How can you relieve pain at the front of the knee?
If you have front knee pain, the first thing you need to do is rest the knee. Exercises to strengthen the thigh and hip muscles can stabilize the kneecap and have been proven to relieve the pain. It’s also a good idea to pay attention to the position of your legs in everyday life.
Pain at the front of the knee – known as patellofemoral pain – is one of the most common knee problems. It often occurs in people who do a lot of sports, particularly runners. That's why it’s also often referred to as “runner’s knee.”
How can you rest your knee?
Front knee pain is usually a result of overuse. In other words, the knee might have been exposed to too much or too frequent strain without being able to adapt to it fast enough. So the knee isn’t weak; it can still carry your weight and there’s no need to worry if it hurts every now and then.
The main thing to do at first is rest the knee. If the pain is very bad, you should stop doing the sport that is making it worse. If the pain is mild, it might be enough to do less of that sport and avoid activities that make it worse, such as interval running, hill running or tower running.
A study in which runners focused on resting their knee found that it helped. The runners in the study were advised to
- run shorter distances than usual (and instead run more often if possible),
- run more slowly,
- avoid hill running and tower running,
- take breaks while running if their knee hurts, and walk for a bit before running again,
- make sure that any pain when running isn’t worse than 2 on a scale of 0 (no pain) to 10 (maximum pain),
- limit the strain on the knee so that the pain goes away within an hour at the latest and isn't worse the morning after running.
By following these recommendations, a lot of the runners managed to get their knee pain under control within a few months.
This suggested approach can be followed when doing other types of sports, too. For instance, cyclists can use an easier gear to cycle with less stress on their knee, and also avoid cycling up long or steep hills. You often have to try things out first in order to find the right amount of strain.
If there's still no improvement after some time, it can be worth trying out a new running technique:
- While running, try not to land on your heel first but on the center of your foot instead, and then push off the ground with the front of your foot. This reduces the strain on the kneecap (see illustration).
- Take smaller steps.
- Make sure that your hips stay straight and don’t tilt sideways.
There are currently no good studies on whether changing your running technique helps in the long term. There’s also hardly any research on whether professional (running) gait analyses can help.
How can you strengthen your knee?
Strengthening the thigh and hip muscles is the only treatment approach that has been proven to help relieve front knee pain in many studies.
Strong muscles protect the knee by stabilizing the leg axis (the alignment of the leg). The hip, knee and ankle joint are usually positioned above and below each other in a straight vertical line. That puts the optimal amount of strain on the kneecap. If the muscles are weak, the pelvis may tilt and the knees and feet lean inward.
A number of studies have suggested that individually adapted knee taping can sometimes temporarily relieve the pain. This can make it easier to do the strengthening exercises at first. But knee tape isn't a long-term solution and also isn't suitable when used on its own. This kinesiology taping approach hasn’t been proven to help in studies. The costs aren’t covered by statutory health insurance in Germany.
How can you improve the alignment of your legs in daily life?
It is generally a good idea to pay attention to the alignment of your legs – particularly during activities that put a lot of strain on the kneecaps. These mainly include going up and down stairs, running, cycling, squatting, and getting out of bed or a chair.
The alignment is considered to be good if
- your hips, kneecap and middle toe form a straight line,
- your hips stay straight when going up and down stairs (see illustration) and
- your body weight is spread equally across both legs.
The following illustrations show examples of correct and incorrect alignment of the leg during various activities.
Alignment of the leg while going down stairs
Alignment of the leg while cycling
Can shoe inserts help?
Shoe inserts can be used if the feet lean too far sideways. They probably help in some people, at least in the short term. But there’s hardly any research on the pros and cons of shoe inserts. The possible side effects include blisters and pain in the arch of the foot. Some specialists recommend that shoe inserts should only be used in addition to strengthening exercises to stabilize the knee.
What other treatments are there?
A wide variety of other treatments are offered for the relief of patellofemoral pain, but there’s no scientific proof that they work, and they aren't currently recommended by specialists. These include
- knee braces or bandages,
- manual therapy,
- electrophysical therapies such as ultrasound, TENS and laser treatment, as well as phonophoresis and iontophoresis (enhancing the delivery of medications to the skin using ultrasound and electricity).
It doesn’t make sense to do an arthroscopy. This is keyhole surgery to remove or scrape off inflamed or scarred tissue, or to try to correct the kneecap issue in another way. Only one study has compared the effectiveness of knee arthoscopy with a different treatment (in this case, exercises to strengthen the thigh and hip muscles). The arthroscopy wasn’t found to be better. And, like all surgical procedures, it is associated with risks.
Collins NJ, Barton CJ, van Middelkoop M, Callaghan MJ, Rathleff MS, Vicenzino BT et al. 2018 Consensus statement on exercise therapy and physical interventions (orthoses, taping and manual therapy) to treat patellofemoral pain: recommendations from the 5th International Patellofemoral Pain Research Retreat, Gold Coast, Australia, 2017. Br J Sports Med 2018; 52(18): 1170-1178.
Esculier JF, Bouyer LJ, Dubois B, Fremont P, Moore L, McFadyen B et al. Is combining gait retraining or an exercise programme with education better than education alone in treating runners with patellofemoral pain? A randomised clinical trial. Br J Sports Med 2018; 52(10): 659-666.
Kettunen JA, Harilainen A, Sandelin J, Schlenzka D, Hietaniemi K, Seitsalo S et al. Knee arthroscopy and exercise versus exercise only for chronic patellofemoral pain syndrome: 5-year follow-up. Br J Sports Med 2012; 46(4): 243-246.
Van der Heijden RA, Lankhorst NE, van Linschoten R, Bierma‐Zeinstra SM, van Middelkoop M. Exercise for treating patellofemoral pain syndrome. Cochrane Database Syst Rev 2015; (1): CD010387.
Willy RW, Hoglund LT, Barton CJ, Bolgla LA, Scalzitti DA, Logerstedt DS et al. Patellofemoral Pain. J Orthop Sports Phys Ther 2019; 49(9): CPG1-CPG95.
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