Overcoming Patellofemoral Pain Syndrome Postpartum
What is Patellofemoral Pain Syndrome?
Patellofemoral pain syndrome (PFPS), also called runner's knee or moviegoer's knee, is a common cause of anterior knee pain. It involves pain around or behind the kneecap (patella). PFPS often occurs without damage to knee structures.
PFPS is especially common in:
Women
Adolescents
Athletes in jumping sports
But anyone can develop PFPS, especially with certain predisposing factors.
PFPS Symptoms
The main symptom is anterior knee pain, which worsens with activities that load the joint surface behind the kneecap.
Symptoms and Descriptions
| Symptom | Description |
|---|---|
| Pain with stairs | Experiencing pain while going up or down stairs. |
| Pain when squatting | Feeling pain when doing squats or sitting on heels. |
| Pain sitting | Experiencing pain in situations like movie theaters, cars, etc., where sitting is involved. |
| Pain after sitting | Feeling pain when getting up after prolonged sitting. |
| Pain with jumping, running | Experiencing pain during athletic activities like jumping and running. |
| Grinding sensation | Feeling a grinding sensation when the kneecap grinds over the femur. |
| Clicking | Experiencing clicking sounds during knee bending. |
Symptoms range from mild to severe. One or both knees may be affected.
What Causes Patellofemoral Syndrome?
Stage 1: Factors Contributing to PFPS
Overuse of knee joint
Muscle tightness or weakness around hips and knees
Overpronation of the feet
High Q-angle (angle between hip and knee)
Previous knee injury
Occupational kneeling
Stage II: Abnormal Patellar Tracking
Excessive lateral glide
Tilting
Rotation
Superior or inferior position
Stage III: Patellofemoral Pain Syndrome Cycle
Pain behind or around kneecap
Worse with loading joint surface
Patellofemoral pain syndrome (PFPS) develops from a combination of factors that lead to abnormal mechanics and increased stresses on the kneecap and knee joint surface. It often begins with overuse or repetitive strain to the knee such as from running, jumping, or kneeling.
Contributing biomechanical factors include muscle imbalances around the hip and knee, overpronation of the feet, high Q-angle, and previous knee trauma. Tight structures like the IT band, hip flexors, and calves paired with weak glutes and core muscles lead to poor tracking of the kneecap.
This abnormal patellar tracking results in issues like excessive lateral gliding, tilting or rotation of the kneecap, or the kneecap sitting too high or low in the trochlear groove. These mechanics increase contact pressure between the back of the kneecap and the femur.
Over time, the repetitive abnormal forces cause irritation and microtrauma to the joint surface and cartilage behind the kneecap. This generates anterior knee pain that is often worse with loading the joint such as climbing stairs, squatting, or sitting for long periods.
The cycle propagates as the pain causes inhibition and weakness of the quadriceps which further reduces dynamic stability around the patella. Patients often adopt poor movement patterns to offload the painful kneecap which can worsen the imbalance.
Breaking this painful cycle requires identifying and addressing the underlying anatomical and biomechanical factors with targeted stretching, strengthening, taping, bracing, and technique adjustments. This comprehensive approach can help realign the kneecap, provide stability, and reduce joint surface pressures to relieve PFPS.
why women may be more susceptible to patellofemoral pain syndrome after pregnancy
The hormonal changes during pregnancy lead to increased ligamentous laxity and collagen remodeling in the knees and other joints. This laxity often persists postpartum and can cause abnormal forces and loads on the knee joint, especially the patellofemoral joint. Additionally, the dramatic postural shifts and weight distribution changes of pregnancy, coupled with postpartum muscular weakness and fatigue from relative inactivity, reduce dynamic knee stability. The lack of muscular support and strength after pregnancy means the knee is less able to properly distribute forces and control normal patellar tracking. Together, the residual laxity and altered biomechanics from pregnancy along with postpartum muscular imbalances lead to abnormal patellofemoral joint mechanics. This significantly increases a woman's susceptibility to developing patellofemoral pain syndrome in the months following pregnancy and childbirth as the knee joint is less able to attenuate forces and control patellar motion properly. Targeted exercise and therapy to address the residual laxity and muscular imbalances can help reduce this risk of knee pain after pregnancy.
Treating Patellofemoral Pain Syndrome
Treatment focuses on correcting contributing factors identified during the evaluation.
Conservative treatment is effective for most PFPS patients. Options include:
Rest/Modify Aggravating Activities: Avoid activities that worsen pain to allow healing.
ICE - Ice massage, cold packs to reduce pain/swelling. Apply ice for 10-15 minutes after activity.
NSAIDs - For symptomatic relief of pain and inflammation
Physical therapy - Stretching tight muscles, strengthening weak muscles, targeted exercises.
Taping/bracing - Improve patellar tracking and positioning. Reduce strain on tissues.
Foot orthotics - Control overpronation. Consider foot orthotics, heel lifts, or shoes with appropriate arch support if needed.
Weight loss - Reduce load on joint
Holistic treatment may also help relieve PFPS pain:
Massage
Acupuncture
Yoga
Pilates
Mind-body therapies
VooDoo Floss Band compression
Modalities & Advanced Treatment
Cold laser, ultrasound, or e-stim to reduce pain.
Manual therapy techniques like massage and Graston.
Dry needling tight trigger points.
Injections if indicated - cortisone or PRP.
Surgery if conservative options fail - arthroscopy or realignment.
Prevention Strategies
Maintain strength, flexibility, proper biomechanics.
Increase training load gradually over time.
Use orthotics or taping if needed.
Wear proper footwear.
Guide to Knee Rehabilitation Exercises
Properly rehabilitating the knee through targeted exercises is crucial for ensuring full recovery and preventing future injuries. This comprehensive guide will overview the essential components of knee rehabilitation programs.
Goals of Knee Rehab Exercises
The primary goals of rehabilitation exercises after a knee injury or surgery are to:
Restore full range of motion in the knee joint
Rebuild strength in the muscles surrounding the knee
Correct any biomechanical or movement pattern issues
Progress activity tolerance and return to sports/exercise
Prevent future re-injury or complications
To achieve these goals, it is important to follow a structured knee rehab protocol under the guidance of a knowledgeable healthcare professional such as an orthopedic surgeon, physical therapist, athletic trainer, or physiatrist.
Trying to take shortcuts with rehab or pushing progress too quickly often backfires and leads to repeat injuries down the line. Patience and consistency with the proper exercises are key for optimal recovery.
Getting Started with Knee Rehabilitation
When beginning a knee rehab program after injury or surgery, there are a few key points to keep in mind:
Warm Up First
Always warm up for 5-10 minutes before starting rehab exercises. This increases blood flow to the knee area and enhances range of motion. Low impact activities like walking on a treadmill or riding a stationary bike work well.
Stretch Before and After
Be sure to perform stretches before moving into strengthening exercises. Stretching helps extend range of motion gains from rehab and reduces post-exercise muscle soreness. Also do stretches after completing strengthening for optimal flexibility improvements.
Avoid Pain
Rehab exercises should not significantly worsen knee pain. Some soreness is expected, but sharp or stabbing pains indicate an issue. Discuss any concerning pain with your doctor or physical therapist.
Targeting Contributing Factors
Stretch tight structures: Hip flexors, quadriceps, IT band, calves.
Strengthen weak muscles: Glutes, hamstrings, hips, core.
Improve flexibility: Quads, hip adductors/abductors, calves.
Retrain proper movement patterns: Reduce knee valgus/hip internal rotation.
Manage weight: Reduce load on the joint.
For optimal results, knee rehab exercises should be performed consistently for 4-6 weeks unless a longer duration is prescribed. Exercises may be continued at a maintenance level after this period.
A SELECTION OF CRUCIAL sTRETCHes TO COMMENCE Knee Rehab
Stretching is a critical component of knee rehabilitation. Improving flexibility helps extend range of motion gains from other exercises. Key stretches include:
Static Gastrocnemius Stretch
Preparation: Stand facing a wall or sturdy object. Bring one leg forward toward the wall for support. Use upper body to lean against the wall, keeping outstretched rear leg straight.
Movement:
Draw abs in and activate glutes.
Keep rear foot flat, with foot pointed straight ahead. Do not allow the rear foot to cave inward or roll outward.
Bend arms, move chest toward the wall and tilt pelvis forward.
Stop movement when slight tension is felt.
Hold for 20-30 seconds.
Switch sides and repeat.
Static Soleus Stretch
Preparation: Stand facing a wall or sturdy object. Bring one leg forward toward the wall for support. Use upper body to lean against wall, keeping outstretched rear leg straight.
Movement:
Draw abs in and activate glutes.
Keep rear foot flat, with foot pointed straight ahead. Do not allow the rear foot to cave inward or roll outward.
Bend rear knee until slight tension is felt.
Hold for 20-30 seconds.
Switch sides and repeat.
Static Peroneal Stretch
Preparation: Stand facing a wall or sturdy object. Bring one leg forward toward the wall for support. Use upper body to lean against wall. Internally rotate rear les and invert (turn in) foot.
Movement:
Draw abs in and activate glutes.
Lean forward until slight tension is felt in the lateral shin of the back leg.
Hold for 20-30 seconds
Switch sides and repeat.
Seated Dynamic Shin Stretch
Preparation: Sit on the floor with your legs straight out. Place a long-loop resistance band or long towel around one of your feet.
Movement:
Gently pull the band towards you.
While keeping resistance in the band, flex and point your foot.
Hold for 24 seconds for 5-10 repetitions
Switch sides and repeat.
Static 90-90 Hamstring Stretch
Preparation: Lie on floor with legs flat. Flex hip and knee of one leg and create a 90-90 position.
Movement:
Draw abs in.
Slightly tilt pelvis anteriorly.
With hands supporting leg, mistuning your knee in line with your hip, slowly extend you heel upwards (without moving at the pelvis) until tension is felt.
Hold for 20-30 seconds.
Switch sides and repeat.
Static Standing Cross-leg Biceps Femoris Stretch
Preparation: Stand with erect posture and one leg straight, hip flexed, adducted and internally rotated on a bench.
Movement:
Draw abs in.
Maintaining an upright posture, slightly lean forward at the hip until a slight stretch is felt in the back of the thigh.
Hold for 20-30 seconds.
Switch sides and repeat.
Quadriceps Stretch
Preparation: Stand facing a wall or sturdy object. Stand with erect posture.
Movement:
Draw abs in and activate glutes.
Gently draw the heel of one foot toward the buttock while standing upright balancing on the opposite leg until a stretch is felt in the front of the thigh.
Hold for 30 seconds,
Switch sides and repeat.
Static Standing Psoas Stretch
Preparation: Stand with one leg bent and slightly forward. Internally rotate back leg.
Movement:
Draw abs in and activate glutes.
Squeeze buttocks, while rotating pelvis posteriorly.
Slowly, move body forward until a mild tension is achieved in the front of the hip being stretched.
Raise the arm (on the same side as the back leg) up and over to the opposite side, while maintaining pelvis position.
Hold side bend position and slowly rotate backward.
Hold for 20-30 seconds.
Switch sides and repeat.
Static Kneeling Hip Flexor/Quadriceps Stretch
Preparation: Kneel with front leg bent at a 90-degree angle. Internally rotate back leg.
Movement:
Draw abs in and activate glutes.
Squeeze buttocks, while rotating pelvis posteriorly.
Slowly move body forward until a mild tension is achieved in the front of the hip being stretched.
Raise stretch side arm up and over to the opposite side, while maintaining pelvis position.
Hold side bend position and slowly rotate backward.
Hold for 20-30 seconds
Switch sides and repeat.
Static Supine Piriformis Stretch
Preparation: Lie supine with right leg crossed over the left
Movement:
Draw abs in.
Place left hand on the lateral right knee and slowly pull to opposite shoulder, until a slight tension is felt in buttock region.
Hold for 20-30 seconds.
Switch sides and repeat.
Aim to perform stretching exercises 2-3 sets, 4-5 days per week. Stretching after strengthening exercises enhances flexibility gains.
A SELECTION OF CRUCIAL strength exercises TO COMMENCE Knee Rehab
To rebuild muscle strength focus on both open and closed chain exercises through the full range of motion. Closed chain exercises involve the foot planted whereas open chain exercises have the leg moving freely.
Floor Bridges
Preparation:
Lie on your back with your knees bent, feet flat on the floor, and toes pointing forward, about shoulder-width apart.
Place your arms at your sides with your palms facing up.
Movement:
Engage your abdominal muscles and activate your glutes.
Raise your pelvis off the floor until your knees, hips, and shoulders are in a straight line.
Slowly lower your pelvis back to the floor.
Repeat 10 reps.
To advance the exercise, try it as a single-leg variation.
Side Hip Abduction with Internal Rotation
Preparation:
Lie on your side on an exercise mat with your legs fully extended.
Support your head with one arm, either bent or stretched out.
Place the hand of your other arm on the floor in front of your abdomen to stabilize your upper body.
Rotate your upper leg inward at the hip joint.
Movement:
Lift your upper leg sideways towards the ceiling, leading with your heel, briefly hold it in this position, and then lower it back down.
Repeat 10 reps each leg
Ensure your body remains stable and perform the movements slowly and and under control. Your upper body should remain still as your leg moves.
For added challenge, consider using an elastic resistance band positioned just above your knee joint.
90-90 Banded Ankle Rotations
Preparation:
Lie down on your side in a 90-90 position; knees forward in line with your hips and feet in line with your knees.
Position the back of your thighs against a box.
Place a resistances band around your ankles and yoga block between your knees.
Movement:
Push the top leg's hamstring into the box.
Perform a slight posterior pelvic tilt.
Slowly turn your toes down, leading with your heel toward the ceiling.
Stay within your active range of hip internal rotation.
Repeat 10 reps each leg.
Focus on maintaining a slight posterior pelvic tilt throughout.
Feel the forward fibers of your glute muscles working.
Control the movement and maintain controlled breathing.
Ensure your head, ribs, and hips stay stacked in alignment.
Seated Straight Leg Raise
Preparation:
Sit on the floor with your right leg straight in front of you. Bend your left leg at a 90-degree angle, putting your left foot flat on the floor.
Draw your shoulder down your back and place your hands on the floor behind your body, for support.
Movement:
Engage your abdominal muscles.
Flex your right foot and tighten the thigh muscles of your right leg. Raise your right leg 6 to 8 inches off the floor. Don’t arch your back or hunch your shoulders.
Hold the right leg in the air for 10 seconds if you can.
Then lower the leg slowly and steadily down to the floor. Relax.
Repeat 5 reps each side.
To change sides bend your right leg and place your right foot flat on the floor, extend your left leg straight.
Leg Extensions While Sitting
Preparation:
Sit on a chair or stool that is high enough for you to bend your legs at a right angle (90 degrees).
You can wear a lightweight cuff on your lower leg (above the ankle) if you like.
Movement:
Slowly stretch out one leg in front of you and lift it up, then slowly bend and lower it. It should take about 5 seconds to lower it.
Repeat 10 reps each leg.
Hamstring Curls
Preparation:
Lie down prone or standing up.
Movement:
Bend your left knee, drawing your left heel towards your buttock, focusing on the hamstrings (back of the thigh).
Slowly lower your heel back to the starting position.
Repeat 10 reps each leg.
Wall Sits
Preparation:
Stand with your back flat against a wall.
Place your feet about 60 centimetres away from the wall. Your feet should be shoulder-width apart and flat on the floor, facing forward.
Movement:
Fold your arms in front of you and slowly slide your upper body down the wall until your thighs and lower legs are at a 90-degree angle.
You’ve arrived in the correct position when your thighs are horizontal, your kneecaps are facing forward, and your back is pressed flat against the wall.
Hold this position for about 20 seconds. After some time, you can gradually increase to one minute by adding 5 to 10 seconds each time.
Repeat 3 sets. After each wall sit, slide your upper body back up the wall by straightening your legs and have a 30-second break.
Calf Raises
Preparation:
Stand on a flat surface.
You can hold onto a chair or wall for support and balance.
Movement:
Raise your body onto the balls of your feet, lifting your heels off the ground.
Slowly lower your heels down while engaging the calf muscles.
Repeat 10 reps each leg.
Single Leg Balance
Preparation:
Stand with your feet positioned shoulder-width apart, pointing straight ahead. Ensure your hips are in a neutral position.
Lift your chest, slightly retract your shoulders, and tuck your chin.
Movement:
Engage your abs and activate your glutes.
Lift one leg directly beside your supporting leg. Flex your hip at a 90-degree angle, dorsiflex your toe, and slightly flex your knee. Maintain optimal alignment, including level hips and shoulders.
Hold this position for a duration of twenty seconds.
Gently return to your original position.
Repeat 3 sets each leg.
Single-leg Romanian Deadlift
Preparation:
Stand on one leg in optimal posture, keeping raised leg parallel to the standing leg.
Movement:
Draw abs in and activate glutes.
Without allowing further knee movement, maintain a straight torso and hinge forward at the hips, touching toe of standing leg with opposite hand.
While maintaining abdominal drawing in maneuver and gluteal activity, return to starting position.
Repeat 8 reps each leg.
Body Weight Squat to Calf Raise
Preparation:
Stand with feet shoulder-width apart, toes pointing forward and knees over second and third toes.
Place your hands on hips or behind the ears.
Movement:
Draw abs in and activate glutes.
Slowly begin to squat down, bending knees and flexing hips, keeping feet straight (as if sitting back into a chair). Do not allow any internal rotation at the hips or knees.
Allow the pelvis to sit back while maintaining a neutral spine. Keep the chest up and put pressure through the heels.
To rise back up, contract glutes and place pressure through the heels as knees are extended.
Stand up straight until hips, knees and feet are fully extended and then rise up on to the balls of your feet.
Avoid compensation in the low back or lower extremities.
Repeat 10 reps each leg.
Regression:
In cases of tight calfs elevate your heels whilst squatting (by placing a block under your heels).
Omit calf raise.
Holding on to a stable support.
Progression:
Unstable surface
Gradually build your strength up to 3 sets over a 4-6 weeks time frame and then progress increasing resistance with weights or resistance bands.
Optimizing Results from Knee Rehabilitation Exercises
To get the most out of knee rehab exercises:
Focus on proper form - avoid compromising form to increase reps
Build up resistance slowly over time
Ice the knee after exercise to control inflammation
Discuss any exercise-related pain with your clinician
Supplement rehab with cardiovascular exercise as tolerated
Listen to your body and allow adequate rest between sessions
Consider massage, acupuncture, or other modalities for enhancement
*Additionally its advise to incorporate active dynamic pelvic floor training around your rehabilitation routine to improve over all posture. The pelvic floor plays an important role for the coordinated triggering of almost all movements, as well as for balance and good body posture. Many back, knee and foot problems can be relieved through conscious training of the pelvic floor.
Patellofemoral pain syndrome can be a frustrating and recurrent condition for many women after pregnancy. The combination of ligament laxity, altered biomechanics, and muscle imbalances often predisposes women to knee pain postpartum. However, with a dedicated rehabilitation approach, PFPS can be effectively managed.
The key is addressing the underlying factors contributing to poor patellar tracking and increased joint stresses. This requires consistency with stretches, targeted strengthening exercises, taping, bracing, and technique adjustments over an extended duration. Consulting sports medicine specialists and physical therapists to design a customized treatment plan optimizes outcomes.
While recovering from PFPS after pregnancy demands commitment and patience, significant improvements in knee pain and function are achievable. Taking a comprehensive approach allows women to regain strength, stability, and comfort in their knees so they can return to their active lifestyles and keep up with their new bundles of joy. With proper education, support, and early intervention, the achy knees that frequently follow pregnancy do not have to be an inevitable long-term struggle.
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