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Treating Patellofemoral Knee Pain

First, not all knee pain is the same. Exactly where does your knee hurt? Is it in the back, above the knee cap, under the knee cap, on one side or the other? PF knee pain is always located in the front of the knee and it often feels as if it is radiating from under the knee cap. Please read Knee Pain: Patellofemoral Pain Syndrome Symptoms and Cause to learn about the pain and symptoms associated with PF pain syndrome. And remember, ongoing knee pain should always be evaluated by a physician.

Knee cap pain

Patellofemoral pain is located at the front of the knee. It often feels as if it is radiating from under the knee cap.

If knee pain is sudden onset or due to a recent injury, apply the RICE method.

  • Rest – stop doing activities that cause pain! If pain is caused by exercise including running, jogging and power walking, you need to stop for a period of time to allow the tissues time to heal. Working through the pain will NOT work and will make it worse. Limit stair climbing, walking up and down inclines and any exercise that requires bending and straightening of the knee. If your job requires you to sit at a desk, consider a standing workstation or take frequent breaks to stand, stretch and walk around.
  • Ice –  apply ice for 20 minutes at a time. If knee is swollen and extremely painful you can use ice for 20 minutes every hour, longer than 20 minutes you risk soft tissue damage. Packages of frozen corn or peas can be used as ice packs. You can also use an ice pack that will wrap around the knee. This wearable ice pack is excellent and can be used on all parts of the body.
  • Compression – wrap the knee or use a knee brace to apply pressure to the knee area. This helps with pain, provides support and will help reduce swelling. Do not apply compression directly to the knee cap as this will make the pain worse by aggravating the soft tissues. If using a knee brace, make sure there is a cut out over the knee cap, a sleeve wrap will not help as it will press on the knee cap.  If wrapping, use the figure 8 method and wrap so that the knee cap is exposed.
  • Elevate – because sitting often makes pain worse, it helps to support the upper thigh and knee with pillows. This is also a good time to apply ice!
  • If possible take NSAIDs such as Aleve, Advil, Motrin, or aspirin. This will help with pain relief as well as help keep swelling down.
  • Use a cold therapy cream for recent pain, injury and swelling. I recommend BioFreeze Pain Relieving Gel. Studies have shown BioFreeze relieves pain 2 times more than ice and the effects last 9 – 10 times longer than ice alone.  If swelling is occurring a cold gel or cream is better than a warming cream as the cold effect does not promote swelling. However, it is not known if cooling creams/gels actually reduce inflammation, so ice should still be used. BioFreeze is excellent to use with ice as it helps to ease that cold shock feeling when ice is first applied.

Medical Treatments for Patellofemoral Pain Syndrome

Medical treatments vary depending on damage in the knee joint and pain. Early interventions are often resting the knee along with pain medication and possibly a brace.

Physical Therapy: Muscle Strengthening, Stretching and Orthotics

If the condition does not resolve the doctor may suggest physical therapy.  A physical therapist will assess your range of movement in the joint, determine which muscles need to be strengthened, which need to stretch, and help you work to regain muscle balance. A PT will also help you learn how to do certain movements and motions properly to reduce the stress on your knee as well as reduce pain.

Foot position as well as how you walk and run will also be examined and orthotics may be prescribed. Orthotics provides support to the arches as well as help with foot pronation and foot supination.

Patellofemoral Joint Injections

If rest, pain medication and physical therapy do not help your physician may suggest an injection of cortisone or hyaluronic acid. Each type of injection is used to treat a specific problem. It should be noted that cortisone and hyaluronic acid are not pain relieving medications but can help reduce pain by treating underlying conditions.

Cortisone injections

Cortisone injections are used primarily to reduce inflammation in the joint and surrounding soft tissues. By relieving internal inflammation pressure is removed from the joint and surrounding tissues and can help reduce pain. The injection can be very beneficial for some and may only bring limited relief for others.

Because cortisone is a hormone that can have side effects, doctors limit the number of injections. For more information including a list of possible side effects, check out the Mayo’s Clinics Cortisone shots.

Hyaluronic Acid Also Called Viscosupplementation

Simply put, hyaluronic acid is joint oil, it provides lubrication and cushion for the joint.  Hyaluronic acid naturally occurs throughout the body and is found in the synovial fluid that surrounds the joints.  In people with osteoarthritis this fluid becomes thin.  The idea behind injections is to help replace the fluid and provide better cushioning and lubrication for the joint.  Unlike cortisone which is one injection, hyaluronic acid requires a series of injections, one per week for 3 to 5 weeks.

Like cortisone, hyaluronic acid injections work very well for some people while others find it does not help with pain.

Surgical Procedures for Patellofemoral Pain Syndrome

Surgical intervention is rare for patellofemoral pain. However for those with debilitating pain surgery maybe considered.  Surgical treatments can range from an arthroscopic procedure that cleans up frayed cartilage to a total knee replacement.

Suggestions for Managing PF Knee Pain

  • Stop doing things that cause pain. If an activity or motion causes pain, stop or limit it as much as possible for a few days. However, it is important that you keep moving! Even if your doctor recommends staying off the leg, do upper body stretching and strengthening. Do stretches in which you do not have to bend and straighten the knee for the lower body as it will help to offset lower back and hip stiffness. If you have access to a swimming pool, swim! Swimming is an excellent total body exercise that will not stress the knee joint.
  • Lose weight. I know that everyone harps about being overweight and people are sick of hearing this. But those extra pounds put extra stress on all joints in the body and are especially hard on the knees, hips and back. Losing weight is the best start toward a reducing muscle and joint pain.
  • Muscle Balance. Find a physical therapist or a massage therapist trained in sports injuries or structural integration. Learn strengthening and stretching exercises to help balance the upper thigh muscles. A trained therapist can also help with pronation or supination of the feet. Core strengthening is also important to improve posture.

Sombra Warm Therapy Gel provides pain relief.

  • For arthritic knees use a warming gel. If your pain has been ongoing over weeks or months and swelling is intermittent or does not occur, a warming cream such as Sombra Warming Therapy Gel  helps relieve the pain and stiffness.  I use Sombra gel extensively in my massage therapy practice as it warms without the harsh heating and burning that often happens with other over the counter warming creams and gels. It also relieves pain longer than many other warming agents and can be used several times a day without skin irritation. It is excellent for arthritis pain.
    Do not apply Sombra while using a heating pad! Use the pad and apply Sombra afterward to extend the heating effect and pain relief.
Bio Skin Q Brace used on patients in the study

The brace used on patients in the University of Manchester study. Note the patella (knee cap) strap.

  • Consider a  knee brace – A recent study (2013) conducted by The University of Manchester found that using a knee brace with a patella (knee cap) strap significantly reduced pain for those with patellofemoral osteoarthritis. It is important to note that the knee brace used had an adjustable patella strap which could be moved and adjusted as well as Velcro bands to adjust the tightness brace. Patients using the brace reported not only pain reduction but also better knee stability and the ability to move the knee more normally. To read the study and get information about the brace read PF Osteoarthritis Knee Pain Is Reduced With Knee Brace.
  • Use leg spacers. For those who sleep on your side consider getting a leg spacer or leg pillow. They work better at keeping pressure off the inside of the knees than regular pillows and are not so bulky. Here is a regular leg pillow and a knee separator that straps to your thigh to hold in place while you sleep.
  • Stand at your desk. Sitting for long periods is one of the most common signs of patellofemoral pain syndrome. If your work requires sitting at a desk for hours a day, consider getting a stand up work station. Stand up desks allow you stand while working and take pressure off the low back, abdomen, upper legs, hips and knees. If space is limited portable standing desks like this sleek plexiglass workstation  or traditional wood portable desk will allow you to stand while working at the computer or doing paper work. If you have the room and the desire to get fit while you work, there is the TrekDesk Treadmill Desk, a desk with a built in treadmill!

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