Knee cap pain is the most common form of knee pain. Pain can be hard to pin point but may be around, behind, or under the knee cap.
It affects both males and females of all activity levels and ages. It can cause problems that limit your ability to complete simple daily activities such as walking, running, sitting, squatting and walking on stairs.
If you would like more online support beyond this post, please visit the Royal Australian College of General Practitioners (RACGP) endorsed online toolkit ‘My Knee Cap’ here.
The development paper can be found here: https://www.jmir.org/2020/7/e18584/ De Oliveira Silva et al. Novel Stepped Care Approach to Provide Education and Exercise Therapy for Patellofemoral Pain: Feasibility Study. Journal of Medical Internet Research. 2020.
Knee cap pain has a lot of potential causes and treatment options (https://doi.org/10.1093/pm/pny177).
Information provided should not replace treatment with a health care professional such as a physiotherapist. Seeing a qualified physiotherapist to discuss and guide your treatment options further is recommended.
The above information should help you develop a treatment plan with your physiotherapist.
You can also download a detailed education leaflet called ‘Managing My Patellofemoral Pain’ to help guide your knee cap pain treatment:
For those who like to know more about treating their knee cap pain, please read on.
Why do I need to be sensible with how much exercise I do?
The exact reason why people develop knee cap pain is unclear. However, experts around the world tend agree that doing ‘too much, too soon’ in relation to exercise may be a key reason.
There seems to be a spike in the number of people with knee cap pain following rapid increases to how much exercise you do – e.g. basic military training or ‘start to run’ programs (e.g. couch to 5KTM).
There are no specific rules on how much exercise you should complete in order to avoid developing knee cap pain. It is also not clear exactly how quickly to increase exercise when returning to sports and other activities if you are recovering from knee cap pain.
The most sensible option is to monitor your pain levels during and after exercise. Experts frequently recommend that if you have a large increase in pain, or pain stays increased for more than 24 hours after exercise, you may be doing ‘too much, too soon’.
Further guidance on how much exercise you should do and how quickly to increase it can be provided by your physiotherapist.
The following graphs taken from the education leaflet titled ‘Managing My Patellofemoral Pain’ provide a great visualisation to guide you on returning to exercise.
Why is it important to complete exercises targeting my thigh muscles?
It is also thought your thigh muscles become weaker after you have had knee cap pain for a long period of time. This is because people with knee pain move differently – e.g. you are likely to bend your knee less when walking on stairs and when running.
Weak and poorly functioning thigh muscles are thought to lead to greater stress on, and poor tracking of the knee cap. Specifically, the knee cap is thought move too far toward the outside of the thigh (i.e. maltracking) when the knee bends and straightens, causing pain (see illustration to the right).
Based on this maltracking theory, exercises targeting the knee muscles have been a primary focus of physiotherapists treating knee cap pain for many years. There is consistent evidence that this approach can be very effective.
You can find more information about patient education for knee cap pain in the following systematic review: https://www.jospt.org/doi/10.2519/jospt.2020.9400 De Oliveira Silva et al. Patient Education for Patellofemoral Pain: A Systematic Review. 2020.
Why is it important to complete exercises targeting my hip muscles?
People with knee cap pain generally have weak and poorly functioning hip muscles. It is thought that this weakness and poor function may not be the reason as to why you develop pain in the first place. Instead, your hip muscles may become weak because you have changed the way you move, or move less to avoid pain.
Weak and poorly functioning hip muscles are thought to put more stress onto your knee cap during activities like running, walking on stairs and squatting. This is because the muscles can no longer control your thigh well enough, allowing it to roll under the knee cap.
A good way to understand this, is to think of your knee cap as the train, and your thigh as the tracks. If the train (knee cap) moves or tries to derail off the tracks (thigh), this can be because your thigh muscles don’t control the train well enough. However, when the hip is not controlled well enough, the tracks (or thigh) may move underneath the train, having the same derailing effect.
A number of good research trials report that hip targeted exercises are effective in reducing knee cap pain. In the longer term, combining both thigh and hip muscle targeted exercise is the most effective approach to reduce pain.
Why is it important to change the way I move?
People with knee cap pain often have more movement at their hips (collapsing in) and pelvis (dropping down) during activities that cause them pain.
Although exercises targeting the hip muscles can reduce pain, they don’t always improve the way you move during activities like running and walking on stairs.
In order to improve the way you move during tasks that often cause knee pain (e.g. less hip collapse during running), you need to practice the new movement pattern you want to achieve. It is good to do specific exercises for this as part of your rehabilitation. These often referred to as movement pattern retraining, and can be particularly effective in runners with knee cap pain.
Why might taping or bracing help?
There are various ways to tape your knee. The most effective way is to use tape to control how much your knee cap moves toward the outside of your thigh.
There is also a bursa (fluid sack) below the knee cap which often becomes inflammed and swollen in people with knee cap pain. Taping to support this bursa often helps too.
The following video shows an effective taping method to control how much your knee cap moves, and how to support the bursa (fluid sack) below it:
The most effective way to tape you knee can be different for each person, and research shows that tailoring it to your needs may optimise how much pain reduction you get. You may wish to discuss this with your physiotherapist who can assess your knee and find the most effective way for you.
Some people can have allergies to the tape required, or get tired of taping their knee. In these instances, there are bracing options which aim to achieve similar things to the tape. There is not as much evidence to support using braces for knee cap pain, but you can discuss options with your physiotherapist.
Why might shoe inserts help?
Research suggests that shoe inserts will significantly help reduce pain in anywhere between 25 and 50% of people with knee cap pain over the first 6-12 weeks of treatment. They may also help in the longer term too.
Traditionally, shoe inserts have been provided to people because they have flat (pronated) feet. However, there is a lot of debate about whether this is the right approach. In people with knee cap pain, having flatter feet does not predict strongly whether or not shoe inserts will help. Equally, shoe inserts can help people who are not considered to have flat feet.
A couple of studies have reported that people with flexible feet measured using a specific device are more likely benefit from shoe inserts if they have knee cap pain. This is something you could discuss and assess with the assistance of your physiotherapist or podiatrist.
One of the simplest ways to work out if shoe inserts will help is to try them during an activity that normally causes pain. If the inserts immediately reduce your pain, then they are likely to help. If they do not immediately reduce pain, they are unlikely to help you. It is that simple!
In one study, this test was the strongest predictor of success with shoe inserts given to people with knee cap pain. In the same study, the amount of foot movement (pronation) occurring during walking also predicted success, but not as well.
Aren’t shoe inserts expensive?
If shoe inserts are customised specifically for you by a podiatrist, they can be quite expensive. However, research tells us that this is not necessary for most people with knee cap pain.
Less expensive prefabricated shoe inserts (usually less than $100) can be used to treat knee cap pain. If you complete your rehabilitation exercises given to you by a physiotherapist and get stronger, shoe inserts may only be needed for a short time.
Some physiotherapists have the knowledge and skills to provide you shoe inserts and you should discuss this with the physiotherapist treating you. If not, they can refer you to see a podiatrist to help.
Can’t I just have surgery and fix my knee pain?
Listen to world renowned physiotherapist and expert in managing knee cap pain, Professor Kay Crossley (La Trobe Sport and Exercise Medicine Research Centre) discuss surgery, exercise and other treatments for knee cap pain:
One problem for people trying to find a solution for their knee cap pain is getting the right advice and guidance on what treatments might help them. Not everyone is aware of the information contained on this page or consults with a physiotherapist to help treat their pain.
“We have a really big challenge on our hands to try and get the information out about how effective physiotherapy can be” says professor Crossley.
A lot of people with knee cap pain who consult their general practitioner are referred straight to a surgeon, without previously receiving physiotherapy and exercise guidance. They “won’t even think about looking for a second opinion to see if they need to see a surgeon…… Then, the surgeon does surgery. That’s what they know.”
Some surgeries, including a lateral release may actually cause more harm than good for somebody with knee cap pain says Professor Crossley. There are many surgical options, but these should be a last resort.
If you are not convinced yet, Rhys’s story might motivate you to make sure you try other treatments properly before considering surgery. Rhys underwent 10 surgeries ineffective surgeries before finally receiving the right physiotherapy guidance and exercise advice.
Not all surgeons will operate on people with knee cap pain. Professor Crossley says when consulting with people suffering knee cap pain, “there are some good surgeons that will then stop at that point and say, hang on, you need to have some physiotherapy before we even consider surgery.”
However, not all patients are given the option to see a physiotherapist and receive exercise guidance. “Exercise is really the key” Professor Crossley says.
The challenge though is making people aware of the benefits of exercise therapy and getting them to do it.
This short clip summarises the key treatments Professor Crossley believes are needed to treat knee cap pain:
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