I am currently working with a 30-year-old male ex paratrooper with a left knee injury. He has only the posterior horn of the medial meniscus remaining. He is showing early signs of osteo arthritis. All ligaments are in tact (this was all shown via MRI). He has no weight issues and is extremely fit apart from his knee. I have found that his glute minimus and medius are weak. Measuring around his VMO, there is a 1 1/2 inch diffrerence between legs. He has tight psoas and rectus femoris in the left leg and tight quadratus lumborum on the left side. He is also lordotic. He has no problems squatting with both legs; however, when he tries a single leg squat, he gets a shooting pain behind the patella tendon. This comes on in the first quarter of the squat and is so severe he cannot go down any further. This also causes inflamation for a couple of days after. Can you advise me on what this pain may be?
Thanks for your question! As you can imagine, this is very hard to pinpoint without seeing your client's multi-planar movement pattern. However, based on what you have said, it sounds like the rectus femorus is adhered to the vastus intermedius. During lower extremity function (i.e., squatting), the rectus femoris and the vastus intermedius move in OPPOSITE directions requiring a sliding motion. Therefore, if they are "stuck," the patella will track abnormally, potentially creating your client's complaint.
Other possible causes...
- Joint capsule could be fused to surrounding structures such as the patellar retinaculae and collateral ligaments.
- The femur is not translating of the tibia correctly. This can occur when the hamstrings or gastrocnemius are not fully functioning.
- The quadriceps become fibrotic and non-resilient and therefore transmit a sharper force to the patella during loading (acts like a rope as opposed to a rubber band).
- The articularis genu is not functioning correctly. This muscle is deep and short. It positions the suprapatellar bursa. When dysfunctional, the bursa can become pinched leading to sharp pain and/or swelling.
What the solution? See if you can resolve on your own by performing the following:
- Foam roll the quads (medial, lateral, midline and iliotibial band). However, after rolling slowly (providing there isn't protective tightening), have your client actively knee flex so tissue slides beneath the foam roll contact.
- Even better and more functionally specific, apply a two thumb contact (not too compressive - apply a high level of tension) while your client is in the squat position. Start by having him hold onto an object with his hands. You contact above the patella - tension superior – then instruct client to squat down slowly as your tension increases (do not slide - allow the tissue to slide beneath your contact). This is a form of Active Release, which will help to break the adhesion.
- Refer to a soft tissue therapist so the entire hip, knee and ankle can be addressed. For a therapist in your area, log on to www.activerelease.com and search under provider.
Most likely, this is a kinetic chain insult and not isolated to your client’s knee; however, the knee undoubtedly has been traumatized and therefore will need special attention in conjunction with a functional re-conditioning approach. Remember, pain is a symptom - not a cause!