knee pain

[swindon-kev]

Hi i have a client with pain coming from the centre off the knee behind the patella, i have done all ligament tests and found nothing ,ive checked the area around the knee for any problem but nothing. When he does a leg extension in the gym he can only manage a third of wot his other leg can do. pain come every so often when exercising but is not a constant pain.

any help

thanks

kev

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[alophysio]

Patellofemoral pain. More accurately retropatella pain (behind the patella!)

Shouldn't be doing knee extensions as the pressure on the kneecap can exceed 8 times normal pressure.

You will probably find that compression of the patella then gliding it would be painful.

Check for ITB and Glut med and TFL imbalances.

[Physio33]

I agree with alophysio. It's Patellofemoral Pain (PFPS).

Had a similar client myself with her experiencing pain during leg extensions in the gym.

On assessment, she had:
- underdeveloped Vastus Medilus Oblique (VMO)
- pain was also eased by applying a medial glide to patella.
- Tight ITB and Weak Glut Med.

Initial Treatment
- Rest from aggravating activity ie no leg extension
in conjunction with
- VMO strengthening ex's (to help realign the patellar tracking. The patella was being pulled laterally and was the root of the pain the client was experiencing)

Additional Tretment
- ITB stetches
- Glut Med strengthening ex's

After a month of REHAB the condition resolved.
However, it's worth noting that the client did not return back to the leg extension ex's for fear of the injury returning.

Best of luck.

[alophysio]

Hi physio33,

Your are indeed right - PFPS - however i am a cynic sometimes and the 'syndrome' of PFPS just means 'i don't have a clue why there are so many reasons for the pain so we call it a syndrome'!!

[not accusing anyone...] How do people find knee extension exercises functional anyway? Aside from kicking someone in the butt. It might be good for the quads but i think it is bad for PFPS...

[uranfeman]

[not accusing anyone...] How do people find knee extension exercises functional anyway? Aside from kicking someone in the butt. It might be good for the quads but i think it is bad for PFPS...

I agree that knee extension exercises are not in any way functional. I will only give open-chain knee extension exercises for clients at either end of the spectrum:
1. Unable to do functional movements (eg first few days after knee surgery, irritable osteoarthritis, or very weak quads).
2. Advanced athletes who primary goal is hypertrophy (ie those who you would actually class as a 'bodybuilder', and 'function' doesn't matter).

As for PFP - I agree with alophysio - ITB/TFL tightness and glute function are crucial. A tight rectus femoris will increase patella compression, which will be especially noticeable in loaded knee extension exercises.

[Physio33]

alophysio!

I agree with you when you say leg extension exercises are NOT functional. However this is the main exercise one will see athletes do in the gymnasium, to increase their leg strength!

What knee extension exercise do you recommend athletes to do to increase knee strength which is FUNCTIONAL, taking into account it needs to be high level?

Thanking you in advance.

[uranfeman]

Hope you don't mind me jumping in with my 2c worth alophysio!

If we are looking at function for an athlete, then it is important to realise that knee extension never occurs in isolation. It most commonly occurs with hip extension and ankle plantarflexion during concentric actions in order to create movement (seen in athletes during jumping, running, accelerating etc). You will also see the quads working eccentrically to decelerate movement at the knee (along with the glutes and calves to decelerate the hip and ankle), which will be seen on the athletic field in stopping, changing direction, as well as the preparatory phase of vertical leap and in landing.

Most of the strength of these muscles will be used when the foot is on the ground, very much unlike a knee extension machine. When preparing athletes, I prefer to use Schultz's classification of functional human movement, which for the lower limb would transfer to:
Squat
Deadlift
Lunge

There are also tons of variations that you could use to keep an athlete progressing. Here are a couple:
Squat: Back sq, Front sq, Box sq, Zercher sq, Goblet sq.
Deadlift: Regular DL, Snatch grip DL, Romanian DL, Stiff legged DL, 1 legged DL.
Lunge: Split squat, forward lunge, rear lunge, lateral lunge, rotational lunge, step up, lateral step up, Bulgarian Split Squat (my favourite!), single leg squat.

One should never play down the 1-legged movements - how many athletic movements actually use both legs in the same way simultaneously? Jumping and rowing are the only ones that come to mind.

Obviously, this discussion has shifted from the original question, but if a high level athlete develops patellofemoral pain, these are the movements I would be looking a t getting back to being able to perform pain free.