Anterior Knee

Pain –an
Enigma for
Clinician
Dr. Dharam Pandey
 Patho-kinesiological
mechanism

MUSCULOSKELETAL
PAIN for both
must be assessed
Kinesio-pathological
Mechanism
Patellofemoral
Tibiofemoral
 Patellofemoral

Relatively young 30-50 years (women more

common)
The pain is more…
on climbing up and down stairs,
on sitting for long (Theater sign), and while driving
car.
on getting up from sitting

Almost NO least pain on walking

Often bilateral
Causes of
Anterior
Knee Pain
Bony Structural abnormality
Altered Soft Tissue Integrity
Examination of Anterior
Knee Pain

Look for Bony abnormalities

 Examination of
Anterior Knee Pain
Look for pes planus, tibial torsion, genu varum or
valgum, genu recurvatum, femoral anteversion or
limb length discrepancy
Examination of
Anterior Knee Pain
Functional assessment muscle length and
integrity ---
MUSCLE AND SOFT TISSUE
IMBALANCES
Examination of
IMBALANCE BETWEEN VMO AND VL
Anterior Knee
VMO weakness
Timing deficit with delayed onset of VMO
Pain
Functional assessment muscle length
strength and integrity ---
ABNORMAL SOFT TISSUE LENGTH
TIGHTNESS IN QUADRICEPS Distal and proximal joint contribution
Directly increase contact pressure PF joint to altered biomechanics
TIGHTNESS IN HAMSTRINGS, CALF
Constant flexion movement to PF joint
TIGHTNESS IN ILIOTIBIAL BAND
Affects normal PF excursion
Contribute to lateral patellar tilt ,excessive
pressure lateral patella
 Functional assessment muscle
Examination of Anterior length and integrity ---
Knee Pain
SEQUENCE OF EXAMINATION

Look for Q angle

 Functional assessment muscle
Examination of Anterior length and integrity ---
Knee Pain
SEQUENCE OF EXAMINATION

Look for IT band

tightness
 Functional assessment muscle
Examination of Anterior length and integrity ---
Knee Pain
SEQUENCE OF EXAMINATION

Functional
gastrocnemius Test
 Functional assessment muscle
Examination of Anterior length and integrity ---
Knee Pain
SEQUENCE OF EXAMINATION

Functional Quadriceps
Flexibility Test [Prone Knee
Bending Test]
 Functional assessment muscle
Examination of Anterior length and integrity ---
Knee Pain
SEQUENCE OF EXAMINATION

Functional Hamstring Flexibility

Test [Sitting Knee Extension
Test]
 Functional assessment muscle
Examination of Anterior length and integrity ---
Knee Pain
SEQUENCE OF EXAMINATION

Do orthopaedic tests for cruciate,

collaterals, meniscus and for
patella / patello-femoral complex.
 Functional assessment muscle
Examination of Anterior length and integrity ---
Knee Pain
SEQUENCE OF EXAMINATION

Do orthopaedic tests for cruciate,

collaterals, meniscus and for
patella / patello-femoral complex.
 Functional assessment muscle
Examination of Anterior length and integrity ---
Knee Pain
SEQUENCE OF EXAMINATION

Do orthopaedic tests for cruciate,

collaterals, meniscus and for
patella / patello-femoral complex.
 Functional assessment muscle
Examination of Anterior length and integrity ---
Knee Pain
SEQUENCE OF EXAMINATION

Assessment must includes FOOT

LEG
KNEE
THIGH
HIP
SPINE
GAIT
 Functional assessment muscle
Examination of Anterior length and integrity ---
Knee Pain
SEQUENCE OF EXAMINATION
Impaired muscle length:
• Tight hamstring, Iliotibial band, lateral retinaculum, and quadriceps.
Pain:
• goal to increase joint protection and self-management of sx’s.
Impaired muscle performance:
• Muscle imbalance between hip internal rotators and external rotators. VMO atrophy. Weak quadriceps, hamstrings,
and hip abductors.
Impaired joint mobility:
• Lateral tracking of the patella.
Loss of function: Intolerance to…

Impaired posture:
• Poor foot/knee/ hip posture during gait/functional activity.
 • Pain relief
• Correct bio-mechanical dysfunctions

Rehabilitation
Goal
Goal
Correction and realignment of biomechanical Derangement
Rehabilitation –
Principles Restore Muscle Strength and emphasize the neuro-motor control of
Quadriceps specially VMO

Control the Knee Through the Hip and ankle

Enhance Soft Tissue Flexibility and Mobility

Enhance Proprioception and Neuromuscular Control

Gradually Progress Back to Activities

Key Principles
Therapeutic
Exercises
Protocol
Review
Therapeutic
Exercises Clark DI, Downing N, Mitchell J, Syzpryt EP, Doherty M. Physiotherapy for anterior knee pain. Ann

Protocol
Rheum Dis. 2000;59:700-704.

Boling MC, Bolga LA, Mattacola CG, Uhl TL. Outcomes of a weight-bearing rehabilitation program for
patients diagnosed with patellofemoral pain syndrome. Arch Phys Med Rehabil. 2006;87;1428-1435.

Earl JE, Hoch AZ. A proximal strengthening program improves pain, function, and biomechanics in
Review women with patellofemoral pain syndrome. Am J Sports Med. 2010;20.

Tyler TF, Nicholas SJ, Mullaney MJ, McHugh MP. The role of hip muscle function in the treatment of
patellofemoral pain syndrome. Sports Med. 2006;34:30-636.

Lowry CD, Cleland JA, Dyke K. Management of patients with patellofemoral pain syndrome using a
multimodal approach: a case series. J Othrop Sports Phys Ther. 2008: 38 691-702.

Christina D. Daviin, MS, ATC; William R. Holcomb, PhD, ATC, CSCS; Mark A. Guadagnoli, PhD. The Effect
of Hip Position and Electromyographic Biofeedback Training on the Vastus Medialis Oblique: Vastus
Lateralis Ratio. Journal of Athletic Training 1999;34(4):342-349
 Hamstring

Stretching of tight IT band

Therapeutic structures Lateral retinaculum

Calf

Exercises Strengthening &

Core muscles
Knee

Includes facilitation of weak

muscles Hip
Ankle
Review Ankle/hip/knee strategy

Proprioceptive &
Kinesthetic facilitation Plyometric & agility
 Role of EMG BFB-What and
Therapeutic Exercises Includes why……

EMG biofeedback training should be

considered for:
• Correcting excessive lateral tracking of the
patella
• Selective VMO Facilitation

EMG biofeedback coupled with a graded exercise decrease

pain.

Exercises + Bio-feedback ----- more effective

• Davlin CD, HolcombWR, Guadagnoli MA, Worrell TW. The effect of hip position and electromyographic biofeedback
training on the vastus medialis obliquus: vastus lateralis ratio. J Athl Training 1999;4(34): 342–52.
• Dursun N, Dursun E, Kilic Z. Electromyographic biofeedback- controlled exercise versus conservative care for
patellofemoral pain syndrome. Arch Phys Med Rehab 2001;82:1692–5.
• Lam PL, Ng GYF. Activation of the quadriceps muscle during semisquatting with different hip and knee positions in
patients with anterior knee pain. Am J Phys Med Rehab 2001;80(11):804–8.
 Role of EMG BFB-What and
Therapeutic Exercises Includes why……

EMG Bio-feedback

A treatment process using electromyography device as tool to provide return

information about performance in order to enhance subsequent
performance.

More the motor unit

recruitment Stronger the contractile
force generated
Therapeutic Exercises Includes Strengthening & facilitation of weak
muscles

VMO facilitation with NMS

Without NMS VMO With NMS VMO

contraction contraction

Progression: Time: 7-10 minutes

Hold: synchronized with
Gradual increase in hold (surge time) time NMS
Resistance: none
 Our Observation

Therapeutic
Exercises
Includes
Strengthening & facilitation of
weak muscles
 Our Observation
Case
• A 32 year old female with Outcome
complaint of pain over Intervention
anterior aspect of knee 1. Isolated VMO strengthening VAS after activity
since 3 month. based on PRE principle with 8–3

Therapeutic bio-feedback
• Get worst after activity & Stair
Stair activities 2. Knee stabilization exercises 9–0
using thera band. Grind test

Exercises 3. IT band stretching

4. Lateral retinacula stretch
Positive – Negative
Patellar Tilt Angle
270 - 120

Includes
Strengthening & facilitation of
weak muscles
 Case
• A 32 year old female with
complaint of pain over
anterior aspect of knee
Approximately
since 3 month. 15º and 4”

Therapeutic
• Get worst after activity & superiolateral
Stair activities direction for VL

Exercises
Includes
Strengthening & facilitation of
weak muscles Approximately 55º
and 2”
superiomedial
direction for VMO
 Case
• A 32 year old female with
complaint of pain over
anterior aspect of knee
since 3 month.

Therapeutic
• Get worst after activity &
Stair activities

Exercises
Includes
Strengthening & facilitation of
weak muscles
 Therapeutic
Exercises
Includes
Sample Stretching technique of
Tight Muscles
 Therapeutic
Exercises
Includes
Sample Stretching technique of
Tight Muscles
 Selective VMO Strengthening

Reps: 7-10
Hold: 10 Seconds

Therapeutic
Hip in external
rotation

Exercises
Includes Precaution:
Precaution:
•• No
No Gluteal
Gluteal contraction
contraction
•• Make
Make sure
sure VMO
VMO is
is in
in contraction
contraction by
by palpation
palpation
Sample Strengthening and
•• Verbally
Verbally encourage
encourage patient
patient
facilitation

Progression:

Without resistance to gradual increasing resistance

 Hip abductor and external rotator strengthening

Precaution: No trunk
rotation allowed

Therapeutic
Exercises
Includes
Reps: 7-10
Sample Strengthening and Hold: 10 Seconds
facilitation Resistance: Thera Loop
Progression:

Without resistance to gradual increasing resistance

 Trunk control exercise

Precaution:
• Watch sitting posture
• Both side to be done

Therapeutic
Exercises
Includes
Sample Strengthening and Reps: 5-7
facilitation Progression: Hold: 10 second
Resistance: none
With slight support to without support
 Side Semi Lunges

Therapeutic
Exercises
Includes
Reps: 5-7
Sample Strengthening and
Progression: Hold: 10 second
facilitation
Resistance: none
Gradual progress in hold time
 Wide Semi Squat
Precaution:
• No forward trunk
bending

Therapeutic
Exercises
Includes
Sample Strengthening and Reps: 5-7
Progression:
facilitation Hold: 10 second
Resistance: none
Gradual progress in hold time
 Proprioceptive training on trampoline

Therapeutic
Exercises
Includes
Reps: 5-7
Sample Strengthening and
Progression: Hold: 10 second
facilitation
Resistance: none
Gradual progress in hold time
 Forward semi Lunges

Therapeutic
Exercises
Includes
Reps: 5-7
Sample Strengthening and Progression: Hold: 10 second
facilitation Resistance: none
Gradual progress in hold time
 Pilate based core and kinesthetic facilitation

Therapeutic
Exercises
Includes
Sample Strengthening and
facilitation

Progression: Reps: 7-10

Hold: 10 Seconds
Gradual progress in time Resistance: none
 Strengthening –
Strengthening the gluteus maximus and medius, quadriceps, and
Therapeutic hamstrings are needed. Specifically strengthening hip external
rotators eccentrically will help with gait and stability. Strengthening

Exercises of the quadriceps needs to be in a pain free ROM. This can be done
with lateral step-ups and limited ROM squats.

Includes Stretching of tight structures –

Iliotibial band, Lateral retinaculum.
Stretching of shortened muscles –
Sample Strengthening and Hamstrings, quadriceps, hip flexors, and gastroc soleus complex.
facilitation Stabilization –
Stabilization/balance/proprioceptive exercises for the hip and knee.
Patient education –
Footwear, and patella taping.
Anterior Knee Pain
Protocol
Principle
• Correction of biomechanical derangement.
• Realignment of extensor mechanism.
 Anterior Knee Pain Protocol
Supportive therapy for pain control and to decrease
Inflammation
•LEVEL I 1. Ultrasonic therapy to tender points
2 . I F T/ TENS
•A. Exercises 3.Cryotherapy
•1.Stretching of tight structures
• a) hamstrings
• b)IT band (in sidelying)
• c) Lateral retinaculum
• d) calf
•2 .Strengthening and facilitation
• a) Non wt bearing strengthening and facilitation of VMO in half sitting knee extension 30º-0 º ( hold for 7- 10 second )
• b) Hip abductor strengthening in NWB ie. Side lying hip abduction resisted with TheraBand and knee flexion 20 º-30º
• c) Trunk core muscle strengthening on swiss ball .
• d) Lumbar stabilization exercises with 10 sec hold .
• e) Neuromuscular electrical stimulation to VMO.
Anterior Knee Pain Protocol
LEVEL II
Exercises
1.Closed kinematic Chain (CKC) Exercises
a. Lateral step up ( gradual progression )
b. Sumo semi squats ( wall slides)
2.Cycling within 90º of knee flexion ( restricted range) without resistance initially
gradually progressing to resistive .
3.Theraband strengthening of VMO( 15º-20º hip lateral rotation ) in supine 30º- 0º
extension.
4. Calf raises with 5º- 10º knee flexion (CKC).
5. Proprioceptive facilitation on trampoline.
 Anterior Knee Pain Protocol

LEVEL III
1. Wide base leg press hip in 10º-15º lateral rotation .
2. Cross trainer
3. Agility and plyometrics
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