Mick: That's very sensible Tom! We talked a little bit so far about some treatment options; strengthening and gait-retraining. Are there any others?
Tom: I think the most important one is activity modification. I think that really is absolutely key. What we're looking to do here is try to bring whatever their goal activity is, and obviously in our running population, it's their running, down to a level that they can manage. And in particular, running that doesn't cause lasting irritation of symptoms. Without activity modification, it's quite hard to manage patellofemoral pain in running, because you might be trying to strengthen, you might be trying to change gait, but the knee can stay quite irritable if people continually overload and irritate their knee.
And there is evidence to support activity modification. Esculier did a really fantastic paper in 2017 (LINK to paper) in runners, and they looked at three groups who all had activity modification and education about bringing the running down to a manageable level that didn't cause lasting irritation. All three groups received this advice, with the difference being that one group also had gait re-education, and one group also had strength work for the quads and the glutes.
Now you might expect that those that did the strengthening work on top of the activity modification, or those that changed their gait on top of activity modification, did better. They didn’t. All three groups improved the same in that study. Which led the authors to conclude that it's the activity modification that seems to be the key thing to improve symptoms and function.
In summary, activity modification should be considered first. And then yes, bring in strength work to address their needs. Have a look at their gait, and then ask that question: is there anything in their running pattern that puts more stress on this patellofemoral joint and can we change that? And if there is, great. If there isn't, we may not choose to change it.
Mick: Excellent. What about orthotics or taping?
Tom: I think there is evidence for orthotics. My understanding is it's likely to be effective in those with an increase in foot mobility. So, you might try that as a way of altering the load through the lower limb to reduce pain. Importantly, we’re not trying to correct an “abnormal movement” or “abnormal foot posture” necessarily. We're not saying, “This movement isn't correct, therefore we need an orthosis to change it,” but rather we’re trying to alter the load distribution.
There is also some evidence for taping. But my preference is to look for more active solutions, more long-term solutions, so I've moved away from taping in the last two or three years. Maybe it comes in handy if you've got a runner that's got an event at the weekend and you need something to try and create short-term reduction in symptoms. But I find activity modification, education, progressive strength work, are very effective in runners. As a result, I don't often find I need to go down the orthosis or taping route really.
Mick: Very sensible, and I agree too. You have eluded a little bit to this question already, but strengthening or stretching for anterior knee pain? or potentially both? And if we're going to strengthen, what muscles should we focus on? Or if we're going to stretch, what muscles should we focus on?
Tom: Great question. I much prefer strengthening over stretching for patellofemoral pain. If you think about static stretching, the evidence would suggest it has quite short-term effects, in terms of change of range of movement. And I think with runners, if they're struggling to manage the forces involved in running, it's making them stronger that's likely to help, rather than lots and lots of static stretches. So over the two, I'd prefer the strength work really.
Then if you look at when muscles are active in the running gait cycle, during load absorption where patellofemoral load is at its highest, there's lots of activity from the quads, the glutes, and the calf muscles to help manage that load. So those are the three key muscles I would aim to try and strengthen.
In regards to prioritising these three muscles for strengthening, for me clinically, I quite like the idea of working down the leg. So, strengthen at the hip, because it's been found to reduce pain at the knee. Then strengthen around the knee, particularly the quads. Then hopefully because you've reduced irritability by strengthening at the hip, that they're more tolerant of loading at the knee to strengthen the quads, you may not need to worry about the calf too much. But if you have assessed them and you still feel that they have deficits lower down to the calf, you'd work down the leg and address the calf.
I also think it's very important that PFPS patients address their lower limb control too; especially the ones that struggle with single-leg loading, like single-leg squat. Don’t just focus on pure strength. Have a good look at the basic movement foundations of single-leg balance, single-leg squat, step down, lunge, and actually look at the control aspect of that as well as the strength.
And then don’t forget power. We know there's power deficits in patellofemoral pain too. Particularly around the hip. So at the end stage, when we've got the strength, and you've got the control, then maybe bring in some plyometric work, or some more speed-based strength work, to develop the power.