Daughter gymnast (12 yrs) with patellar compression syndrome...how can we help her?

[campbells7]

Hi all

My dd is 12 years old, a talented acrobatic gymnast, and has just had a diagnosis of patellar compression syndrome with chondromalacea (sp?).

She's due to start physio next week, - the orthopedic consultant says she should have physio for 3 to 6 months and reduce her training to 80 percent. What does this mean in terms of what exercises she should avoid, what she shouldn't avoid? Will she be able to compete again? How do I know if the physiotherapist she gets really understands the problem? How do we help her to understand the injury, so she can help herself as much as possible?

She is convinced at the moment that her knee will never be good again and is very sad, so I would really appreciate any help you guys/gals could give.

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[ginger]

Campbells7, a few brief tips to orient you to the knee pain problem that your daughter is most likely suffering.
Doctors of medicine vary in their education and expertise, just like other professionals. This certainly includes othopaedic specialists. The central tenet of a medical approach , with few variations, is to attempt to label a condition as a pathology. hence the term chondromalacia. This term is now quite outdated, as the most recent research has lead to a new understanding about patello femoral dysfunction ( a better decriptor ), which has seen a shift away from the presumption that a pathology exists at all in these cases.

Pain associated with abnormal patella position and movement, is usually felt around the kneecap. This commonly occurs when the nerve associated with the normal function of the vastus medialis oblique muscle is irritated. ( a small part of the quadriceps group found on the inside of the knee on the thigh )
Vastus medialis ( VMO ) is responsible for the normal position of the kneecap under load. If this muscle fails in its attempt to maintain optimum position of the bony feature contained within the main tendon across the knee, then abnormal forces will occur, which will often give rise to swelling, pain and dysfunction.
This is now better understood to be a motor control problem. Focal irritations , of the femoral nerve , related to spinal protective behaviour is the key feature . In particular, when the mid lumbar region is stiff ( L3), referred pain may be felt at the inside of the knee. This same irritation will cause a temporary ( and non pathological ) alteration to the firing of VMO, leading to dysfunction pain swelling etc.
There are several approaches that have value , when provided by a well trained physiotherapist. The most important of which , is to establish a non protected , normal state of mobility to L3.
Spinal protective behaviour may have been associated with ankle foot pronation. There is a strong connection between overpronation and L3 hypomobility , leading to referred events as above. Have her checked for this and if needed, have her fitted with anti pronation orthotic devices , preferably made by an orthotist.
It will be possible to relieve much of the patella pain temporarily, by a taping proceedure known as the Mcconnell method. I recommend this as a first step , so that your daughter can resume her gynastics. Most physios will know this method.
This is a fixable and common complaint. The period of six months (for resolution )has been greatly exagerated. A period of one to two weeks is more likely , provided you are able to find someone sufficiently connected to the above mentioned notions, who is skilled in spinal mobilisation.
I wish you good luck.

[physiobob]

Nice response Ginger and this helps the support of the notion of see someone who actually has an interest in the biomechanics of the entire gymnastic repertoire. I can imagine this involves a lot of tumbling? Perhaps also a lot of landing from mini trampolines etc. In more advanced landing from uneven bars.

I once heard it said that unless a young female gymnast had at least 2 levels of spondylolithesis (essentially fractured vertebrae) then they could never be any good! campbells7, this means excessive curve in the very low back so they can create a very (hyper) extended line in arabesque etc. Hyper movement at L4/5 and L5/S1 could mean that the higher levels are less mobile but that would need to be proven. One could assume that those levels could also be irritated by excessive movement.

All of the above factors place the pelvis and therefore the femoral heads in less optimal positions (that will load the knees excessively). I think everyone could go on and on about the possibilities suffice to say that the patella is exhibiting signs of overload. Nothing abnormal, just overload. The physio etc that looks after her needs to understand what and why those loads are being problematic and then to work out a solution.

It a really interesting topic and needs a physio who works in that area. See who is milling about the local training areas as there's bound to be a physio there somewhere.

Perhaps also help your daughter to understand that gymnatics comes with 'pain'. As does ballet, rugby, piano etc etc. The human body was never meant to do those types of things in such repetitive ways. Therefore to undertake them in the first place means that pain will be part of the package (not that much of it can't be avoided).

[campbells7]

Ginger, thanks for your reply.

What you say ties in with the Doc's comments, and also with what I have researched so far on the internet. I can see that the problem/or its causes is not isolated within the knee which makes it even more important that she gets a physio who understands this kind of injury.

I am quite careful not to follow blindly all medical advice and strongly believe in patient participation - in fact the Ortho said to my daughter that she must try to understand her problem so that she can better learn how to deal with it. This is what I'm trying to help her to do.

No swelling, but pain coming and going over a year. Pain seems to be behind the knee, "inside" -she says, and sometimes to the sides. She has had xray, TAC and
MRI. Orthopaedic doc also mentions Vastus exterior and said her patella seems tilted. (I am attempting to translate from the Portuguese so I may just be confusing the issue!)

I will look into the orthotic devices you mention, I have no idea what they are but...knowledge is power! Also the taping method.

If you are a physio yourself, how would you advise her to look after her knee at home...eg. would you tell her to avoid sitting with it very bent, would you advise her not to wear flip flops for walking - or is all that irrelevant?

I am glad you say it's fixable, she also loves to ski and I would hate to think she's heading for a lifetime of knee problems.

Thanks again.

[campbells7]

physiobob,

lol, don't worry - she definately understands that gymnastics comes with pain...she is constantly telling me that as I worry and fuss! However, this time she wants it dealt with - she has been at National level with competition and is desperate to continue and feels that her knee won't let her.

Yes, involves a lot of hard landings....backward somersaults off her partner's shoulders, tumbling, backflips - you can imagine.

Our Regional hospital (30 mins drive) has a Sports injury department - but I am at present planning to find a physio in our local town to better tie in with school, training etc. But your comments have confirmed what I already had in mind - that she needs a specialist physio and if I can't find one locally I'll try and get to the hospital.

All your comments are really helpful, thanks.

[ginger]

Campbell7, overpronation is a tendency for "flat feet", where the longitudinal arches of the feet fail ( for various reasons ) to offer normal support. The forces that travel up the leg and thigh then tend to push the pelvis together somewhat, this has the effect of causing loss of sacroliliac joint movement ( a large pair of pelvic joints that are largely involved in buffering these forces ) and a stiff pelvis results. The Lumbar spine then becomes party to abnormal forces which contribute to the L3 problem I mentioned. In my own experience as a physiotherapist, all these issues are fixable within a two week time frame. Antipronation orthotic devices will re establish a normal arch posture and prevent abnormal forces . These are worn in the shoe as insoles, shaped to fit the person precisely. While it is possible to obtain these off the shelf , I recommend definitive devices made with skill.
I offer of course only general guidance and it must not be presumed that your daughter has or has not got a pair of "flat feet", or any other biomechanical disturbance without the guidance of a good physio.
Cheers

[iliastolos]

Hi everyone!

Firstly, let me stress the importance of ginger's last sentence that he offers general guidance. Campbells7, it is obvious that we are trying to guess what could help your daughter and that we are only making assumptions of what could be the cause/causes of the problem. I'm sure that everybody agrees and maybe I shouldn't point that out.

Moreover, I would like to add some things to what has already been mentioned. Both ginger and physiobob focused on intrinsic (anatomical) factors acting on the knee joint and specifically on the patella. Although weakness of vastus medialis (VM) has been involved greatly in patellofemoral pain, a therapist should always remember that it is not only VM that attaches to the patella. It is also the rest of the quadriceps bands, the iliotibial band (ITB), the retinaculum and the patellar tendon that act directly on the patella and, therefore, affect its function. Any malfunctioning of these structures (e.g. a tight ITB or a weak quadriceps) could also lead to patellofemoral pain. It is obvious that numerous structures around the knee should be clinically assessed.

Of course, other structures of neighboring joints should also be examined. Foot pronation was correctly stated that it could fire patellar pain. Subtalar joint pronation could be secondary to a tight gastrocnemius/soleus muscles as well. This pronation could lead to tibial internal rotation; this to femoral internal rotation and this could increase the Q angle (angle between the quadriceps action vector line and the line of the patellar tendon), which could trigger joint pain. Furthermore, structures that have attachments to the ones mentioned above, such as gluteus maximus to the ITB or hip adductors (adductor magnus) to the VM, could also affect the patella indirectly. Hip and pelvic structures might also be responsible, as well as spinal deformities. It is not worthwhile to mention all possibilities but they should be taken into account.

Another important factor is the girl’s age. She is 12 years old, signifying that her skeleton is still growing up and forces acting on it have a high impact on its final formation.

Apart from body biomechanics, external factors could cause this problem too. Shoes, landing surfaces, even the skis that your daughter uses during her free time are factors that could affect her knee.

And of course, acrobatic gymnastics is a very demanding sport. Flexibility/mobility is fundamental in performance and more mobility leads inevitably to less stability. A generalized ligamentous laxity of the knee has been assumed to be associated with chondromalacia patella. Physiobob was successful in his comment about ‘necessary’ pathology on a gymnast’s body in order to perform competitively.

All of the above have one common conclusion; every person should be treated independently. This is where I go back to ginger’s first comments about existence of this kind of pathology and adding that there are no true pathologies but true patients. That is why there are always exceptions. Everybody is unique and that’s how he/she should be treated.

I hope I didn’t confuse anyone and that campbells7’ daughter will be fine and able to do what she loves.

With best wishes

[campbells7]

iliastolos and ginger, I really appreciate your taking the time to reply.

I have taken on board your emphasis that your advice is only general. I really do understand that. But you have helped me to focus on the daunting task of finding the right physiotherapist. Your explanations have given me some idea of the questions I might need to ask, though I will possibly be seen as an interfering mother!

Nevertheless I am determined to get the correct treatment for my daughter, and your comments have really helped. I am very conscious of the fact that she is only 12, still growing, and has to depend on her joints not just now but for the rest of her life.

Tell me something else. Should I expect the physiotherapist to examine the xray, TAC and MRI of her knee? Is this something you professionals normally do? Sorry if stupid question

[ginger]

Campbell7, Physios are certainly capable of taking any advantage , should there be any , of x-rays scans etc. In Australia these normally would be reported on by a radiologist, whose professional opinion is reliable as a way to interpret these. In most cases I would rely on these reports to satisfy myself that no serious abnormalities were present. These include fracture, tumor and dislocation. Once these have been eliminated , the value of scans and x-rays diminishes rapidly as a means to understand a pain /dysfunction problem.
By all means take them , but don't be surprised if he/she seems to take little interest in them, beyond a scan of the report.

[iliastolos]

I agree with ginger. This is a radiologist's job in Greece too and then an orthopaedist's or physio's or whoever's involved. A physio's skills could allow him/her to 'read' an x-ray or an MRI but that is not formal, it is just his/her professional opinion. Do not appreciate it as a main skill when looking for a physio though. Try to look for a specialist in sports/musculoskeletal physiotherapy or manual therapy or some special skills like PNF or McConnell tape or Kinesiotape practitioner. These are just examples.

ilias

[campbells7]

Thanks again, Ginger and Ilias.

I will take along the exams she's had just so I know that no stone has been left unturned. Both the Tac and the MRI carry written reports too so it would be sensible to offer the physio the option to read them.

Am expecting the hospital authorisation for the physio treatment to arrive in the post any day. In the meantime daughter is trying to train without using the leg with the problem knee - she's complaining she doesn't know what she should and shouldn't do in training. We really do need a physio with sports injury experience so that he/she can not only try to solve the problem but also tell dd clearly what she can do to help herself.

I'll let you know how we get on.

Thanks again.

[iliastolos]

Looking forward to hearing from you campbell7. All my best wishes to you and your daughter.

[estherderu]

dear Campells7,

you have already had some good suggestions.
I will add a few.
Girls her age are in the middle of a growth spurt.
Many girls with knee function problems have been found to also have weak external rotators of the hip.

Advice for your daughter so far:
- she should refrain from any action that causes pain
- not sit with knees fully bent for long periods of time
- not passively extend her knees, feet on table and knees unsupported at all.

A good therapist is your best bet. Trust your gut feeling as a parent. A good health professional should understand your worry and appreciate your imput. They should do a proper assessment and then treat. If you, or your daughter do not trust your health professional, try finding another.

I realize that being in another country, with a different culture, doesn´t make it easier. Good luck to you all.

Esther

[estherderu]

dear Campbells7,

I found a free access article about patella dysfunction problems that I suggest would be good reading for everyone treating these patients. Might be good to give to your daughters physio.

Dynamic Medicine | Full text | Patellofemoral Pain Syndrome (PFPS): A systematic review of anatomy and potential risk factors
It is a systematic review of PFPS anatomy and potential risk factors.

kind regards

Esther

[estherderu]

Sorry folks, forgot to send this one as well.

Scientific Research - Neural Aspect to Patellofemoral Pain Syndrome | Shacklock's Clinical Neurodynamic Solutions (NDS) | NDS Global

Esther

[campbells7]

esther, thanks for your reply - sorry I have only just seen it.

I will try to suggest the physio evaluates her hip and core strength, not just the knee itself, but judging by the reaction so far I will be seen as an armchair physiotherapist who should leave the job to the professionals! I do believe, of course, that the right therapist will not be offended by my input but am not sure yet whether that is the reality.

So far since my last post.

Have not actually started physiotherapy because the authorisation from the hospital has not yet arrived - they say it was posted on 16th October. More phone calls tomorrow trying to track it down. In the meantime we have seen a doctor specialising in rehabilitation (who is also a friend). He will start her on physio at his clinic even without the hospital document, but there are no vacancies at present. He examined her knee (both knees in fact) and has said she needs physio 30 to 60 mins every day for three months. He says she can train, but to stop if it hurts.

We also saw a physio connected to the gym club, who told her to stop all training, not to do anything that involves a "reception" (translating here but I'm sure you know what I mean). She has water on the knee too.

Neither of these professionals investigated anything other than her knee, not feet, hips, back etc....so this is what I'm up against. Grrrrrrr

Daughter herself is frustrated and depressed - her knee is hurting a lot in the last few days - We have allowed her to go to training and she confirms she's avoiding all actions involving the knee. However, I'm thinking of pulling her out of it totally for the next week - which she will won't like one little bit. She has just started training with a fab new partner who's 16 and at European level. It would be easier if she was in plaster from hip to ankle then she would be forced to stop!

Am very frustrated that I still haven't managed to get her started on physio which she obviously desperately needs.

[vam44]

Hi, I am an australian physiotherapist and have 30 years of experience seeing patients and have looked after girls doing elite gymnastics. I think that you have a good lot of treatment ideas above so hopefully you can get your daughter treated soon.


I would start with
stop gym training for a week to allow the effusion to settle ( I presume this is the water that you can feel behind the patella)
Start with specific quadriceps retraining as per the Maconnnail programme
Maintain good hamstring stretches but no quadriceps stretching for a month

When the pain and swelling is settling start increasing the strengthening programme. The knee should be OK for everyday activities especially walking up and down stairs before starting the gymnastic programme . ...with absolutely no impact loading eg landing off the beam, she could probably work on the bar and get really good at this and only land in the foam pit. I would suggest this for around 6 months.

A lot of physios may not appreciate the huge number of impacts that gymnasts do in training and I have seen a case like this get diagnosed as a patella stress fracture. (However I think the MRI she has had would have ruled this out)

good luck!

[campbells7]

thanks vam,

she's finally starting the physio tomorrow so I'll let you all know how it goes.

[cathy29]

Campbell7, Physios are certainly capable of taking any advantage , should there be any , of x-rays scans etc. In Australia these normally would be reported on by a radiologist, whose professional opinion is reliable as a way to interpret these. In most cases I would rely on these reports to satisfy myself that no serious abnormalities were present. These include fracture, tumor and dislocation. Once these have been eliminated , the value of scans and x-rays diminishes rapidly as a means to understand a pain /dysfunction problem.
By all means take them , but don't be surprised if he/she seems to take little interest in them, beyond a scan of the report.

[campbells7]

Hi all,

I said I would let you know how things are going though there isn't much to report.

Daughter has had physio five nights a week for the last three weeks. The pain is more or less gone. The physiotherapist she has is a youngish guy - he's not a sports specialist and not very communicative but I am not going to rock the boat yet! When she sits on a chair with feet on the floor you can still see her kneecap pointing off to the side!

Parents are not permitted in the treatment gym so I can't report exactly what exercises she's doing. Suffice to say she finds it all very boring and is still going to gym training after physio.

Daughter had a three week check yesterday by the physio clinic medical director who says he see signs of improvement but it's very early days. He feels that the treatment is starting to show results and is targetted correctly. He's given her some exercises to do at home, - put a kilo weight on the foot - flex the knee slightly and lift the leg to the side.


Am thinking of printing out an explanation of McConnell taping and giving it to the physiotherapist but I think he would just gawp at me. Could my daughter and I learn how to do it? Would it be worth it?

I showed this thread to my daughter - she was happy to see how the world is rooting for her! Any other advice for her?

Thanks again everyone.

[pudding_bowl]

Its good to hear that shes getting better at least!
To hear that you weren't allowed into her treatment was a shock to me. Thats the patients right here in NZ. If any child shows up I usually insist the parents come with us (that way everyone is on board with the treatement). I suppose its a difference in culture...

If your physio doesn't know how to mcconnel tape then your just as good as he is at doing it!, you could always give it a go and see how she feels about it. With practice I'm sure you'd get it. generally we like to treat our patients but if there isn't anyone who can do it then you could be doing far worse things than trying a bit of taping.

[estherderu]

Hi Campbells7,

Good to hear that the treatment has started...
not as suprised about not being allowed in therapy room..... is something that happens more in the south of europe.....
but I agree with puddingbowl.....
It is a fundamental right for you as a parent to be with your daughter, not only to see the treatment, but to be imformed about the whole procedure beforehand, and during treatment... in fact, all the time. You are the responsible person to act on her behalf.

The therapists who do not agree, either do not know the Law or are insecure when others are watching (which is very human indeed).

Regarding taping the knee, I might even have a better suggestion. I personally prefer elastic tape(kinesiotaping, vendajeneuromuscular) to rigid tape (which is the McConnell tape or the Mulligan tape).

You might want to have a look at....ANEID | Productos Farmacêuticos, Lda. in Portugal

You can ask for contact information of instructors living in your area to see your daughter. If you are lucky, they might even know both tape methods and can choose how to treat.
PS, you can use my name, I am the instructor paediatric taping in Spain.

good luck with everything

kind regards

Esther

[campbells7]

Thanks to both of you for your replies.

Just to be clear, I did go in to the treatment room with her on the first visit, but after that am not encouraged to do so. I can understand to some extent as it is a large room, with around ten or twelve patients, five pts, and loads of equipment. There's not really much room for visitors. I think that the deal is the Physician in charge of the clinic liaises with the patient/parent and the pt. I assure you I am not shy, and if I need to see my dd in there, or talk to the pt I will.....but I am allowing the pt to do his job for the moment.

Thanks Esther for the link - it looks interesting.

[uglyfatboy]

hi
I dont usually comment on these thing but the sanctimonious comments previously posted really annoyed me.
I would give u one piece of really sound advice. Relax, let the physio (however young and spotty he is) get on with his job. she is getting better!
If you listen to some posts you will end up putting your daughter in a wheelchair to protect her from all these big long words!
There is no evidence that any physiotherapeutic intervention works for anterior knee pain or any other condition. As long as she is doing exercises and having regular rest it will probably resolve.
Previous posts have been largely non evidence based: L3 hypomobility!!!! in a 12 yr old gymnast????? i dont think so! as one chap said he is more likely to be hypermobile with a spondylolysthesis. VMO ?? dated theories, there is even a question as to whether VMO really exists! Patellar malalignment? there are no reproducible tests, its impossible to judge! Taping?- massive evidence to show it does nothing to the patellar position, you can try with gaffer tape as evidence shows pain relieves a bit irrelevant of taping used!
Orthotics?? why do you want to put a young developing girl in a pair of ghastly expensive orthotics for the rest of her life when she gets her pain from doing barefoot gymnastics??? Sacroiliac joint stiffness?? again no evidence it even moves?

Please, please, please, take a step back and dont take all this self important diagnostic rubbish to heart. the only person that can assess your little girl is the person that can see her knee! and it sounds like hes doing a great job so far!

[ginger]

Campbell7, as evidenced by the previous two posts, it would seem you are wise to be pursuing physio treatment on the continent. Although , the standards of physiotherapy training have improved in Britain during the past decade, vast discrepancies linger.