Treating Patellofemoral Pain Syndrome | What can work, what can make Patellofemoral Pain Syndrome worse

Danielle.Steilen.ProlotherapistDanielle R. Steilen-Matias, MMS, PA-C

If you are experiencing severe knee pain centered around the patella, your pain may be worse than the damage. This may be especially true in runners. Researchers and our own clinical experience and outcome studies at Caring Medical explain how comprehensive Prolotherapy may handle the problem of Patellofemoral Pain Syndrome.

The Patellofemoral Pain Syndrome patient experience

Leading university researchers in the United Kingdom and Denmark, working within the UK’s National Health Services at Derby, made some observations of the patient’s mindset in regard to his/her diagnosis of Patellofemoral Pain Syndrome.(1) These published 2018 findings are similar to what we see in patients here are Caring Medical and Rehabilitation Services. Something is going on beyond normal biomechanical problems. Here is the UK research:

  • Participants offered rich and detailed accounts of the impact and lived experience of Patellofemoral Pain Syndrome, including:
    • loss of physical and functional ability;
    • loss of self-identity;
    • pain-related confusion and
    • difficulty making sense of their pain;
      • pain-related fear, including fear-avoidance and ‘damage’ beliefs;
      • inappropriate coping strategies and fear of the future.

The researchers concluded: “The current consensus that best-evidence treatments consisting of hip and knee strengthening (physical therapy and exercise) may not be adequate to address the fears and beliefs identified in the current study.

Hip and knee strengthening (physical therapy and exercise) may not be adequate to heal the problem. Are they actually making it worse? Especially in women?

Doctors in the Netherlands writing in the medical journal Pain Medicine, (2) reviewed the theory that repeated stress and overloading on a knee with patellofemoral pain may sensitize nociceptors (nerve cell endings) to be even more sensitive to painful stimuli (hyperalgesia).

Let’s sidetrack for a moment. The person with patellofemoral pain may have gotten that way because of repeated overload, as in running. He/she may have embarked on an aggressive physical therapy campaign to get themselves back to running. Their symptoms got worse. See below on how this impacts women runners.

Here is the conclusion from this research: “Local and generalized pressure hyperalgesia, suggesting alterations in both peripheral and central pain processing (you feel pain more), were present in patients with patellofemoral pain, though females with patellofemoral pain were most likely to suffer from generalized hyperalgesia.” In women, the pain became more generalized and pain spread beyond the knee.

Patellofemoral Pain Syndrome

The Problem of Runner’s Knee – You feel more pain than the damage to the knee should be causing.

Runner’s knee got its name for an obvious and very unfortunate reason—it’s common among runners. The stress of running can cause irritation where the kneecap (patella) rests on the thighbone. Forty percent of all runners’ injuries are related to the knee area.

Runner’s knee is really an umbrella term used to refer to a number of medical conditions that cause patellofemoral pain around the front of the knee. These conditions include anterior knee pain syndrome, patellofemoral pain syndrome, and chondromalacia patella.

In a third 2018 study, doctors at the Erasmus University Medical Center in The Netherlands published findings that help understand patellofemoral pain syndrome impacting the whole body. Publishing in the journal Pain Medicine,(3) the Dutch team found knee and generalized (whole body) stress and overload hyperalgesia in these patients  suggesting the knee pain caused alterations in both peripheral (musculoskeletal nerves outside of the brain and spinal cord) and central pain (nerves in the central nervous system) processing.  What this all means is that continued stress on the knee accelerated pain sensitivity. You feel more pain than the damage to the knee should be causing.

These troubling findings were expanded on in research published in May 2017 in the British journal of sports medicine where the physiological component of Patellofemoral Pain Syndrome were examined:

Patellofemoral Pain Syndrome – Why women feel more pain

In April 2017,  Brazilian and English researchers combined to publish research in the Journal of science and medicine in sport suggesting a serious problem for female runners.

  • Women who had a lower pain threshold in their knee, found themselves with heightened pain throughout their body.
  • Additionally, this heightened pain, which is related to self-reported knee function, appears to be increased by greater running volumes.(5)

We touched on this briefly above, over training, physical therapy, continuance of running may make for more pain than the damage should be creating.

A combined research team from the University of Kentucky and the University of Iowa wrote in the Clinical Journal of Pain:

  • Little is understood of how pain processing is changed with Patellofemoral Pain Syndrome and how a patient can suffer from  hyperalgesia or hypoesthesia (a reduced sense of pain) and what type of alterations to natural knee movement can cause these changes.

In their study, the researchers looked at twenty females diagnosed with Patellofemoral Pain and 20 age-matched pain-free females participated in this study. What they found was the frontal plane knee angle (an unnatural knee alignment)  existed in the Patellofemoral Pain group which was not present in the control group.

  • This suggested that Patellofemoral Pain Syndrome is characterized by an increase in both localized and centralized pain sensitivity that is related to movement mechanics. Knee pain and knee instability caused greater and heightened pain.(6)

Patellofemoral Pain Syndrome treatment

Physiotherapist Jenny McConnell wrote in the medical journal Manual therapy:

“Although the management of Patellofemoral Pain has improved greatly, there is still a category of patient who tends to have recalcitrant symptoms, which are difficult to manage. The patient often bounces from practitioner to practitioner, physiotherapist as well as surgeon, for some relief of symptoms. However, often the underlying source of the pain is not well understood, so treatment can aggravate the symptoms.”(7)

In our opinion, knee stability is the key. Let’s look at the temporary benefits of wearing a knee braces and other treatment options.

Medical university researchers in Iran shared their observations on what a knee brace could do for patellofemoral pain symptoms. Writing in the European journal Gait Posture published by Oxford University, the researchers discovered that the most beneficial aspect of wearing a brace was during walking and that the brace helped coordinate muscle activity around the knee.(8) This theory was tested among 12 women aged 20-30 years with diagnosis of patellofemoral pain.

What is this study suggesting the knee brace provides stability so the muscles could function correctly. Of course knee braces are not long-term treatments for knee cap instability. Treatments that stabilize the knee by strengthening the ligaments and tendons are.

University researchers in Germany offered these observations in the Open access journal of sports medicine. One of the things to notice is that to treat patellofemoral pain is the need for a whole leg approach – from hip to knee – this is also the basis of our Comprehensive Prolotherapy treatment program.

Here is what the study says: The available evidence suggests that patients with patellofemoral pain symptoms are best managed with a tailored, multimodal, nonoperative treatment program that includes short-term pain relief with nonsteroidal anti-inflammatory drugs (NSAIDs), passive correction of patellar maltracking with medially directed tape or braces (holding the knee cap in place with tape and brace), correction of the dynamic valgus (the collapse of knee stability and proper alignment) with exercise programs that target the muscles of the lower extremity, hip, and trunk, and the use of foot orthoses in patients with additional foot abnormalities.(9)

So now that we have the idea that something holding your knee more stable would get your knee to work properly. Let’s explore more long-term and possibly curative treatments.


Comprehensive Prolotherapy for problems of knee instability

Comprehensive Prolotherapy used in some cases with Platelet Rich Plasma Therapy and Stem Cells works at the root of the problem, the ligament or soft tissue damage. A series of injections are placed at the tender and weakened areas of the affected structures of the knee. These injections contain a proliferant to stimulate the body to repair and heal by inducing a mild inflammatory reaction. The body heals by inflammation, and Prolotherapy stimulates this healing. The localized inflammation causes healing cells to arrive at the injured area and lay down new tissue, creating stronger ligaments and rebuilding soft tissue. As the ligaments tighten and the soft tissues heal, the knee structures function normally rather than subluxing and moving out of place. When the knee functions normally, the pain goes away.

If you have questions about Patellofemoral Pain Syndrome repair and treatment options, get help and information from Caring Medical

1 Smith BE, Moffatt F, Hendrick P, Bateman M, Rathleff MS, Selfe J, Smith TO, Logan P. The experience of living with patellofemoral pain—loss, confusion and fear-avoidance: a UK qualitative study. BMJ open. 2018 Jan 1;8(1):e018624. [Google Scholar]

2 van der Heijden RA, Rijndertse MM, Bierma-Zeinstra SM, van Middelkoop M. Lower Pressure Pain Thresholds in Patellofemoral Pain Patients, Especially in Female Patients: A Cross-Sectional Case-Control Study. Pain Medicine. 2017 Apr 6;19(1):184-92. [Google Scholar]

3 van der Heijden RA, Rijndertse MM, Bierma-Zeinstra SM, van Middelkoop M. Lower Pressure Pain Thresholds in Patellofemoral Pain Patients, Especially in Female Patients: A Cross-Sectional Case-Control Study. Pain Med. Epub 2017 Apr 6 Jan 2018 [Google Scholar]

4 Maclachlan LR, Collins NJ, Matthews MLG, Hodges PW, Vicenzino B. The psychological features of patellofemoral pain: a systematic review. Br J Sports Med. 2017 May;51(9):732-742. [Google Scholar]

5 Pazzinatto MF, de Oliveira Silva D, Pradela J, Coura MB, Barton C, de Azevedo FM. Local and widespread hyperalgesia in female runners with patellofemoral pain are influenced by running volume. J Sci Med Sport. 2017 Apr;20(4):362-367. [Google Scholar]

6 Noehren B, Shuping L, Jones A, Akers DA, Bush HM, Sluka KA. Somatosensory and Biomechanical Abnormalities in Females With Patellofemoral Pain. Clin J Pain. 2016 Oct;32(10):915-9. [Google Scholar]

7 McConnell J. Management of a difficult knee problem. Man Ther. 2012 Jun 27. [Google Scholar]

8 Sker FS, Anbarian M, Yazdani AH, Hesari P, Babaei-Ghazani A. Patellar bracing affects sEMG activity of leg and thigh muscles during stance phase in patellofemoral pain syndrome. Gait & Posture. 2017 Jun 29. [Google Scholar]

9 Petersen W, Rembitzki I, Liebau C. Patellofemoral pain in athletes. Open Access Journal of Sports Medicine. 2017;8:143. [Google Scholar]

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