Patellar Femoral Dysfunction

Question:

I would be grateful for your advice. I have a 54-year-old female client. She has a healthy lifestyle and previously worked out regularly, but she has developed bilateral "stressed patellae." She has knee pain when going up and down stairs, cycling or rowing. She has been treated for almost a year by rest and NSAIDs. Firstly, I am not sure of the nature of this condition, and secondly, I would be grateful for some advice about her exercise management. Thank you very much.

Answer:

I believe “stressed patellae” is another term for patellar femoral dysfunction. The knee is the junction between the tibia and femur and will do what the tibia and femur dictate upon it. The tibia is highly influenced by the foot and the femur by the gluteal complex. The patella is “riding” on the track of the tibia and femur. If the track does not line up correctly, the patella cannot run smoothly on the track.

Most approaches of patella femoral dysfunction look at the tightness of the quadriceps compressing upon the patella. This is a good place to start, but we must ask the question: why are the quadriceps tight and causing this compression? I believe there is more information gained by understanding the actions of the foot and ankle complex and making sure there is good mobility in the foot to allow the tibia to react properly. If the foot is flat, this could cause the tibia to internally rotate and improper tibial/femoral alignment. Likewise, if the foot has a high arch, the tibia may be externally rotated and impact the alignment as well. During gait, the calcaneus must go through eversion to allow dorsiflexion and tibial internal rotation. As this occurs, the femur and hip will also internally rotate. Upon the propulsive phase of gait, the calcaneus must invert to allow plantar flexion and tibial external rotation, femoral and pelvic external rotation. If these events do not occur, a myriad of dysfunction can potentially transpire.

I would also address the mobility of the hips and gluteal muscles. If the gluteals are tight, this can cause the femur to externally rotate and contribute to improper tracking of the patella. Additionally, if the adductors are tight and weak, the femur may be internally rotated and pelvis becomes anteriorly tilted, resulting in improper alignment of the femur on the tibia.

The rationale for this thinking is the knee has the symptoms, but the cause may be a joint level or two above or below the symptomatic area. My suggestion is to stretch the areas above and below in all three planes of motion as well as try attempting tri-plane lunges with medial and lateral arm reaches to allow the foot to react in a tri-plane manner, which will affect the leg, knee and hip. If you need more specific movement patterns and integrated flexibility patterns, please check the PTN Exercise Library.