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Patellofemoral Syndrome refers to a condition of generalized frontal knee pain. It has been alternatively referred to as Chondromalacia or Runner's Knee. It is an extremely common cause of knee pain in athletes, comprising nearly 90% of all nontraumatic knee pain in certain sports.
The causes of this common disorder are multiple and varied, but far and away the leading cause is due to an overuse-type of injury, also known as Repetitive Motion Injury. This "overuse" can range from beginning a new or novel activity, or sport, to merely increasing your running mileage too quickly. Other causes of "overuse" might include a change in equipment, worn or obsolete equipment (such as shoes), too rapid an increase in weights during weight training (or incorrect stance), or incorrect seat height in a cyclist. The most common athletes affected by this syndrome are runners (including soccer and football players), dancers, gymnasts, skiers, weight lifters, and females (due to the shape of the pelvic bones). Less frequently, it can be caused by trauma to the knee.

SYMPTOMS:

The symptoms of Patellofemoral Syndrome can be varied and somewhat vague, but usually the athlete will have pain in the front of the knee, surrounding the kneecap patella) and extending, to varying degrees, away from the kneecap, more often to the inner side of the knee. The pain may worsen when descending (or climbing) stairs or hills, upon standing after sitting for a time, and shortly after, or even during, the causative activity or sport. The pain can be either sharp, well-localized pain or a dull, nagging type of discomfort.
The diagnosis is made almost exclusively based on your symptoms and the exam of your knee. Although there are specialized tests and x-rays that can identify problems in the kneecap and knee joint, few are reliable at pinpointing the exact cause of your symptoms.

TREATMENT

Treatment of this sometimes very stubborn problem should be thought of as an ongoing process of rehabilitation. Although there are times when it is impossible to continue your usual sport or activity due to the severity of the pain, usually a middle ground can be found where you are able to continue a high level of fitness while mending your knee at the same time. In a worst case scenario, when the pain is so severe that even normal walking is painful, crutches and total rest from training may be necessary. However, this level of pain is unusual and more commonly, one is able to continue to participate in an alternative fitness program during the healing phase. The most important point to remember is to avoid the harmful activities such as: running hills, doing squats and lunges (where the knee bends past 45 degrees in the flexed knee) kneeling and leg extension exercises in the painful range, while you are attempting to remain active and fit.

1. RELATIVE REST:
The term, Relative Rest, suggests that you avoid those activities known to aggravate the condition (see above), cut back on your training schedule (for example, 1/2 your usual mileage) to a level where you are either painfree, or where the discomfort is tolerable and not worsening, and switch to cross-training activities to maintain fitness. Stay at that level of exercise until your knee pain begins to improve. Once the pain is decreasing, very gradually increase your training regimen.
Remember - The 10% Rule: advance your mileage, weight, duration of workout no more than 10%/week. An example would be, if you ran 10 miles a week to begin, then the next week you would run 11 miles (10 plus 10% = 11.) Renewed pain during this progression stage requires a return to the lower, painfree level for a longer time period and resumption of very gradual increases. This is sometimes also known as "Plateau Training"- find a plateau you can do without worsening pain.
Good cross-training activities may include Pool Aerobics or pool-running, cycling (with the seat height adjusted properly - knee bent only slightly at the bottom of pedal throw), Norditrac, Elliptical trainer, and Stairmasters.

2. STRENGTHENING THE QUADRICEPS (THIGH) MUSCLE:
Although there is much dispute about the ability to isolate out one muscle from another in the quadiceps group, it is clear that strengthening this muscle group is a mainstay of therapy.
There are a number of satisfactory methods to strengthen the Quadriceps Muscle using weights, Theraband, or machines. There are two forms of exercises in the lower extremity, Closed Chain and Open Chain exercises.Closed chain exercises are more "natural" as you will have your foot planted on the ground or on the object you are pushing against, similar to how you normally would use your thigh muscles.

"Closed-Chain" type of weight training has been shown to give the best results in this disorder. These are exercises that have you exercising with your feet either on the ground or pushing against a movable resistance.

One good Closed Chain exercise, which can be done at home without special equipment, is the "1/4 Squat". Simply stand upright, knees straight, then slowly bend the knees to approximately 1/4 of a full squat (that is, knees bent 30-45 degrees), hold for 5-10 seconds, then slowly straighten again, to full extension. More advanced alternatives would be to add weights, say hold two 5 lb. weights, one is each hand, as you do this exercise, or use Theraband (examples are shown in the graphics section).You can also concentrate your efforts by doing the entire squat sequence bearing all your weight on one leg, then the other. Remember: exercise both legs. Another very good "Closed-chain" exercise is the Wall Slide. It is easily done at home, with no special equipment and has the benefit of being the most "physiologically correct" of the various exercises. It is done by placing your back against a wall, feet 12-18 inches from the wall, and sliding slowly down until the knees are bent at approximately 45-60 degrees; hold this position for the count of ten, then slowly slide back up to standing. Do 10-12 repititions. If you find you have pain doing this exercise, try doing it with your feet farther away from the wall and don't slide down as far.
If you are lucky enough to have access to a gym, you can use the "closed-chain" machines, such as the "sled" using free-weights(see the illustration), or the Nautilus machine, using stacked weights. Remember to bend the knees only to no more than 30-45 degrees, as this keeps the harmful forces in the knee to a minimum.
Keep in mind, during this phase of conditioning, that as you advance, you may experience some recurrence of your symptoms. This does not mean you should stop the conditioning and strengthening exercises. If the discomfort resolves with rest (after less than a day), you can stay at that same level until the pains begin to decrease before "moving up". If the pain does not resolve with rest, you should go back to a lower level, for instance less weights or less reps, to a level where you are able to do the exercise without increasing the pain, stay at that level (plateau) as the pain subsides, then slowly increase weight again. This is known as "Plateau training"; think of advancing as going from one plateau to the next. If you falter, go back to the previous "plateau".


Cybex or other Quad Machines (as part of a general "resistance"or weight-training routine) are Open-Chain exercisers and should be used with some degree of caution, and may best be saved until you have already begun to improve. Begin at a very low weight, exercising only through the nonpainful range of arc, which is often the range between 30-90 degrees. You should progress very slowly, to the level where you will be doing slightly higher weights, with two separate sets on the quad extension machine: one from hanging down to approximately 30 degrees, the other: only working through the last 30 degrees of extension (bring the first one up from 90, then drop just 30 degrees and back up to full extension and repeat x 8-12 reps). Remember: Concentrate on increasing reps, not weight, with this form of rehab. If, at any point, you find you are having more pain using this exercise, stop and continue with the closed-chain exercises and cross/alternative training. If you do use the Leg Extension machine, be sure to work the Hamstrings also, being careful to use less weight than the quads.

As noted above, alternative exercises, or "cross-training" exercises, such as Cycling, Stairmaster, and Norditrac are excellent choices, especially if running was the causative sport of your knee pain. Once you begin to return to running, a treadmill is a good place to start, as the surface and "hills" are predictable and stable (also, there are no downhills).

3. STRETCHING:
It is very important to remember to do stretches of all the muscle groups that cross the knee joint to provide stability; these include the Hamstrings (back of thigh) and Calf muscles, as well as the Quadriceps (front of thigh). Stretch after a short warm-up, then again after finishing your exercise routine. Remember that a tight muscle is as bad as a weakened one.
Another very important stretch, not really a muscle of the knee, is the Iliotibial Band stretch. The Iliotibial Band is a large "strap" of band of tissue that has some connections to the outside of the kneecap and causes it to pull to the outside, as noted before, the most common cause of this problem. You might also try the "alternative ITB stretch" shown.

4. BRACING:
It is often wise to invest in a slip-on Patellar Knee Brace or Runner's Knee Brace, which can be worn during all your exercise routines until the problem is completely cleared. These braces prevent abnormal tracking of the kneecap in its underlying groove and, thus, decrease friction with the thighbone (femur), which, in turn, decreases inflammation. They can be found at any good running shoe or sports store. The small, notched, Patellar Strap, found at running stores, is also a good alternative. Remember: whatever brace you get, it MUST have a cutout for the kneecap built in to it; never use the elastic knee braces that cover the kneecap. An alternative to bracing would be taping, which a physical therapist could show you, but it is cumbersome and only a temporary fix to use during rehab.

5. ICING:
Using ice after a workout, on the painful area can alleviate the swelling that sometimes occurs and may decrease some of the inflammation. Be careful to wrap the ice in a towel and use for only 15-20 minutes at a time, as you can sustain a burn from prolonged icing of the skin.

6. CORRECTION OF ANATOMIC VARIATIONS:
Many people have minor abnormalities in their running stride or their lower extremity or foot anatomy that gives them no problems when they are not pushing themselves, but become a source of irritation and pain when they take on a repetitive exercise, such as running. Examples would include flat feet ("fallen arches"),"knock-knees", leg length differences and "over-pronators" (feet that rotate too much during the gait cycle). All these otherwise minor problems will translate into knee pain when "stressed" by endurance sports. Most often, athletes that develop Patellofemoral Syndrome are classified as Over-Pronators, which means there is excessive rotation of the foot as it goes from heel-strike (when you land on the heel of your foot) to push-off (when you push off with the ball of your foot). There is no single BEST answer for all these problems, but in general, motion-control type running shoes, sometimes with arch supports, orthotics and, infrequently, heel spacers (for leg length discrepancies) are indicated. It is very important to remember that your running shoes
have a limited "life-span" and new running shoes every 400-500 miles are a must. It is best to have two pairs of your running shoes, alternating frequently, as this extends the useful life of the shoes. For avid runners or serious athletes who run as part of their sport, custom-made orthotics may be a worthwhile investment (these are not covered under Kaiser benefits.


7. SURGERY:
A very small proportion of athletes with Patellofemoral Syndrome do not improve with the therapy outlined above. For the very stubborn, unusual cases, unresponsive to a dedicated conservative management regimen, surgical release of the structures anchoring the outer side of the kneecap can be undertaken. Sometimes, severe arthritic changes behind the kneecap (termed Chondromalacia) will require surgical "cleanup". Surgical management does not obviate the need to continue the conservative steps of therapy, as well


More Quad Exercises:
For those less fortunate of you who do not have access to the high-tech resistance machines at the gym: fear not . Here is a nifty little trick,which can be done at home, and utilizes a one-gallon milk or water bottle (the ones with a handle). You can fill the bottle to varying weights, by remembering that each quart is two pounds (32oz.) and there are four quarts in a gallon.
Tie a strap (rope, scarf, etc) through the handle with enough space to slip over your foot, in order to suspend the bottle from your ankle. Sit yourself on a desk, countertop, or high stool or chair, that has your knee bent at about 30 degrees when the bottle is suspended from your ankle and just touching the floor. Sit back far enough that the back of your knees touch the edge of the surface on which you are sitting. Begin doing lifts with 2 lbs. (1 qt.) weight. Extend the knee from 30 degrees of bend to straight, hold for 5 seconds, then down. When you are able to do 3 sets of 15-20 lifts with ease, increase the weight by 2 lbs. (max.) increments, until you are able to use a full bottle, same number of exercises. At that point, you should either get a second one gallon bottle or a two gallon container, gradually increasing the weight until you can lift 12-16 lbs. without difficulty. Remember to exercise both knees separately. Alternatively, you can use a plastic grocery shopping bag, using cans of food (remember: l6oz.=lLb). Just drape the bag over your foot and ankle, but be sure to sit yourself high enough to get some benefit from this technique.
Another thing you can use is ankle weights; the type you can get at running and workout stores. There is a picture of this in the Graphics section. Both the above exercises are Open Chain type exercises, so use the cautions and range of bend noted above in that section


REMEMBER: This problem did not occur overnight. It represents an ongoing process of inflammation that was aggravated by a specific activity, or change in activity, thereby overwhelming your body's healing mechanisms. You cannot expect to heal overnight or even in a week. However, you should feel comfortable in the knowledge that the same steps you are taking to heal this problem are the very things that will prevent its return. If you are failing to improve after a concerted trial of rehab, call your doctor to be re-evaluated

GOOD LUCK AND GOOD EXERCISE!