• Dr. Daniel P. Berthold

Anterior Knee Pain: What’s all the hype around the Runner’s and the Jumper’s knee? Part II.

Updated: Dec 17, 2020


This part of the article is now focusing more on symptoms and the subsequent therapy of anterior knee pain. The most common symptom is often described as aching and dull in the front knee, accompanied by a popping or crackling sound in the affected (or both) knee(s). The pain can be related to a change in activity level or intensity. Interestingly, patients often described that they feel the pain after sitting for a long period when riding cars or airplanes or sitting in their office. Yes, a lot of people have knee pain while just sitting in front of their desk. And you may be surprised, but most of them are female.

The clinical examination and subsequent diagnostic can be challenging and will be highlighted in a later episode of the Lab. As such, stay tuned! We will provide you interesting case-reports with some nice radiographs or magnetic resonance imaging (MRI) scans.

Therapy

When encountering patients with anterior knee pain, the exact etiology of the anterior knee pain has to be detected! In some cases, the above-mentioned symptoms may be caused to the well-known jumper’s knee or a runner’s knee. An experienced physician may find it easy to differentiate between these or may use MRI scans to further evaluate the cause of your pain. In brief, the jumper’s knee is primarily known as the Patellar tendinitis, which is an overuse of the patellar tendon. Typically, the pain and tenderness are located at the lower part of the kneecap, even though the upper part may also be at risk in some cases. The term runner’s knee, however, is defined as an acute or chronic overuse (inflammation) of the tibial insertion of the iliotibial band (at Gerdy’s Tubercle, named after the French Surgeon Nicolas Gerdy). As the iliotibial tract is a known stabilizer of the knee joint, overuse, disbalance, or muscle weakness may put this structure is at high risk for acute or chronic inflammations.


The most common home remedies for acute pain are activity changes that will place less stress on the knee joint. Running, high-Pivoting sports (such as soccer, handball, basketball, volleyball), skiing, biking, and rowing should be avoided for a couple of weeks. If you feel that your knee is “killing” you, you may use the well-known POLICE Method.

POLICE is an acronym that stands for protection, optimal loading, ice compression, and elevation. Most of you probably know the RICE Methode (Rest; Ice; Compression; Elevation), but we think that the POLICE method will guide you safely through acute injuries.


Make sure not to apply ice directly on the skin. For compression, you may use a Flossing Band or a VooDoo band. The effect of the Flossing Band is well known: Tissue compression and partial vascular occlusion result in re-perfusion of blood to the muscle/tendon tissue. Simplified: After a brief period of ischemia, you are flooding the myofascial structures with blood, which notably contains oxygen and growth-factors. (Reeves, Kraemer et al. 2006) As such, if you are interested in this kind of training, drop me a message, and we will prepare another review article on Flossing and blood flow restriction training.


Another form of training you may be familiar with is the use of a Foam-Roll or the omnipresent BlackRoll. Even though we are huge fans of Foam-rolling, it should not be considered as a panacea for all kinds of myofascial dysfunction, but more as an additive approach. However, current literature suggests that there is no established or proven Foam-Roll training so far. (McKenney, Elder et al. 2013, Freiwald, Baumgart et al. 2016) What we know is that flexibility and delayed onset of muscular soreness can be enhanced through external loads which are almost 10-fold higher than the highest medical compression (Category 4) and exceed twice the pressure loads that are used in occlusion studies. (Freiwald, Baumgart et al. 2016) And let’s be honest: it’s painful. Just make sure not to overuse the Foam-Roll, and never “roll” on bony structures, as fractures may result.

In patients with anterior knee pain, the use of a foam-roll in the quadriceps and hamstring muscle group as well as on the iliotibial band should be considered. Additionally, you may use the foam-roll for your calf muscles.


Medication can be used for a short period of time (Nonsteroidal anti-inflammatory drugs; Ibuprofen; Diclofenac; and Naproxen) or just before the competition. However, make sure to take the right dose and do not use NSAIDs if you are having kidney, stomach, or heart disease. However, the use of NSAIDs can be associated with severe adverse digestive effects. As such, proton pump inhibitors (e.g. Pantoprazole; Omeprazole; Proton-pump inhibitor) are proven to be effective in preventing and healing NSAID-induced gastroduodenal lesions

If none of the above-mentioned therapy approaches is helping you, you should be seen by an experienced physical therapist. Specialized functional training and leg axis training are needed to help you align and stabilize your foot and ankle. The focus should be on strengthening and stretching your muscles around the knee, as they are the main stabilizers of your kneecap. As always, CORE training should be recommended, as you will learn: the better your CORE, the better your performance.

But not least, if you are still struggling with chronic knee pain, you may see a knee surgeon. Overall, operating on a patient with chronic anterior knee pain should be considered a salvage procedure. In these patients, we mainly use knee arthroscopy, whereas the surgeon inserts a small camera into your joint to guide the surgical instruments. In very rare cases, the Hoffa fat-pad needs to be removed due to chronic hypertrophy. Additionally, the cartilage on the bone can be assessed and treated accordingly. However, this should only be done if the cartilage damage may be at cause for the knee pain.

One thing, which we would not recommend, is long-term cortisone infiltrations. In a later episode of the Lab, we will tell you why our expert team is not a fan of this kind of therapy.


Prevention

Prevention is knee, sorry, I meant key. We feel that it is essential to maintain proper strength of the muscles, ligaments, and tendons around the knee (and of the CORE, of course) to prevent chronic anterior knee pain. So, make sure:


- Warming up before physical activity

- Incorporate proprioception exercises into your daily workout routine

- Incorporate CORE exercises and functional leg axis training

- Wear shoes appropriate for your activities

- Increase your mobility around the knee, hip, and ankle

- Avoid overstressing your knee

- Try to reduce activities, that hurt your knees in the past


Alright. If you have further questions, feel free to contact us! Cheers.



References

Allaire, R., M. Muriuki, L. Gilbertson and C. D. Harner (2008). "Biomechanical consequences of a tear of the posterior root of the medial meniscus: similar to total meniscectomy." J Bone Joint Surg Am 90(9): 1922-1931.

Freiwald, J., C. Baumgart, M. Kühnemann and M. W. Hoppe (2016). "Foam-Rolling in sport and therapy – Potential benefits and risks: Part 2 – Positive and adverse effects on athletic performance." Sports Orthopaedics and Traumatology 32(3): 267-275.

Hoshino, A. and W. A. Wallace (1987). "Impact-absorbing properties of the human knee." J Bone Joint Surg Br 69(5): 807-811.

Kohn, D. and B. Moreno (1995). "Meniscus insertion anatomy as a basis for meniscus replacement: a morphological cadaveric study." Arthroscopy 11(1): 96-103.

Makris, E. A., P. Hadidi and K. A. Athanasiou (2011). "The knee meniscus: structure-function, pathophysiology, current repair techniques, and prospects for regeneration." Biomaterials 32(30): 7411-7431.

McKenney, K., A. S. Elder, C. Elder and A. Hutchins (2013). "Myofascial release as a treatment for orthopaedic conditions: a systematic review." Journal of athletic training 48(4): 522-527.

Reeves, G. V., R. R. Kraemer, D. B. Hollander, J. Clavier, C. Thomas, M. Francois and V. D. Castracane (2006). "Comparison of hormone responses following light resistance exercise with partial vascular occlusion and moderately difficult resistance exercise without occlusion." Journal of applied physiology 101(6): 1616-1622.

Willinger, L., J. J. Lang, C. von Deimling, T. Diermeier, W. Petersen, A. B. Imhoff, R. Burgkart and A. Achtnich (2019). "Varus alignment increases medial meniscus extrusion and peak contact pressure: a biomechanical study." Knee Surgery, Sports Traumatology, Arthroscopy: 1-7.

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