Patellofemoral Syndrome - Member Case Study

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When running, I experience pain in my right knee that is inferolateral patella and subpatellar. It can get quite sharp at times. How do I treat this?

Question from umbach:

When running, I experience pain in my right knee that is inferolateral patella and subpatellar. It can get quite sharp at times. Usually it doesn't bother me unless my stride lengthens, going downhill or I try to up my distance too quickly. By descriptions I have read, it sounds like patellofemoral syndrome. How can I best treat this? I have tried standard leg raises, but they just don't seem to get the job done. Any other thoughts would be appreciated.


Answer

Your question regarding PFS (patellofemoral syndrome): yes your history and pain location does correlate with what we see in PFS. The treatment is non-operative most of the time. Several factors are involved in the lower extremity. We evaluate the whole leg, pelvis and back as a kinetic chain: several parts that are each linked to the other in the mechanics of motion. For relative rest aspect of treatment, you have identified in your history those areas to decrease(i.e. the things like increased stride length, etc. that increase your pain).

If we start at the foot, there can be issues with your shoes. Frankly, some of my runners and triathletes use onset of PFS to determine when it is time to get new shoes (not the recommended determination!).

Your shoes, your foot mechanics such as stiff ankle joint or excessive pronation without corresponding adaption by the leg and knee, and stiff mid foot have all been components in the feet.

Alignment issues in the lower extremity, more commonly seen in female athletes, may also play a role. Imbalance in muscle strength between the hamstrings and the quadriceps, or, imbalance in the flexibility of the quadriceps and hamstrings can play a role. I often find tightness in the iliotibial band as a component of this issue in men and women. Additionally, imbalance in the hip flexor and hip extensors, weakness in the muscles that stabilize your hip in side to side motion can be a component. In cycling, it can be due to excessive side to side motion on the downstroke.

With the numerous causes for this condition, it is best to get an assessment by a sports medicine physician that can outline a rehab program that addresses the specific components that contribute to your PFS. In a general recommendation, I find stretching of the iliotibial band, quad, hip flexor, hamstring and heel cord is important; strengthening of a small medial muscle in the quadriceps called VMO (vastus medialis obliquus), done in a ¼ squat motion, being sure to keep the patella aligned above the 1st web space of your toes(tracking issue); addressing any weakness in your hip stabilizing muscles are all thing you can look at now.

Addressing potential proprioception issues (position sense of the joint) through exercises, a strapping technique with tape (McConnell taping) or wearing a neoprene patellofemoral brace with an outside (lateral) buttress can help with proprioception, and joint contact areas that may be contributing to your pain. Shoe inserts have also been used as part of treatment plan for the above. Of course, ice massage is great for the post-workout pain.

There are several other aspects to treatment and should be individualized to your particular biomechanical issues. A basic outline of patellofemoral syndrome and some exercises can be seen on AMSSM.org, under “position statements and publications”. Hopefully this gives you a starting point.

Katherine L. Dec, MD Member AMSSM

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date: April 9, 2005

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The American Medical Society for Sports Medicine (AMSSM) was formed in 1991 to fill a void that has existed in sports medicine from its earliest beginnings. The founders most recognized and expert sports medicine specialists realized that while there are several physician organizations which support sports medicine, there has not been a forum specific for primary care non-surgical sports medicine physicians.

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The American Medical Society for Sports Medicine (AMSSM) was formed in 1991 to fill a void that has existed in sports medicine from its earliest beginnings. The founders most recognized and expert sports medicine specialists realized that while there are several physician organizations which support sports medicine, there has not been a forum specific for primary care non-surgical sports medicine physicians.

FIND A SPORTS MEDICINE DOCTOR

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