Solutions for Patello-femoral knee pain presented by Tim Keeley B.Phty, Cred.MDT, APAM Principal Physiotherapist Physio Fitness Australia physiofitness.com.au facebook.com/physiofitness Today s session Patello-femoral knee pain what s going wrong? Signs and symptoms what to look for Physio treatment and rehab what we need to do Rehab exercises the hard stuff Progression to normal training more hard stuff Program adherence the even harder stuff Patello-femoral knee pain Muscles and structures around the PFJ Movement of the patella on the femur Hip and knee alignment The role of the hip stabilisers - open vs closed The role of the VMO 0º to 30º Foot pronation effect Patello-femoral tracking the need for balance Positional faults and effect on underlying structures Patella vs hip vs soft tissue
Patello-femoral knee pain Positional fault + overload = primary cause Joint pain, force pressure pain, tissue damage and inflammation Cartilage loading/unloading, joint inflammation, soft tissue loading Bursitis, ITB Syndrome, tendinopathy, cartilage wear, chomdromalacia Relative weakness of VMO and hip stabilisers Internal rotation of the femur Incorrect alignment in the patello-femoral joint Mal-tracking of the patella ITB, Quads, and gluteal tightness Viscous circle of pain, muscle inhibition and weakness Patello-femoral abnormalities / hypermobility / dislocations Patient understand what s happening better outcomes Signs and symptoms Volunteer from crowd! Constant and intermittent pain, areas of pain Painful one leg squat through range Change in tracking Crackling and cracking Hip drop on stance and squat Internal rotation of femur / external foot ITB, gluteal and quads tightness Muscle atrophy of the VMO and hip stabilisers Physio treatment and rehab Assessment / referral to Physio / confirmation Acute care / settle symptoms Soft tissue release, inflammation control, dry needling, kinesio taping Advice and program instruction *(see below) Ice, anti-inflammatories, relative rest / change in exercise, home program Restore correct hip stabilisation and PFJ alignment Build strength, control and endurance Integrate into gym routine / Progression to normal training *Physio role of education getting them on board Not enough treatments = poor outcomes the pain is gone syndrome Onward referral, scans etc
Rehab exercises Hip stabilisation exercises Gluteus medius and minimus function Hip lateral rotators Role of glute max and hip flexion VMO and quads exercises Closed chain vs open chain Combined exercises with hip stabilisation Minimal need for isolation Isometric and Isokinetic Pain-free range Reps and Sets -> Left and Right differences Hip stabilisation exercises Prone glutes Glute bridges Clams Side lying leg raises 4 point hip extension Ball hip extension Physio lunges * Step down * VMO working with all closed chain exercise! Prone glutes Isometric Activation / Squeeze only if needed Lumbar spine neutral Core stabilisation Use a plank Lumbar extensor overactivity
Glute bridges Lumbar extension Push through heels Progression: one leg Clams Heels together Feel the muscle Isometrics Pilates progressions Side lying leg raises Leg and foot position Feel the muscle Watch TFL and hip flexors Isometrics Pilates progressions
4 point hip extension Lumbar spine neutral Core stabilisation Squeezing gluteals Planks Lumbar extensors Ball hip extension Heels and glutes Don t overextend lumbar spine Progression: Add weight Physio lunges Leg and back angles Weight through front heel 80% of body weight Knee over foot issue Watch drop of opposite hip Knee alignment Push ground away **VIDEO** Can do only 30º if needed Pain free range / adaptation
Step down Knee alignment Hip drop / level Hip flexion / dissociation Pain free range Adaptation for injury / pain Weight over box VMO and quads exercises Physio lunges Step down One leg rehab press One leg ball / wall squat Single leg skier squat Hip stabilisers working every exercise! Isometric first week Isokinetic One leg rehab press Closed chain movement Weight through heel Hip level Can do only 30º if needed
One leg ball / wall squat Pushing out not pushing in! Swiss ball or Medicine ball Isometric and isokinetic Hip flexion and level Single leg skier squat Band tension Pain free range Elbow and scapula set position Pull back when pulling forward Progressions to normal training Warm up the hip stabilisers and the PFJ! Apply rehab principles of movement Adding BOSU and band work BOSU side steps and side jumps Use of bands with squats and deadlifts One leg romanian deadlifts Pistol squats Step ups *Eccentric leg extension
Adding BOSU and band work Bands before weights BOSU before impact BOSU side steps and side jumps Squatting technique Knee alignment Bands with squats and deadlifts Knee alignment Remember rhythm! Arm - shoulder, shoulder - arm Eccentric control of scapula
One leg romanian deadlifts Knee alignment Hip control Pistol squats Watch knee loading Glute and hammy strength Step ups Hip flexion on start Hip level on push up and down Eccentric control
Eccentric knee extension Cartilage loading / damage Open chain isolated Things to be aware of Quads, hip and ITB tightness -> foam roller, massage and stretching Muscle balance quads vs hamstrings Q Angle, pronation, orthotics, shoe support Core stability Cartilage wear, tendinopathy Rehab press > leg press Single leg work > double leg work Physio lunges > normal lunges Running distances Change of routine / exercise type Program adherence Pain free at rest and walking: 1-2 weeks Pain free single leg squat: 2-3 weeks Rehab exercises: 1-4 weeks Normal weights / cardio training: 4-6 weeks Running / sport: 6-8 weeks Maintenance of rehab exercises in program Use in warm up Relative exercises on body part days Personal trainer programming Regular reviews with Physio to keep on track Education on pumping up the tyres