1. Patello-Femoral Syndrome
2. Patellar Tendinopathy

Diagnosing these conditions can often be difficult as they often have similar symptoms, and can even present together.

The patello-femoral joint is formed by the knee cap (patella) sitting on the front of the knee joint, which consists of the femur (thigh bone) and the tibia (leg bone). As the knee bends, the patella moves in a groove found at the end of the femur.

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1. Patellofemoral Pain

What is it?

Patello-femoral pain is due to inflammation of the under surface of the patella (knee cap). This is caused by incorrect tracking, or movement, of the patella, as the knee bends and straightens. This results in the patella rubbing against the femur bone, instead of gliding in the groove it is supposed to.

What causes it?

It is usually a combination of factors associated with tightness in the lateral thigh structures (iliotibial band, quadriceps, hamstrings, calf) and a loss of muscular control (and strength) of the inner quadriceps muscle, the vastus medialis oblique (VMO). This results in abnormal movement of the patella, which leads to inflammation, pain, swelling and a progressive inability of the knee to perform as required, if left untreated. 

What are the symptoms? 

• Pain that gradually worsens with activity i.e. running
• Pain going up or down stairs
• Pain with squatting
• Pain with prolonged sitting (movie-goers knee)
• Pain deep in the front of the knee
• Giving way or a feeling of instability
• Swelling
• Recurrent clicking

What can be done?

A thorough physical and biomechanical assessment, including functional testing to reproduce the patient's pain and locate the nature of the symptoms is required. Physiotherapy management is based on an abundance of scientific research led by physiotherapists, which is concentrated on improving the control of the patella, leading to a successful recovery and return to sport. This will include:

• Rest: without rest the under surface of the patella will become more sensitive and painful.
• Minimise inflammation: regular application of ice will provide pain relief. Anti-inflammatories prescribed from your doctor may also assist at this time.
• Taping: of the patella to correct abnormal patellar position, will minimize pain and facilitate the contraction of the VMO / quadriceps muscle.
• Massage: plays an important role in allowing the lateral structures to stretch by ironing out any tight knots.
• Increase Strength: of the VMO, to improve the control of the patella, and pelvic stabilisers (i.e. gluteal muscles of the buttock), to minimise the load on the patellofemoral joint.
• Correction of Pre-Disposing Factors: this ensures that the problem doesn't re-occur and can include:

(a) Education on correct training principles of duration, intensity and frequency, to ensure the knee can progressively adapt to the demands placed upon it with training.

(b) Biomechanical factors such as over-pronation (flattening) of the feet can cause the lower leg, and subsequently the knee, to roll inwards. Wearing appropriate running shoes for your foot type will minimise these problems.

2. Patella Tendinopathy

In the past this injury was often diagnosed as ‘patella tendonitis', an inflammation of the patella tendon, however recent clinical research has more accurately termed it ‘patella tendinopathy'.

What is it?

Patella tendinopathy, or ‘Jumper's knee', refers to a painful overuse injury of the patella tendon, which connects the kneecap (patella) to the tibia. This occurs as a result of degeneration (either acute or chronic) within the patella tendon itself, without the presence of any inflammation being present. Many cases of patella tendinopathy also co-exist with patellofemoral syndrome.

What causes it?

It is caused by excessive loads on the patella tendon, particularly if there are insufficient rest periods. It is most commonly seen in athletes that engage in running and jumping type sports, such as netball or basketball.

What are the symptoms?

• Pain is well localised (from a dull ache to severe and sharp) at the front of the knee
• Anterior knee pain is usually of a gradual onset
• Jumping and landing activities will increase the pain
• The bottom of the patella will be tender to touch
• Pain will occur with squats and stairs, particularly descending
• Below the patella can be swollen, or ‘puffy', but this is rare
• Unlikely to be episodes of giving way or instability

What can be done?

Rehabilitation is a lengthy process and the athlete may take from 3 - 6 months to return to sport. This may include:

• Rest / Ice: Reducing your activity levels and regular periods of applying ice is essential to prevent the patella tendon becoming more sensitive and painful.
• Taping: of the patellofemoral joint should be used if it is contributing to the symptoms. Taping the patella tendon itself can also assist in reducing the load on the tendon.
• Massage: is performed on the patella tendon to improve local blood flow and release adhesions between the collagen fibres that compose the patella tendon. Often other thigh structures (quadriceps, iliotibial bands) will also need to have any tight knots ironed out.
• Stretching: poor hamstring and quadriceps muscle flexibility can overload the patella tendon. Hence, a regular stretching program, particularly in ‘growing' children, is essential.
• Increase Strength: a quadriceps strengthening program is needed to increase the tensile strength of the patella tendon. This involves a graduated series of exercises, that start slowly, and then progress by increasing the speed and weight involved during exercise.
• Correction of Pre-Disposing Factors: as already outlined in ‘patellofemoral pain' above, these changes ensure that the problem doesn't re-occur in the future.
• Surgery: if conservative management fails, then surgery can be a possibility with long-standing patella tendinopathy. Further investigations (ultrasound, MRI) can assist in determining whether surgery is required. The rehabilitation process is slow and lengthy, following the principles outlined above. A return to sport is approximately 6 - 12 months, with only 60-75% of patients returning to their previous levels of sport.

Published by Balmain Sports Physiotherapy