Author: Kate Durnin

By: Cody Gramlich, Physiotherapist

You really don’t realize how fortunate you are to be able to perform simple day-to-day tasks until something limits you from these tasks. This thought has likely crossed your mind if you have ever had knee pain while running to catch the bus, going up stairs at the office, or squatting to pick up your child. This hits close to home for me, as this was similar to what I was experiencing when  I developed knee pain two months prior to running my first half marathon. With proper activity modification and management of the injury, I was able to complete the half marathon as planned! In this blog, you will learn about the presentation and management of one of the most common types of knee pain, patellofemoral pain syndrome.

What is Patellofemoral Pain Syndrome?

Patellofemoral pain syndrome (aka runner’s knee) is an umbrella term for any long-standing knee pain behind your patella (kneecap) or around the patella. It has also been referred to in literature as runner’s knee or anterior knee pain. Runner’s knee is usually aggravated by any activities performed with your knee in a flexed position, usually while weight bearing. These activities include running, squatting, and stairs. However, your pain may also be aggravated by long periods of sitting. The common theme with all of these is that your knee is undergoing increased compressive forces in a flexed position^2,5.

The patellofemoral joint is where your patella (kneecap) articulates with your femur (thigh bone). As you can see in the image above, there are a lot of structures that contribute to the stability and control of the knee and patellofemoral joint. This includes bony structures, ligaments, and muscles. However, stability and control of your knee is also significantly affected by positioning and control of your hip and ankle. So, when you see a physiotherapist, they will likely be addressing any dysfunction at all three of these regions.

Many mechanisms have been proposed as contributing factors to runner’s knee:

• • • Patellar maltracking
    • Quadriceps weakness
    • Hip abductor or external rotator weakness
    • Foot pronation
    • Muscular imbalance causing dynamic knee valgus
    • Anatomical abnormalities
    • Overuse or overloading
    • Improper footwear

The literature tends to disagree or be inconclusive on the specific etiology of runner’s knee. Although, a common theme exists in that runner’s knee occurs as a result of biomechanical breakdowns at the hip, knee, and ankle. As a result, this causes a sensitivity in the patellofemoral region, but does not involve any conclusive structural damage.

Why is it Important to Understand Patellofemoral Pain Syndrome?

Patellofemoral Pain Syndrome is one of the most common knee pathologies, especially for those of you who are runners. It is estimated to have an incidence of 3-15% in active populations and a prevalence of up to 23% in the general population^3,4. In my personal caseload, I have treated this condition numerous times, both in adolescents and adults.

When breaking down the stress your knee undergoes when running, it is easy to see why patellofemoral pain is more common in an active population. It is suggested that during running, the ground pushes back on your foot with forces of around 2.5x your bodyweight¹. By the time this force is transmitted to the knee, the amount of compression by the quadriceps on the patellofemoral joint can be up to 4x your bodyweight¹. This doesn’t mean you shouldn’t be running! This just means that it is important to identify and prevent functional breakdowns in your lower extremity that may lead to injuries associated with the high loads required by running. A physiotherapist or rehab professional will be able to help identify your areas of weakness and work to ensure you can be successful in your sports and leisure activities.

The good news is exercise therapy has strong evidence to support improving short and long term pain in individuals with runner’s knee². Both strengthening exercises and running retraining have shown to have positive effects in terms of function³. One study suggested education on runner’s knee alone to be more effective than no management at all. The most effective intervention at a 3 month follow up was education combined with physical therapy⁶.

Taking a step further, recent literature suggests that a multimodal/individualized approach is necessary in treating runner’s knee, as there are many contributing factors to the onset of the pain in the first place^1,2. This should include education on taping and footwear.  This should include managing beliefs/expectations on recovery. This should also include education on load/capacity, exercise, and run re-training¹. A physiotherapist will be able to support you in most of these areas to give you an opportunity to get back to doing what you love.

Some Risk Factors for Developing Patellofemoral Pain Syndrome²

• • • Frequent activity such as running, squatting, and stairs
    • Overuse or sudden increase in physical activity level
    • Quadriceps weakness
    • Dynamic knee valgus (collapsing inwards)
    • Patellar (kneecap) instability
    • Foot abnormalities
    • More common in female sex

*There is a variability and inconsistency in research when it comes to risk factors for developing runner’s knee. Some studies even suggest these issues may be a consequence of patellofemoral pain syndrome, not a cause. This further indicates a need for thorough assessment and multimodal treatment of your knee pain.

How Do I Know If I Have Patellofemoral Pain Syndrome?

• • • Knee pain is usually non-traumatic or gradual onset (although you may have a  history of knee trauma/injury).
    • Pain on the anterior (front) of the knee or around the patella (kneecap).
    • You have high activity levels or a recent increase in activity levels.
    • Knee pain with activity such as running, squatting, or stairs.
    • Knee pain with prolonged periods of sitting while your knee is in a flexed/bent position.
    • Knee pain typically does not have associated swelling or locking.

3 Strategies to Help Manage Your Patellofemoral Pain Syndrome Symptoms

1. Activity Modification

*Patellofemoral pain syndrome often occurs as a result of an imbalance between your body’s capacity and the loads it is undergoing with activity. A period of activity modification is likely necessary to manage this imbalance. If you are a runner, try a 1 minute jog, 1 minute walk cycle to see if your pain is better managed.

2. Quadriceps Rolling

*Tight quadriceps can contribute to patellar maltracking related to patellofemoral pain syndrome. Alternatively, quadriceps tightness can come as a result of your knee pain. Rolling will help decrease the tension on the front of your knee when it is in a flexed position. Try 2-5 minutes, 1-2 times per day.

3. Hip Strengthening (Glute Bridge)

*Strengthening the hip girdle will help with biomechanical alignment during dynamic activity such as squatting and running. This will help to decrease your knee pain with activity. Try 3 sets of 10-15 repetitions. You can do this with or without a band around your knees.

FAQ

How long does patellofemoral pain syndrome take to heal?

Healing timelines vary for patellofemoral pain syndrome depending on factors such as your age, activity level, and general health. Pain can often be alleviated with rest and stretching. However, changing the biomechanical breakdowns that contributed to your knee pain takes more time and effort. It is recommended to see a healthcare professional for recommendations to help resolve and prevent your symptoms.

Do I need surgery for my patellofemoral pain syndrome?

Typically, surgery is not required for patellofemoral pain syndrome, as there is no specific structural damage that is causing your pain. If other signs and symptoms exist such as direct trauma to the knee or persistent patellar dislocations, a referral for surgical consultation may be indicated.

What can I not do with patellofemoral pain syndrome?

There are no specific activities that need to be completely avoided with patellofemoral pain syndrome. However, many activities such as squatting, running, and stairs may further aggravate your symptoms. A short term period of rest followed by a gradual increase to full activity is recommended during recovery from patellofemoral pain syndrome.

What Comes Next?

Remember, patellofemoral pain syndrome is knee pain that occurs beneath or around your kneecap. It is one of the most common knee issues, especially for those of you who are active or run a lot. This type of knee pain is typically multifactorial and usually requires individualized management, depending on your specific presentation.

Start by trying some of the strategies listed above and see how it goes! Afterwards, it would benefit you to see a Peak Health physiotherapist to guide you through treatment, depending on your response.

Feel free to reach out if you have any additional questions on runner’s knee or you can book an appointment online by clicking here.

References:

• • • Esculier, JF., Maggs, K., Maggs, E., Dubois, B. (2020). “A Contemporary Approach to Patellofemoral Pain in Runners”. Journal of Athletic Training. 55 (12): 1206–1214. https://doi.org/10.4085/1062-6050-0535.19
    • Gaitonde, D.Y., Ericksen, A., Robbins, R.C.; Dwight D. Eisenhower Army Medical Center, Fort Gordon, Georgia (2019). “Patellofemoral Pain Syndrome”. American Family Physician, 99 (2): 88-94, https://www.aafp.org/afp/2019/0115/p88.html?utm_medium=email&utm_source=transaction
    • Neal, B. S., Barton, C. J., Gallie, R., O’Halloran, P., & Morrissey, D. (2016). “Runners with patellofemoral pain have altered biomechanics which targeted interventions can modify: A systematic review and meta-analysis”. Gait & Posture, 45, 69–82. doi:10.1016/j.gaitpost.2015.11.018
    • Neal B.S., Lack S.D., Lankhorst N.E., et al (2019). “Risk factors for patellofemoral pain: a systematic review and meta-analysis” British Journal of Sports Medicine; 53: 270-281. https://bjsm.bmj.com/content/53/5/270
    • Physiopedia 2021. “Patellofemoral Pain Syndrome”. Physiopedia. Accessed March 3, 2021, https://www.physio-pedia.com/Patellofemoral_Pain_Syndrome
    • Winters M., Holden S., Lura C.B., et al. (2020). ”Comparative effectiveness of treatments for patellofemoral pain: a living systematic review with network meta-analysis” British Journal of Sports Medicine. doi:10.1136/ bjsports-2020-102819

Media References:

Knee Anatomy Picture:

• • • Comprehensive Orthopaedics, S.C. (2016). “Anatomy of the Knee”. Accessed March 3, 2021 via Google Image Search. https://comportho.com/anatomy/anatomy-of-the-knee/. [Original Source Unknown]

Load/Capacity Diagram:

• • • Esculier, JF., Maggs, K., Maggs, E., Dubois, B. (2020). “A Contemporary Approach to Patellofemoral Pain in Runners”. Journal of Athletic Training. 55 (12): 1206–1214. https://doi.org/10.4085/1062-6050-0535.19

By: Cody Gramlich, Physiotherapist

Shoulder pain can be a frustrating issue, as those of you who have experienced it know. You can’t ignore the ache throughout the day, you can’t reach to grab a plate from the cupboard, or you can’t roll over at night to sleep on your side. This is what one client was struggling with before choosing to start physiotherapy. With a better understanding of his issue and how to manage it, he was able to return to playing pickleball up to five times per week without shoulder pain! One common cause of shoulder pain is commonly referred to as subacromial impingement, or subacromial pain syndrome. In this blog, you will learn what subacromial pain syndrome is, why it is important to understand, and what you can do to manage it.

What is Subacromial Pain Syndrome?

You may have previously heard the term or been diagnosed with shoulder impingement. However, there has been movement away from the utilization of this diagnosis in recent years, for two main reasons:

• • Impingement only describes a compression mechanism of shoulder pain, whereas subacromial pain syndrome is NOT limited to only a compression of structures.
  • Shoulder impingement as a diagnosis can be further broken down into four categories on its own.

As a result, subacromial pain syndrome is the most up to date terminology used to describe pain that is located on the lateral aspect (outside) or anterior aspect (front) of your shoulder. This type of shoulder pain is non-traumatic and usually worsened with lifting your arm overhead.

Subacromial pain syndrome is an umbrella term that helps describe pain related to any structures in the subacromial space of the shoulder. Your subacromial space is the region located between the acromion of the scapula (bony prominence on the top of your shoulder) and the head of the humerus. This region is displayed in the image below.

Structures included in the subacromial space⁵:

• • Coracoacromial Arch, composed of the Acromion, Coracoid Process and Coracoacromial Ligaments
  • Humeral Head
  • Subacromial Bursa
  • Tendons of the Rotator Cuff; Supraspinatus, Infraspinatus, Teres Minor and Subscapularis
  • Tendon of the Long Head of Biceps Brachii
  • Coracoacromial ligament
  • G-H Joint Capsule

Since so many structures are located in this region, subacromial pain syndrome encompasses a variety of pathologies that may lead to shoulder pain. This includes conditions such as a shoulder bursitis, biceps tendinopathy, or a rotator cuff issue.

Why Is It Important to Understand Subacromial Pain Syndrome?

Shoulder pain is common and can result in significant loss of function or participation in your day-to-day activities. It is suggested that up to 67% of community dwelling individuals may experience shoulder pain¹. 44-65% of all reports of shoulder pain are thought to involve symptoms arising from the subacromial space¹. Subacromial pain syndrome is a prevalent issue, so it is important to understand how to prevent and manage it.

Since subacromial pain syndrome is a generic term that encompasses many structures or more specific diagnoses, it is important that you consult a professional to determine which structures may be most affected. Your treatment can be individualized to your specific presentation. This will lead to optimal outcomes, and help you reach your personal goals.

Regardless of the specific pathology or cause of your subacromial pain syndrome, it has been indicated in many studies that physiotherapy can help. One systematic review made a strong recommendation for exercise therapy as the first-line treatment in subacromial pain syndrome⁶. A strong recommendation to include manual therapy as an integrated treatment was also made⁶. Another systematic review even suggested exercise to be as effective as arthroscopic surgery for subacromial pain syndrome³.

Some Risk Factors for Developing Subacromial Pain Syndrome^2,5,6

• • Repetitive movements of the shoulder or hand/wrist during work.
  • Work that requires much or prolonged strength of the upper arms.
  • Hand-arm vibration (high vibration and/or prolonged exposure) at work.
  • Working with a poor ergonomic shoulder posture.
  • Altered shoulder kinematics associated with capsular tightness.
  • Rotator cuff and scapular muscle dysfunction.
  • Age (older).

How Do I Know If I Have Subacromial Pain Syndrome?

• • No injury or trauma to cause your shoulder pain (gradual onset)
  • Pain on the anterior (front) or lateral (outer) aspect of your shoulder.
  • Shoulder pain when lifting your arm or with your arm in overhead positions (work or sports with overhead positions).
  • Shoulder pain while lying on your affected side.
  • Shoulder pain when lifting or holding objects in front of your body.

*Remember that these are the most common symptoms that would indicate you may have subacromial pain syndrome. It may present with different signs/symptoms depending on the individual. If this sounds like you, reach out to a physiotherapist or another healthcare practitioner for a thorough assessment to determine the cause of your specific symptoms.

3 Strategies to Help Manage Your Subacromial Pain Syndrome Symptoms

You may have been struggling with shoulder pain recently and are looking for some guidance. As mentioned earlier, research has consistently shown the benefits of physiotherapy. It even suggests supervised exercise should be the first-line management in subacromial pain syndrome.

1) Postural Awareness

*Being aware of your posture will optimize the position of your shoulders and decrease irritation on structures in the subacromial space. Set a timer for every 30-60 minutes to remind yourself to think about your posture or change up your positioning.

2) Thoracic (Upper Back) Mobility

*Decreased upper back mobility or tension in the muscles of the chest can affect posture or shoulder positioning. The exercise above can help with these areas. Try the exercise with your hands across your chest if it is too uncomfortable to have your hands behind your head. Try 2-3 sets of 8-10 repetitions.

3) Rotator Cuff Strengthening

*Strengthening the rotator cuff muscles allows for better positioning and control of the shoulder with activity. This will help lead to decreased shoulder pain. Try 2-3 sets of 8-12 repetitions.

FAQ

How Long Does It Take Subacromial Pain Syndrome to Heal?

Healing timelines vary for subacromial pain syndrome depending on factors such as your age, activity level, and general health. Some of the strongest positive outcomes for subacromial pain syndrome have been shown with a combination manual therapy and supervised exercise program. It is recommended to see a healthcare professional to determine how you can optimize your healing timelines.

Do I Need Surgery for My Subacromial Pain Syndrome?

Conservative treatment and exercise therapy is the first line of treatment for subacromial pain syndrome. It is suggested that conservative treatment should be considered for up to a year and surgery be contemplated only after exhaustive conservative management⁵. A healthcare professional will be able to help rule out immediate need for surgery and recommend best treatment options for your subacromial pain syndrome.

What Is the Best Way to Sleep With Subacromial Pain Syndrome?

Typically, sleeping on the affected shoulder will be the most uncomfortable position. The ideal sleeping position will change from individual to individual. Sleeping on your back or sleeping on your unaffected side with the painful shoulder supported by a pillow will likely be the most comfortable positions.

What Comes Next?

Remember, subacromial pain syndrome is non-traumatic pain on the front or outside aspect of your shoulder and is typically worsened with lifting your arm overhead. It is thought to be the most common shoulder issue and can significantly affect your ability to participate in hobbies and work. This is why it is important to be able to identify the signs of subacromial pain syndrome and have a plan to treat and prevent the issue.

Start by trying some of the strategies listed above and see how it goes! Afterwards, it would benefit you to see a physiotherapist in Calgary to guide you through treatment depending on your response.

Feel free to reach out if you have any additional questions on shoulder pain or subacromial pain syndrome or you can book an appointment online by clicking here.

References:

• • Chaconas E.J., Kolber M.J., Hanney W.J., Daugherty M.L., Wilson S.H., Sheets C. “SHOULDER EXTERNAL ROTATOR ECCENTRIC TRAINING VERSUS GENERAL SHOULDER EXERCISE FOR SUBACROMIAL PAIN SYNDROME: A RANDOMIZED CONTROLLED TRIAL”. International Journal of Sports Physical Therapy. 12 (7): 1121-1133. (2017) doi:10.26603/ijspt20171121
  • Diercks, R., Bron, C., Dorrestijn, O., Meskers, C., Naber, R., de Ruiter, T., Willems, J., Winters, J., van der Woude, H. J. (2014). “Guideline for diagnosis and treatment of subacromial pain syndrome”. Acta Orthopaedica, 85 (3), 314–322. (2014) doi:10.3109/17453674.2014.920991
  • Haik, M.N., Alburquerque-Sendín, F., Moreira, R.F.C., Pires, E.D., and Camargo, P.R. “Effectiveness of physical therapy treatment of clearly defined subacromial pain: a systematic review of randomised controlled trials”. British Journal of Sports Medicine, 50(18), 1124–1134. (2016) doi:10.1136/bjsports-2015-095771
  • Hanratty, C.E., McVeigh, J.G., Kerr, D.P., Basford, J.R., Finch, M.B., Pendleton, A., and Sim, J. “The Effectiveness of Physiotherapy Exercises in Subacromial Impingement Syndrome: A Systematic Review and Meta-Analysis”. Seminars in Arthritis and Rheumatism, 42 (3), 297–316. (2012) doi:10.1016/j.semarthrit.2012.03.015
  • Physiopedia 2021. “Subacromial Pain Syndrome”. Physiopedia. Accessed February 15, 2021, https://physio-pedia.com/Subacromial_Pain_Syndrome?utm_source=physiopedia&utm_medium=search&utm_campaign=ongoing_internal
  • Pieters, L., Lewis, J., Kuppens, K., Jochems, J., Bruijstens, T., Joossens, L., Struyf, F. “An Update of Systematic Reviews Examining the Effectiveness of Conservative Physical Therapy Interventions for Subacromial Shoulder Pain” Journal of Orthopaedic & Sports Physical Therapy. Volume 50, Issue3, Pages 131-141. (February 2020). https://www.jospt.org/doi/10.2519/jospt.2020.8498

Media References:

Shoulder Anatomy Picture:

• • Fairview Health Services (2019). “Patient Education: The Shoulder Joint”. Accessed February 26, 2021 via Google Image Search. https://www.fairview.org/patient-education/85899. [Original Source Unknown]

Dr. Logan from Peak Health and Performance takes time in this video to show you some simple exercises that you can do to overcome foot pain while running. He will show you the technique that you need to do in order to make them effective, and He will talk about how often you need to do the exercises in order to get optimal results. Dr. Logan is a chiropractor at Peak Health that focuses on sports injuries as well as chronic injuries in the active population. If you suffer from foot pain while running or cycling, or just get foot pain in general, this video is for you!

Dr. Riley Sjodin of Peak health and Performance shows three ways to help strengthen and add capacity to your hamstrings so that you can run and partake in your summer activities pain-free and injury free. These three exercises are simple and easy to do and require very little equipment making them easy to do at home. If you have any questions regarding these exercises please do not hesitate to contact Dr. Riley at our clinic or seek the care or advice from any other member of our sports injury team.

Janelle Juss, PT, discusses the importance of doing the clamshell exercise properly. This exercise can be an excellent first step in knee and hip rehab to make sure there is ample glute activation to stabilize the lower limb. Keeping the hips still during the movement and not using momentum is key! Let us know if you have any questions or if you would like the next step in lower limb stability and rehabilitation.

Peak physiotherapist Alyssa talks about the importance of body mechanics of the lower body position while doing squats. She places importance of activation of the hip and knee position making sure you do this prime movement in a manner that is safe. Office workers can greatly benefit from doing 15 or 20 repetitions of this exercise while at the office as a mini break. If you have any questions about the mechanics of squad or other things that you can do at the office to relieve your lower back or postural pain please do not hesitate to call us at Peak Pealth and Performance.