I had the pleasure of spending a day with Claire Robertson the Consultant Physiotherapist at Wimbledon Clinics yesterday focusing on Patellofemoral Pain, the potential causes and rehabilitation.  You can read Claire’s biography here but it is safe to say she knows her stuff leading and releasing ground breaking research in this area.  This leads me to today’s blog, what do you do if you are suffering from knee pain, the MRI is clear but your pain is very real?

This is often where we as Sports Therapists and Massage Therapists find ourselves.  MRI comes back clear and the client may have been recommended physiotherapy, massage or rehabilitation.Many people are confused if the MRI comes back clear but what does this actually mean?  It indicates that your knee is structurally sound, but we must remember that your knee is surrounded by muscles, tendons, fat pads and ligaments that if loaded incorrectly can create excess pressure around the knee and patella and may be the cause of your pain.  Finding the cause of your personal issue will be the deciding factor in identifying how to move forward and to get you to a pain free place once more.

Assessment

Number one for me is ‘Listen to your client!’.  Given the sheer volume of tests that can be performed how do you narrow these down in your first assessment to hone in on the specifics and increase the likelihood of identifying the cause of the problem as soon as possible?  Here, subjective assessment is critical.  It is not enough to know if the pain is sharp or acute, at the front or at the back.  We need to get into detective mode and get as many clues as possible in solving this complex problem:

  • ‘Is the knee fine when active, but when you sit for a long time like at the theatre the pain builds?’
    • Clearly there is no firing or strength issue, but the knee is in flexion so lets start thinking about what the problem could me including muscular tension, fat pad irritation or sitting posture.
  • ‘Is the pain only present when walking uphill?’ (My own personal problem when pushing my golf cart uphill!)
    • Walking uphill increases the range of dorsi flexion required in the ankle so could there be some calf tension involve?  Or are the glutes perhaps lacking the strength to carry the legs through the motion causing the knee to flex and the pressure to build?
  • One of the most common – ‘ Is the pain when walking up the stairs or down?’
    • Walking up, that one legged action requires hip stability so check for gluteal control and VM strength to control the knee position through the motion.
    • Coming down – which leg?  Back leg needs flexion so again is there muscular tension in the quadriceps

Shoes, Standing, Picking things up….. the list goes on, but I hope you see where we are going with this?  Understand the movements, understand what is required mechanically to execute these movements and we see the clues appear that may just solve the problem.Next comes the objective assessment.  Based on the information provided we can identify what muscles we need to test, we need to test that they fire, that they have strength, endurance and stability.   We are also looking for mechanics from the feet up through the knee and into the hips.  How is the femur sitting in relation to the Tibia and Patella, how is the Patella sitting relative to the Femur and Tibia, the Tibia to the femur and so on.  We need to understand this when seated, standing, running, jumping, whatever it is that causes the pain.

Gathering this information will help us to create the treatment plan required to get our clients back on the road to recovery.  We can identify the muscles that require hands on treatment to release tension, to get fired up or stimulated.  Foot and hip mechanics have a significant bearing on the pressure and mechanics at the knee so don’t be surprised if working on your glutes is part of the solution to solving your knee pain.
Treatment & Homecare

Deep tissue massage, myofascial release, instrument assisted massage and active/passive stretching can all be used to help release tension and regulate pressure through the knee.  In addition some neuromuscular techniques can be leveraged to stimulate and fire up those muscles that are not firing and affecting our lower limb mechanics.  Finally, I find that taping can also help depending on the specifics we are working on.  There are three aspects to taping that I find useful:

  • Pain Relief
  • Proprioceptive Stimulus
  • Mechanical Correction

As taping can help continue what we are started in a treatment for an additional 3-5 days it helps to give your body a chance to start on the homecare needed to correct the problem longer term.  Although many people feel better following treatment, it can be short lived as if a mechanics or strength issue as at the root of the problem, the pain will reoccur until this is corrected.  To this end identifying the right stretches, exercises and frequencies are key.Do not give up if your MRI is clear, you do not need to live with pain and keep looking  for the solution that works for you.  Good luck!

References
Patellofemoral Pain Syndrome Uncovered – Claire Robertson, Wimbledon Clinics.

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