ANTERIOR KNEE PAIN Explanation Anterior knee pain is most commonly caused by irritation and inflammation of the patellofemoral joint of the knee (where the patella/kneecap connects to the femur/thigh bone). The normally smooth, easy gliding connectivity of the knee cap and femur becomes inflamed, rough, and irritable, often resulting in chondromalacia. This is only exacerbated with physical activities, such as walking, running, or climbing. Continued activity while the joint is inflamed can result in mild to severe pain and significant swelling. Causes There are many causes of anterior knee pain, such as injury or incident, scar tissue, and localized arthritis; however, the most common cause is overuse. This can occur in anyone involved in consistent, especially extreme, physical activity that exercises the patellofemoral joint, such as running, hiking, and the like. This injury is more common in women than in men, increasing in incident after age 40. It is possible to be predisposed to anterior knee pain with issues such as scar tissue or even, weakened thigh muscles, which could cause friction between the patella and the femur, resulting in this injury. Poor mechanics can also greatly contribute to anterior knee pain. Poor balance, a lack of proper stretching before and after physical activity, and awkward or incorrect placement of the feet while active (walking, running, etc.), such as turning the ankle inward as the foot meets the ground, result in poor mechanics, which in turn, can result in anterior knee pain. Signs of this can be seen in the wear of your shoes. Significantly worn heels, especially if the wear can be seen in the center of the heel, can be a sign of poor mechanics. Wear should occur only on the outer borders of the heel when exhibiting proper mechanics. Shoes, in general, can be an issue. Avoid partaking in physical activity while wearing badly worn shoes or shoes that are inappropriate for the activity. This is a particular issue with running. Be sure to wear shoes with a proper inner support system, which have been broken in, but not worn down. It is best to wear shoes that are designed for the activity. Anterior knee pain may also be a result of direct trauma or injury to the kneecap, though this is less common. Motor vehicle accidents as well as heavy contact sports, such as football, have been known to lead to this injury. Symptoms Anterior knee pain most commonly starts out as a slight irritation, evolving with further activity, and eventually, growing into severe pain. This pain becomes exacerbated with activities such as running, walking, jumping, hiking, squatting, etc., and usually begins below the kneecap or radiating from both sides of the knee. 1
Diagnosis Your health care provider will ask a number of questions in order to obtain a history of the injury, including the type of physical activity relative to the injury, when the pain first occurred, if any specific incident may have taken place that would result in the injury, and what specific activities both intensify as well as relieve the pain. He or she will then determine swelling and pain degree through physical manipulate of the knee (bending, moving, flexing, etc.), which could also include doing specific exercises. In extreme cases, or if further imaging is needed, your health care provider may order x-rays or an MRI. Treatment In most cases of anterior knee pain, standard treatment involves significant rest as well as ice therapy (application of cold). Ceasing physical activities, especially those relative to or causative of the injury, is recommended, along with applying cold (ice packs) to reduce swelling and inflammation. Pain management consists of non-steroidal anti-inflammatory drugs, such as Ibuprofen, elevation, and compression (such as a tight bandaging). In some cases, your health care provider may suggest wearing a brace to help control the movement of the patella. Orthotic shoe inserts may also be helpful in correcting mechanical issues, such as poor balance and placement when running, walking, and climbing. In more severe cases with resistant symptoms, physical therapy may be needed, or direct injections of anti-inflammatory drugs into the knee may be required and provided, and in even rarer instances, surgery may be required to correct the problem. Exercises designed to strengthen the musculature of the thigh are another common part of treatment for anterior knee pain, and can be seen in the Rehabilitation section below. Lasting Effects When the cause of anterior knee pain is overuse, recovery can often be fairly quick with a return to activity within a week or two; that is, if treatment (rest, ice therapy, compression, and elevation) is thorough. When you first return to activity, though, you should perform at a lower intensity and with less frequency. If the condition is due to poor mechanics, return to activity may be prolonged, as not only the injury must be treated, but the cause of the injury must also be corrected. Orthotic devices can be corrective and possibly speed up return. Healing Time and Return to Play The amount and intensity of your pain is generally the best guide to knowing when you are ready to return to activity. It is best to be pain-free (symptom-free) before returning to activity; however, a slow return to activity can be gradually made throughout recovery, maintaining a reduction in intensity. If pain, swelling, and inflammation have subsided, it is generally acceptable to return to activity, beginning slowly and gradually working into a higher intensity; however, if minor activity such as walking is painful, then more strenuous activity should be avoided entirely. With patients using corrective devices, such as orthotic shoe inserts, activity should be restricted and regulated until all pain, inflammation, and swelling has subsided and the device has proven effective. 2
Prevention The best preventative measures for anterior knee pain is to thoroughly develop and maintain strength of the thigh muscles. However, one common misunderstanding is the thought that repetitive use of a muscle in an endurance activity, such as running or climbing, will increase strength of the muscle, when factually, it fails to do. This enhances durability, not strength, and in order to prevent anterior knee pain, the thigh muscles must be both durable and strong. The exercises explained below can increase strength. Warm-up should always be performed prior to fully-involved activity, such as walking and running, and should be specific to the activity (building from slower pace to higher intensity). Proper stretching before each workout can be preventative and can easily be incorporated as part of your warm-up routine. Be sure to stretch the quadriceps, hamstrings, and calves. FIGURE-4 HAMSTRING STRETCH 1. Sit on the floor with one leg fully extended then flex the knee of the other leg and place foot next to the inner thigh of the extended leg. 2. While keeping the knee of the extended leg on the floor, exhale as you bend your trunk and reach forward with both hands, attempting to touch your toes. 3. Hold statically for 5-10 seconds, and then inhale as you slowly come up out of the stretch. STANDING CALF STRETCH 1. From a standing position, step one leg back 24-36 inches. 2. Begin stretch by extending the knee of the back leg and pushing the heel to the floor while slightly flexing the front knee. 3. If this does not produce an adequate level of stretch, lunge deeper on the front leg by flexing that knee further down while keeping the heel of the opposite foot down. 4. Hold statically for 5-10 seconds. SOLEUS STRETCH 1. From a standing position, step one leg back 24-36 inches. 2. Begin stretch by flexing the front knee and pushing the heel of the back foot toward the floor while maintaining a slight flexion in the back knee. If you begin feel more stretch in the calf, bend that back knee a little more. 3. Hold statically for 5-10 seconds. 3
Varying your workouts can help to prevent or avoid further anterior knee pain. Substituting activities can be beneficial from time to time, such as swimming or cycling in place of running. Applying cold (ice packs) to the knee after each workout, especially extensive workouts or those that result in tenderness, can help prevent recurrence. With cases involving the use of corrective devices, patients should focus on strengthening the thigh muscles and enhancing flexibility to help prevent symptoms, though full recovery may be prolonged until mechanical issues have been corrected. Some people are genetically predisposed to anterior knee pain, such as those with wide hips and inwardly-canted thighs who are active runners, hikers, etc. Rehab Recommendations The following exercises can be performed to increase hip and knee flexibility, muscle strength in the thighs, as well as range of motion. In some cases, reduced intensity may be required, and in more severe cases, total abstention from physical activities relative to the injury. Both legs are exercised in several of the following exercises, in order to prevent future anterior knee pain in the uninjured leg (as the uninjured leg has had to assume much of the work of the injured leg, which makes it prone to injury). Perform these exercises three times daily for maximum effect, though work gradually up to this. THIGH CONTRACTIONS 1. Sit up on a table or any comfortable surface with both legs fully extended with feet close together and place both hands behind you to support your torso. (Starting position) 2. With thighs feeling relaxed, begin Thigh Contraction by fully exerting and contracting the muscles of the quadriceps and hold that contraction for 3-5 seconds. 3. Slowing release the contraction and allow quadriceps to relax back to the starting position. SUPINE UNILATERAL HIP RAISE 1. Lie back on a comfortable surface with the leg of the injured hip fully extended and the knee of the uninjured side bent up. (Starting position) 2. Begin Hip Raise by lifting the extended leg upward 12-24 inches off the floor, as you inhale and hold leg up for 3-5 seconds. 3. Slowing lower the leg as you inhale and return back to the starting position. 4
PRONE UNILATERAL HIP EXTENSION 1. Lie facedown on a comfortable surface with both legs fully extended, both elbows flexed and hands placed under your chin. (Starting position) 2. Begin Hip Extension by lifting the leg of the injured hip upward around 12 inches off the floor, or as far as your hip will comfortably allow, as you inhale and hold leg up for 3-5 seconds. 3. Slowing lower the leg as you inhale and return back to the starting position. 5. For rehab purposes, repeat movement only on the injured hip for prescribed number of reps. HALF SQUATS 1. Begin by placing your feet slightly wider than shoulder-width apart with your toes slightly angled out and your hands on your hips. 2. Inhale (breathe in) while you lower yourself as if you were preparing to sit down. A chair can be used with pads or pillows to adjust height. As you descend, be sure to maintain control all the way down, keeping your heels down, head up, and back slightly arched. 3. Once at the bottom (or on chair), stand by simply reversing the movement while maintaining a neutral (slightly arched) back, exhaling (breathing out) on the way up. PLIE 1. Begin by standing with both the heels of your feet together and toes rotated outward (everted) as far as your legs will comfortably allow. 2. Place hands on your hips or one hand holding on to a stationary object. (Starting position) 3. Begin Plie as you inhale and bend the knees, descending to the point where your knees are flexed between 45 and 80 degrees. Be sure to maintain control on the way down, keeping your heels together, head up, and back erect. 4. From the bottom, stand back up by reversing the motion and extending the knees, as you exhale on the way up. Once the effects of anterior knee pain has been minimized, you can begin to incorporate other exercise activities like swimming, cycling, jogging, weight training, to name a few. Just be sure to work at a level that will not cause discomfort and that none of the activities will do anything to aggravate the injury. Such activities will allow a gradual path to resuming full training. Even after a full recovery, stretching, strengthening, and range-of-motion exercises should continue to be performed in order to reduce the risk of recurrence. 5