Knee Knowledge

By Tamela Thomas, Wellness Manager

What is the weakest joint in your body? For most of us it would be the knee. Whether you are a hardcore sports enthusiast or a weekend hiker, you are likely to find yourself with some sort of knee pain at some point in time. This wellness article addresses anterior knee pain—pain primarily associated with the kneecap.

Our guest columnist is Don Labourr, PT, ATC. Don is Senior Vice President of Health Practice Partners, a health care management company. Don has spent many years in the field going all the way back to his days as an athletic trainer with the University of Washington. He is very familiar with the intricate engineering of the knee and its common injuries.

Don also conducts injury screenings at the Club each month. Members can get an evaluation by a licensed physical therapist with recommendations for home treatment or specific rehab activities at the Club. Call me for more information: 206.464.4639.

So if you have a little twinge starting to happen, a chronic throb you've been dealing with too long, or just want to know how to prevent an acute condition, you can benefit from the information in this article.

Anterior Knee Pain

By Don Labourr, PT, ATC

Ever have discomfort or pain in the front of your knee when going up or down stairs? How about with squatting or sitting for long periods of time? How about all those crackles you hear when you bend and straighten your knee—is that normal? Actually, these complaints are some of the most common of the numerous musculoskeletal complaints heard daily by physicians.

This type of pain is usually associated with dysfunction of the patellofemoral joint or the joint formed by your kneecap and the end of your femur. The kneecap is designed to follow a specific course as it slides up and down the groove of the femur. It is supported throughout this movement by the bony groove itself, plus specific muscles, ligaments and tendons, which usually do a remarkable job of working together to guide the kneecap in its proper course.

Occasionally, due to injury, muscle weakness, lack of flexibility, excessive activity levels or faulty biomechanics, the kneecap can be forced into an abnormal course as it moves up and down the groove. Usually it is forced laterally or to the outside of the groove. This causes excessive pressure between the outside undersurface of the patella and the lateral edge of the femoral groove resulting in pain. It may also cause an overstressing or pinching of the soft tissue structures trying to hold the kneecap in its proper course. As this abnormal tracking continues, symptoms become more constant and debilitating due to increased damage to the supporting tissues. Climbing and especially descending stairs puts a lot of pressure on the patellofemoral joint, so naturally it is this type of activity that first elicits pain.

Injuries

The common injuries associated with dysfunctions of the patellofemoral joint are:

Patellar tendinitis (jumper's knee)—In this condition, the attachment of the patellar tendon to the patella becomes irritated. Usually there is pinpoint tenderness at the inferior pole of the patella. Pain is often elicited with jumping or landing activities and therefore very common in basketball. Less commonly there will be pain at the superior pole of the patella and this is referred to as quadriceps tendinitis.

Excessive lateral pressure syndrome—In this condition, the lateral undersurface of the patella has become irritated and inflamed. Occasionally the soft cartilage surface of this area has worn thin and in more severe cases some of the bone may be exposed. More commonly, the tissues in this area have become pinched and inflamed. Pain can be elicited by pressing a finger against or underneath the lateral edge of the patella.

Medial stress syndrome—In this condition, the structures on the inside of the kneecap that are responsible for holding the kneecap medially in the femoral grove have been overstressed due to lateral tracking. They become inflamed and pain results each time they are stressed, as in descending stairs. Usually there will be tenderness to palpation of the medial side of the kneecap.

Plica syndrome—Occasionally there are folds or thickenings in the lining around the knee that are less elastic than the rest of the tissue. These plicas, as they are called, can become overstretched and, thus, irritated and inflamed.

Treatment

As with all injuries, the first course of treatment is to ICE the injured tissues and allow them to REST and heal by avoiding painful activities (try the elevator for a few days). Long-term resolution of the problem lies in the ability to restore the normal tracking motion of the patella by correcting any areas of muscle weakness, tightness or biomechanical faults that might be present. A thorough evaluation by an experienced musculoskeletal physician can identify problem areas and outline specific exercises to correct these problems.

Strengthening exercises are designed to strengthen the specific part of the quadricep's muscle that pulls the kneecap medially. One basic exercise is called Quad Sets. The patient sits on the floor with the leg out straight and tightens the thigh muscle making sure that the inside part of the muscle is firm. The contraction is held for 10 seconds and repeated 10 times several times per day. Your physician or physical therapist can prescribe other more functional exercises. All exercises must be pain-free.

Stretching exercises should include all the major muscles of the lower extremity including the calf and soleus, hamstrings, quadriceps and hip musculature. All stretches should be held for at least 30 seconds and repeated several times during the day.

Often, a person's body is not suitably aligned for a particular activity or activity level. One example would be excessive foot pronation (flat feet) which may be fine for daily activities but not for long distance running. If a pronation problem exists an orthotic or arch support may be recommended.

One sometimes overlooked treatment regimen is simply to make sure that the person's activities are being done correctly and not excessively. Frequently, people will overdo their regular routine and experience kneecap pain due to fatigue. An example of pain due to technique is skiers who experience kneecap pain because they have their weight too far back on their skis.

Knee braces are often used to help control proper tracking of the patella. Physical therapists have also developed taping techniques that are very effective in controlling motion and eliminating pain allowing exercises and functional activities to be done.

Patellofemoral dysfunctions and their resulting pain are usually easily treatable but should be addressed early before a chronic condition develops. If ice and rest have not helped and you are forced to continue to limit your activities, you should seek the help of an experienced musculoskeletal physician. By the way, the crackles you hear when you bend and straighten your knee... if not associated with pain, they are normal and should not be of concern.