Name this pain: 1 in 14 adolescents and 1 in 5 adults experience it at some point in time, it is common in active populations, and is often a result of overuse and/or load management (Rathleff et al. 2023). If you guessed patellofemoral pain (aka anterior knee pain), you’re correct! PFP is one of the most common conditions we see here at Made 2 Move; what is it and how do we approach it?
What is PFP?
Patellofemoral pain or PFP has a pretty nebulous definition no matter where you look. The non-descript nature of the condition lends itself to a wide range of definitions in the literature such as this one: “Pain around or behind the patella, which is aggravated by at least one activity that loads the patellofemoral joint during weight bearing on a flexed knee (e.g., squatting, stair ambulation, jogging/running, hopping/jumping)” (Rathleff et al. 2023).
PFP is typically non-traumatic (ie not the result of acute injury) knee pain that is localized to the anterior knee. Whether this knee pain is the aftermath of acute injury from sport, overuse injury from poor load management, or post-op knee pain as we start to reintroduce movements, we believe there is always a way to make movement tolerable. Our approach includes introducing load on the knee in a manageable range in order to build up the capacity in the structures surrounding the knee, as well as the athlete’s confidence in their knee (s).
Patellofemoral Joint Loading
A 2023 article delved into 35 movements common to knee rehab and other activities of daily living. Researchers looked at different exercises and their “loading peaks,” and found numbers ranging from 0.6x body weight during walking to 8.2x body weight during the single leg decline squat (aka squatting with the heels elevated)
Researchers also noted that most rehab exercises generated a moderate amount of PF joint loading. This is good! Our joints and tissues need load to adapt!
At Made 2 Move, we are big advocates for loading on a continuum throughout the rehab process. Let’s look at that single leg decline squat as an example. If a Crossfit athlete or runner comes in with a pretty aggravated knee, it wouldn’t make sense for to start with an exercise that loads the patellofemoral joint (i.e. the area that is super painful for them) with 8.2x their body weight. However, as rehab progresses, we may likely progress to exercises of this caliber.
Another example from the gym: Most people wouldn’t consider the push jerk to be a lower body exercise, considering that the the barbell is being pressed overhead. Thus, this is often an exercise an athlete will scale to when squatting, box jumping, or wall balls are aggravating on the knees. However, a 2013 article noted that exercises such as the push jerk, common to our olympic weightlifters and Crossfitters weekly programming, actually loads the PF joint up to 4.6x bodyweight (Cleather et al. 2013).
For our marathon runner? A single step during running puts 4x a person’s bodyweight through the PF joint. That means that if you were running a marathon in 4 hours and 20 minutes, that would equate to a “cumulative load beyond 80, 000 times the body weight,” (Esculier et al. 2020) during that single race (not including the weeks and months of training beforehand).
Now let’s be clear, our outlining of the amount of forces, load, and stress exeprienced at the PFJ is NOT us saying that these movements are bad, harmful, or dangerous to your body. In fact, quite the contrary. The cartilage (a protective structure surrounding our weightbearing joints) at the PFJ is some of the thickest in the body, and even more so in those who are active.
Methods to Modify Around Knee Pain…
Can we adjust overall load?
At Made 2 Move, many of our PTs do Crossfit too, so we know how satisfying it is to RX every workout. However, rehab often consists of scaling both during rehab sessions and at the gym, which can serve as a successful remedy for knee pain while we work on progressing back to RX. Scaling could look like adding an additional rest day, utilizing less weight (lowering intensity) or less reps (lowering volume), or switching from the barbell to the leg press or banded goblet squats.
Can we adjust depth?
The knee flexion angles that are aggravating differ from person to person with PFP so playing around with different squat depths is often a good solution. This could look like box squats! Or deadlifts until squatting becomes tolerable again! We are still able to load heavy with these 2 alternative movements but are doing so in a comfortable range.
Can we adjust step length?
With split squats and lunges, adjusting the step length to be wider (less knee translation over the toes) is going to naturally lessen the stress placed on the patellofemoral joint. This is a great way to modify when anterior knee pain is heightened the farther the knees travel over toes. While we can modify in the meantime, we will eventually progress back to this knee over toe pattern, as this is common and vital for movements both in the gym (squats) and in everyday life (stairs).
Can we adjust tempo?
Often times, PFP is velocity dependent, meaning that higher speeds (think jumping and running) aggravates the knee (s) further. Slowing down the tempo allows us to load the knee while not overloading the knee.
Our point is this: no matter what type of knee pain you come into Made 2 Move with, there is a way to modify the load to accommodate pain, while still loading enough to encourage adaptation. Over time, if your body is given the rest and appropriate stimuli, your capacity for load will increase and your subsequent ability to perform previously aggravating activities will also increase.
Knee pain got you down?
It is important to note that we can tweak the loading on the knee all we want, but if we aren’t
managing overall load well (ie- you are still doing too much, not recovering properly, or not fueling adequately), then you may just keep going in circles with the same stubborn knee pain.
Interested in working with a PT who won’t just tell you to stop doing the exercise that hurts you but rather will help you figure out why it’s happening and how to get back to doing these movements comfortably? Reach out to email@example.com today to set up an initial consultation!