5 Keys to Training the Person With Patellofemoral Pain Michael M. Reinold, PT, DPT, SCS, ATC, CSCS

5 Keys to Training the Person with Patellofemoral Pain Michael M. Reinold, PT, DPT, SCS, ATC, CSCS Training the person with patellofemoral pain can often be daunting and challenging. This is true even for those with a history of patellofemoral pain, as it often seems like any small change in their training program could lead to another flare up of the condition. Considering that patellofemoral pain has been referred to as the “black hole of orthopedics,” it’s not surprising that many people struggle when training people with this condition. Fortunately, working with people with patellofemoral pain does not have to be challenging, however, this does require taking a step back and rethinking a few common assumptions and misconceptions. Below are 5 keys that I consider valuable to consider when training a person with current or past symptoms of patellofemoral pain. By understanding these basic principles, you should have a little easier time working with these people.

Key # 1 - The Term “Patellofemoral Pain” Really Doesn’t Mean Anything Unfortunately, the term “patellofemoral pain” itself is vague and misleading. Pathologies grouped into this “syndrome” can range anywhere from patellar tendonitis, to full thickness chondral lesions, to even patellar dislocations. This isn’t the only area of the body that we do this to, subacromial impingement and low back pain come to mind as well. But using a vague term does not help us when dealing with this issue. There isn’t a magical program you can pull out of your desk drawer and give to everyone that has patellofemoral pain; each person’s cause and symptoms are different. So next time you are working with someone with “patellofemoral pain,” challenge yourself to look beyond the vague terminology and see the injury more clearly. Is it tendonitis? Is it instability? Is it a mechanical alignment problem? Is it secondary to poor hip or foot mechanics? The more we understand the issue, the better we can help the person and avoid any potential flare ups do to our training programs

Key # 2 - Realize that the source of patellofemoral pain isn't always the cartilage Similar to the previous key, a common misconception is that patellofemoral pain is from “chondromalacia” or some sort of defect to the articular cartilage of the patellofemoral joint. This is basically either degenerative (basically arthritis) or from an acute injury such as a cartilage defect after a patellar dislocation. While this may be true, several researches have challenged the notion that patellofemoral pain is solely from the cartilage. In fact, studies have shown that the cartilage itself does not produce a significant amount of pain. Furthermore, the majority of pain that is found in patellofemoral patients is difficult to localize. This makes sense as people often report vague complaints and the inability to pin point the location of soreness. This is actually normal! The structures within the knee are not mapped to the brain in a manner that allows us to localize the pain very well. This certainly makes our jobs harder, but realizing this helps us understand the person’s complaints.

Another interesting finding in several research studies was that the source of patellofemoral pain might actually originate more from the surrounding retinaculum and soft tissue. These tissues have more neurological innervations than the cartilage itself. So, the bottom line is that not all people with patellofemoral pain have issues with their cartilage. Conversely, their source of pain may be more from the soft tissue surrounding the joint. So designing programs solely to reduce patellofemoral forces may not be necessary in every person. But using techniques to work on the soft tissue, such as foam roll, massage stick, and other similar forms of self-myofascial release, may have an impact on these people’s symptoms. Remember, numerous structures of the leg, such as the quadriceps, hamstrings, and the IT band, are all heavily integrated into the retinaculum, so working on these areas can help the knee.

Key #3 - Understand the biomechanics of exercise selection and the impact on the patellofemoral joint An important concept to understand is that different exercises produce different forces to the patellofemoral joint. Within the scientific literature, several research studies have been performed to compare different exercises, such as the leg press and knee extension. These two exercises are the most commonly studied to represent both open and closed kinetic chain exercises, but the results can be applied to other exercises such as lunges and squats. In a nutshell, weight bearing and non-weight bearing exercises are different. When you perform non-weight bearing exercises, such as knee extension, patellofemoral forces are highest as the knee extends. Conversely, when performing weight-bearing exercises, patellofemoral forces are highest as the knee flexes. The answer behind all of this is the biomechanics of the joint but the important concept to understand is that exercises are different. The knee extension exercise has a really bad reputation at this point, but realistically it is an excellent method of producing pure quadriceps strength. However, the negative is the impact on the knee, as forces on the patellofemoral joint can get very high. But if you perform the exercise in deeper angles, let’s say from about 90 to 50 degrees of knee extension, you can reduce the strain on the knee. I’m not advocating the exercise, but just using it as an example for the power of understanding the biomechanics of exercises. Conversely, if weight bearing exercises such as squats and lunges are causing some issues, rather than avoiding them, try to perform them in a more shallow range of motion, maybe 0-45 degrees of knee flexion. As the person gets stronger, slowly incorporate deeper angles in a gradual progression. This will put less stress on the joint but still allow you to get some strength gains. In regard to the lunge, the forces on the patellofemoral joint are similar to the lunge and the squat, the deeper you go, the more the force. This goes for both the forward and side lunge. Interestingly, there are two modifications to the lunge that can reduce patellofemoral force: 1) performing the lunge from a split-stance position (not actually striding to perform the lunge) and 2) using a longer stride. Something to consider as potential starting points in your programs.

I could go on and on about the biomechanics of the patellofemoral joint, something that really interests me, but I tried to keep it simple here, check out my website at MikeReinold.com where I actually dive into all of this in a lot more detail.

Key #4 - Train the kinetic chain to treat the knee The influence of the kinetic chain on the patellofemoral cannot be underestimated. Because the knee is located mid-way through a weight bearing extremity, it is vulnerable to excessive force from biomechanical faults located both proximally and distally to the knee itself. I believe a significant reason why “patellofemoral pain” has been such a challenging diagnosis in the past is because we were treating the symptoms, not the cause of the pain, which many times may be coming from elsewhere within the kinetic chain. The influence of the hip on the patellofemoral joint has been well documented over the last decade. The biomechanical works of several researchers have shown that excessive hip adduction and internal rotation places the patellofemoral joint in a disadvantageous position. Unfortunately, our population is dominated by sagittal plane strength and weakness in the coronal and transverse planes. It seems like it is a normal part of daily living now as the majority of our functional tasks take place in the sagittal plane. Even more unfortunate is the fact that exercises outside of the sagittal plane are often neglected in strength training programs. This creates a significant biomechanical disadvantage. Training people with patellofemoral pain requires training the hip to abduct and externally rotate. Also, it is important to train the hip abductors and external rotators to isometrically stabilize the knee during sagittal plane movements and to eccentrically control hip adduction and internal rotation. A simple test I perform is the step-down exercise. I am specifically looking for the ability to eccentrically lower the body in the sagittal plane while preventing the hip from dipping into adduction and internal rotation. This is harder than it looks and will often be an issue. But trust me, overtime this will improve, and POOF! Your client’s patellofemoral pain while training, climbing stairs, and running will have vanished! You are a genius now. Just as forces located proximal to the knee can have a significant impact on the patellofemoral joint, forces distal to the knee may also contribute. These people may have issues such as excessive pronation or supination that are influencing their symptoms at their knee. These people may benefit from seeing an orthopedist or physical therapist to address some of these concerns before you get too deep into their training programs.

Key #5 - Don’t Forget that we can’t Always “Solve” the Patellofemoral Mystery One thing is certain when dealing with patellofemoral pain – working with people with patellofemoral pain can be tricky. Why wouldn’t it be considering that there are several different sources of pain, multiple classification of injuries, and a combination of both intrinsic and extrinsic factors that could be influencing the knee. Next time you have someone with some issues that are not resolving, take a step back and reflect on these 5 keys and think outside the box. Do they have poor mechanics during movements? Do they

have deficiencies at places proximal or distal from the knee? Are there any other issues that may be feeding into their symptoms? And don’t forget, when in doubt refer out to a qualified orthopedist and physical therapist when needed to properly diagnose the issue and help collaborate on a game plan. Best of luck in the future,

Mike Reinold MikeReinold.com

About the Author Mike is a physical therapist, athletic trainer, strength coach, and a leading clinician, researcher, and educator in sports and orthopedic rehabilitation. Mike has published dozens of books, chapters, and scientific journal articles, including his latest textbook The Athlete's Shoulder. He is currently the head athletic trainer of the Boston red sox and shares his experience and latest research findings at his website at MikeReinold.com.