Patellofemoral pain... maybe the ultimate garbage can diagnosis, next to "non-specific low back pain" as it effectively describes nothing. When you have arrived at this diagnosis with medication as your only treatment plan feel confident your doctor has no idea what is wrong. Feel good about it now? Me neither. Let's pick apart this junk diagnosis and find out what is actually causing your knee pain and bring together the most recent research for the best possible prehabilitation, rehabilitation and pain management.
What is Patellofemoral Pain?
Varying in description from dull to sharp diffuse pain in the front and side of the knee. Often the athlete will be unable to pinpoint the site but describe movement, inconsistency, and radiation. The actual strutures within the knee complicate the diagnosis. Possible pain generators range form the patellar tendon, fat pad, meniscus, cruciate ligaments, and the joint capsule itself. Identifying the actual pain generator in each case is vital to proper diagnosis, and proper diagnosis is vital to proper treatment/rehab.
Through research on Mike Reinold's website I found reference to one incredibly interesting study in which the lead author actually scoped his knee without anesthesia to essentially poke different structures and scale the sensation. We all owe this guy a thank you because I for one would not have volunteered for this. The findings were very interesting, it was discovered that the author actually had mild degeneration of the chondromalacia and that in itself was not a pain generator, rather the author concluded the primary pain generators must be the surrounding retinaculum and soft tissue.
Finding this true pain generator and dysfunction is the primary objective of our assessment. By ditching the Patellofemoral Pain Syndrome in favor of a more descriptive and definitive diagnosis we start our rehab process with real direction and not a shot gun approach at the knee. This is more intelligent leading to more accurate diagnosis and more effective rehabilitation. Leave the diagnosis to the doctor but if you're diagnosis is simply PFPS or knee pain, find a new doctor, as the treatment varies greatly depending on a compression syndrome, overuse, soft tissue, biomechanical dysfunction, or trauma.
How we get you back faster
Depending on the condition we either want to reduce inflammation or cause inflammation. Let me explain. If you happen to be suffering from tendonitis, odds are you are in more of chronic situation, having delt with the condition for a few months and the condition has likely progressed to chronic degeneration or tendonosis. In this case we actually want to cause inflammation and kick start the healing process. Inflammation has a bad rap, but we must understand inflammation has a purpose. The swelling is a sign of increased microcirculation to the area. Macrophages are like a giant clean up crew devouring the damaged tissue and dragging along Insulin like growth factor 1, which acts as the paramedics on scene helping to regenerate tissue. In an interview with Dr. Kelly Starrett, Gary Reinl explains the process and why it is vital to proper injury recovery. The problem becomes when the swelling is stuck and we get stagnant effusion. This brings us to the next stage of our rehab.
HOW? At Engineered Per4mance we often use cross friction massage to initiate the healing process. We also have a class IV litecure medical laser therapy unit to jump start microcirculation and healing.
2. Reduce Swelling
Several studies have shown a surprisingly small amount of fluid within the joint (effusion) can cause very dramatic decreases in voluntary muscle contraction about the joint. One study showed that just 20cc of joint effusion has the ability to reduce the contractile strength of the quadriceps significantly. Due to the fact that re establishing voluntary control and strength about the joint is crucial in successful rehabilitation we must first take off the brakes by removing the swelling.
HOW? We do this with a variety of techniques and tools from Instrument Assisted Mobilization with HawkGrips, manual massage, active muscle pumping, rock tape, or with electronic stimulation using the Marc Pro unit.
3. Reduce Pain
One of the first things we must address is pain. For obvious reasons, the patient is coming to me to get out of pain! I doubt they care much beyond the initial bandaid, what can I do to feel better? Secondly, pain also inhibits voluntary muscle force and as we just described this will hinder all progress in the rehab.
HOW? At Engineered Per4mance we are well equipped to quickly reduce your pain sensation. We often begin with manual therapy and mobilization. The neruoregulatory mechanisms through simple movement will almost certainly reduce perceived risk and reduce your pain experience. Utilizing the pain gate theory we are further able to reduce pain using Rock Tape application. I like to explain this effect with an analogy. Imagine running up your stairs and your trip and smoke your shin on the next step. We've all been there, what is the first thing you do? You rub your shin like crazy right? This rubbing is stimulating your mechanoreception and your brain is bombarded with sensory information. Think of your brain as needing to prioritize and it is getting too much information at once, which effectively quiets down the nocieception (pain). In this example the tape acts as the rubbing and stimulating those mechanoreceptors thereby reducing your perceived pain.
4. Improve Soft Tissue Mobility
We need to ensure we have all the pre-requiesits for proper movement and that starts with full passive range of motion about the joint. Think muscles (hamstrings, quads, gastroc, and soleus) and soft tissue (retinaculum and joint capsule). While tight, imbalanced or inhibited these tissues all have potential to change the kinematics or movement of the joint causing dysfunction and pain.
HOW? As a chiropractor mobility is kind of my thing. The joint adjustment (Grade V), mulligan mobilization (Grade 4 and below), Active Release Technique, Active Muscle Pumping, Strapping, Taping, stretching, and Instrument Assisted Techniques including Hawkgrips and Graston are all tools in our tool box at Engineered Per4mance to ensure soft tissue mobility.
If you think you may be lacking in mobility requisites above and below the knee start here and check out the ankle. Check out this EP | TV video of a quick ankle dorsiflexion assessment you can do on yourself.
5. ENHANCE PROPRIOCEPTION AND CONTROL OF THE JOINT
The knee joint craves stability, which is achieved only with full mobility at the hip and ankle. Accurate control of the knee through the hip and ankle during functional tasks is vital to patellofemoral health. At our fitness evaluation we take each perspective athlete through a vertical jump testing protocol. During the jump each athlete is filmed so we can analyze not only the power production but the biomechanical control of the lower extremity. We see this far too often. The hips lack external rotation strength or the ankle lacks mobility and the knee pays the price. This may not hurt today, but it will during sport, when asked to quickly change direction or absorb force. An ounce of prevention is worth a pound of treatment, but if we are arleady in pain, normalizing these mechanics will greatly expedite the rehab process and help to mitigate risk of re-injury in the future.
HOW? Therapeutic exercise emphasizes hip external rotation, abduction, and proprioceptive improvement. Beginning on the ground with the classic clam shells and resisted abductions. The athlete is eventually progressed to standing side shifts, mini band walking and standing resisted external rotation work. Adding in the tilt board for balance and proprioceptive input we show the athlete how to control the hip, knee and ankle in uncertain circumstance. This strength and proprioceptive control that develops is exactly the formula to return to full functional activity.
As you can see a lot of our methods overlap. At Engineered Per4mance we start with a through evaluation and diagnosis. Treating the true cause of your knee pain is where the magic happens and you get back to doing what you love faster. If you are suffering from undiagnosed knee pain or worse yet, diagnosed patellofemoral pain syndrome please call us today at 515-964-2322.