We’ve all been there. In a group environment and the ageing athlete starts going on about ‘their knees’ and how the ageing process is catching up with them. As a young pup I remember looking speculatively on colleagues of mine when we were all coming into the morning classes and hearing them wax lyrical about the degrees of pain they were in and how the ‘old knees were acting up again in the stormy weather’. I would shake my head in disdain and mutter something like “well you should have got here earlier and done some warming up” or some such. Now as an ageing athlete myself I perhaps have a little more compassion for those 40 something year olds and if I had my time now, I would probably be a little more sympathetic - well…. maybe a ‘little more. I’d still probably expect them to do more than turn up 4min before class with a cigarette in one hand and a coffee in the other.
But knee pain is a horrible thing to endure. I have been on the receiving end of it and remember actually having to curtail a piece of choreography because my knee just wasn’t up to doing the single leg lunge at exceptionally slow pace after 60 shows on a long tour. Thankfully not all knee issues are the same and sometimes we can get ourselves out of trouble. At other times I am struck trying to convince an especially wonderful teammate that perhaps their days of being the star striker may be limited and that it is time to consider moving to another position on the field. Knowing exactly what type of knee pain is occuring in your joints can pinpoint how you can, if at all, address it and get a better idea of whether you are going to be on court, or trying on your cheerleaders outfit for the rest of the season - even if it is a shiny red with tassled pleats.
When we look at the knee the most prevailing information is the anatomy. The patella sits over the anterior femur and connects the femur to the tibia in the lower leg. It’s job is to increase the angle of the quadricep muscles so they are able to exert more force on the extension of the leg. Often it can be confusing when discussing the ‘tendons’ of the knee as there are two main deviations. The Quadriceps Tendon connects the superior (top) aspect of the knee to the femur and the Patellar Tendon connects the inferior (bottom) aspect of the knee to the tibia. These two tendons often get mixed up so it is important to be clear about which is which.
The other major anatomical factor to consider with the knee is that the patella (kneecap) ‘floats’ over the Femur and has a ‘groove’ (trochlear groove) in which it slides. It is this articulation that is most important for this article as any misalignment of the patella in this groove will result in anterior knee pain (Patellofemoral Syndrome). Deviation here can be a result of uneven muscular development, tightness in the strutures that act on the knee in the lateral aspect (Vastus Lateralis/Iliotibial Band) and the uneven strength in the quadriceps in general. A tight Lateral quad with a weak Vastus Medialis Obliqous for example will result in a misalignment of the knee articulation which will create a contact between cartilages, thus leading to knee pain.
Patellofemoral Syndrome (PFS) is a well known and well used term to describe the onset of anterior knee pain. It’s bandied about by many sports practitioners, coaches and athletes and is a common issue that prevents athletes from taking part in their sport and rendering any walking on an incline or up a flight of stairs a venture in patience, reconciliation and pain tolerance.
It’s a slow onset injury that most commonly occurs from overuse of the knee in flexion and movement, usually from jumping or explosive movements such as sprinting. Many footballers (across all codes) suffer from the condition as well as runners, track and field athletes, court sports, dancers, gymnasts and pretty much anyone involved in explosive movement through the legs.
A similar condition which was often used in conjunction with Patellofemoral Syndrome is Chondromalacia Patellae. For the distinction of this condition, the presence of wearing away of the articular cartilage of the femur and the patellar just be present. Articular Cartilage is determined by DNA and it is true that some people are born with more cartilage than others and so this can predispose some people to this condition over others. The gradual wearing of cartilage creates pain and irritation underneath the knee cap itself and this condition is perhaps more difficult to rectify due to the loss of integrity of the cartilage itself.
The two conditions are very synonymous and the presence of cartilage damage itself determines Chondromalacia over PFS. Only imaging can determine whether there is actual cartilage damage and distinguish one over the other. Generically, the presence of the anterior knee pain needs to be addressed and if PFS is the presenting symptom then rectifying the muscular imbalance in the quadriceps will yield results. For articular wear the prognosis is perhaps a little more dire and the expected perception of being pain free is not usually true. This is where many older athletes find themselves being told to give away high explosive sports and take up lawn bowls.
The other presenting injury that can be concurrent with PFS and Chondromalacia is Patella Tendinitis. This condition is an inflammation of the patellar tendon itself. Tears in this structure and associated inflammation can be a cause directly for jumpers, so those involved in sports like basketball, volleyball or those CrossFit bunnies doing their box jumps, this condition is one for you to concentrate on. The slow onset of this condition is one to watch out for and will usually come slowly during sport, then persists afterwards and then gradually becoming more ominous in both sport and resting. The other aspect of this injury is to look at the ankle and the ability of the ankle to dorsiflex. Restriction in this articulation can result in the patellar tendon being overloaded.
The differentiation for these conditions is sometimes able to be determined by the nature of the injury at the early stages. When pain is present going upstairs and loading the knee in extension, you would be looking at Patellar Tendinitis, whereas going downstairs loads the pressure on the patella itself and the pressure of the patella against the femur and would more likely indicate PFS. Patellar Tendinitis responds beautifully to palpation and massage and usually can be pain free within a short time frame.
However, there are factors that can contribute to the health of ageing knees and cartilage and whilst these conditions may not be able to stop the onset and eventual wearing out of old knees, they can help to give you a little more pain free playing time.
Ensuring length in the quadriceps is paramount. As the patella is a floating bone, you want to ensure that there is enough space in the kneecap to float and not be pushed into the joint space. So much of knee pain can often be alleviated with characteristic stretching of the quadriceps. Of course if Patellar Tendonitis is your condition, you have to be careful not to stretch the tendon when it is in trauma.
The other aspect to be aware of is that if you have true PFS, then addressing the muscular imbalances in the muscles around the knee is important. This can be addressing tension in the Iliotibial band, looking at the Tensor Fascia Latae muscle and the corresponding strength and ability of the Vastus Medialis Obliquous. The balancing act between these factors can often have an immediate effect on patellar alignment and help address the condition. Taping of the knee can sometimes also be a most effective way of managing the impact of misalignment. Using specific techniques to encourage the correct alignment of the patella can help to manage the injury especially when you are involved in playing sports.
Unfortunately for those suffering from Chondromalacia Patellae, the prognosis is a little more bitter. We can’t re-build cartilage and this wearing is unfortunately not warranted for surgical procedure. However there are more cases where increasing strength in the hip flexors (to reduce reliance on quadricep power) and increasing flexibility in the quadriceps themselves helps to reduce the irritation. This is however usually combined with a reduction in activity and a change in action that doesn’t involve the power moves of jumping or fast powerful acceleration through the extension of the knee. There has however been some positive feedback from people using allied health infusions of chilli oil and capsicum loaded balms to assist with cartilage issues. Although not scientifically proven, balms incorporating these aspects have been known to be beneficial in these fields and can help with easing pain from deteriorating cartilage.
So knee pain can be a tricky affair. Knowing what type of knee pain is important as the treatment protocols do differ for each one and understanding what the presenting issues are can help you to target exactly why you are getting the knee pain. This also determines what type of remedial activity you can indulge in and whether you can rebuild yourself back into your sports activity, or whether it is time to hang up the boots, pads, or runners. However as with all issues, knowing whether you can move it or lose it is best. And I say in this instance, keep exploring your options and being active in your recovery and hang on to those actions for as long as you can endure them.