As I was training for my first marathon about six weeks ago, I developed a case of patellofemoral pain. I went to a sports medicine doc who referred me to physical therapy where they suggested I switch down to the half marathon. After the race, my knee hurt when I tried to run but that was it. PT started a program of hamstring/calf stretching, quad strengthening, and hip strengthening. I stopped running completely and stuck with easy biking (painless) and swimming. Four weeks after starting that program, the pain is worse than ever and now flares up sitting at a desk, driving the car, or doing stairs. I was prepared for a slow recovery and return to running but it’s killing me that, after taking more time off running than I ever have, I now have more pain than when I started.
Last week the physical therapist switched things up and is now focusing more on the IT band - thinking that it being tight might be causing the patella to track laterally. A week later, no appreciable change. Has anyone else experienced PFPS getting worse with relative rest and strengthening? The PT’s plan seems in line with the forum’s consensus for treatment but it doesn’t seem to be working and may actually be making things worse.
Things on focusing on now: VMO/quad strengthening (terminal knee extensions, leg raises), abductor strengthening (bands), hamstring stretching, IT band stretching/foam rolling.
Good point. I’ve been giving it time because I understand that problems don’t go away overnight but the lack of progress is discouraging and concerning. For others that have had something that presented like PFPS - is giving it a month or so enough time to see some improvement? Is getting worse before it gets better normal?
ITB length has a very weak association with patella tracking. Studies just don’t show much of a correlation. Has anyone taken a closer look at this knee? Thorough physical exam (lots of special tests during evaluation), imaging, anything? Most PT’s and othopaedic docs should be able to diagnose most meniscal tears but not all as they tear in tricky manners sometimes. It sounds like your PT is following a script an ortho sent over and has reached the end of line here. Someone needs to take a step back and review this. No problems cycling and swimming so low loading exercise seems ok. Running equals pain. It sounds like weight training exercises cause some pain? Loading with stairs etc… Static flexed positions cause pain ie prolonged sitting. Sounds like it could be more than generic PF pain. Meniscal derangement, femoral condyle derangement etc…
If strength training was going to help I would expect to see at least some change within 6 weeks. Try as he or she may this might be something a PT isn’t going to fix.
The quad strengthening exercises you mentioned are both considered “open kinetic chain” exercises. AKA the foot is not attached to the floor. I would try switching to closed kinetic chain exercises, which would be quadriceps strengthening exercises that involve the foot planted on the floor. These are more functional and may do the trick. Most controlled clinical trials do not show significant difference in results between the two, but in your n=1 situation, it might not be a bad way to go right now since what seems like generally smart treatment for PFPS isn’t having the desired effect.
(possible exercises… leg press, squats, 1/2 squats, 1/4 squats, lunges, diagonal lunges, lunges to the side, etc…etc…etc…)
Did your PT evaluate how your body moves? Weaknesses that may make your body not move correctly?
I’m on my 4th PT in past year for knee issues and have seen very different methods of treating me. I had my knee scoped a year ago and I still have pain, swelling, can’t fully extend it, and quad strength is poor compared to other. It is extremely frustrating.
Keep looking for the answer. I’ve been to 3 orthos, a sports med specialist and a couple other specialists trying to figure out what’s wrong with no real diagnosis. I will have another MRI this week.
The sports medicine doc did x-rays to rule out stress fracture, tested range of motion, and applied pressure/torque in various ways that I can’t recall in detail. The PT prescription he wrote out said “evaluate and treat - crosstrain” (in my home state you can’t see a PT without a doctor’s referral). The PT did range of motion and strength tests. She indicated that I have tight hamstrings, tight IT band, and weak abductors.
Many weight training exercises seem to cause pain after the fact. Reverse step-ups and squats cause immediate pain. Thanks for the feedback everyone, it looks like the next step is finding a good sports medicine doc for a second opinion.
Did your PT evaluate how your body moves? Weaknesses that may make your body not move correctly?
I’m on my 4th PT in past year for knee issues and have seen very different methods of treating me. I had my knee scoped a year ago and I still have pain, swelling, can’t fully extend it, and quad strength is poor compared to other. It is extremely frustrating.
Keep looking for the answer. I’ve been to 3 orthos, a sports med specialist and a couple other specialists trying to figure out what’s wrong with no real diagnosis. I will have another MRI this week.
Good luck with your recovery! I’m suddenly not feeling so bad about my relatively short-lived problem. I hope they figure it out and get you back to full strength.
I feel your frustration. I was away from all running and most cycling for about 5 months this past winter, due to knee problems (both legs) that were never properly diagnosed. I was very frustrated indeed, and was worried that I might never be able to run properly again.
I initially felt soreness around the patellar tendon area, no clear evidence of tracking issues, nor the lateral pain that’s sometimes associated with ITBS. I attributed it to stepping up the distance and intensity too quickly on my running in the fall. I did lots of different PT exercises. I saw two sports ortho docs who specialize in knees, and they weren’t able to tell me anything much. X-ray ruled out some possibilities. Despite all the rest and exercises, I saw no real change, and even seemed to see more pain when I was doing the most resting. Often most sore when sitting still at work, and when driving. The second doc gave up on me, as he had no idea what was wrong. He also helped to make me feel even more depressed by telling me that my running days might be over. But I also got a couple of useful things from him. First, cortisone shots: I’m not sure that these improved things, but he said that this ruled out another possible diagnosis, because the shots will help some types of problem but not others. Second, and most important, he said he was confident that I wasn’t doing long-term damage to my knees. Armed with that, I decided what the hell, I was going to start running again. But I switched from my old style of training to something more like the BarryP method. I run every day, almost always easy/steady, and I started from very short distances - just 10 minutes at a time. Iced and stretched after every run. Six weeks into that, and the knees are doing surprisingly well. The running has built to 20-25 mpw, and I feel much better. Specific training seems to matter. Yesterday I took a 5 mile walk with my wife, and the knees were more sore than they had been in weeks - I expected the walking to be trivial, but it must have been loading the knees slightly different than running.
And one other thing that I did that may have been important is I got my bike fit re-checked, by a couple of different people, including one who really knows his stuff. Turns out my seat was much too low. This may have been contributing to the knee problems, even though I generally felt fine while riding the bike.