Kurt Lisle shared a lot of great information on Physio Edge podcast episode 33 “How to treat anterior knee pain” on assessment and treatment. Here are 10 highlights I learnt from Kurt about anterior knee pain on the podcast, working our way through subjective clues, objective assessment and treatment of the knee.
1. Infrapatellar fat pad
Infrapatellar fat pad doesn’t tend to refer to other areas – causes localised pain medial and/or lateral to the patellar tendon, inferior to the patella. May be worse in extension where it is getting pinched, e.g. Standing in hyperextension, whereas PFJ doesn’t tend to get sore standing with the knee in extension.
2. Patellar tendinopathy
Patellar tendinopathy has focal pain on the inferior pole of the patellar commonly, but pain may sometimes be over the mid tendon
3. Patello Femoral Joint (PFJ) patterns
PFJ can refer to the posterior knee and inferior knee. The PFJ is often aggravated by squatting, lunging, up down stairs, hills, kneeling on it, sitting, and is relieved by rest
4. PFJ Behaviour –
There is no real night pain, but patients may report some short term morning pain relieved with activity. Both PFJ and patellar tendinopathy can come on from increased activity
5. Objective Assessment
Active and passive extension – may reproduce pain in the fat pad, but passive extension does not load up the PFJ or Patellar tendon.
6. Resisted isometric muscle tests Resisted Inner range extension on the side of the bed may enable you to locate the site of their pain, and they may be more able to be specific about the location of the pain in this position compared to functional tests e.g. squat
7. Specific palpation – Palpate * tendon attachments e.g. If it is the whole tendon, and the medial or lateral parts of the tendon
- Medial and lateral to the tendon over the fat pad, in extension, up towards the inferior pole of the patellar, and down closer to the tibial tuberosity (still off the patellar tendon
- PFJ – medial and lateral aspects of the patellar. You are also pushing through the retinaculum, which may be painful, which means it is very difficult to palpate the trochlear groove
8. The importance of thorough assessment Create a routine for knee assessment e.g. medial to lateral, and assess each of the structures to ensure you do not miss something. 9. Functional tests If the person is getting pain with a squat or lunge, you can asses their squat or lunge to see if you can identify any neuromuscular control issues around the hip, pelvis, foot and ankle, if correcting their technique improves their pain Squat – important factors what is happening around the knee. Is knee staying in line with their foot and ankle,
- is the knee moving side to side e.g. Medially or laterally.
- Is the knee movement happening with dynamic valgus, e.g. The femur is moving into IR/ER, or Hip abd/add
- Is the patellar moving up and down in the trochlear groove
- At what point does the person get their pain e.g. 30, 60, 90 F
- Is there a “catching” or giving way at a point in range, which could give you clues that there is PFJP, PF pathology on the retropatellar surface or the trochlear groove, chondral tear, flap tear, osteochondral defect, and possibly the meniscus.
- The patient may describe pain behind the patellar, which gives you a clue that this may be PFJ in origin
- Proximal to the knee- e.g. trunk LF, pelvic tilt, IR/ER/Abd/Add of the hip and femur
- Foot – restriction to DF
10. Factors that may load the PFJ
- Walking on a bent knee e.g. From a previous injury
- Patellar sitting laterally may affect the forces going through the PFJ in functional tasks
- High or low riding patella
- Lack of muscular size on one side compared to the other, and still pushing the knee through sport or activity
- Hypo mobile PFJ – assessed with accessory mobilisation
- Hypermobile person – stand in hyperextension
- The way they control jumping and landing
- Soft tissue flexibility – e.g. In the Quadriceps may increase the compressive forces on the PFJ
- Hip and pelvis, foot and ankle control
- Their functional tasks e.g. How they serve, how they jump and land
PS If you would like more a free eBook on anterior knee pain based on this podcast, including notes on the information above, as well as imaging, treatment of the Patella-Femoral joint, exercise prescription, further details on palpation, functional tests, and taping, you can download this free 10 page eBook below