Do Your Knees Hurt?
Do your knees hurt? If they do, the odds are that you have anterior knee pain (AKP). AKP goes by many different names, including patellofemoral pain syndrome, chondromalacia patella, and runner’s knee. Recently a group of experts met and produced a consensus paper1 to better define the diagnosis and treatment in AKP.
There are many different types of knee pain, but AKP is the leading type; up to 74% of knee pain is AKP! What’s worse, it is a type of pain that tends to stick around – up to 40% of people with AKP report that they haven’t fully recovered 12 months after their diagnosis2 and 70% to 90% have recurrent or chronic pain3. This may be because AKP can be challenging to treat; the causes of this pain are not only found local to the knee, but also the back, hip, and ankle. For athletes, overtraining, training too much or too hard, or not allowing enough rest can also contribute to AKP. The fact that pain can persist beyond the typical healing time also tells us that there is likely some degree of psychosocial component – e.g. factors such as work stress, lack of sleep, etc affecting intensity and ease of provocation of pain.
Historically, the approach to AKP has been rather near-sighted, with a focus on the knee itself. Doctors know that when a patient has pain, they typically would like to have a named diagnosis for the pain they are struggling with. Given the time pressures that providers are under, often a patient will receive a specific knee diagnosis, and any subsequent may be focused solely on that diagnosis. If your provider does not address all contributing factors, including the biomechanics of the entire kinematic chain and possible training and lifestyle contributors, you may be left with the dissatisfaction and residual or recurrent problems described above.
Recommendations for Diagnosis:
The main indication for this diagnosis is pain behind/around the patella elicited by weight-bearing activity that loads the patellofemoral joint (e.g. squatting, stairs, jogging, running, hopping. You may also see crepitus/grinding, tenderness on the edges (facets) of the patella, small effusion (swelling), or pain on sitting, rising from sitting, or straightening the knee following sitting. People who have had full or partial dislocations are a subgroup of people suffering from AKP. The best physical test to make a diagnosis (positive in 80% of people) is AKP on squatting. No other testing is particularly helpful for diagnosis. Initial diagnosis does not require imaging, however, this may become necessary in cases where the pain is not changing over time and it’s going to be helpful in potentially planning surgery.
Recommendations for Treatment
- Treatments were assessed for effectiveness in the short (6-month), mid (6-12-month) and long term (12+ months).
- Exercise Therapy has been shown to reduce pain and improve function in the short, mid, and long term.
- Combined hip and knee targeted exercise therapy is better than knee targeted exercises alone for both pain and function in the short, mid, and long term.
- Combined interventions of exercises and taping, bracing and orthoses provide benefit in the short and mid term.
- Foot orthoses are recommended for the short-term.
- It is uncertain if acupuncture, or taping on their own provide relief.
- Joint mobilizations (a form of manual therapy) to the knee or back are not recommended.
- Electrophysical agents are not recommended (e.g. e-stim, ultrasound).
I underlined the final two items because these are oftentimes performed in clinics around the country as standard practice, and many PTs truly think it benefits their patients. Some might even look at these recommendations with disdain. However, the reason the study group listed these treatments as not recommended is that good quality studies have found that they provide no meaningful improvements. Some will read this and say “I had stim on my kneecap and I felt better after, these people are wrong!”, and I can understand that, as stim certainly feels good. However, feeling good and perhaps providing a few hours of pain relief is different than getting 6 or more months of benefit. When a healthcare professional is doing stim as part of a program that includes other treatments such as exercise, and the former is the most enjoyable part, it is understandable that people assume it is effective. However, the best research which we call a randomized control trial does what it says and controls the variables used so that we can work out which ones are truly effective. Stim, ultrasound, joint mobs to the knee have been shown to not be effective. The reason that acupuncture and taping are listed as uncertain is that there is not good quality evidence for or against yet. As such they should not be first choice treatments, even if anecdotally the therapist thinks they work. So, spending your and/or your insurance company’s dollars, wouldn’t you rather invest in treatment that provides proven longer relief?
Here’s the really awesome part: EXERCISE not only helps your body heal and be pain-free in the long-term, it can actually provide short-term pain relief, which is the only benefit that stim and ultrasound (and maybe acupuncture) provide. But, unlike stim/ultrasound, exercise doesn’t require a PT office visit or any special equipment. Once your PT has prescribed your exercises and taught them to you, you can do them anytime, anywhere, whenever you need pain relief! AND, they are also helping you to get better, not just masking your pain! How great is that?!
Summary of AKP diagnosis and treatment:
- Exercise therapy that targets the hip and knee will help in the short, mid, and long-term if you have pain in the front of your knee that is worse with weight-bearing activity.
- Bracing/taping and an orthotic in addition to exercise may help In the short and mid term
- Traditional treatments of stim, ultrasound, and manual therapy to the knee are not beneficial.
- Acupuncture and taping on their own have an uncertain benefit and should probably not be used as a first line treatment.
So, do you have knee pain? Contact me if you feel you have not had the right treatment in the past and are still struggling.
- Crossley KM, Van middelkoop M, Callaghan MJ, Collins NJ, Rathleff MS, Barton CJ. 2016 Patellofemoral pain consensus statement from the 4th International Patellofemoral Pain Research Retreat, Manchester. Part 2: recommended physical interventions (exercise, taping, bracing, foot orthoses and combined interventions). Br J Sports Med. 2016;50(14):844-52.
- Collins NJ, Bierma-Zeinstra SM, Crossley KM, et al. Prognostic factors for patellofemoral pain: a multicentre observational analysis. Br J Sports Med 2013;47:227–33.
- Powers CM, Bolgla LA, Callaghan MJ, et al. Patellofemoral pain: proximal, distal, and local factors, 2nd International Research Retreat. J Orthop Sports Phys Ther 2012;42:A1–54.