You don’t need a baseball bat and a Sicilian accent to get intimate with kneecap pain. Pain in the patella (kneecap) region is one of the most common complaints afflicting athletes from many sports. Common provoking activities include squatting, walking up and downstairs, prolonged sitting or standing, kneeling, cycling and running and there may also be an associated grinding feeling or click in the kneecap.
To help your physio you need to locate precisely where you feel the pain as there are many possible causes. Our treatment will vary accordingly but I will only be referring to local knee treatment in this article. In a full clinical examination we would also assess and treat (as required) the biomechanics of the foot and lower limb and also the muscular balance around the hip and trunk region. Let’s investigate patella pain:
1. Retro-patella pain
Pain which is located deep directly behind the patella is called retro-patella pain. It is most likely due to wear and tear of the joint surface of the underside of the patella and changes may be visible on an x-ray. Treatment priorities would be weight-loss (if overweight), quadriceps and hamstring muscle stretching, avoidance of knee hyper-extension in standing and during exercise, quadriceps strengthening and patella taping to correct any specific patella positional abnormality.
2. Lateral patella pain
Pain along the lateral (or outside) edge of the patella is most likely due to tightness in the lateral fibrous capsule of the patella and the iliotibial band (ITB). You may be able to see that the patella does not sit flat on the front of your knee but may be pulled a little to the side and tilted laterally too. Treatment in this case involves massage releases and stretching of the lateral capsule and ITB, taping of the patella to correct the pull and tilt, and exercises to specifically improve the use of the medial quadriceps muscle (VMO).
3. Medial patella pain
Pain in the medial (or inner) edge of the patella may be from repetitive traction/stretching on the medial fibrous capsule of the patella if the lateral structures are tight (as for lateral patella pain). Treatment would be similar to that listed previously. However the pain may also be due to medial muscular attachment strain or joint surface irritation if the patella is too loose e.g. in those people who have subluxed or dislocated their patella. In this case taping to stabilise the patella, VMO exercises and avoidance of knee hyperextension are more effective treatments.
4. Infra-patella pain
This refers to pain below the patella and may come from a number of structures. The patella tendon is the thick central cord running down to the shin bone. If it is inflamed (tendonitis) treatment includes rest or reduced exercise, ice, electrotherapy, anti-inflammatories and taping to unload the painful spot. If the tendon fibres are degenerating (tendonosis) treatment involves massage releases, reduced exercise and unloading taping. Sometimes the tendon attachment to the patella causes a bone stress reaction which requires rest and unloading taping. In growing adolescents, inflammation at the shin insertion of the tendon is known as Osgood-Schlatters’ syndrome and requires reduced exercise, ice, quads stretches and unloading taping to manage the pain which may come and go for 2-3 years.
There is also a fat pad and a bursa sac sitting deep to the patella tendon and extending out to either side from behind it. Inflammation of the bursa (bursitis) or fat pad can be extremely painful conditions which may be due to repetitive pressure from the bottom of the patella sticking into them. Puffy swelling is often visible on either side of the patella tendon. It is also common to have tenderness after arthroscopic surgery of the knee when the scope is inserted through this area. Treatment of fat pad and bursa sac irritation includes rest, ice, anti-inflammatories, electrotherapy and a taping technique which tilts the bottom of the patella away from the body.
5. Supra-patella pain
This refers to pain above the patella and is generally less common. The quadriceps fascial tissue expands from the top of the patella and blends into the quads muscle itself. Normally I will find musculo-fascial adhesions or knots in this area which are causing the pain. Treatment includes massage releases and quads stretching in particular. There is also another large bursa sac in the supra-patella region which can fill with fluid after an acute knee injury or surgery. Sometimes this will also be painful and require massage and electrotherapy to resolve it.
Well that completes my totally open and honest overview of patella pain. Really! That’s all I know! Honest! Hey where did that baseball bat come from? AAAGH!