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