Anterior Knee Pain The management of knee pain has several parts: 1. Gradually increasing the number of repetitions or resistance of the exercises performed. It is important to stay within a zone that allows the body to adapt to the new stresses and not increase your present level of pain. To help with that, please use the following guideline. Pain is generally rated on a scale of 0 (no pain/normal) to 10 (worst pain). Any exercise performed should never create more than a pain level of 1-4. At no point should exercise cause a steady rise in pain. Any increase in pain should be temporary and should be relieved with rest or modalities mentioned below. After a few sessions, you should notice an overall decrease in your pain. It is also important to make note of your function. You may first note that you are more active before the onset of your usual pain. Should you have an increase in your pain: Stay at the same number of repetitions and resistance until your soreness decreases Decrease the number of repetitions, staying at the same intensity, progressing more slowly the number of repetitions Decrease both intensity and repetitions, progressing more slowly the number of repetitions Guidelines for Using Ice (cold) or Heat Cold: Either bagged frozen vegetables (peas and corn form best) or bag of ice about one inch thick with a small amount of water in the bottom. Get as much air out of the bag as possible. In the winter you can also use snow. Apply for 20 minutes, leaving at least one hour between applications. You can secure the ice with a compression wrap if desired. Ice massage- by making a small block of ice in a paper cup or mold and rubbing the affected area 5-10 minutes until the skin turns red. May use this technique once an hour. Heat: Generally, several layers of damp cloth are placed between the skin and the heat source. It is left in place for no more than 30 minutes with two hours between applications. Do not secure heat in place with a compression wrap or weight.
2. Improving lower extremity posture: A contributing factor to knee pain is poor lower extremity posture. The first series of pictures show poor posture (knee over foot and inside a line between the foot and hip). The second series of pictures show proper posture (knee over mid-foot/big toe and in line with hip and foot). It is important that all strengthening and stretching exercises utilize proper posture shown in the second series of pictures. Through the exercises, proper position should be carried over to activity. 3. Improving Torso Posture: Along with poor lower extremity posture and control, poor torso and head posture can contribute to knee pain. Strengthening and re-activating the back muscles is the first step to restoring as close to a normal torso posture and head position in sitting and standing as possible. Picture shows poor posture. The back is rounded or shifted to one side and the head is looking down, with the ear in front of the shoulder.
The first step in correcting this posture is to sit up as straight as possible, level the chin and attempt to pull the ear back in line with the shoulder as seen here. Once the torso is elevated as far as possible, you then want to relearn how to engage the torso muscles by feeling for their contraction. This technique is called abdominal hollowing. Place one hand in the small of the back, the other over the belly button (picture1). You then want to suck in your gut (hollow) as shown in picture 2. When you suck in your gut: 1. Use the hand in the small of the back to make sure you do not feel your back start to round 2. The hand over the belly must feel as it is moving backwards towards your insides. If your hand does not move or you feel your muscles tighten but your hand does not move, your technique is incorrect. 3. The natural reaction when first attempting this technique is to hold your breath. Holding your breath is simply a substitution for a weak diaphragm. The proper technique is sucking in without holding your breath. It will take some time to be able to accomplish this. You may notice an increase in your back (and possibly neck) soreness as the muscles strengthen. However, the goal is to be able to have this become your normal posture Picture 1 Picture 2 In addition to practicing this technique in sitting, you must also practice it in standing The last technique point for this exercise is to make sure the small muscles involved with stabilizing each vertebra are working. This involves putting the fingers in the area as shown or using a small rolled
towel or round object about 1 in diameter to provide sensory feedback that they are working. This is a difficult muscle to find and learn how to contract. It is important to do so as it is these muscles that prevent slouching by balancing the forces created by abdominal hollowing. For Young ITBFS For this exercise you will need a table/bench to place your leg on. As shown in Picture 1, place either leg on the bench/table, drape the other leg over the side and place a strap that will not stretch around the middle of the foot. Using the strap as an anchor, attempt to sit as upright as possible by elevating the torso. Do not elevate the leg! You want to feel a moderate pulling sensation (1-2 on the pain scale) in the back of the leg. Perform 3-30s stretches 2-3 times a day. Rest 5 seconds between stretches. Picture 1 For this exercise you will need a table/bench/chair. As shown in Picture, place either leg on the bench/table/chair and place the outside of the ankle on the opposite knee. Do not push down on the knee. You do want to attempt to sit as upright as possible by elevating the torso. You want to feel a moderate pulling sensation (1-2 on the pain scale) in the back of the hip. Perform 3-30s stretches 2-3 times a day. Rest 5 seconds between stretches. Picture
The next set of exercises is a graduated progression for strengthening the hip muscles. Care must be taken to keep the pelvis stable. You do don t want to roll forward or back on the hip, nor elevate the leg by having the waist bend toward you. If need be, place your hand on your hip joint to feel it move. Side-lying Abduction There are three positions to step one. Position 1- lie on your side, feet together. Lift the top leg until parallel with the floor (Picture..). Position 2- Move the leg forward and point the foot upward (Picture ). Position 3- Move the leg backward and rotate the foot down (picture.). Start with one set of 6 reps with a 10 second hold in each position. Rest 5 seconds between reps. Build up to 2, 30 second holds with a 15 second rest between reps. Backward Neutral Forward Side Plank. Starting as shown in Picture.raise your hip in the air, supporting yourself on your knee and elbow. Maintain a straight line between your knee, hip and shoulder. It is not unusual for your shoulder to feel tired or achy after this exercise. If that happens, maintain your present level until it goes away. Once it goes away and you are able to maintain a straight line in this base position, you can progress to a foot supported position as shown in Picture.. Start with one set of 6 reps with a 10 second hold in each position. Rest 5 seconds between reps. Build up to 2, 30 second holds with a 15 second rest between reps.
Bridge The next exercise is a 5-step progression to strengthen the connection between the back, glutes and hamstrings. The base position is shown in Picture.The hips become the hinge. The shoulders to the hips stay rigid. Stage 1- Pick the hips off the floor as shown in Picture..Your hips want to be the first thing off the ground and the first thing to touch it. Stage 2- Raise your hips high enough to form a straight line from the shoulder to the knees (picture ). Stage 3- Assuming the fully elevated position, then alternate picking up the right and left foot in a marching pattern (picture..). Stage 4- Involves performing a leg curl with both feet on a ball. Place both feet on a ball, elevate the hips as in stage one, then roll the ball to you by flexing the knees and hips. Do not let your hips touch the ground. From base position to stage 3, start with one set of 10 reps with a 5 second hold. Build up to 4 sets of 10 reps before moving on to the next level of difficulty. For Stage 4, perform 4 sets of 10 reps with a 60 second rest between sets. Base position Stage 1 Stage 2 Stage 3 Stage 4A and B
To help manage the pain associated with this injury, you can perform an ice massage. Fill a small cup with water to make a block of ice. As the tendon you want to massage runs toward the knee, start in the area indicated and massage in a straight line going toward the knee. Stop massaging when the area turns red (5-10 minutes).