I have posted on the perils of patello-femoral pain in the past on this blog.  Today, I will share how surgery to fix one knee problem may lead to a new problem.  For privacy reasons, I will refer to my client as player x. 

History: Player x is a 15 y/o healthy female soccer player who suffered a lateral menscus tear in the summer of 2009.  She had arthroscopic repair followed by a brief stint (4-6 weeks) of rehab.  Surgery went well, but she did not regain full extension in rehab (she has about 5 degrees of hyper extension naturally).

Prior to fall high school season, player x came to me for sport reconditioning.  She had obvious quad atrophy (particularly the VMO) and lacked speed and explosiveness.  She worked with me 1-2x/week for 4-6 weeks and made good progress but did note some mild persistent soreness in her knee.

She played the entire fall season without injury/limitation but continued to have the same mild persistent knee pain.  The first week she began club practice (fall high school season had ended), her club coach had the players do a lot of plyometrics.  The exercises did not seem hazardous, but player x immediately had a significant increase in knee pain.

Her mother contacted me and she recently came back in for an assessment.  Ironically enough, her single leg squat and single leg broad jump were within 90% of her uninvolved leg.  However, she had mild swelling, Quad atrophy (about a 1 1/2 inch deficit) and she had significant pain with lateral movement to the side of her involved knee and could not decelerate without pain.

Hmmm…..   So what is the issue here?  After carefully evaluating her and performing functional testing I was able to rule out quadriceps tendinitis.  Her pain occurs primarily at or beneath the superioir and lateral portion of the knee cap at 30-40 degrees of flexion when she is weight-bearing.

I am fairly confident she has patello-femoral joint irritation with excess compression along the lateral facet.  Why?

  1. Perhaps the slight extension deficit allowed her to run more on a slightly bent knee (more PF force)
  2. Weak VMO is overpowered by the vastus lateralis creating abnormal lateral translation of the patella
  3. Pain is worse with deceleration and eccentric strength exercise going past (greater quad pull and patellar compression occurs with these activities)
  4. Pain with lateral movement and change of direction suggest lack of proper medial stability and dynamic control of femoral internal rotation which would subject the kneecap to abnormal joint reaction forces especially laterally where her pain is felt
  5. No pin point tenderness consistent with soft tissue inflammation

The entire scenario has likely been perpetuated by the volume of training/running in soccer and was then exacerbated by the plyometrics.  She compensated and ignored the mild pain all fall, but the knee finally reached a breaking point with the plyos (keep in mind she did no plyos in the high school fall season).

I see patello-femoral pain all the time in female year-round soccer players.  What is the solution?  Stay tuned as I will share more details about patella balancing training and my corrective exercise program for player x in the next post.