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Anterior knee pain

6/1/2016

7 Comments

 
Also known as patellofemoral syndrome, anterior knee pain can be extremely frustrating for patients and surgeons alike.  Anterior knee pain is extremely common and can have a variety of causes. Patellofemoral arthritis (knee-cap arthritis), and knee-cap dislocation (patellofemoral instability) are two diagnoses that can cause anterior knee pain, but they each will require a separate blog posting of their own. 

Patients experiencing patellofemoral syndrome complain of aching pain in the front of the knee which can range in severity from mild to intense. It is often made worse by sitting with the knee bent for a prolonged period (movie theater or back seat of car). In this situation the pain can  be improved by extending the knee (straightening it). Climbing or descending stairs can also be quite irritating. 

This condition affects people of all ages and of all fitness and activity levels. I have diagnosed and treated this condition in  marathon runners, adolescents, and patients who previously underwent total knee replacement. Usually the problem gradually worsened and has been present for a fairly long time when it gets to me. The key to the diagnosis is to listen to the patient. The history given tends to be very consistent. 

To better understand this condition, let's start with some background information.

The patella (knee-cap) is subjected to the greatest force of any cartilage in the body (3-5 times body weight during normal activity and up to 10 times body weight when jumping). It is embedded within the extensor mechanism of the knee so that it can provide leverage to the quadriceps muscle group. The front of the knee is richly innervated and is thus very sensitive to abnormal pressures. The position of the femur (thigh bone) during activity will change the amount and distribution of forces on the patella. 


There is a very consistent examination finding associated with this diagnosis. Patients usually will have very weak hip flexors (muscles than bring the thigh forward relative to the torso) and hip abductors (muscles that bring the thigh away from the midline). Usually the hip external rotators will also be affected.

What does the hip have to do with the knee-cap?

The hip flexors and abductors are very important during the gait cycle (walking). The abductors must contract with great force to keep the pelvis level during single leg stance. The hip muscles together act as the "foundation" for your leg. If they are weak, your leg will be poorly controlled when walking. This can result in abnormal gait mechanics, abnormal rotation of the femur when weight bearing, and abnormal patellofemoral mechanics. 

This combination of issues multiplied over thousands of steps each day can result in anterior knee pain. 

Ok, so how do we fix it?

My recommendation is to focus on the hip. Strengthening the weak hip muscles will almost always result in a cure. Unfortunately, this can sometimes takes weeks or months. Remember, we are rebuilding muscles that have gotten deconditioned over a long period of time. This takes time. Knee pain gradually resolves as hip strength gradually improves. The exercises I recommend are very simple:
Dr. Gorczynski demonstrates straight leg raise for patellofemoral syndromeStraight leg raise.
Keep your knee locked in extension. Raise your leg from your hip keeping your toes pointing toward ceiling. Up and down counts as one repetition. Aim for a set of 30 repetitions. Then add sets.
It is important to do these exercises on both sides, even if only one knee hurts. You want to keep things balanced. 

Here is a video demonstrating the straight leg raise.
Dr. Gorczynski demonstrates lateral hip raise for patellofemoral syndromeLateral raise.
Lateral raise. This exercise focuses on the hip abductor muscles. Lying on your side, slowly elevate the leg from your hip, keeping your knee straight and your toes pointing forward (not toward the ceiling). You should feel the burn on the side of your butt. 

Here is a video demonstrating the lateral raise. 
So, that's basically it. Remember, we are building hip muscles. It takes time. I recommend doing these exercises on both sides (even if only one knee is painful) so everything stays balanced. Each repetition should be done slowly when raising and lowering.  You may be surprised by how challenging this set of hip exercises can be. You should work up to 3 sets of 30 repetitions for each muscle group. Repeat the workout twice per week.  The total work-out should only take about 15 minutes. Resist the urge to do these exercises more frequently. The purpose of exercise is to stimulate the muscle to grow. It then needs to be allowed to grow, and this takes time. Stimulating the muscles with resistance exercise too frequently will be counter-productive. 

When doing this exercise becomes easy, feel free to add some additional resistance. You can wear a boot, or use an ankle weight. 

It is a common misconception that one should exercise the quadriceps  using a leg extension machine. This is a mistake and I would strongly suggest avoiding any knee isolation exercises in general, but when dealing with patellofemoral syndrome in particular. The knee extension machine will worsen anterior knee pain. 

Be patient, and consistent with these exercises. As your hip strength improves, your knee pain will improve as well. 
7 Comments
Dale Heeks
10/23/2016 03:34:42 pm

Thanks Dr, this worked well for problems I've been fighting for years.

Reply
Christopher Gorczynski, MD link
10/23/2016 06:35:18 pm

Very pleased to hear this!

Reply
Nancy B
8/9/2019 02:03:52 pm

Thank you! This seems the answer I have been looking for. I was told to do these same exercises but only (3 sets of 10). Stopping short of pain! I was afraid to do any more damage but maybe this is why I am still walking weak, unbalanced and in pain.
Dr G,
The surgery to remove my hardware was postponed twice now so I’m a bit of an emotional mess.
My question is...
Is it normal at 8 months (post patella fracture op) to still be like this? (Pain, stiff, weak, unsteady) Should I expect after the metal removal to feel noticeable relief and improvement? (Unfortunately I am on blood thinner so can’t take anti inflammatory, pain meds.) so I hope there is not a lot of new swelling. (Btw, I am 55 yr old, 20 lbs overweight)
I had read if you have the ROM everything else will follow, is that true?

Reply
Christopher Gorczynski, MD link
8/11/2019 12:33:36 am

Unfortunately there are simply too many variables associated with a fracture (fracture pattern, degree of cartilage damage, pre-existing arthritis, pain tolerance, quality of surgical repair) to be able to define normal. In general though I would say it is not normal to have ongoing weakness, pain, and poor balance 8 months after a well done, well rehabilitated, patellar fracture repair.

Studies done on removal of hardware for pain suggest a 50% chance of pain relief following hardware removal.

Range of motion is crucial. Without adequate range of motion, proper knee function is not possible, strengthening will not be adequate, and gait will be abnormal.

Simply removing hardware would not be expected to automatically cause full range of motion to return. This is because the hardware typically used to repair patellar fractures does not in anyway restrict knee motion. Scar tissue forms between the quadriceps tendon and the femur, anteriorly, and between the patella and femur, medially and laterally after trauma, surgery, immobilization. This is the tissue that needs to be stretched out early in rehabilitation (first 6-8 weeks) or surgically released late(arthroscopic lysis of adhesions/manipulation under anesthesia).

Reply
Nancy B
8/14/2019 01:40:34 pm

Hi, Sorry, I should have put that my ROM is already excellent (practically the same as the other leg) so I was hoping now that the “if you have the ROM everything else will follow” was true. (That I had read)
I am also hoping that doing the strength training exercises in this post will eventually help with the pain as it has for others.
Question:
Considering that my leg/knee is weak after so long:
Is it still possible to get my strength back (that there was no window of opportunity that has closed) or its permanent muscle loss? sorry, maybe a silly question but I am at a loss for what to do and have had such a hard time getting answers from anyone or anywhere online.
Are there other things I should look into besides what I am doing now (hardware removal and strength/balance training) ?

Christopher Gorczynski, MD link
8/15/2019 04:32:09 pm

To be clear, getting range of motion back is the key to maximizing outcomes following knee surgery. It unfortunately does not guarantee a completely normal knee. In general, when a patient regains relatively normal range of motion following total knee replacement, everything else does indeed follow.

After a fracture, a patient may develop post-traumatic arthritis. This can be painful in spite of regaining excellent motion.

Strength training can basically be done, with the expectations of progress at any point. While there is a window of opportunity to regain muscle function following a nerve injury (meaning muscle weakness may become permanent if a nerve is damaged/compressed and not repaired/decompressed in a reasonable period of time), typical muscle weakness that follows trauma/surgery/or a period of reduced activity is definitely reversible and there is not a defined period after which progress is not possible. This can be made more difficult by pain or diminished range of motion, but definitely can be overcome with hard work, and persistence.

Reply
Nancy B
8/16/2019 12:22:30 pm

Thank you Dr for your help. I really appreciate your time. I had the hardware removed yesterday and will see what happens next.

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