Footballer with anterior knee pain

[physio7]

I have a patient who has had anterior knee pain for over 1 year. Initially he was having pain every time that he ran. He still played football matches and
felt that the pain did not affect him as much as the adrenaline took his mind away from it.
On assessment there was decreased quads strength on full squat and decreased conrtol of gluts on squatting single leg.

Lig tests and meniscal tests were normal.
The pain he experienced was very much around the patella region.

He has been working on gluts strengthening in functional positions (weight bearing) and squats with control
of knee position. As well as inclined single leg squats to focus on quads strengthening.

His pain on running has improved and now he can run 2-3 miles with no pain. When the patient hops he has the feeling of a lack of propulsion and he gets knee pain on trying to perform multiple hops on the same leg.

To combat this i have started him on early plyometric exercises such as 2 leg box jumps and 1 leg step hops which can be done without pain. However he seems to be struggling to progress to the next stage of hoping exercises any advice?

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[maithili85]

i think development of patellar balance with the help of patellar mobilisation and vastus medialis training(wt bearing and non wt bearing) would help the patient to progress in step by step manner.

[physioro]

Does he have any other biomechanical issues such as tight TFL/ITB, tight Rec Fem, tight lateral Patella tissue, or over pronation that could be limiting his recovery?
Medial patella taping is great to control pain while he exercises so that he can go further and for longer.
Hope this helps.

[physiobob]

This sounds like some degeneration of the tendon insertion. If so it is a tendinosis injury which a a slowly progressing, chronic type condition. Plyometric exercises would NOT be indicated at this time. Correction of biomechanical factors yes but if this is the case he needs rest, good diet and avoidance of load on the tendon insertion while it is healing.

[physio7]

the patella tendon is not painful on palpation and he does not have pain on resisted knee extension. There Does not seem to be particular tightness of TFL/ITB and his foot biomechanics look good in standing walking and running he doesn't show signs of overpronation.

[alophysio]

Hi - i agree with physiobob...

Plyometrics is not indicated if he can't do repeated exercises like hopping - which is a plyometric-type exercise (just a lower level one).

Alternatively, he could have a load transfer problem. The Active SLR is a good test for this - basically ask the patient to lie supine and lift one leg up. Then repeat for the other side. Compare the effort between the two. If the affected side is "heavier" or "harder" to lift up, he most certainly has a load-transfer problem. If this is the case, he will need a lumbopelvic-hip assessment to determine the cause of the failed load transfer.

Diane Lee's Pelvic Girdle book is a good read for this type of problem. Also the research by A Vleeming et al will also help you.

Thanks - hope it helps

[Konradslavinskis]

Hi Guys,

If it is a Patella Tendon issue (Tendinopathy). An excellent assessment tool is using a slant board (25 degrees) and asking the patient to squat (single leg) - ask for a pain (0 - no pain and 10 - worst pain) and measure the angle at the knee. Compare side to side. It is also important to assess functional and isolated glut strength (max and med) and also calf strength (approx 25+ single leg calf raises), these 2 muscles are important in the shock absorption process of the LL kinetic chain.

Some simple exercises are SL leg press 4 sets of 8 reps (take approx. 60 sec to complete reps) and then change legs and also SL leg extesions 4 sets of 12 reps. You need to complete these exercises 4 times per week. Once you have adequate strength --> power --> sport specific strengthening work.

See how you go there is lots more to do but this is a start.

Cheers

KS

[21stcenturyPhysio]

Is his TFL tight? I find particularly with patients that have weak glut medius their TFL is overactive to stabilise the hip during single leg stance (as both TFL and glut medius are abductors). Overactivity in TFL causes Medial rotation of the femur (increased Q angle). Combine this with a tight ITB and the patella is pulled laterally. You may find soem deep soft tissue work through TFL realyl reduces the patients symptoms - but be careful as this is most likley not the main contributing factor - as long as glut medius is weak or ineffective in its action, TFL will be overactive

Lateral displacement of the patella changes the pressure distribution in the trochlear - causes pain.

I suggest assessing the TFL but also determine what angle of knee flexion the patient is getting pain, tape their patella medially and reassess in the same position (McConnell Critical Test). If this seems to reduce their pain then it is most likely of a PFJ origin and your treatment must be based around getting the patella to move up/down flush in the trochlear.

On top of this as previously posted you must address the shock absorbing muscles - gluteus maximus, quads and calf as inadequate strength in these muscles will increase the load through the PFJ.

The key to PFJ pain is making sure you adequately address the contributing factors or otherwise this guys pain will persist.

21stcenturyphysio

[physio7]

Thanks for all the replies.
TFL does not seem to be over tight.
I have looked at the patient squatting and the patient does not have pain on simle one leg squat.
The patient does not get pain on a decline squat and has no tenderness in the patella tendon. He also reports his pain to be behind the knee cap rather than in the tendon when it does come on.
Would you say that this combination rules out patella tendinopathy or are there other test you would perform?
When looking at the shock absorbing muscles there seems to be a weakness in the glut max and a very slight weakness in the calf. Quads strength has improved and he is now able to lower and rise up from complete squat of the edge of plynth. Although this movement does not seem as controlled as the other side. However, numerous other muscles would be involved in this action.

At present he is continuing quads strengthening and adding in more glut max/med strengthening as well as calf exercises.