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Patellofemoral Joint Pain – August Newsletter

Effectively Treating Patellofemoral Joint Pain

John Fiore, PT

Patellofemoral joint pain (PFJP) is familiar to individuals of all ages and activity levels. Named for the joint formed by the patella (knee cap) and the trochlear groove of the femur (thigh bone), PFJP may be referred to as runner’s knee, anterior knee pain, or chondromalacia. Patellofemoral joint pain accounts for 25% of all knee disorders1 and 42% of all running injuries.2 The difficulty in treating PFJP lies in the numerous causes and complex structures involved.

Patellofemoral Joint Pain - Knee image of joint, muscle and boneSymptoms are usually located beneath the patella, in the patella tendon (below the patella), or along the medial-lateral sides of the patella. Symptoms may include crepitus (clicking, cracking), swelling, tenderness to touch, and pain with squatting, descending stairs, running, or prolonged sitting.


Poor joint kinematics or poor tracking of the patella over the trochlear groove of the patella combined with excessive or repeated joint loading may cause PFJP. Squatting or deep knee flexion (bending) increases the compression of the patella over the femur. Mitigating impact loading through the knee and addressing the presence of tracking issues is a necessary treatment component.

Poor strength and stabilization in the supporting musculature results in increased compression and-or torsional forces through the patellofemoral joint. 3 Thorough evaluation of hip, quadriceps, hamstring, and foot-ankle strength should guide comprehensive physical therapy strengthening program.

Training errors may be the most prevalent cause of PFJP. Increasing activity or exercise intensity or duration too rapidly results in tissue breakdown (muscle, bone, connective tissue). In the absence of adequate recovery, tissue breakdown may lead to tissue failure, resulting in an overuse injury.

History of prior injury contributes to the health and function of our joints. Prior fractures, orthopedic surgeries, and trauma predispose the knee joint to degenerative changes. Research involving runners has shown a higher incidence of injuries in runners with a prior history of injury and higher impact loading forces during running. 4

Body mass index (BMI) and social factors must not be overlooked when treating PFJP. BMI is the ratio of height to weight. Simply put, the higher your BMI, the greater the impact load through the patellofemoral joint. Adequate sleep and proper nutrition are vital for tissue health and recovery to reduce injury risk. Eight hours of sleep per night should not be considered a luxury for athletes and non- athletes alike.

Physical therapy alone will not cure patellofemoral joint pain. The correct physical therapy intervention over a period of time coupled with appropriate diagnostic testing will. A physical therapist trained in effective evaluation of strength, functional movement, medical history, and sport or activity demands can narrow the cause of one’s unique PFJP symptoms.

John demo knee excercise

Knee excercises

An individualized rehabilitation program should address joint mechanics, quadriceps, hip, gluteal, and foot-ankle strength exercises. Gradual eccentric (muscle lengthened) loading of the patellofemoral joint at varying degrees of knee flexion will improve tensile strength of the patella tendon and supporting structures. Utilizing visual and verbal feedback while performing single leg strengthening exercises has been shown to be effective in reducing compensatory movements of the hip, pelvis, and knee which contribute to PTJP. 5 Finally, simulating the necessary functional demands through a return to sport or activity program will insure long-term success. Utilize Missoula’s medical and training experts to enjoy our incredible recreational opportunities without patellofemoral joint pain.

The Fantastic Foot: Understanding the role of the foot in injury prevention

Foot bone diagramJohn Fiore, PT

Feet are generally underappreciated. We cover our feet in shoes. We often hide our feet for some unknown reason, yet our feet are the primary anatomical structure which allows us to run. While nearly all other animals travel on four legs, humans, birds, some apes, lizards, and cockroaches (at their highest rate of speed) travel on two legs. Humans walk and run with a highly efficient bipedal (on two legs) gait. Long distance running on two legs is possible thanks in large part to our amazing foot anatomy. Understanding foot anatomy will lead to an appreciation of the job our feet do during every walking and running stride.

The human foot contains 26 bones (28 if you count the two floating sesamoid bones on each foot). The bones of the foot form three distinct structural and functional units. The rear foot is made up of the large calcaneus and talus. The rear foot is built for weight bearing and articulates with the lower leg bones (tibia, fibula). The mid foot is made up of the navicular, talus, and cuneiform bones. The mid foot has a dual role. It absorbs shock during weight bearing and forms the stability we rely on (the arch) when pushing off to initiate the next step. The fore foot is made up of the five metatarsal bones and 14 bones in our toes (phalanges).

diagram of foot bone - side viewFoot function is responsible for the unique shape of each bone within the foot. The wedge-shaped mid foot bones allow shock absorption during pronation (weight bearing acceptance), but with muscle contraction the flexible wedge becomes a rigid supporting structure which drives body propulsion. In contrast, the beefy calcaneus and talus are weight bearing structures. Even though mid foot and fore foot running has been shown to be more efficient and decrease running injuries, humans naturally heel strike when we walk. Finally, the fore foot is the region of the foot which allows us to “feel” the road or trail when we run. Balance, agility, and proprioception are duties of the fore foot.

The skeletal anatomy of the foot must be combined with the stability and mobility provided by our connective tissue (ligaments, tendons, fascia) and muscular tissue (Intrinsic: within the foot; Extrinsic: lower leg muscles). The ability to react to uneven surfaces in a fraction of a second and rhythmically run without active concentration is made possible by the neuromuscular (nerves activating muscles) component of the foot. Continuous, two-way nerve messages from and to the foot to the spinal cord and brain result in split-second shock absorption, foot agility, and propulsion power.

John Fiore running downhillGiven the anatomical and physiological complexity of the foot, it is no wonder runners frequently experience foot and ankle pain. Foot and ankle specific exercises and basic foot care will reduce your overuse injury risk. The average human travels 100,000 miles on their feet in a lifetime. Runners can multiply this number by a factor of two! Running places 2.5 to 5.0 times the weight of the body through each foot strike, depending on gait efficiency. Impact alone can break down the structural integrity of the foot, including the joints, connective tissue, and muscular integrity. The greatest enemy of the foot, however, is torsion. Bones, joints, and connective tissue are happy when movement is through designated movement planes. Torsion through a joint, or musculotendinous structure, however, greatly increases its chance of fatigue, overuse, and injury. Stress fractures are often the result of excessive torsion through a bone secondary to inadequate stability (muscle weakness or lack of connective tissue tensile strength).

John demonstrating foot excercises

To prevent structural failure and subsequent injury in the foot, attention must be regularly placed on addressing foot-related strength, proper joint mobility, and tissue recovery. Yes, TLC is the best medicine for happy, healthy feet to allow you to run. Below are two examples of foot exercises designed to combine mobility and stability for foot injury prevention and treatment. Call or email Sapphire Physical Therapy to find out how our staff can help prevent and treat foot-related injuries to enable you to achieve your fitness goals.
demonstration for foot stretches and excercises

Photo credit (anatomical knee): orthoinfo.aaos.org
Photo credit (The Rut runner): Steven Gnam

1 Mullaney MJ, Fukunaga T. Current concept sand treatment of patellofemoral compressive issues. Int J Sports Phys Ther 2016 Dec;11(6):891-902.
2 Taunton, et al. A retrospective case-control analysis of 2002 running injuries. Br J Sports Med 2000;36:95-101
3 Lankhorst NE, Bierma-Zeinstra SM, VanMiddelkoop M. Factors associated with patellofemoral pain syndrome: a systematic review. Br J Sports Med 2013; Mar;47(4):193-206.
4 Davis et al. Greater vertical impact loading in female runners with medically diagnosed injuries: a prospective study. Br J Sports Med; 2015.
5 Willy RW, Davis IS. The effect of a hip-strengthening program on mechanics during running and during a single-leg squat. J Orthop Sports Phys Ther; 2011 Sep;41(9):625-632.