Patellofermoal Pain Syndrome

Bigger Stronger Leaner Injuries and Rehab
1

since April 2010 i have been decommissioned with PFPS, which doesn’t sit right with me—not just because of my active lifestyle, but also because i feel as though it’s a knee pain “otherwise unspecified” with no consensus amongst medical professionals as to what causes or cures the condition.

June 2010 i saw a family practice/sports medicine doc who ordered X-rays, gave me the diagnosis, and opted to pursue conservative treatment with physical therapy. X-rays are normal, and my follow up with him is in 2 weeks (after which, i will seek the opinion of an orthopedic surgeon). i don’t know if he will order an MRI at that time, but while i have insurance, i am willing to go through with any and all tests before my lay-off scheduled for September 2010.

physical therapist detects a weakness in my hips, particularly medical glutes. my femur is also 22", and my height is 66". i am working on strengthening my hips, spending at least 30 min a day on prescribed corrective exercises.

i have a patellar tilt, which is taped with leukotape prior to anything like spinning or running. without the taping, running, stair climbing, ellipticals, and even biking is out of the question.

symptoms are retropatellar and peripatellar pain, with crepitus. i am so frustrated and wondering if there’s anyone else out there who would like to share their own experiences with this condition. i foam roll and stretch after EVERY workout. i was running in older running shoes, def due for a change (tsk tsk, naughty naughty me!).

when not running or engaging in high impact activities, i was wearing Vibrams Sprint to walk around in, lift weights, sit around in, do yoga, etc. in the past three years of activity and cross-training, WHY NOW?!! WHY ME?!

2

well of the opinions that might come back that have more direct experience - if it is a strength thing - two things come to mind

  1. shoes may just be ONE factor in this picture, and unless there’s a reason not to do so i’d encourage you to ask if your shoes pass the twist test?
    begin to dig: Do your Shoes Pass the Twist Test? How to tell if your Shoes are Good for you (not just your feet)

and otherwise FREE YOUR FEET
http://nopain2.org/geekfit/2008/09/kick_your_shoes_off_free_your.html

  1. you might want to work with a coach who also is experienced/certified on doing movement assessments and can help look at your joint work. I’m not a big stretch/foam roller fan as that tends to be a “site of pain = source of pain” response, and when it’s not so, it’s not so.

hope that helps a bit.

mc

3

I can share my experience, but I doubt I’ll be of much actual help… I had PFPS about a year ago. My problem was “opposite” to yours, since my doctor had me strengthen my Vastus Medialis instead of my glutes. In addition, I threw out the cushy shoes and tried to eliminate any side slope from my running path. I’m totally pain-free now.

How’s your running technique? If you’ve been running in nasty shoes, you could have some fundamental technique issues. If you’ve never given technique more than a passing thought, I’m sure we could help you onto the right track.

4

@ hastalles: i’m glad to hear you don’t have any further issues. i’ve been strengthening my VM as well through weighted straight leg lifts. my running technique could probably use some work. half-jokingly, people have told me that i “run funny”.

i’m not quite sure what that means, but i think i have a tendency to “crouch” when i run, which could exacerbate my lordosis and tilt my pelvis further. the PT says that i am a pronator when i run, but this is not necessarily due to my stride, but could be an indicator that the glutes (esp. medial glutes) are at cause for allowing the femur to internally rotate, which thereby upsets the lower leg, ankle, and foot.

an orthopedic MD seems to think that i am not a pronator, but he examined me standing (as opposed to running or walking).
at this point, the pain seems to be lessening. but i am still not ready to run. the bike is becoming easier, especially when i adjust the seat to the correct height. thanks for your input :slight_smile:

@ mc: thank you for the links :slight_smile: i used to wear the Vibrams five fingers (from Jan 2010 until April 2010), and the MD who initially diagnosed me had never heard of them (RED FLAG!!!) the orthopedic MD seems to think the Vibrams have nothing to do with my pain (and that they were mostly likely not a contributing factor), and although he seemed to be an advocate for them, he also indicated that it’s too early to make a conclusion about the safety of those “freed” shoes.

i respect his medical opinion, as he was very thorough and sympathetic to the fears my injury engenders. in the meantime, i’ve discontinued use of the Vibrams, with the exception of Yoga practice. I think the problem is in my hips, as the PT and orthopedic MD seem to agree upon. i just hope this doesn’t become a chronic, disabling condition. what an eye-opener this experience has been!!!

5

Thanks for coming back dbv
may i ask what are the “corrective exercises” you’ve been prescribed to do?

pain sucks.

best with your practice

mc

6

Death by Violet,

Some questions, because I have seen this shit before. Good to see you strengtening your VMO, but I would HIGHLY recommend working on stretching your Ilio-Tbial Band and Tensor Fascia Lata (TFL), they are located on the outside of your leg and run all the down the length of the leg, to below the knee. Your TFL crosses 2 joints (your hip and knee), so you need to find a good stretch that addresses this, if you need help with this, holla at me.

Crouching when running is not an ideal running position, if anything you should be more upright, where your shoulders rest under your knees, and DO NOT HEEL STRIKE !!! Running is not fast walking, trust me, I am a big fucker who can hoof it around a track or on a field.

If you make efforts at foam rolling your calves, use a tennis ball on your arches (I learned this from CBear), many of your posture issues will correct themselves. Our bodies develop habits, unfortunately some of habits are bad.

7

I have been really focusing on doing negatives in the following

Lunge
Leg Press
Squat

and that has really helped mine alot, in fact I feel better the next day after doing them then I did by trying to just rest it.

8

[quote]MaximusB wrote:
Death by Violet,

Some questions, because I have seen this shit before. Good to see you strengtening your VMO, but I would HIGHLY recommend working on stretching your Ilio-Tbial Band and Tensor Fascia Lata (TFL), they are located on the outside of your leg and run all the down the length of the leg, to below the knee. Your TFL crosses 2 joints (your hip and knee), so you need to find a good stretch that addresses this, if you need help with this, holla at me.

[/quote]

for a slightly different perspective, if we go up the chain to the nervous system we might ask “why are we getting tight TFL’s”? - if that indeed is the case here or anywhere?

(overview of what tfl does: Tensor fasciae latae muscle - Wikipedia)

If we get that the nervous system governs what our body does, and that it’s very good at looking out for our survival, there may be something more systemic happening in our bodies that is saying, nope, don’t want to let that TFL go because of this other thing not being ok, and if you do let that go, you might just hurt yourself more"

SO, if we back up from the site as the source of the issue (the TFL is tight, therefore stretch the TFL), what can we do?

In practice, what i see a lot is actually that people’s feet are so restricted and weak in terms of mobility that no wonder these muscles are putting on the breaks. By doing mobility with the feet - or wherever the issues show up - suddenly AH stretch.

for instance, there’s a strong correlation between cuboid/calcaneus joint and hamstrings. Work this with say an outside toe pull and voila - better movement sans stretching in about the time it takes to move the joint.

After all, the goal is less about stretching something out, than having a muscle be able to tense and relax on cue.

[quote]
If you make efforts at foam rolling your calves, use a tennis ball on your arches (I learned this from CBear), many of your posture issues will correct themselves. Our bodies develop habits, unfortunately some of habits are bad. [/quote]

as above on foam rolling. a bit more grist for the mill: http://extremehumanperformance.com/blog/foam-roller-exercises-just-say-no/

Likewise FR has a further disadvantage neurologically in terms of repatterning those “bad habits” of being manual rather than active.

it can be great as a little skin stim to bring awareness to an area - if it needs it - but as a therapy - again, it’s treating site of pain as the source of pain, and that has a history of not being an optimal path. Sorta like keep adding oil to a car cause the gage says “low” rather than figuring out why the heck it’s leaking in the first place and dealing with that.

just another perspective.

mc

9

I have all kinds of patellofemoral issues. After seeing six physical therapists before settling on a chiropractor/manual therapist with a lifting/sports background, I’ve learned a few things:

  1. Distance running sucks for anyone with a high center of gravity. Hill sprints win.

  2. Single-leg work is your friend. Heavy split squats, reverse lunges, etc. - just get your technique right and make sure that your hips are loose and your glutes are activating.

  3. Trap bar deadlifts > squats if you have knee/center of gravity issues.

  4. You can never go wrong with conventional deadlifts and posterior chain work.

  5. Foam roll and stretch hips/IT band and magic happens.

10

MC,

That is some awesome input you gave, and I like talking shop with people who know their shit. Very much appreciated. I agree that ankle weakness could be the culprit of many issues seen, which is why I am trying to work into barefoot jogging on the grass. From college football, I fractured my left ankle, and dislocated my right ankle, just imagine the shit I am dealing with. My right foot is constantly supinated, and while I try to work some of the lateral calf, it’s like the malleolus is just fucked since it happened.

I would also love to lift barefoot, but my gym will not allow that.

11

[quote]MaximusB wrote:
MC,

That is some awesome input you gave, and I like talking shop with people who know their shit. Very much appreciated. I agree that ankle weakness could be the culprit of many issues seen, which is why I am trying to work into barefoot jogging on the grass. From college football, I fractured my left ankle, and dislocated my right ankle, just imagine the shit I am dealing with. My right foot is constantly supinated, and while I try to work some of the lateral calf, it’s like the malleolus is just fucked since it happened.

I would also love to lift barefoot, but my gym will not allow that.[/quote]

thank you. that’s very kind feedback.
so sorry to hear about the ankle.
you may find vff classics a nice approximation to bare feet for lifting.

mc

111

12

Wow, everyone! Thanks for all the great input! I will try to address all suggestions in this single message…

As per the physical therapist, I’ve been doing a lot of external rotation, single legged squats through a small range of motion, and straight lifts. It’s a lot of hip work. Abductors, medial glutes, gluteus minimus, adductors, hamstrings, etc. I’ve always always ALWAYS foam rolled after exercise, whether it be cardio or strength work. I’ve looked into trigger point therapy, too… I think I may have some serious “knots”, especially in my quads. Massage therapy starts tomorrow, but is rather expensive so I’ve been trying to self-massage using a lacrosse ball and arnica oil.

This past Monday I went for a second opinion to see an Orthopedic Physician, and he says I am not a pronator statically, but I def pronate as I walk.
This past Wednesday my PT referred me to her husband (also a PT, but more experienced in dealing with college-level athletes)… he performed a “muscular functionality test” (name right?). AWESOME diagnostic tool! He concludes that my strength and flexibility is up to par (actually VERY good for a female), but the weakness is in my CORE and my LORDOTIC TENDENCY.

I’ve always known I had what Janda would call “lower crossed syndrome”, but I didn’t realize that the tilt of my pelvis was preventing me from attaining optimal gluteal contraction. Since beginning the PT exercises, I’ve had to “re-learn” how to squat—emphasizing the need to “tuck my tail bone under” in order to straighten my back and align my pelvis. Little did I know I was “sticking my butt out” — thereby exacerbating my lordosis.

As this new PT indicated, even as I perform a simple bridge (hip extension), my hamstrings and glutes don’t function the way they should until I contract my lower belly and tilt that pelvis. Whether or not this is the DIRECT cause of my knee pain, it certainly couldn’t hurt to fix for the sake of my back health (if nothing else!). I am going to continue to work with this new PT in an effort to correct any musculoskeletal imbalances. As mentioned, I want to treat the CAUSE of the pain, not the EFFECT.

I will check out all those links from MC, thanks. No feedback to provide about those yet…

13

[quote]MaximusB wrote:
Death by Violet,

Some questions, because I have seen this shit before. Good to see you strengtening your VMO, but I would HIGHLY recommend working on stretching your Ilio-Tbial Band and Tensor Fascia Lata (TFL), they are located on the outside of your leg and run all the down the length of the leg, to below the knee. Your TFL crosses 2 joints (your hip and knee), so you need to find a good stretch that addresses this, if you need help with this, holla at me.

Crouching when running is not an ideal running position, if anything you should be more upright, where your shoulders rest under your knees, and DO NOT HEEL STRIKE !!! Running is not fast walking, trust me, I am a big fucker who can hoof it around a track or on a field.

If you make efforts at foam rolling your calves, use a tennis ball on your arches (I learned this from CBear), many of your posture issues will correct themselves. Our bodies develop habits, unfortunately some of habits are bad. [/quote]

i’ve been trying to google some running techniques, but everything i’ve found is geared towards “the beginner”. i’d love to video-tape myself running to see what a mess i am! today i experimented with running a lap or two around a track, and i think i’m heel striking. a friend watching me said (half-jokingly), “looking at you, i don’t know how you get your body to move forward. it’s like you TROT when you run. there’s no follow-through”.

oh and btw, my TFL doesn’t feel tight when i foam roll it. but my quads always are. my hip flexors have already been evaluated by professionals and found to be tight. i’ve been told to do the following hip flexor exercise (see pic)

if MC (or anyone else!) is reading this, maybe she’s come across something about running gait. this is great to have a thread going—i hope others are reading this and getting some help, too!

14

Thanks for coming back on this,

hmm. maybe.
guess what? as a runner in particular - an immobile tarsal in the foot will shut down your glutes and ham strings and quads and illio psoas faster and harder than just about anything else.

What can immobilize those bones? sneakers laced up too tight. That’s just one. What can fix it? learning some drills to mobilize those bones in your feet. It’s related to the anrthrokinetic reflex.

what you may want to consider is that the site of the issue is not the source of the issue. as above with the feet being the way to get the muscles to fire again, do that and the hip won’t have to compensate for locked up feet.

And in the squat, where are you “tucking the tail?” that’s kinda not what you want to do ever at all anywhere throught the squat - and when people do this - especially at the bottom of a squat -they have gone too too far.

in a way that you do how often in real life?

Well sure.
Here’s the thing about a neurological approach rather than muscular.
Muscles take awhile to rebuild. And i bet those muscles are pretty strong.

The nervous system on the other hand moves mechanorecption at about 300mph. Deal with what’s causing the nervous system to send signals to shut down performance, and you get performnace/out of pain benefits pretty much at that speed.

THen if you want to work with someone for more weeks, it’s to train to be better.

how do you do this? work with someone who does neuromuscular re-education and rehab
if you’re interested, let me know what city you’re in and i’d be happy to recommend someone.

just food for thought.
best
mc

ps on the running technique,
here’s a review of the complete athlete. once you’re out of pain and moving nicely again, this will get you moving faster, stronger, better. really.

15

my Vibrams hurt my knees when i wear them. since the knee pain, the Vibrams make it worse. walking barefoot is slightly better, but also painful in comparison to the cushioned support of sneakers and/or shoes (even Chuck Taylors are okay).
interestingly, there are two spots in my right foot/ankle that hurt lately. pain began after the knee problem, and it comes and goes in both locations. i figured it was a result of the knee pain (compensation or something?). but maybe it’s the cause… ? one spot is on the medial side of the talus. the other site of come-and-go pain is at the joint where the phalange meets the metatarsal on my second toe (next to the big toe). again, all of this occurs on the right foot only, and while the knee pain is on both legs, it’s far worse on right knee. can’t help but feel this is more than a coincidence…

(side note: able to do the elliptical and upright bike if the seat is positioned correctly. still no running. 25 jumping jack on saturday awokened the peripatellar pain!)

when i say “tucking the tailbone under”, i’m not performing what could be interpretted as a “butt wink”—or what is common seen if a squatter with poor flexibility attempts to go ass to grass. previously, i was hinging at T12 - L1 junction… in sticking my butt out, my pelivs was tilted anteriorly, immobilizing my glutes and rendering them useless. with “tucking my tail bone under”, i’m actually just using my glutes and abs (and less lower back) the way they should be used throughout the motion. i hope i’m explaining this well enough…

good point, but i’m afraid your knowledge of fitness is on a level in which i am having great difficulting comprehending. there is SOO MUCH INFORMATION out there, and i guess what i’m doing is better than being a cough potato with metabolic syndrome. i don’t necessarily need to be an elite athlete, but i do want to maintain wellness through physical activity.

i’ve tried to google Dr. Eric Cobb’s Dynamic Joint Mobility drills, but can’t get a clear understanding of anything. i’m finding a lot of interviews about and introductions to the training, but no drills, examples, or demos that i could practice at home.
i am very much intrigued by the involvement of the nervous system, but again, there’s a lot of information out there that surpasses my level of understanding. is there an experienced professional in Maine?

thanks, mc :slight_smile:

16

[quote]DEATHbyViOLET wrote:

i’ve tried to google Dr. Eric Cobb’s Dynamic Joint Mobility drills, but can’t get a clear understanding of anything. i’m finding a lot of interviews about and introductions to the training, but no drills, examples, or demos that i could practice at home.
i am very much intrigued by the involvement of the nervous system, but again, there’s a lot of information out there that surpasses my level of understanding. is there an experienced professional in Maine?

thanks, mc :)[/quote]

no their aren’t a lot of drills online at all. there’s one TMUSCLE example though, here, mid page

also, if you’d like to take a gamble on the recommendation of a stranger
a fast way to get into djm with z is something called the quickstart -
it’s 6 drills that have been tested to have the biggest fastest bang for the buck when done precisely - and the “how to” is very good.
http://edge.affiliateshop.com/public/AIDLink?AID=91587&BID=13445
(full disclosure - i get 3.50 USD if you use this link to get the disk, so you don’t have to; you can use this one: http://www.zhealth.net/store/products/quick-start.html

As for Maine, not at the moment, but there is a great guy in Montreal - and a bunch i know in new york and MA and even Connecticut. PM me if any of those locations suit. and of course if you’re travelling to other states, might be able to help there, too.

best
mc

17

Sorry it has taken me so long to comment. Thanks for the link, MC. I have not purchased the information yet, but I’m very thankful for the suggestion and I may end up doing it if all else fails. I’m trying not to spend any more money than I already have to.

The problem with this condition is the lack of consensus. A podiatrist thinks it’s the Q angle and that orthotics are necessary, while a neurologist would want to call it a neuroma, a chiropractor thinks it’s a subluxation in my lumbar spine, and a massage therapist thinks I need myofascial release.

I followed up with the orthopedist, and he thinks I don’t know the difference between discomfort and pain. What a jackass… and he wouldn’t order an MRI to rule out other possibilities. Sooooooo, I don’t know it I have patellar tendinitis, bursitis, plica syndrome, synovitis, chondromalacia, or none of the above!

All I know is that I can’t WALK a quarter mile without feeling retropatellar irritation and/or sensation at the patello-tibial and/or patello-femoral locations.

The PT had me doing single-leggeed squats in a limited ROM, and those were obnoxious so I modified by incorporating static wall sits (another exercise we did) in place of the dynamic quad-hip work. I can’t even do the static stuff anymore without “awakening” the knees. Still the medial glute stuff and external rotation, but it would only make sense that all that stuff is contributing the IT / TFL tightness… ??? Also, I’ve been stretching quads, hams, calves, adductors, IT band, and hip flexors two-six times a day. Using PVC pipe for rolling daily.

I am currently beginning my 13th week of physical therapy, and I have stopped seeing improvement over 6 weeks ago. To me, that means one of two things: either the diagnosis is wrong or the therapy is wrong.

18

Yup can relate to the feeling of everyone giving you everything under the sun. And you know what? they all could have a piece of the issue.

The Q angle may be wonky.

You may well have a tilt in your spine as well

you may have some inflammation (some kind of itis, somewhere)

Likewise, orthotics could be 1 way to help get you out of pain - if you have pain - that will allow you to pursue other treatments. And while doing workouts is grand to get your muscles stronger, if you’re noticing no change, that’s as you point out, no change.

the main thing about the neurological movement model is that it doesn’t treat the site of pain as the source of pain (eg: your q angle is weird so lets fix that)

It goes higher up and asks the question WHY is this happening? usually performance shut down happens when there’s a perceived threat, and pain is a signal to change to reduce threat - so what needs to change for your nervous system to feel safe again? An awful lot of the time addressing quality of movement - not necessarily at the site of pain - lets that happen.

Now me, here’s what i’d do, or what folks trained the same as me would do: see how you move; based on that, show you some drills that you do yourself; retest these immediately to see if they’re working (in your case is the pain experience decreasing); if they’re not keep going till we find something that does. The ability to test everything immediately and to have a big toolbox of things to investigate seems to help.

One of the first things i’d likely suggest is stop all the stretching and rolling: if there’s inflammation, that’s not going to help. Imagine this: imagine a big puffy bruise on your skin: would you squish that with a tennis ball to make it better? Same thing. Wrong model.

Now for going about this on the cheap to restore your faith in your body’s ability to fix itself with some coaching of where to focus:

Did you try the foot drills from tmuscle linked above? Do them first and THEN

One other thing:
as a bench mark, before doing any drills, touch your toes keeping your legs straight - go as far as you can. Now, do the foot drills, then,
get on a step where your leg can hang lose and unimpeded. stand straight and keep your pelvis immobile. Swing your STRAIGHT leg back and forth, just so you can feel the hip joint (the top of the femur connect into the pelvis - close to your jean’s zipper)

Then when you have the feel of that, make cirles without moving your pelvis so that your leg comes to the front the side and the back (don’t lean forward)

do a few of those one direction then the other, then do same thing other side. keep the pelvis immobile level no torquing.

then try to touch your toes - see if there’s improvement for your knee. don’t go looking for the pain, just see how you feel.

let us know how that goes.
mc

19

[quote]-mc- wrote:
The Q angle may be wonky.

You may well have a tilt in your spine as well

you may have some inflammation (some kind of itis, somewhere)

the main thing about the neurological movement model is that it doesn’t treat the site of pain as the source of pain (eg: your q angle is weird so lets fix that)

It goes higher up and asks the question WHY is this happening? usually performance shut down happens when there’s a perceived threat, and pain is a signal to change to reduce threat - so what needs to change for your nervous system to feel safe again? An awful lot of the time addressing quality of movement - not necessarily at the site of pain - lets that happen.

[/quote]

if there’s a difference between a static and dynamic q angle (i could be making this up), i should note that i am not a “pear” shape, and my hips are what i would call narrow. for instance, waist measurement was 28", navel at 36", and hips at 39". however, i think i recall reading somewhere that a q-angle (as a risk factor) can be found in some people as they run or with dynamic movement.

a tilt in my spine? interesting you say this because T12 / L1 area feels awkward when i hyperextend in my back. no other neurological symptoms typical of disc problems, so i wonder if it’s just some muscle tightness or a subluxation of some kind. when i look up the nerves that leave that are of the spinal column, i see that they’re related to the iliopsoas. hmm… could this be a coincidence?

i have an appointment with yet another orthopedist. i’m going to scream for an MRI, just to rule out -itis possibilities and damage to the articular cartilage.

went for a .7 mile run yesterday… took me 7 minutes, as i’m VERY deconditioned!!! but the knees were okay (don’t know if this was a result of warmed tissue, but it didn’t really bother me so much… more of an issue for my cardiovascular system). i’ve also changed my running stride. i’m trying more forefoot/midfoot running, whereas my heel just ever so lightly kisses the pavement. i was DEFINITELY a HEEL-STRIKER!!! damn, i put so many miles on my body… the WRONG way! ;( strange, how isometric squats at 40-60 degrees are somewhat bothersome, but the running is not so much. this “syndrome” is so bizarre!

i’m going to test those drills tomorrow. will def keep you posted!

20

oh, and when i do foam roll or use PVC pipe, i can “awaken” the various “pulling” sensations around my knee, around the quad tendons and so on…

poor running form,

  • old sneakers,
  • lordosis
  • strength training
    = one very BIG MISTAKE… my knees took the grunt on this one!