Why Do I Have Knee Pain? Complete Guide to Patellofemoral Pain Syndrome: Part 7 - Rehabilitation - FITNESS PAIN FREE

Why Do I Have Knee Pain? Complete Guide to Patellofemoral Pain Syndrome: Part 7 – Rehabilitation

Patellofemoral pain syndrome (PFPS) is the most common form of knee pain treated in physical therapy clinics.  I made this series to help people better understand this condition, why it occurs and how to fix it.

In case you missed it:

Today we’ll be discussing how we rebuild our knee’s capacity and get out of pain.

So what do we need to do to get out of pain and back to training?

  1. Modify training and lifestyle
  2. Slowly load and build strength in a graded fashion
  3. Move right, enhance mobility and decrease pain with self soft tissue work
  4. Clean up poor psychosocial influences
  5. Normalize your body mass index (BMI)

1: Modifying training and lifestyle

So after our discussion on pain and restoring homeostasis of the knee it becomes pretty obvious that we have to find the right dosage of stress to get the knee to recover.

The reason I say “stress” is because it’s not just exercise that has to be dosed appropriately in order to get out of pain.  Initially our regular activities may have to be dosed as well.  If you perform a manual job (or even sedentary) and are regularly performing activities such as stair climbing, kneeling or prolonged sitting you may have to modify some of these activities for a period of time before returning back.

If you’re already training (weight training or running) these activities will have to be modified or eliminated temporarily to respect the capacity of the knee and allow progress.

Side Note: Here’s a quick way to tell if you’re modifying appropriately.  Your modifications should create minimal to no pain while performing them and no increase in pain following activity or the next day

2: Slowly load and build strength in a graded fashion

Once you’ve got your modifications squared away it’s time to start applying stress to the system.  In order to slowly increase stress on the PF joint we should keep in mind that increasing knee flexion and quad contraction directly increases stress on the PF joint (2, 4).  We can use these principles along with some help from our medical literature on the topic to develop a progressive program for the knee.

This program would be at it’s shortest 4 weeks long and at it’s longest 3 months.  Most of the research studying PFPS has their participants performing an exercise program for 4-12 weeks with an average frequency of 3 times per week (30, 31).  Usually these exercises are progressive in nature to create further adaptations as capacity improves (30, 31).

In the physical therapy realm we often use the term “phases” to help categorize exercise difficulty and total stress.  Phase 1 is easiest and as the phases increase the challenge of the program increases progressively.  Here are some of my favorite PFPS strengthening exercises in a phased format

Phase 1 Rehab:

Phase 2 Rehab:

Phase 3 Rehab:

Each of these phases lasts 2-4 weeks and should last as long as needed to progress to the next phase with minimal pain.  Everyone is an individual and some will need more time in each phase then another.

Once you start getting toward the advanced stages of rehabilitation (Phase 3 and beyond) we’ll have to start thinking about the specific demands of the activities you want to get back to.  For example:

  • Return to running
  • Return to weightlifting
  • Return to crossfit

Each of these activities stresses the knee in a unique way and rehabilitation will have to reflect these specific needs.  The runner will need to start introducing low level plyometrics that stress the knee in a similar way to running with an emphasis on endurance.  The weightlifter will have to introduce weighted squats in a gradual fashion slowly increasing depth, load and volume over time.

3: Move right, enhance mobility and reduce pain using self soft tissue techniques

Remember in part 1 and 2 we discussed how tightness in the lateral structures of the hip and quadriceps can be related to increased compression within the PF joint and subsequent pain?  Well, it’s time to address this.

We want to first assess to see if there are any restrictions in either a Thomas or Ober’s test.  Remember that our literature shows that improving these with physical therapy are predictors of who has successful rehabilitation after PFPS (1).

Thomas Test

Ober’s Test

Side Note: The Ober’s Test was traditional thought to assess limitations of the IT band, TFL and Glute.  More recent research has shown that the IT band does not restrict the Ober’s Test but rather the glute medius, glute minimus and hip capsule.  An intervention to address these muscles may be more prudent then the IT band.

If we find these then we’ll want to address them:

Side Note: Foam rolling has been shown to improve something called pressure pain threshold (PPT) (32).  PPT is basically the amount of pressure the body can handle before pain is experienced.  After foam rolling your pain threshold (for pressure) improves.   Foam rolling may directly improve pain in the knee through this mechanism.  However, I see far too many people who’s rehabilitation program consists exclusively of self soft tissue work and stretching.  Keep in mind this is NOT the gold standard when treating knee pain.

After we’ve taken care of these mobility issues it’s also important to address any limitations in mobility that are driving dynamic valgus of the knee during activity.  As discussed earlier, limitations in ankle dorsiflexion can cause faulty movement at the knee and hip during step down, jumping and landing activities.

We’ll want to first assess ankle dorsiflexion range of motion:

If we find a restriction then we correct it:

Next we’ll want to fix up any faulty movement patterns we see during the athlete’s activities.  This could be during running, agility d rills, squatting, jumping and landing drills.  Remember that hip strength is not necessarily a predictor of who moves poorly and improving hip strength on it’s own does not clean up movement (2, 4).

What does tend to improve an athlete’s movement is either some form of verbal cueing or the use of biofeedback tools like putting a mirror in front of an athlete while performing their sport specific task (2, 4).  Also remember that cleaning up someone’s movement during a specific task like a single leg squat will not carry over to correct biomechanics during running (2, 4).  Cues and biofeedback need to be utilized during all tasks our athletes wish to get back to.

Some examples would be:

  1. Cueing your athlete to keep their knees out during a squat
  2. Putting a mirror in front of an athlete while running and telling them not to allow the knees to come in while running

Also keep in mind that the foot can affect movement up the chain just as an issue at the hip can cause problems down stream.  Remember our discussion on excessive foot pronation causing femoral internal rotation:

If you are concerned yourself or an athlete has excessive pronation at the foot (and subtalar joint as discussed in the first article in the series) driving issues at the knee you might have to learn how to correct this with a technique called the short foot:

Once you learn how to create this arch in the foot it can be strengthened through specific exercises.  This short foot posture can also be trained through your normal lower body exercise routine, which I would recommend doing.

Side Note: Keep in mind that limited ankle dorsiflexion can cause faulty mechanics during squatting and jumping.  Also, excessive pronation can alter movement creating poor mechanics at the knee.  However, the evidence is mixed in this regard.  Some research shows that limited dorsiflexion is correlated to injury, some not and some shows the opposite (more mobility can predict who gets knee pain) (4,9).  The same thing goes for pronation, some studies show it is correlated with knee issues and some not (4, 9).  I think the take home message is to try and work on the factors you believe may be contributing to poor movement and pain but also don’t assume that having a flat foot or poor ankle mobility will condemn you to a future of miserable knee pain.  Remember that having pain and injury is multi-factorial and in theory if all other factors are optimized (to improve capacity) you may never have knee pain in the future.  

4: Clean up poor psychosocial influences

Now, this topic is starting to go beyond the scope of a typical physical therapist’s set of skills.  However, it is an important player in terms of rehabilitation and injury prevention.  If you believe you’ve got an athlete on your hands that needs more in depth work in this realm, definitely make sure you go see a professional that’s suited for the job.

With that being said, there are some simple things we can focus on to help in this regard (33).

  1. Identify anxiety and depression and refer out for additional services
  2. Identify any poor beliefs
  3. Patient education
  4. Influence positive beliefs and behaviors through the use of cognitive behavioral therapy (CBT) techniques
  5. Improve mental health through behavioral strategies

Some inherent conditions that are linked to PFPS are having anxiety and depression.  Obviously these are linked to stress.  We know that chronic stress increases cortisol levels and also makes our system more sensitive (28).  This may be a potential explanation for the increased likelihood of these conditions and PFPS.  Any individuals you suspect may have issues with anxiety or depression should see a professional to help in this area.

Poor beliefs are implicated in individuals with PFPS (2, 25).  Poor beliefs include things like a fear of movement, a belief that pain is a sign of more damage to the body, catastrophizations and beliefs that returning back to regular activities will worsen your condition.  We have quite a bit of research to show that these beliefs tend to keep people from getting better when attempting to rehabilitate (34, 35).

Keep in mind that poor beliefs can lead to poor behaviors.  If an individual believes that knee pain means they should rest the body they may never get moving.  As we know individuals with PFPS need movement in order to get better.  You can see how a belief like this can perpetuate pain.

Catastrophization is having an irrational thought and believing that something is far worse than it actually is.  These often happen after a triggering event and result in irrational negative thoughts.  For an athlete with PFPS a triggering event may be feeling his or her knee pain when attempting to train the squat in the gym.  The ensuing catastrophization may be:

“I can’t believe my knee hurts when I try to squat.  It will never get better and I’ll never be able to compete in weightlifting ever again”

When we evaluate the above statement we realize pretty quickly the statement isn’t very factual or logical.  PFPS is a condition that gets better with the right rehabilitation and competing in the future is not only a possibility but also much more likely then not being able to compete in the future.  Having these thoughts are thought to increase sensitivity of the nervous system and perpetuate pain (36).

If you have any of these poor beliefs they need to be addressed via education and strategies like cognitive behavioral therapy (CBT).  CBT is basically a strategy of disputing negative thoughts that create poor behaviors and perpetuate pain (33, 35).  In this way people in pain can be more objective about their pain, more positive about their outcomes and better able to make behavioral changes that lead to improved pain levels.

Anxiety, stress and depression can elevate cortisol levels in the body (28).  These chronically elevated cortisol levels can also lead to increased pain levels in the body (28).  Improving mental health can improve anxiety, depression, stress and with it it’s cascade of problems that can exacerbate pain.  This can be done through reducing stress, sleeping 7-8 hours per night, getting some mental health professional guidance, regular exercise and starting a meditation practice (33).

5: Normalize your Body Mass Index (BMI)

Now this one is pretty obvious.  The more weight you carry around on a regular basis, the more stress on the knees.  Getting on a solid nutrition and exercise program can help out in this regard.

So to recap:

  • Modify training and lifestyle activities to respect the joint’s limited capacity after an injury
  • Start gradually loading the hip and knee through a progressive strengthening program
  • Identify and correct soft tissue and mobility limitations in the ankle, quads, glutes and hip flexors
  • Reduce pain levels using soft tissue techniques like foam rollers
  • Correct any movement faults through biofeedback and verbal cues.  Movement corrections must be specific to the task you’re trying to improve (i.e. running or squatting)
  • Clean up poor psychosocial influences using therapeutic neuroscience education and techniques like CBT
  • Normalize your BMI to reduce stress on the knee

That’s it guys!  I hope you enjoyed the series.  If you found it useful please share it with anyone else you think could benefit from it.  Making this series was a colossal undertaking for me (took a few months of research, writing, filming and editing).  Thank you for taking the time to read it.  Hopefully it helps you with your knee pain or helps others get out of knee pain!

Knee pain no more,

Dan Pope DPT, OCS, CSCS, CF L1 

Works Cited:

  1. Current Concepts and Treatment of Patellofemoral Compressive Issues IJSPT 2016 https://www.ncbi.nlm.nih.gov/pubmed/27904792
  2. Current Concepts in Biomechanical Interventions for Patellofemoral Pain IJSPT 2016 https://www.ncbi.nlm.nih.gov/pubmed/27904791
  3. Examination of the Patellofemoral Joint IJSPT 2016 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5095938/
  4. Biomechanics and pathomechanics of the Patellofemoral Joint IJSPT 2016 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5095937/
  5. Salsich GB, Perman WH. Patellofemoral joint contact area is influenced by tibiofemoral rotation alignment in individuals who have patellofemoral pain. J Orthop Sports Phys Ther. 2007;37(9):521-528.
  6. Tibiofemoral and Patellofemoral Mechanics are Altered at Small Knee Flexion Angles in People with Patellofemoral Pain https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3425715/
  7. Kay M Crossley, Marienke van Middelkoop, Michael J Callaghan, Natalie J Collins, Michael Skovdal Rathleff, Christian J Barton, 2016 Patellofemoral pain consensus statement from the 4th International Patellofemoral Pain Research Retreat, Manchester. Part 2: recommended physical interventions (exercise, taping, bracing, foot orthoses and combined interventions) BJSM http://bjsm.bmj.com/content/early/2016/05/31/bjsports-2016-096268
  8. Christian John Barton, Simon Lack, Steph Hemmings, Saad Tufail, Dylan Morrissey, The ‘Best Practice Guide to Conservative Management of Patellofemoral Pain’: incorporating level 1 evidence with expert clinical reasoning BJSM 2015http://bjsm.bmj.com/content/49/14/923#T
  9. Patellofemoral pain syndrome and its association with hip, ankle, and foot function in 16- to 18-year-old high school students: a single-blind case-control study. https://www.ncbi.nlm.nih.gov/pubmed/21622633
  10. Factors associated with patellofemoral pain syndrome: a systematic review. BJSM 2013 https://www.ncbi.nlm.nih.gov/pubmed/22815424
  11. The Pathophysiology of Patellofemoral Pain Syndrome – Scott Dye http://prdupl02.ynet.co.il/ForumFiles_2/19447772.pdf
  12. Hartmann, H., Wirth, K., & Klusemann, M. (2013). Analysis of the Load on the Knee Joint and Vertebral Column with Changes in Squatting Depth and Weight Load. Sports Med.
  13. 2016 Patellofemoral pain consensus statement from the 4th International Patellofemoral Pain Research Retreat, Manchester. Part 1: Terminology, definitions, clinical examination, natural history, patellofemoral osteoarthritis and patient-reported outcome measures” in Br J Sports Med, volume 50 on page 839.
  14. Trunk and lower extremity segment kinematics and their relationship to pain following movement instruction during a single-leg squat in females with dynamic knee valgus and patellofemoral pain. 2015 https://www.ncbi.nlm.nih.gov/pubmed/24836048
  15. The Basic Science of Articular Cartilage – Sports Health 2009 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3445147/
  16. Patellofemoral joint kinetics while squatting with and without an external load. JOSPT 2002 https://www.ncbi.nlm.nih.gov/pubmed/11949662
  17. The Development and Application of an Injury Prediction Model for Noncontact, Soft-Tissue Injuries in Elite Collision Sport Athletes. (n.d.). Retrieved August 01, 2016, from https://www.researchgate.net/publication/46288877_The_Development_and_Application_of_an_Injury_Prediction_Model_for_Noncontact_Soft-Tissue_Injuries_in_Elite_Collision_Sport_Athletes
  18. Relationship Between Training Load and Injury in Professional Rugby League https://www.researchgate.net/profile/Tim_Gabbett/publication/49775412_Relationship_between_training_load_and_injury_in_professional_rugby_league_players/links/551894590cf2d70ee27b41ad.pdf
  19. Training and game loads and injury risk in elite Australian footballers. (n.d.). Retrieved from https://www.researchgate.net/profile/Brent_Rogalski/publication/234699103_Training_and_game_loads_and_injury_risk_in_elite_Australian_footballers/links/53dadd6b0cf2a19eee8b3f9f.pdf
  20. The acute:chronic workload ratio predicts injury: high chronic workload may decrease injury risk in elite rugby league players. Retrieved from http://bjsm.bmj.com/content/50/4/231 Hulin, Gabbett, Lawson, Caputi, Sampson
  21. Prospective Predictors of Patellofemoral Pain Syndrome: A Systematic Review With Meta-analysis. Sports Health 2012
  22. Factors associated with patellofemoral pain syndrome: a systematic review. BJSM 2013 https://www.ncbi.nlm.nih.gov/pubmed/22815424
  23. Is body mass index associated with patellofemoral pain and patellofemoral osteoarthritis? A systematic review and meta-regression and analysis. BJSM 2017 https://www.ncbi.nlm.nih.gov/pubmed/27927675
  24. Is Knee Pain During Adolescence a Self-limiting Condition? Prognosis of Patellofemoral Pain and Other Types of Knee Pain. AJSM 2016 https://www.ncbi.nlm.nih.gov/pubmed/26792702
  25. The psychological features of patellofemoral pain: a systematic review. BJSM 2017 https://www.ncbi.nlm.nih.gov/pubmed/28320733
  26. The Association of Ankle Dorsiflexion Range of Motion With Hip and Knee Kinematics During the Lateral Step-down Test. JOSPT 2016
  27. The effect of reduced ankle dorsiflexion on lower extremity mechanics during landing: A systematic review Journal Sci Med Sport 2017 https://www.ncbi.nlm.nih.gov/pubmed/26117159
  28. Stress and Your Body: The Great Courses by Robert Sapolsky
  29. Effectiveness of Manual Therapy on Pain and Self-Reported Function in Individuals With Patellofemoral Pain: Systematic Review and Meta-Analysis JOSPT 2018 https://www.jospt.org/doi/pdf/10.2519/jospt.2018.7243
  30. Effectiveness of hip muscle strengthening in patellofemoral pain syndrome patients: a systematic review https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4518569/
  31. Exercise for treating patellofemoral pain syndrome: an abridged version of Cochrane systematic review. https://www.ncbi.nlm.nih.gov/pubmed/26158920 Cochrane 2016
  32. Differences in pressure pain threshold among men and women after foam rolling. https://www.ncbi.nlm.nih.gov/pubmed/29037655
  33. Managing Chronic Pain – John Otis: Treatments that Work
  34. A prospective study predicting the outcome of chronic low back pain and physical therapy: the role of fear-avoidance beliefs and extraspinal painhttps://www.ncbi.nlm.nih.gov/pubmed/26995499
  35. Nonspecific Low Back Pain and Return to Work https://www.aafp.org/afp/2007/1115/p1497.html#sec-7
  36. Therapeutic Neuroscience Education – Adriaan Louw

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