In this post, I am going to look at one of the most common knee complaints that I will see in the clinic for physiotherapy treatment. It can be an issue for a huge variety of individuals of various ages, activity levels, and habits. It is commonly diagnosed as Patellofemoral Pain Syndrome (PFPS). PFPS is a common complaint of runners, with 28% of running injuries being knee-related.
The Academy of Orthopaedic Physical Therapy has published a Clinical Practice Guideline last year on Patellofemoral Pain Syndrome (PFPS), so here is some info on PFPS and let's see what is being recommended for physiotherapy treatment.
What is a Clinical Practice Guideline and why should we care about them?
Clinical Practice Guidelines are a set of recommendations that help professionals make appropriate clinical decisions. A group of researchers does an extensive search of the literature, rate the quality of the studies and results, and then come up with recommendations from this. Importantly, this DOES NOT become a gold standard in how to treat the condition. Research is never perfect, and the results should be taken as recommendations, alongside professional experience, expertise, and client preference, to create an effective and personalized treatment plan. However, it is a nice summary of recommendations based on up to date research, and we should be aware of it to help guide our management and treatment plans for PFPS.
What is PFPS?
Good question, unfortunately, Dr. Google gives us a bunch of different answers.
PFPS is a term used to describe pain in the front of the knee.
Patello = knee cap
Femoral= Femur (thigh bone)
Syndrome= we don’t really understand what it is, so let's use an umbrella term
Generally, it is:
1. Vague/diffuse and difficult to describe or pinpoint
2. Identified as around the knee cap, under the knee cap, or behind the knee cap
3. Symptoms start slowly and worsen with continued loading of the leg- for example with squats, stairs, running, hills, jumping etc.
4. Usually better with rest
PFPS can present in a range of clientele, and commonly we look to find a recent increase in the person's exercise/activity levels as the reason for developing it. This can be a seasoned runner who quickly increased their weekly mileage, weekend warriors who maybe didn’t play for a few weeks and then returned to their jumping sport or inactive people who suddenly spent all weekend walking.
Symptoms will usually go away with rest, and the person feels better, but then with the return of the same activity, the symptoms come back. Due to this, I will regularly see this as a chronic presentation in the clinic, with on/off symptoms going on for multiple months if not years. A lot of the time the symptoms stop the person from continuing their activity and exercise of choice.
In clinics (and on the internet) these symptoms are usually explained by "too much contact" of the knee cap in the groove below it, or as a "tracking" problem where the knee cap is getting pulled one way or the other. To be honest, if this was 100% true, that would be awesome and much easier to manage and explain. However, there is a lot of research into why people get pain around the knee cap and no definitive answer as to what causes the pain exactly. In Physiotherapy, we are moving away from this description of a "tracking" problem, as it does not explain symptoms well enough.
The general understanding now is that PFPS is due to “mechanical overload”. This means we do something that puts a lot more stress on the knee joint than “normal” and it becomes irritated. This can purely be a training error- i.e. too much too quickly. It can also be because of an individual's movement habits that put more stress and load on certain parts of the body more than others. An example of this may be stiff hips or ankles, or weakness around the hips that cause people to put more stress on the knee with certain exercise. When the amount of stress on the knee gets too much, it may create a pain response.
What is recommended in the new guidelines?
What are my opinions on this?
I don’t think any of this is new information and is consistent with how I will continue to manage clients with PFPS symptoms. I would say that clinically, I find education to be a very useful tool for PFPS and it is surprising to see that there is not greater research for this. It is common my clients will come in not understanding why their knee hurts, or how they can control and manage their symptoms better day-to-day. It is important to modify their activity in the short term and teach them strategies that keep them moving and exercising without just aggravating their symptoms further. This is different for everybody depending on their symptoms and daily habits.
I also find that dry needling and acupuncture to be useful techniques to help with pain and mobility for some individuals. The research papers for acupuncture and dry needling they used in the guideline were limited, and so I will continue to use these techniques for individuals that it is indicated for, as I do find it useful in the clinic. This may well be personal bias, and not for everybody. The Dry Needling study only used the technique locally around the knee. With what we understand about biomechanics and PFPS, I find success using Dry Needling around the hips/low back and ankle, as well as the knee, to help with the tightness of other joints that will contribute to the increased stress on the knee. This is an example of how we need to take care when reading clinical practice guidelines.
Interestingly, I will probably start using orthotics in the short term as it is something I am currently not recommending in my physiotherapy treatment plan, but has more evidence to support it than I thought!
My ongoing issue with types of guideline like this, is that it lays out the results in a very systemic way, and says do this, don’t do this. Unfortunately, it is not that easy. There are many other factors involved with treating people and there are always limitations and further research that needs to be done. Exercise rehabilitation will continue to be the most researched area and continually have the strongest evidence for PFPS. I think that everything else may or may not have a role in helping different people, and the challenge is finding the combination of treatment that helps the individual.
What do you recommend if my knee hurts?
PFPS is just one of many possible diagnoses for knee pain. I will always recommend seeing a rehab professional (like a physio) who will do a detailed history and exam for proper diagnosis and advice. As useful as the internet is, it does lack the ability to interact with you and ask you for more information and question your symptoms. Do you also have back pain? Does your hip hurt? Does your pain radiate into your calf, or up the leg? Did you have a trauma, or was there a noticeable incident that started the knee pain? These are just some of the extra questions a professional will want to ask to help guide their exam.
If you do truly have PFPS, my advice is to MODIFY your activity in the short term. Reduce the intensity, frequency or type. In some cases you may need to stop for a short period of time. It is very rare that you will need to stop all exercise for a prolonged period of time. Then as the guideline suggests, work on some strengthening exercises for the hip and knee, and slowly increase your activity levels back up. This will be easier to do if your knee pain is new and if it is easy to identify what you have done to "overload" the knee. If your problems have been going on for a long time (more than 6 weeks), or keep coming back, then definitely get it looked at by a professional!
If you are in Collingwood and struggling with knee pain and have been diagnosed with PFPS, or think that is what you have, get in touch and I will happily assess you, provide a detailed physiotherapy plan, and help you get through it so that you reach your goals!
1. Patellofemoral Pain. Clinical Practice Guidelines Linked to the International Classification of Functioning, Disability and Health. From The Academy of Orthopaedic Physical Therapy of the American Physical Therapy Association. Willy et al., 2019. J Orthop Sports Phys Ther 2019;49(9).