video, 1.24 MB).

3. If the above test doesn’t turn up any findings, then you can grasp your thigh firmly just above the kneecap, and then tighten your thigh muscle. You may notice a sharp pain when the kneecap glides under your hand. This represents a patellofemoral problem. It is painful and unnecessary to perform this test if you already had symptoms with test 1 or 2.

Resisted proximal glide. Click on the picture to see the video (Windows Media Video, 1.56 MB).

Treatment
Treatment of this problem should involve stretches and strengthening exercise not only at the knee, but higher up—at the hip, and lower—at the ankle. Both the ankle and the hip affect the rotation of the entire leg, and therefore directly affect the way the kneecap relates to the femur. You might also benefit from an external support device.


External Support Devices
Lateral tracking patella brace—this can be purchased at a pharmacy or a sporting goods store. Arrange the brace so that that patellar cutout puts some pressure against the outside edge of the kneecap, directing it inward.

Orthotics—if your arches “fall” or pronate when you stand, then you may want to try a set of orthotics. Lifting the arch of the foot with an orthotic will help the leg rotate outward, which will improve alignment between the kneecap and the femur.
           
McConnell taping—An athletic trainer or physical therapist can help train you to tape yourself. The goal is to place one layer of underlayment cotton-based tape on the knee, and then use another more rigid tape to glide and tilt the kneecap inward.

McConnell taping. Click on the picture to see the video (Windows Media Video, 7.15 MB).

Massage Techniques
Cross fiber massage to the outside of the thigh, deeply and aggressively at the level of the kneecap and 8 inches above the kneecap. You will be working the iliotibial band, which when tight, exerts an outward force on the kneecap, pulling it out of alignment. The iliotibial band (ITB) is a thickening of the fascia (tendinous covering of the muscles) on the outer part of the thigh. It is an extension of the fascia covering the gluteus maximus, gluteus medius and tensor fascia latae muscles. It crosses the hip joint and extends to the kneecap and top of the shin.

Massage iliotibial band. Click on the picture to see the video (Windows Media Video, 3.45 MB).

Inward Glides—push the kneecap firmly inward. Your legs need to be out straight, and you should lean backward if possible.

Inward glide. Click on the picture to see the video (Windows Media Video, 1.62 MB).


Strengthening Exercises

Butterfly. Sit down, bend your knees and pull your feet together. Lower your thighs using only the strength of the muscles on the outside of your hips and thighs. Do not push with your hands.

Exercise for strengthening hip abductors and external rotators. Click on the picture to see the video (Windows Media Video, 1.15 MB).

Lying Leg Raise to the Side. Lie on your side and lift your leg up.

Exercises for strengthening hip abductors. Click on the picture to see the video (Windows Media Video, 1.06 MB).

External Rotation of the Hip. Sit or stand and lift one leg (bending its knee) as if you wanted to see the sole of its foot.

Exercises for strengthening external rotators of the hip. Click on the picture to see the video (Windows Media Video, 2.18 MB).

Leg Lift with Hip Extension (below left). Stand upright and lift one leg like for a standing leg curl, but at the end of the curl keep raising the thigh to extend your hip. For better balance you may simultaneously lean your trunk forward. To make your hip extensors work harder in this exercise, curl your leg less, i.e., raise it while keeping its knee bent as little as possible.

Good Morning (below right). Stand upright with your feet between shoulder-width and hip-width apart. Grasp the bar using an overhand grip and place it behind your shoulders on top of your shoulder blades. Lean forward from the hips until your trunk is parallel with the floor. Make sure your whole spine, from the lower back to the neck, feels “straight”—keeps its normal, natural curves just like when you are standing upright—so the movement occurs mainly in your hip joints. Rounding the lower back can overstretch its muscles and ligaments and cause a lifetime of back pain. Do not arch your neck much. Before leaning forward look straight ahead and at the end of the forward lean look at the ground a yard or less in front of your feet. In the standard form of the good morning you bend your knees slightly—so they are not locked. In the advanced form of the good morning you keep your knees straight. Width of feet placement can vary depending on where you want to feel the stretch and tension during the lift. Your breathing pattern depends on the weight of the bar. With light weights it is possible to inhale as you lean forward and exhale as you straighten up the trunk. With heavy weights you have to inhale before leaning forward and hold your breath until your trunk is horizontal, then exhale as you raise your trunk.

I especially like good mornings (leaning forward and straightening up with bar on the shoulders) because they combine a light dynamic hamstring stretch with strengthening the hip extensors.

Exercises for strengthening hip extensors. Click on the picture to see the video (Windows Media Video, 4.14 MB).

In the exercises shown on the right, Tom Kurz uses barbell and kettlebells. To get the best deals and a fast delivery on all kinds of weights, click on the image below:

Squat. Stand upright. Look straight ahead, or slightly up, not down. Place your feet approximately shoulder-width apart and point them forward or slightly out. Feet stay flat on the ground throughout the whole movement. Descend as if sinking down on your legs, without letting your buttocks jut backward. Lean forward from the hips only a little—you should keep your back as close to vertical as possible and “straight” (with natural curves). Do not allow your buttocks to jut backward at the start of the ascent and do not let the hips lead the movement up. Do not bounce at the bottom to help with the ascent. Do not descend so low as to make a bounce necessary to raise up. Inhale as you squat down and exhale as you raise up.

You may have heard the myth that deep squats destabilize the knees. It is not true. Deep squats with weights improve knee stability provided that the feet are placed so there is no lateral rotation in the knees. For more inormation on squats see Tom Kurz column 22.

The squat is usually very problematic for people with very painful kneecaps. Especially if they don't understand what a good squat is . . . and most of people who have the patellofemoral syndrome don't (this ignorance of correct squatting is one of the reasons they suffer). To learn the correct squatting technique practice the squat facing the wall. That will keep your knees from moving far forward over the feet. Nevertheless, even with the correct technique, if you already have the patellofemoral syndrome, the deep squat probably won't be tolerable until late stage rehab.

Exercises for strengthening Vastus Medialis Oblique (VMO). Click on the picture to see the video (Windows Media Video, 6.28 MB).

Stretches
Iliotibial band pretzel stretch. Lay on your left side, hold your right foot behind your buttock with your right hand. Keep your thigh back, and then place your left ankle up on your right knee and push down. Hold for 30 seconds and perform 3 repetitions.

Distal ITB stretch or pretzel stretch. Click on the picture to see the video (Windows Media Video, 4.32 MB).

Hamstring Stretch. Lie on your back, bend one leg and lift it toward your chest, so you can grasp it behind the knee. The other leg should rest flat on the ground. Straighten the bent leg while holding it behind its knee. Don't forcibly pull the leg toward your chest—your hands only hold it in position. The stretch results from actively straightening the leg. Hold the stretch for 15–30 seconds.

Hamstring stretch. Click on the picture to see the video (Windows Media Video, 1.46 MB).

Summary: You should plan to follow the program above for at least 2–3 weeks before you notice significant gains. If you experience an increase of symptoms, try to figure out what exercise is provoking you and discontinue it. If you fail to get any results after 3 weeks, this would be a good time to visit a health practitioner.

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Information on the injury prevention, diagnosis, and treatment provided on this site is for educational use only, and is not intended as medical advice. Every attempt has been made for accuracy, but none is guaranteed. If you have any serious health concerns, you should always check with your health care practitioner before treating yourself or others.

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