Knee pain-Patellofemoral. A functional approach.

Knee pain is very, very common. Although there are many types of knee pain affecting the various bursars, tendons and ligaments in that area, one of the most common is patellofemoral pain.

Rather than delve too deep into the minutia in this blog post it maybe much better to have a conceptual understanding of what is needed for successful patella femoral mechanics.

The patella is attached to the femur and tibia via the patella tendon.  In fact it sits in the groove or Condyles that are both medial and lateral on both bones. This means that for successful movement of the patella, these grooves need to stay pretty close. A great way of describing it would be “in sequence”.  Otherwise the patella can smash into the groove causing pain.

We have two pretty important bits of the body attached to these two bones.  Namely the hip which attaches to the femur and the foot attaching to the tibia. That means the sequencing of the grooves can be affected by excessive movement or limitations in movement at either end, the hip or foot.

A common approach is to try to limit the movement at the hip and foot by tracking the knee in the sagittal plane, in effect reducing the variability of motion. The wondrous nature of a ball and socket joint is the huge freedom and variety of movement it gives us.  In fact this freedom and variety could be described as tri plane. An attempted reduction of motion into the sagittal plane will reduce the load to the hip musculature that displays a distinct tri plane nature. Look at the glute and its oblique fibre orientation. Without frontal and transverse plane motion of the femur it will not work effectively. In fact the glute will control the femurs motion into adduction and internal rotation.  Deviations away from the sagittal plane, that occur frequently in functional weight bearing movement, of knee valgus (femur adduction) and femoral internal rotation will need to be slowed by eccentric activation of the glute and hip musculature. This maintains the optimum sequencing between femur and tibia for healthy patellofemoral mechanics

Equally the operation of the foot will affect the sequencing of the tibia. This will also disrupt the patella in the groove. Using gait as an example (and universal function) a rearfoot or forefoot varus will have an acceleratory effect of the tibia following the foot into pronation, creating increased tibial internal rotation and abduction. The sequencing of pronation will also affect the sequencing of the patella femoral mechanics. Late rearfoot pronation will decrease the external rotation of the tibia that along with femoral external rotation keeps the grooves closely sequenced. In fact we may get opposite rotation of femur and tibia. The patella attached to both, as my friend Gary Gray says, “gets caught in the middle with no place to go’.

A lack of motion in sagittal plane such as ankle dorsi flexion may also increase pronation affecting the knee.  This is why people may complain of feeling their knee more when using the stairs. Increased dorsi flexion is required when ascending or descending the stairs. If this dorsi flexion is not available at the talo-crural joint the body may use increased pronation at the Sub-talar and mid-tarsal joints to create more flexion. This increases the frontal and transverse plane forces on the tibia and therefore patella. So increasing the sagittal plane demand as traditional exercise aimed at dealing with patellofemoral mechanics does, may actually cause an increase in the motions that cause pain! An understanding of why dorsi flexion maybe limited could be a more successful approach rather than just try to force more sagittal plane knee motion!

Functional tri plane assessment of both of the hip and ankle are required to understand what maybe causing knee pain rather than generic one size fits all exercise. So many structural foot dysfunctions are present in the general population that without understanding functional biomechanics and structure we cannot effectively treat these problems. A knowledge of how the knee acts when weight bearing rather than just on a plinth is vital as tri plane motion occurs mainly when weight bearing.

Something that always confuses me is the dissociation between foot pronation and knee motion. We classify pronation as movement into dorsi flexion, abduction and eversion and is well documented. This will create tibial internal rotation following the talus. This tibial motion connected to the femur will create internal rotation of the knee. How then can the knee work as a simple hinge joint when weight bearing moving exclusively in the sagittal plane??? Equally the abduction of the tibia at the distal end will result in the proximal end falling in towards the midline of the body creating a valgus at the knee. Again how can we see the knee simply as a hinge???

It is vital that close association of both the femur and tibia occurs in all 3 planes for functional success. This means assessing the foot and ankle in weight bearing and dynamic positions! At Cor-kinetic we always use this thought process when dealing with these types of problems!

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