Now, some ground rules!
Knee pain can sometimes seem very simple. I mean, it’s mostly just a modified hinge joint, right? I would beg to differ. So, here’s a quick guide on a select few of the common knee pain presentations we encounter weekly at Roar Physio;
As it is hopefully becoming apparent, there is a huge amount of diagnostic variance in knee pain. When you combine this with the enormous variety between individuals, it begins to become increasingly difficult to make generalisations about all types of anterior knee pain.
This isn’t to say that there are not factors that most of the above types of knee pain will have in common though. As such, you can apply most of these considerations and exercise advice to a variety of pain presentations and disorders, but it certainly won’t be a perfect fit.
Here are some key considerations when you have anterior knee pain;
One of the key questions that all clients at Roar Physiotherapy will be asked is about their training history and current training loads. This provides pivotal information as to what may be the primary pain driver and at times guides a rehabilitation plan and program.
Increasing training intensity/volume/frequency/ modality will push you up and beyond your current physical capability. In the right dose, this leads to supercompensation, adaptation and building resilience – the good stuff!
When we push the boundary further, we move outside our ‘envelope of function’ and this can result in pain and dysfunction. This is demonstrated in the following image.
In summary, when increasing your training, be smart and understand that this comes with risk and reward – it’s up to you or your coach to decide the balance!
To learn more about training load and its impact on training and injury, check out these previous blog posts, HERE and HERE.
More often than not, knee-pain sufferers tend to not find every activity painful, but rather a select few. There are some broad patterns I have observed in practice;
These can also be present in combination with one another. Accurately identifying the category, or categories, you fall in to can enable effective training modification, whilst recovering.
It can be broadly considered that adaptation occurs between the balance of fitness and fatigue. We develop fitness over time through training; depletion of energy; and recovery. This process is known as supercompensation (as illustrated in the diagram below).
If we interrupt the recovery process prematurely (prior to achieving supercompensation), then we accumulate fatigue, instead of positive adaptation.
Essential components for recovery are time, diet and sleep.
In fact, one study found that adolescent athletes who sleep, on average, less than eight hours have 1.7 times greater risk of being injured than those who sleep longer than eight hours.
By interfering with our sleep and recovery time, we potentially steer ourselves to developing pain. To learn more about sleep and its impact on training and injury, check out a previous blog post, HERE.
Furthermore, our mood & stress levels have been shown to be associated with the development/resolution of anterior knee pain. In one study, an individual’s beliefs surrounding their pain and activity levels were the strongest predictor of recovery from their knee pain.
So, when things don’t tend to make sense in regard to training itself, step back and consider how you have been recovering and what your stress has been like in recent times. This can start to build a clearer picture of why knee pain may have developed in the first place and what needs to be considered for optimal recovery.
Times they need a changin’..?
Ok, now we’ve established WHY you’re probably in pain, but what do we do about it?
Firstly, don’t freak out! Remember, pain is normal and is UNDOUBTABLY going to happen sometime in your training career.
If we look back to ‘Consideration Two,’ try to figure out what your sensitising features are;
The easiest method to begin managing this is to regress the aggravating activity. Perhaps for you this means reducing the weight, volume or depth of the movement. This is the option we promote most at Roar Physio and tends to be the most effective, whilst still keeping you very active.
If this doesn’t achieve our goal of pain reduction or functional improvement, then removing the aggravating activity should be considered. Seems like a no-brainer. The awesome thing about CrossFit is how ‘constantly varied’ it is. Take advantage of that and take a break from the one or two activities that’s are causing you pain for a week. It won’t kill you!
After implementing the above considerations and relevant activity modifications, there is usually a role for exercise rehabilitation to get you back into optimal function.
Here are a few favourites from Roar Physiotherapy to assist you in getting back to it!
Spanish Squats are very useful for warming up tendon-related pain and to practice a more ‘hip-dominant’ style squat, which reduces anterior knee force.
CrossFit is massively bilateral, until it’s not… Just ask the recent Games Day 2019 competitors how their 100 pistols for time went!
As such, I think it’s important to regularly include and practice single leg movements. A simple regression/progression ladder may be;
For some knee-pain sufferers, training the gluteal muscle group has an effect on pain reduction and functional improvement. Have a go at this example of a banded glute !
I hope this has provided some assistance for anyone suffering from knee pain. As a long-term knee pain sufferer myself, I understand how difficult and frustrating it can be to be limited by a cranky knee.
To learn a little more about knee pain, HERE is a previous blog piece I have written on common sources of knee pain.
If anyone is struggling to get on top of their pain or regain their function and performance, get in touch with us on the details below and get a plan in place!
Phone: 0421 833 801
Milewski, M. D., Skaggs, D. L., Bishop, G. A., Pace, J. L., Ibrahim, D. A., Wren, T. A., & Barzdukas, A. (2014). Chronic lack of sleep is associated with increased sports injuries in adolescent athletes. Journal of Pediatric Orthopaedics, 34(2), 129-133.
Piva, S. R., Fitzgerald, G. K., Wisniewski, S., & Delitto, A. (2009). Predictors of pain and function outcome after rehabilitation in patients with patellofemoral pain syndrome. Journal of rehabilitation medicine, 41(8), 604-612.
Piva, S. R., Fitzgerald, G. K., Irrgang, J. J., Fritz, J. M., Wisniewski, S., McGinty, G. T., … & Delitto, A. (2009). Associates of physical function and pain in patients with patellofemoral pain syndrome. Archives of physical medicine and rehabilitation, 90(2), 285-295.
Willy, R. W., & Meira, E. P. (2016). Current concepts in biomechanical interventions for patellofemoral pain. International Journal of Sports Physical Therapy, 11(6), 877.
I decided to write this article on knee pain, as it is something I see frequently, as well as deal with myself. Check out our other resources on knee pain on YouTube, here, and Facebook, here.
Knee pain is a common experience for many people and has a variety of possible diagnoses. The most common amongst these are patellofemoral pain syndrome, osteoarthritis, patella tendinopathy and a range of juvenile disorders such as Osgood-Schlatters. There are also multiple traumatic injuries which can occur around the knee, which are commonly seen on the sporting field, such as ACL, PCL, MCL, LCL and meniscus injuries.
Physiotherapy treatment has demonstrated assistance with all of these disorders, and generally will have great results.
I will now focus in on, arguably, the most common cause of knee pain, patellofemoral pain syndrome, which was estimated by Boling et al (2010) to affect up to 15% of females and 12% of males. Patellofemoral pain syndrome, or PFPS for short, is a disorder generally affecting the soft tissue of the patella (kneecap) and underlying joint surfaces, the femur and tibia. Symptoms, however, can arise from any structure in the knee (see Figure 1).
Figure 1 – Patellofemoral joint anatomy
The primary symptom is a diffuse pain, often felt around the sides or behind the kneecap, which is generally worse on bending, squatting or going up stairs, as well as sitting for long periods of time (often called the ‘movie sitters’ sign). There can be occasional stiffness, usually felt first thing in the morning.
As aforementioned, women are more prone to PFPS, with the same study suggesting women are 2.23 times more likely than men to develop PFPS. This is likely due to a number of biomechanical factors, such as pelvic, hip and knee joint angles.
There are many reasons why PFPS develops. Primarily though it is thought to be due to patella maltracking, brought on by factors at the knee joint itself, but also at the joints above and below. The multifactorial nature of PFPS is reflected in the physiotherapy treatment commonly provided. Treatment may consist of RICER, analgesia (pain-killers), exercise rehabilitation, movement retraining, taping and foot orthoses.
A recent systematic review (Lack et al (2015)) looked into the growing pool of evidence surrounding proximal strengthening in the treatment of PFPS. The results of the review displayed strong evidence to support the efficacy of proximal, combined with quadriceps, exercise on improving pain and function in the short, medium and long term. The study was unable to determine a specific protocol for intensity and duration of rehab sessions, though suggested pain-free exercises (generally open kinetic chain (OKC)) be undertaken initially.
Figure 2 – Common biomechanical faults
What does that mean for you as a knee pain sufferer?
Well it means that although massage, dry-needling, taping and other modalities will help with pain in the short term, the real key to long term relief of PFPS is exercise! Specifically gluteal and quadriceps exercises.
There are a slew of exercises I find to be very effective in the treatment of PFPS, as well as recently adding a couple of new exercises learned during time I spent with the Kookaburra’s.
If you yourself is struggling with knee pain, know someone who is or have any questions please don’t hesitate to comment below or message me.
Boling, M., Padua, D., Marshall, S., Guskiewicz, K., Pyne, S., & Beutler, A. (2010). Gender differences in the incidence and prevalence of patellofemoral pain syndrome. Scandinavian journal of medicine & science in sports, 20(5), 725-730.
Lack, S., Barton, C., Sohan, O., Crossley, K., & Morrissey, D. (2015). Proximal muscle rehabilitation is effective for patellofemoral pain: a systematic review with meta-analysis. British journal of sports medicine, bjsports-2015.