Osteoarthritis (OA) of the knee and hip is a very common condition associated with aging and something we see quite a bit of at Central Performance. OA is a condition that involves changes to a joint and breakdown of the cartilage inside the joint, this can then also affect the bones and ligaments within the joint. Approximately 2.1 million Australians are affected by OA, with approximately 25% of Australians over the age of 45 affected.
It is becoming more widely recognised that exercise should be a front line treatment for osteoarthritis, particularly for the hip and knee. The Royal Australia College of General Practitioners (RACGP) put out new guidelines for the treatment of knee and hip OA in 2018. Within these guidelines for the treatment of knee and hip OA exercise and weight-loss were the only treatments that were strongly recommended. There was better evidence for exercise than there was for medications or surgery.
While changes to the joint associated with OA cannot be reversed, exercise can help to alleviate or manage the symptoms, improve your ability to perform activities of daily living, reduce disability and improve quality of life. Exercise physiologists, who are trained to prescribe exercise for the treatment of chronic conditions such as OA, are well skilled to develop and prescribe exercise programs for patients who are suffering from OA of the knee and hip.
An exercise physiology treatment program for OA will be personalised depending on the results of your physical assessment, your current functional ability, your confidence with exercise and your goals. A exercise physiology program for a client with knee and hip OA will generally program through three stages:
Your treatment will usually begin with exercises to increase strength of the muscles surrounding the knee and hip joints to help stabilise the joints and improve your symptoms. As your strength and pain improve your treatment will progress to increase range of motion at the hip and knee. The final step of your exercise physiology program is to progress again to full-body exercises that will have great carry over to day-to-day activities. The whole program will be guided by your symptoms and measured against your goals.
Patellofemoral pain syndrome (PFPS) is a condition typified by a vague, diffuse pain around the knee. It is often most noticeable during running and walking up and down stairs or hills and is a frustrating injury because it can severely limit a sufferer’s ability to partake in sports and activities they enjoy. While the pain usually isn’t associated with significant damage, the pain itself can be severely limiting. One of the first steps to getting back to activities pain-free is to reduce the aggravating activities to allow the pain to settle and to start a strength training program.
Traditionally it was thought that the most important muscles to help prevent and relieve PFPS were the VMO (one of the quadriceps muscles on the inside of the patella) and the gluteus medius (one the glute muscle on the outside of the hip). However, recent research shows that specific exercises for those muscles have no better outcomes than general exercises. Therefore, the goal of strength training for PFPS should be to have a comprehensive program to strengthen the whole lower body to not just rehab PFPS but improve performance and reduce the risk of other lower limb injuries.
Here is a sample of exercises we use for runners and other athletes recovering from PFPS:
A fantastic foundational exercise, split squats help develop strength in the quads, hamstrings and lateral (outside of the hip) glutes as well as develop balance in a split stance position. These place more emphasise on the quads and lateral hip muscles than the other exercises in the program.
Another fantastic foundational exercise, deadlifts are great for developing strength in the hamstring, glute max (the big, main glute muscle) and back muscles. Deadlifts particularly strengthen hip extension which is very important in running and athletic movements.
Surprisingly the calf muscles (gastrocnemius and soleus) are the muscles that receive the most load during running (6-8 x bodyweight), more than the quads (4-6 x bodyweight), hamstrings, glute medius (2.6-3.5 x bodyweight) or glute max (1.5-2.8 x bodyweight). Therefore, it is important to strengthen these muscles to improve their ability to cope with the loading they receive during running .
A great, simple exercise for the lateral core muscles which play an important role in helping keep the pelvis level during running.
These four exercises together provide a comprehensive strength program that strengthen almost all the muscle of the lower body. Together with a temporary reduction or modification to activity and exercise they can help get you back to what you want to do pain-free.
Patellofemoral Pain Syndrome (PFPS) is a common complaint we see here in the clinic. This usually presents as a gradual onset of pain in the front of the knee which is generally vague and difficult to pinpoint. This knee pain usually progressively worsens over time and can interfere with your daily activities and overall function. There can be a number of contributing factors to PFPS and therefore it needs a thorough examination to identify the important factors for each individual patient. Factors such as load management, range of motion, strength and control of the hip, knee, ankle and foot can all play a part in the development of PFPS. It is important then, that we identify the contributors and target these factors with an individualised rehabilitation program. Let’s take a look at these factors in some more depth:
Load Management: As with many injuries we see here at Central Performance, the main contributing factor tends to be a sudden increase in activity (running or loading) e.g. getting back to running after a break but trying to do the same distances you were running before you stopped. Although PFPS often affects runners, it can also occur from other repetitive activities such as stair climbing, hiking or hill running as well as excessive compressive activities such as squatting and kneeling. Key to the successful rehabilitation of PFPS is to manage your load in an appropriate and graded way.
Knee Strength and Lateral Tightness: Research shows that people suffering from PFPS tend to have a weakness in the quadriceps muscles. We also see that the structures (eg the ITB) on the outside of the knee and hip are tight and this affects the position of the patella, pulling it laterally and causing increased wear and tear on the cartilage of the knee due to this sub-optimal tracking.
Hip Strength and Control : A lack of hip strength or control, particularly in the gluteal (“glutes”) muscles to the side of your hips, can result in a rolling inwards of the knee during single leg activities (e.g. walking, running, steps etc). This inward rolling (“valgus collapse”) also pulls the patella outwards, which causes further wear and tear on the under surface of the patella itself and on the contact points of the femur.
Ankle and Foot Factors: Stiffness or restriction of the ankle can transfer excess load up the leg and place more stress through the knee. Similarly, if there is a lack of strength in the calf complex, then this can result in an increase in load through the knee joint in order to compensate. Foot posture has also been linked to PFPS, with those people having flat or “pronated” feet more likely to present with patellofemoral pain.
As you can see, managing Patellofemoral Pain Syndrome is as complex as it is to spell it! It requires a thorough assessment and an individualised rehabilitation program addressing the factors that are specific to you and your pain experience – there is no “one size fits all” treatment recipe. So if you are experiencing anterior knee pain our talented team of physio’s can help!
Sydney-siders love a good run! And with the Blackmores running festival coming up, beautiful scenery & awesome weather it’s easy to see why. So today we look at the most common type of knee pain that can affect runners as well as people playing many other sports that involve running and jumping.
The knee is the most common site for pain in runners, but it’s not just “runners” that are at risk. Many other sports that involve running &/or jumping have a relatively high risk of knee injuries. One very common cause of knee pain is Patellofemoral Pain Syndrome, which accounts for up to 40% of all knee problems in sports medicine centres. The pain is felt around or behind the kneecap & occurs when the kneecap (patella) does not align correctly into the groove on the end of the thigh bone (femur). It is common in young people, & affects more women than men.
Pain is either felt around the front part of the knee or along one or both sides of the kneecap. It can sometimes be hard to find a specific spot where the pain is felt the most, especially because sometimes it feels like it is hidden away behind the kneecap. Your knee may be making some grinding or clicking noises, & there may be some swelling.
Often there is no specific cause (eg a fall or twist) of patellofemoral pain. Sometimes you may be able to relate it back to an increase in running or jumping volume, or things like new shoes or more hill running. It often begins as a niggle then gradually gets worse if you continue to exercise on it, eventually stopping you doing your normal training. It usually settles temporarily if you stop exercising but keeps coming back when you return.
Patellofemoral pain is usually made worse with anything that increases the load within your knee, eg taking your weight in a bent-knee position. Examples of painful activities can include;
Some people also get pain from sitting in a bent-knee position for long periods of time, eg working at a desk or sitting in a movie theatre. This is because this position squashes the inflamed back surface the kneecap onto the end of the thigh bone, causing pain after a while.
The main cause of patellofemoral pain is when the kneecap doesn’t “track” properly in the femoral groove when we bend our knee. It can get pulled out to the side of the groove, meaning that it rubs on the wrong places & becomes inflamed. Excessive or rapid increases in loading, usually due to increasing training or running volumes too fast, are also common factors that contribute to patellofemoral pain.
Poor biomechanics (i.e. the way our body controls movement) is the major factor that contributes to incorrect tracking of the kneecap in the femoral groove. Common biomechanical problems include:
Females are more likely to develop patellofemoral pain than males (3:2). This is due to women having a bigger “Q Angle”, which is where the quads muscles have a more outwards pull on the kneecap because women’s hips tend to be wider than mens.
Assessing & correcting your biomechanics is a big part of getting your knee pain resolved. You need to release any tight muscles on your outer thigh & hip, usually by using a foam roller or spikey ball. You will also need to strengthen muscles that are not keeping your leg and knee in the right alignment. The usual problem is that your knee rolls inwards over your big toe too much, so strengthening your glutes muscles to correct this is critical. Making sure that your inner quads muscle (your VMO) is strong enough to balance your outer quads muscle (VL) is also important.
Your foot position also needs to be checked. The most common foot problem is over-pronation, where your inner arch collapses & rotates your shin and knee inwards too much. You will need to ensure that you have the right shoes for your foot type, eg if you are an over-pronator then pronation control shoes or orthotics are likely to help you. However as physio’s we always find that shoe type or orthotics alone are not the full solution – they are only one component. You must correct your other biomechanical factors like hip control as well.
Every day our friendly & experienced physio’s work with runners & athletes at all levels, from weekend warriors to national champions. We can help you with fast relief & get you back out there on the road, track, field or court. We specialise in finding & fixing the underlying cause of your problems so that once we’ve got you feeling good, you stay feeling good.