Many runners, jumpers, and other athletes develop pain behind/around one or both patellas (knee caps) at some point. Although the exact cause of the pain is not known for certain, there is a prevailing theory about what causes it, and that theory has led to some treatments that seem effective, and some changes in running form (biomechanics) that seem also to help. I have suffered from patellofemoral pain several times as an adult. The pain for me was each time coincident with increases in volume of hiking, running, or jumping activities without any obvious sudden event to mark it’s onset. It simply comes on slowly and over time gets worse if I don’t get a handle on it.
What is it?
Patellofemoral pain appears to be due to some soft tissue irritation in the knee, due to pressure and rubbing of the patella in a groove at the bottom end of the femur (at the knee). It is not always known why this irritation occurs mechanistically speaking, but it often coincides with increases in loading on the knee through running/jumping like activities. There is some evidence which suggests tightness or lack of flexibility in the outer quadriceps muscle (vastus lateralis), weakness or insufficiency in the inner quadtriceps (vastus medialis), or a combination of these things may contribute for people with certain anatomical and gait characteristics. The above mechanisms are thought to cause irritation because they hypothetically result in an imbalance that causes the patella to be pulled more forcefully toward the outside of the knee as it slides up and down it’s track/groove in the femur.
The more forceful rubbing against the outer side of the groove in which the patella slides during flexion and extension of the leg at the knee joint. It is thought that this rubbing, particularly in people who have a popping or crackling when extending the knee under load, which indicate some amount of roughness in the cartilage on the back of the patella. The friction of this forceful rubbing is thought to cause inflammation that can spread and radiate to surrounding soft tissues, and causing pain, particularly when running downhill or walking down stairs, often on the opposite side of the kneecap from where side of the rubbing. There may or may not be obvious swelling.
What to do about it
The primary treatment recourse today is a regimen of icing after activities that cause the pain to flare up, and a series of strength and flexibility exercises intended to loosen the forces applied on the outside of the patella by the vastus lateralis and some think by excess tightness in the iliotibial band (although this is less certain), and to strengthen the vastus medialis muscle so the forces on the patella are better balanced during activities in which the leg is forcefully and repeatedly extended under load. Exercises that I have personally used when experiencing patellofemoral pain include well sits, leg extensions, slow quarter squats, slow step ups (8-12″ step), and slow step downs, and bridge pose (yoga). Quadriceps and hamstring stretches are also thought to be useful, as are hip abductor exercises. I also do iliotibial band stretches, although these actually stretch gluteus and hip adductor muscles and not the iliotibial band itself, because it is not a pliable tendon, but rather a thickening of fascial tissue that does not elongate measurably or in any enduring fashion in response to stretching (see previous post). Tension on the iliotibial band instead results from tightening/contraction of the gluteus medius and hip adductor muscles and also indirectly by tightness of the lateral quadriceps musculature that the iliotibial band is stretched over along the outer thigh.
Recent evidence also suggests that patellofemoral pain sufferers might prevent symptoms or experience relief by modifying their running form and strengthening the hip and core musculature that supports improved running form. As a practitioner of a modified midfoot/forefoot running form intended to remedy a variety of biomechanical problems, I have found that there are things I can do while running to reduce patellofemoral pain when it flares up, so I can add my own anecdotal support for the benefits of improved biomechanics as well (also, see my earlier post, which refers to research results on this subject).
You may find recommendations for straps or bands. Nobody I know has used one of these and become convinced that they do any good whatsoever, particularly when positioned below the patella. I found it worsened my symptoms to position one of these straps so, but wearing a strap above my kneecap seemed to help. Still, I wouldn’t recommend using a strap of any kind off-hand. They may help some people, and if you want to give it a shot, you are free to. I just don’t have a lot of faith in the below-knee strap based on my own experiences and those of other runners I know.
The good news
The good news is that for most people the pain goes away without more drastic surgical “smoothing” of the cartilage on the back fo the patella, or release (cutting) of lateral ligaments that attache structures such as the iliotibial band to the patella. That’s good news, because the surgeries are often ineffective anyway, and require a length rehabilitation.
The ‘other’ news
It’s really unclear as yet whether the typical treatments are any more effective than pure rest and recovery. Some studies suggest it is, but more, well-designed studies need to produce similar results before this conclusion can be asserted with greater confidence.
Summary
If you suffer from patellofemoral pain, you don’t have to sit around with an ice pack and feel sorry for yourself. There are some exercises and stretches you can do, and some possible improvements to your running form, that could very well help vanquish your pain. One thing for sure is that these modes of treatment have other probable benefits, and likely won’t hurt you, even if they actually do little or nothing more than simple rest can accomplish.
As with any knee pain, it is still prudent to get an official diagnostic, because more serious ligament and meniscus injuries can easily be confused with the more common patellofemoral pain. This is not a mistake any of us would want to make.
