The knee is made up of a few different joints. The one in focus today is the one between the patella (knee cap) and femur (thigh bone): the patellofemoral joint. The knee cap is an interesting bit of anatomy, it’s a small bone that sits within the tendon that connects the quadricep muscles with the shin. But despite their unassuming size, they have a huge role in the efficacy of the quadricep muscles. This video demonstrates that well. With that in mind, it makes sense that if the positioning of the patella is off, it could have quite a dramatic effect.

Patella Maltracking

One common cause of patellofemoral pain is patella maltracking. This means that when the quadriceps are activated, the knee cap doesn’t follow the route it normally should. Typically, weakness on the most medial quadricep muscle (vastus medialis) causes the other muscles to pull the bone laterally. This is often felt as something being out of place, which can come with a sharp pain or a grinding sensation. You might start moving differently to avoid activating the muscles in the same way, but the problem is easily fixed.

Assuming the weakness is a benign imbalance of strength between the muscles, some simple exercises might be all you need to restore balance. Your osteopath will look at the way the leg and other areas move to determine the cause. This will also give us information about whether anywhere else needs treating for overcompensating. Work to relax tight muscles and improve joint movement will likely make up a big part of your treatment plan.

Patella Alta and Baja (High or Low Knee Cap)

If the knee cap is sitting too high or low, it demonstrates patella alta or baja respectively. The problem with a high knee cap (alta) is that the thigh bone is not shaped to hold the patella in place as well as it is further down. As a result, this predisposes the knee cap to instability and pain. Often patella alta is something you’re born with, but it can also follow a sports injury.

A low-riding knee cap (patella baja) is much more commonly a result of surgery or injury. Knee replacement or ACL repairs are common causes. Up to 1/4 knee replacement patients develop patella baja soon after. Symptoms include a loss of range of movement, pain, and crunchiness behind the patella. Corrective surgery is the usual treatment.

Other Causes of Patellofemoral Pain

Away from the positional issues described above, there are a few other causes of patellofemoral pain. Osteoarthritis is a common one, and fortunately it’s usually very responsive to treatment. In the early stages, treatment and exercises to encourage movement can improve the health of the cartilage behind the kneecap. In the later stages, there may be loose pieces of cartilage in the joint. As scary as that sounds, smaller fragments can reabsorb over time. Surgery is not always necessary (vs placebo), and maintaining maximum range of movement helps the body to clean up on its own.

Your Osteopath’s Role in Knee Cap Pain

For maltracking, the usual aim is to rebalance the muscle strength across the quads. Exercises to target the vastus medialis muscle are the key. Beyond prescribing the exercise and making sure it’s working properly, our role is to keep the rest of the knee happy too. If the maltracking has caused irritation to the cartilage behind the patella, it might be appropriate to provide some movement to this joint. As with osteoarthritis mentioned above, movement here encourages fluid exchange and healing. It also helps to tell the nervous system that the joint is safe, and that it doesn’t need to keep the area tense to protect it.

If your knee pain requires surgery, we can help to keep you comfortable in the meantime. We can also help to prepare the area to recover from surgery, by addressing any imbalances and helping you to maximise your strength.

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