With the onset of Fall, High School Athletics resume in full force. This “New Beginning” can also mean “New Injuries” for some athletes. The knee is no stranger to athletic-type injuries as it is subjected to an incredible amount of stress during sports. Often these injuries are chronic injuries, having resulted from years of wear and tear on the joint. There are, as a result of poor biomechanics, numerous contributing factors, that can help exacerbate kneepain.
Patello-Femoral Syndrome is a form of what some people call “Runner’s Knee” which specifically involves the articulation between the knee cap and the thigh bone. Inflammation of the knee cap at its junction with the thigh bone can be due to either a sudden movement of the knee cap or more commonly, excessive tracking of the knee cap to one side or the other.
Faulty knee cap tracking may be caused by tightness of the Iliotibial band (runs along the outside of your thigh), weakness of the Quadriceps, variation of the position of the thigh bone in relation to the leg bone (‘Q angle’) and poor biomechanics of the foot. We believe biomechanics is the most prevalent of these factors, as the foot is truly the foundation of stability for the rest of the body.
When the foot flattens, the leg internally rotates. Therefore, excessive flattening of the foot can result in poor positioning of the leg. Due to this, the Quadricep muscles pull at an odd angle, rather than straight. This abnormal vector of force causes an appearance of “Knocked Knees.” This can be spotted as athletes run towards you; the foot will appear to be turned out in relation to the knee.
Signs to look out for include the “Theater Sign”, which is a complaint of pain after sitting for an excessive amount of time. This is due to the high degree of compression that comes with bending the knee at 90 degrees. Other signs include discomfort while ambulating up and down hills or stairs. Again, this is due to the excessive amount of knee flexion and increased quadriceps activity.
Please note that patients who also have stiff arches may have signs of PFS. This foot type lends itself to decreased shock absorption which in turn, creates more dependence and instability of the knee joint.
Treatment of this condition involves rehabilitation of the current disease, as well as prevention of future occurrences. Immediate treatment includes RICE (rest, ice, compression, elevation), bracing, taping and limited exercise activities.
For the next several weeks, the patient should begin physical therapy with a concentration on strengthening of the Quadriceps and stretching of the Iliotibial band. We encourage exercises such as Quad Sets, Wall Sits and Side Step-ups. We also recommend that patients have a set of custom orthotics molded for their return to normal activity.
After a few weeks, we hope to have the patient gradually returning to incline training, but special attention should be paid, as this creates excessive stress to the pathological sight. Also at this point, our team likes to work closely with the therapists to ensure proper biomechanical alignment and “Break-In” of the orthotic devices. We pay special attention to neuromuscular reconditioning for orthotic use and have a specific protocol for this time period.
Once acute inflammation has subsided, a gradual return to normal activity and running should begin. The patient should also start their “Break-In” regimen for their custom orthotic devices and ensure they have proper athletic shoe gear.
Communication with the Athletic Trainer is especially vital with this condition. The earlier this condition is spotted, the sooner the athlete may return to his/her sport. Ideally, we like to see continued reinforcement of Iliotibial band stretching and close observation with activities taking place on inclines. Taping techniques, such as Kinesio type or McConnell style strapping may be of use.
We recommend that the Trainer continues to work with the athlete after the transition to athletic activities, especially for those athletes involved withexcessive joint forces (football lineman, basketball centers, high jumpers). Close monitoring of the athlete’s performance technique is extremely important and exercises such as squats, lunges and leg presses should be discouraged for at least one month after recovery.
Obviously, for mild cases, especially with Elite Athletes, this regimen may be shortened and customized to the specific patient. Again, close communication must be maintained between the Therapist, Athletic Trainer and lower extremity doctor specialized in sports medicine. Although PFS can be a painful problem to have, most times it can be treated conservatively and prevented in the future.
Why is identifying this condition important for PRE-PARTICIPATION PHYSICALS?
Identifying knee cap tracking in the early stages can help significantly in the prevention of active disease. Injury can be avoided if the athlete is fitted with proper shoewear and custom orthotic devices. Correction of excessive rotation of the leg with orthotics, as well as education on proper Iliotibial band and hamstring stretching can mean the difference between a full season, and partial season of play!