Patellofemoral Pain

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  • #22426

    Hey guys,

    Thought I’d post in here, as I’m sort of running out of ideas on how to attack this damn patellofemoral pain.

    I’m a snowboard alpinist, and specialize in steep, technical lines. Been doing it coming on 20 years. I also did research in exercise physiology in grad school, so I know my training and orthopedics extremely well.

    I’ve bumped into a brick wall though, and need some feedback….

    Back in late January I was doing some snowboard training, working on “brink of destruction” heelside carving. This is a key skill for us shredders, as the heelside turn on big exposed faces is critical. It takes a moderately deep squat, and puts your lower extremity under tremendous load. I noticed a sharp “TWING” in my left knee on a couple turns, so I backed off. No pain after, and was shredding pain free for several weeks after.

    Fast forward to late February, and I did a regular zone 2 / 3 trail run. It was a mid day “lunch lap”, and so I kept it mellow and short. Just 5 miles and 1,400 vertical over 1 hour. I’ve done this run over a hundred times.

    The next day I had quite a bit of pain in both patellas. This is totally new for me, as I’ve been one of the lucky ones who HASN’T blown his knee out.

    Rested a couple days, then was out on the splitboard and the pain got A LOT worse.

    Its been coming on 3 months, and I keep finding myself in these “rest / rehab until minimal pain, then test the waters” cycles.

    In this time I’ve developed a new crepitus (crackling sound) in my left kneecap, and I can’t seem to get away with even mellow spins on the mountain bike or “walk / jog” exercise without it getting pissed off and feeling like I’m doing more permanent damage. Its also completely stopped my splitboarding dead in the skintrack, and even mellow climbing is off limits because I can’t walk downhill without it becoming very painful.

    I’m extremely well educated in patellofemoral tracking, hip & knee mechanics, proper footwear for pronation etc…

    I don’t think my problem is a mal-alignment issue so much as it is a tissue overload injury. I also know that chondromalacia on its own is not a “strong” statistical predictor for anterior knee pain, as much of the asymptomatic population has some degree of cartilage wear / tear. So the pain has to be coming (probably) from an overload of the subchondral bone or synovium. It feels like bone pain though…

    My question for any other athletes, PT’s or athletic trainers on here, is what is your guy’s / gal’s experience with the prognosis for moderately severe patellofemoral pain syndrome? And what strategies have helped you or your patients / clients? Lastly, what kind of timeline have you all experienced with this damn problem?

    For reference I’m 35 years old, so I’m not made of plastic anymore, but still at my peak physical powers and still full of angst to get rad in the mountains!

    Its a damn frustrating injury. I feel that my fitness has been peaking this year higher than any previous year. I had a Liberty Ridge climb planned, and several other super fun and interesting steep snowboard objectives in line for this spring that are now as far as I can tell, totally fucked by this injury. I’m concerned now that this damn knee pain may severely hamper my mountaineering career, if not has the potential to end it completely.

    I mean, shit man, I survived a rollover car crash that broke my back and blew out a disc, and this knee pain scares me more than THAT injury did!

    Thanks so much for any insight / guidance guys!! -Russell

Posted In: Injury & Rehab

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    Anonymous on #22467

    Hi. Sorry to hear about your injury–I feel your pain, literally. I’ve been struggling with knee/ankle problems related to a ski accident for more than one year, and my I still have serious anterior knee pain, and ankle pain, that prevent me from doing any cycling, running, real climbing, and so on.

    Most recently, I saw a new doctor, which brought some new perspective, and a new planned date for surgery. Ligament reconstruction on ankle, exploratory arthroscopy, fat pad resection, and meniscus repair on knee.

    The MRI shows that the most likely cause of my anterior knee pain is 1) Instability from my ankle injury, 2) fat pad impingement with patella and subsequent irritation, and 2) small tear of posterior horn of medial meniscus which has caused some swelling. After being told that I chronic patellar tendinopathy for one year, looking at the MRI with a perfect patellar tendon was interesting, to say the least. At least now I can look elsewhere for the cause of the ongoing pain.

    One thing my doctor advised is that anterior knee pain can and often is caused by pain in other/deeper parts of the knee. He also would not make any more specific diagnosis than “anterior knee pain” without a set of good scans.

    So, in your case, if you have not already done so, do your best to get an MRI, and maybe try to think beyond just the interaction of patella/femur.

    If they find a clear and operable problem, I would say with your level of activity and drive, just go ahead and do it! Better that then go through the next year(s) of waiting, wondering, and frustration.

    Good luck!


    Pete Dickinson MS,PT on #22606

    I concur that you likely have a chondral injury of some sort. Really, an MRI would help confirm and give a more clear direction to treatment but…. Clearing up the anterior extensor mechanism of pain is a longish process. You will need patience as strength builds slowly in the presence of pain in this area. As strength builds, the stress across this area decreases and you will be able to handle deeper ranges of motion and higher external loads. So yes, there is a treatment, but you aren’t going to enjoy the timelines. You start off with lower loads and manageable ranges of motion (think bike with progression into force tempo work). There are pure strength movements that load the hip (an essential controller of patellar loads), and keep the patelofemoral joint largely out of it (deadlift). Let me know if I can be of help.

    mtcunner on #22629

    Hi Pete, Bruno,

    Thank you guys! Super helpful responses.


    That’s a super helpful perspective. I guess part of my thing is that being a scientist myself, I like to know what structures are compromised, and therefore what the healing potential is. If the subchondral bone is being damaged because of articular cartilage erosion, then I think it’s important to know that and somehow adapt so that I don’t end up with debilitating arthritis. At the same time, bone has great vasculature, so it can actually heal…

    Regarding athletic prognosis, what do you see in your PT practice? Do people get all the way back to being able to jump, run, and even climb big vertical? Its been a bit of an epiphany realizing just how hard mountaineering is on the patellofemoral joint. It’s hard to imagine anything harder on your knees than walking down Mt. Rainier, let alone airing over crevasses on my snowboard.

    Lastly, in terms of time frame, you mention “Clearing up the anterior extensor mechanism of pain is a longish process.” Every human and injury is unique, but can you give me any specifics on what other people experience with this?

    I had a PT give me a program of doing tons of lunges and squats, and it is for sure just making it worse. So I think a nuanced strategy is going to be key for me. Finding an excellent PT in the Seattle area is proving more challenging than I thought.

    Thanks guys, Russell

    Pete Dickinson MS,PT on #22722

    Prognosis depends ‘in part’ with the severity of the injury to the chondral region. It’s amazing the amount of progress you can make in return to function over time. Big injuries in practice take around a year for near-full recovery. If you have ever been in this situation, you’d make a deal with the devil to be that good in a year!! But to get that good, you have to take a true training approach to your rehab employing consistency, the right loads at the right time, and appreciation of attaining small goals along the way, think rehabTFTUA.
    On a side note, I’m in Winthrop so if you would like a more individualized approach, just email me or use that chatbot in the lower right.

    Pete Dickinson MS,PT on #22724


    briguy on #23525

    I have been having issues with patellofemoral pain for a couple of years now. It started when I was doing step-downs as part of a strength routine for a big climbing race.

    Mine flares up when I do a bunch of cycling and strength work where the knee is loaded in a flexed position. Typically, it subsides when I’m tapering for a race so appears to be related to load.

    The problem is I just spent 6 months recovering from an injury/hip-surgery where I rested more than I probably ever have in my life. As soon as I started rehab for the hip with single-leg loading stuff, boom back came the anterior knee pain. So it sure seems like rest isn’t going to fix mine.

    Haven’t had an MRI on that knee, but my orthopedist said this injury is one of the most frustrating to fix as there are a number of things it could be (knee cap tracking, etc).

    The funny thing is I got some relief from doing some ankle mobility work on that limb. (that ankle is noticeably less flexible than the other side – multiple sprains and a fibula break contribute to that) But the relief was fleeting unfortunately.

    Should I completely avoid any of the uphill-athlete suggested strength work on that side (like box steps, lunges etc)?

    Pete Dickinson MS,PT on #24158

    You’re right in that there can be multiple issues contributing to anterior knee pain. This region is very susceptible to subtle tissue tightness affecting the ‘tracking’ on the patella. As a starting point I would roll out the hip and medial quad, then begin strength with deadlifts initially avoiding single leg work until double leg work is pain free. Then its off to the races back to step ups and lunges etc. This can be resolved, but it also takes a strong dose of patience and discipline.

    briguy on #24366


    Thanks very much for the reply.

    I have tried a number of remedies now (the mentioned ankle mobility, a bunch of quad strength work, also hamstring stretches, ice on the knee cap, some topical NSAIDs i. .e voltaren, and some foam rolling and tissue work). I have gotten relief on a rare occasion…one of those situations where I take that initial step up/down and I’m surprised that there is no pain there. But then it comes back and I’m left wondering what gave me the temporary relief.

    I actually think I am plenty strong (I can do the 6×10 sets of step ups with a 20lb vest no problem) so more strength work probably isn’t going to solve it.

    I’ll go back to the foam rolling and tissue work (I use a softball and a lacrosse ball too) and see if that gives me the relief I am seeking. Just to clarify, the medial-quad is about where the VMO is located?

    It’s been frustrating as I had hip labral tear surgery a year ago and that hip is rocking and rolling now, I’m just limited by the opposite knee.

    Thanks again for the information.

    Pete Dickinson MS,PT on #24397

    The fascial spot to work is in the ‘region’ below the VMO, just superior to the medial condyle. You know its the right spot when mobilizing it is quite painful with light pressure.Step ups with 20lbs. is not really a complete picture of your lower extremity strength. I would not say that you have ‘played out’ your strength gains as it relates to patellofemoral pain.

    briguy on #24505

    Thanks Pete. I was only using the step ups (6 sets of 10 reps) as an example since it’s one of the go-to strength workouts in the Uphill Athlete book. I can also do single leg deadlifts with 100lb in dumbells, single legs squats, single leg wall sits etc to a decent level of strength. This has been my method of attempting to counteract this issue over the last couple of years. I am lucky that I gain strength quickly (fast twitch, high ratio of muscle mass etc) so that’s why I feel like I need to go in a different directly with this rehab. I’m happy to try any other strength exercises you recommend of course.

    So superior to the medial condyle but below the VMO. Is that basically where the VMO terminates at the knee? I am poking around in there with some therapy tools and just want to make sure I have the right spot. Thanks again.

    Pete Dickinson MS,PT on #24872

    The fascial region is more medial quad than VMO, I would also address the posterior hip in the same way as that is surprisingly an important area for the knee as well. I also use Ktape until I am painfree with my strength movements.

    briguy on #24894

    Okay thanks. Apologies for all the questions but I’m confused as to the location. Just superior to the medial condyle made me think basically “between the knees” in other words so if I put my knees together it’s roughly where they’d touch. This is roughly where the VMO ends (the bottom of the “tear drop”). But medial quad is somewhere else instead? Does that mean more to the inside of the knee?

    I’ll do some tissue work on the hip area (assuming that means the various glutes) and I have some KT Tape around here somewhere that is worth a try as well.

    Incidentally I had found a very tender spot between where the VMO, kneecap, and medial condyle all meet, and I’ve been working that fairly regularly and seeing some relief! That’s why I was a little surprised when you said to look in a different spot instead. Thanks again for all the helpful advice.

    briguy on #26867

    Pete – Circling back on this. I just went through a round of NSAIDs for that anterior ankle issue I asked you about in another thread. My ortho suggested 2 weeks of NSAIDs to see if it would clear up the inflammation.

    Well, the side effect was that it also cleared up my knee pain! I felt better there than I have in years. I was doing my weighted step ups, going up/down stairs etc with zero pain whatsoever.

    Alas, when the two weeks were over, you guessed it, the pain has come back.

    I really want to get rid of this. I’m doing the stretches and foam rolling you suggested, are there any “go to” strength workouts you suggest for this? As mentioned the step ups produce some pain (it’s tolerable) as do lunges, single leg squats, jumps, etc. They’re all tolerable so I can continue to do them if there is light at the end of the tunnel.

    A buddy of mine resolved his knee problems recently (his was different-mild meniscus tear) and in talking with him I am newly inspired to resolve mine too. I’ve spent a fair amount of time with my local PT and orthos on this and it continues to nag so any wisdom would be greatly appreciated.

    Pete Dickinson MS,PT on #27006

    I would look at performing the single leg work without much pain if possible to start building strength. Work into 3×10 at a load that isn’t painful. If you can, try to migrate to 5×5 at a heavier load. Failing to take load without pain isn’t the end of the world. You can develop pain free movement gradually using lower loads. Depending on you patellofemoral joint health, doing low rpm (40-50) bike work at just below aerobic threshold is helpful for gaining knee extensor strength in a less stressful way. You could supplement this with deadlifts for hip strength that your knee should tolerate. Hope this gives you some ideas!

    briguy on #27444

    Thanks Pete. I hadn’t thought of the low-rpm cycle work for strength purposes. I’m going to start a circuit of the following specifically to address this knee problem:

    – Single Leg step ups (starting with no weight and progress) 3×10 to start
    – Single Leg Dead Lifts
    – Low rpm stationary bike (assuming 15min or so)

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