Knee Pain: Finding the Source

by Billy Cioffredi, PT

Knee pain is a common complaint we see in the clinic, though the source of knee pain can be quite variable and complex. Accurate diagnosis of the cause of the pain is fundamental to providing appropriate treatment and getting lasting results.

In our clinic, people are often surprised to find out that care for their knee pain may include treatment at the back, hip and ankle, and not as much for the knee itself. Treatment is often directed this way because a frequent cause of non-traumatic knee pain is abnormal biomechanics from the pelvis through the whole leg.

Three of the most common types of knee pain are Iliotibial Band (IT Band) Syndrome, Patellofemoral Pain Syndrome or “Runners’ Knee”, and Patellar Tendonitis or “Jumpers’ Knee”. First, how do you know which one you have? Then, how do you treat the issues that are unique to your problem?

Iliotibial Band Syndrome (IT Band Syndrome)

is the most common cause of lateral knee pain in athletes, especially runners. It is often considered an overuse problem, and that can be the case. However, it is most often seen in our clinic in one knee only. If it was simply ‘overuse’ wouldn’t you see it in both knees fairly equally? If you have had this, you’ve rested it, only to find it comes back after you begin to return to your activity, maybe it’s because it’s a biomechanical problem, not overuse.

The IT band is a thick band of fibrous tissue that begins at the hip and runs down the outside of the thigh, ending just below the knee.

Symptoms of IT-Band Syndrome:

• Pain on the outside area of the knee though it can be felt extending up the thigh.
• Pain typically develops during, or worsens after running, biking, or climbing hills or stairs.

Potential Causes of IT-Band Syndrome:

• Tight IT Band: The band itself is leathery-tough. It’s not stretchy, but the muscles it attaches to in the hip are. These are the muscles that are often tight, but because they are not painful, often go undetected as a major contributing component.
• The band can get bound up with the tissue it overlays. This can result in it rubbing or not sliding easily. The friction results in an inflamed IT band.
• Weak muscles in the hip can result in the body compensating by improperly using other muscles that attach to the IT band. It is this improper usage of the muscles that can result in ‘overuse’ of the tissue, not necessarily the activity itself.
• Biomechanical abnormalities such as excessive pronation, the rolling motion when the arch of the foot collapses during walking and running, or having one leg truly longer than the other.
• True, pure overuse certainly can happen. Beginning an activity too aggressively for the individual’s capacity, or extending an activity too long or on too many subsequent days, are all examples on how this aspect happens. These causes predictably respond to relative rest and ice. The others don’t.

Recovery & Treatment of IT-Band Syndrome:

A ‘Shot gun’ approach includes the same host of things that are done for every person, no matter their situation (rest, ice, compression, elevation, stretching, etc.). If your problem happens to adequately get hit in this process then you may find relief, or partial relief. If not, it may be that the treatment just missed the target problems unique to you. Targeted treatment can include:

• Manual therapy, including joint and soft tissue mobilization, to restore lost mobility.
• Stretching selective tight muscles that are contributing to the problem.
• Strengthening muscles that are truly weak.
• Addressing biomechanical abnormalities in the ankle and foot, including appropriate orthotics, only when they are truly effective.
• Appropriate modification of activity. Now more than ever, we know that adequate recovery is an essential part of successful athletic performance. This can be hard for the exercise enthusiast that is not aware of this knowledge, but relative rest and sometimes cross training can be vital in speeding recovery.
• In the end, teaching the person how to handle their unique condition is fundamental to ongoing success

Patella-femoral Pain Syndrome (PFPS) or “Runners’ Knee”

is a common condition in which pain is felt under and around the kneecap. Like many conditions identified by a sport, many people with this diagnosis are not runners. Approximately 70% of anterior knee pain that comes from patellofemoral disorders will resolve with conservative treatment like physical therapy.

Symptoms of PFPS:

• Symptoms may be provoked or aggravated by activities such as walking up stairs or hills, or squatting and crouching activity. Interestingly, prolonged periods of sitting can be painful with this condition.
• Buckling of the knee is possible, although PFPS is not like conditions where the knee is loose from torn ligaments.

Potential Causes of PFPS:

There is not one single cause for the pain, but many potential causes. Here are some fundamental causes:

• Overuse with repetitive action is commonly thought of as the reason for the pain. This is one of the reasons it was thought as a result in some runners. However, some runners who have the diagnosis have only one knee that hurts. Others have not increased their activity, so it does not always easily fit the concept of ‘overuse’.
• An imbalance in the muscles and the dynamic alignment in the leg. Weakness of  muscles in the outside of the hip (Gluteus Medius) and inside of the thigh (Vastus Medialis), often with tightness of other muscles in the hip, IT Band, and/or calf, may result in poor control of the knee during excessive activity. Sometimes the imbalance of the tissues pulls the kneecap out of alignment or causes it to go off track in the groove on the thigh bone.
• When the arch of the foot collapses excessively (excessive pronation), it can result in enough torsional stress at the knee that it causes pain and problems with the kneecap. (And sometimes it may the imbalances in the leg muscles that result in the arch collapsing).
• Trigger Points (TPs) ‘knots’ within muscles, or areas of hyper-irritability. TPs can be responsible for achy pain when sitting for long periods, as well as buckling of the knee joint (Travell, MD).
• Bony abnormalities at the knee or osteoarthritis.

Treatment of PFPS:

The key to successful treatment is that the correct treatment is applied to the actual cause of the problem.

• Manual therapy is used to restore normal movements of joints, full flexibility of tight, restricted tissue, and to eliminate trigger points.
• Stretching exercises to lengthen short muscles and tissue.
• Strengthening weak muscle groups (not the already strong ones).
• Correction of abnormal movement patterns (breaking old habits).
• Taping the kneecap to temporarily control some of the forces until you can restore the body’s natural abilities.
• Orthotics and/or proper shoes to help abnormal forces at the ankle and foot.
• Education about proper training and activity. Have adequate recovery time!

Patellar Tendonitis, also known as “Jumpers’ Knee,”

is also a common problem, and you don’t have to be a jumping athlete to have it. It is, however, most common in athletes that play sports involving a lot of jumping or repetitive impact such as basketball and volleyball.

Symptoms of Patellar Tendonitis:

• Pain in the area just below the kneecap.
• Painful to hop, jog, and jump. At its worst, it hurts to walk on stairs or even on a level surface.
• You can have pain with kneeling or squatting, like work in the garden.

Potential Causes of Patellar Tendonitis:

Like PFPS, there is not one single cause for the pain, but many potential causes. Here are some fundamental causes:

• Tissue Overload. Repetitive impact/loading beyond the body’s physiologic limits results in irritation of the patellar tendon. The overload can be from a gradual, but sustained build up over time or a sudden increase in activity.
• Tight muscles in your thigh such as the quadriceps and hamstring, as well as the calf muscle, can increase the load on the patellar tendon or the knee in general. Adolescents who are going through rapid growth periods are susceptible to this problem (and others about the knee).
• When the front thigh muscle, the Quadriceps, is not adequately strong and developed then the patella tendon can get overloaded. (The quadriceps is the largest shock absorbing tissue in the leg).

Treatment of Patellar Tendonitis:

The key to successful treatment is that the correct treatment is applied to the actual cause of the problem.

• For tendons that are truly inflamed (tender and warm to touch, walking and stairs are painful), then ice and relative rest from irritating activity are important first steps.
• Stretching tight muscles.
• Strengthen weak muscles, particularly the quadriceps, though this may have to wait until the pain is gone.
• Addressing abnormal movement patterns.
• The use of taping to support the knee can be helpful in some cases.
• Education regarding proper training and activities (such as plyometric drills for sports), and especially ensuring adequate recovery periods.

As you can see, the causes of knee pain vary widely, as do the treatments. The key to successful treatment is that the correct treatment is applied to the actual cause of the problem.

OTHER RELATED ARTICLES

Patellofemoral Pain Syndrome (“Runner’s Knee”)
Overview of the Knee Joint
ITB Iliotibial Band Syndrome
Kinesiology Tape: What and Why?
For Athletes and Coaches