Welcome back to Squat University! Today I want to introduce a simple guide to help you figure out which type of knee pain you may have.
When most people develop knee pain while barbell training, they’ll receive a vague diagnosis from the doctor of “Patellofemoral Pain Syndrome” (PFPS). Unfortunately this is a junk term that covers several possibilities. Some have described it as a ‘condition of many conditions’ as the name is often overused as an acceptable diagnosis without a clear understanding for the source of pain. Using such an ambiguous term only leads to confusion.
In 1998 four leaders in the field of sports medicine and rehabilitation (Kevin Wilk, George Davies, Bob Mangine, and Terry Malone) came together to develop the most detailed classification for patellofemoral syndrome or generalized knee pain. (2) By separating the different causes of knee pain into special categories, it allows for a better understanding for how to fix the problem.
Of these categories, there are four commonly sustained by barbell athletes:
- Iliotibibial Band Syndrome
- Patellofemoral Compression Syndrome
- Patella Tendinopathy
- Biomechanical Dysfunction (aka Bad Technique)
There are other causes of knee pain, of course, but a large majority of the problems I see with barbell athletes can be traced back to these four diagnoses.
Iliotibial Band Syndrome
The IT band is a thick band of fascia that starts at the hips and runs the entire length of your leg, connecting to the outside part of the patella (knee cap), tibia, and lateral hamstrings (biceps femoris tendon). (1) This pain usually presents on the lateral part of the knee and is caused by excessive compression of the band as it pushes into the fat that covers the prominent bony part of the femur (lateral epidondyle). While this pain can start off dull and achy, it can often progress to a sharp pain that you can pin point to one specific area on the outer surface of the knee.
How Can You Test For This?
A simple test many medical professionals use to diagnose this injury is called Noble’s test.
In a seated position, the examiner applies pressure on the lateral side of your knee directly over the femoral epicondyle (the most bony prominence that sticks out). The examiner then lifts your leg from this bent position. It is considered a positive test if you have pain as the knee reaches a 30° bend.
Patellofemoral Compression Syndrome
When the tissues that surround the knees are stiff and bogged down, it smashes the patella into the femur (trochlear groove). This type of compression can cause the patella to shift and tilt to the side (creating uneven pressure on the underside of the bone). When this occurs, it can create pain on the inner or medial side of the patella where the tissues are stretched.
Here are a few common tests for patellar compression pain.
One of the most common overuse injuries to the knee is patellar tendon pain. Patella tendinopathy, also called “jumper’s knee”, refers to inflammation and pain located at the lower tip of the patella (inferior pole), patellar tendon, or at the insertion of the tendon into the tibia (tibial tuberosity). The less common quadriceps tendonitis, is often felt in the area directly above the knee cap (superior pole). Both of these issues often elicit pain on the ascent of a squat.
A more severe and chronic version of this injury is patellar tendinosis. With this condition, the tendon fibers fail to repair itself. The tendon becomes crappy in quality and is often degenerative. This is a serious condition in which seeking medical help is highly advised and recommended.
Biomechanical Dysfunction (Lateral Patella Tracking)
It shouldn’t come as any surprise that poor technique when barbell training leads to knee pain. Even the subtlest problems in knee control can lead to the gradual development of pain over time. The two most common causes for this type of knee pain are poor stability and mobility.
The foot is like your bodies ‘house of cards’. Its stability sets the foundation for the rest of your body to move. When the foot collapses over (pronation) it leads to rotation in the tibia that forces the patella to move laterally. (3) This same problem can also occur due to poor hip coordination that leads to knee collapse during the squatting motion.
Flexibility and mobility issues in the lower body can also create a number of movement problems that lead to knee pain. For example, limited hip internal rotation or stiffness in the lateral hamstrings can lead to excessive toe-out angle during the squat that again pulls the patella laterally. When the knee moves in this off-axis manner with enough repetition, pain eventually develops that mimics the patella compression diagnosis. However, loosening up the stiff tissues that surround the knee with this diagnosis will not fix the true cause of the pain.
Diagnosing Your Knee Pain
Patella Tendonitis & Quad Tendinopathy
Pain is on the side of the knee just above the bony prominence (lateral epicondyle). Your knee cap is often not sensitive to touch.
Pain is located in or around the knee cap. It is not comfortable to push on your knee cap while contracting your quads.
Pain is above or below the knee cap (often in the tendon that attaches to the bone).
Finding the source for you aching knees can be a daunting task, however with the proper diagnosis we’ll be able to better direct you in fixing your pain. Be aware that you may have one or more of these issues. For instance, an athlete can demonstrate patellar tendon pain and also have concurrent patellar compression pain.
While some people will have more than one of these conditions at the same time, none bring out locking or clicking, significant swelling, tingling or numbness, or throbbing in the back of the knee. If you have any of these symptoms, it’s likely an indication of a larger problem that requires a medical evaluation by a professional.
For the next few weeks, we’ll go more in-detail into each of these three categories starting with IT Band Syndrome.
Until next time,
- Khaund R & Flynn SH. Iliotibial band syndrome: a common source of knee pain. American Family Physician. April 15, 2005; 71(8): 1545-155
- Wilk KE, Davies GJ, Mangine RE, Malone TR. Patellofemoral disorders: a classification system and clinical guidelines for nonoperative rehabilitation. JOSPT. November 1998; 28(5): 307-322
- Sammarco GJ, Burnstein AH, Frankel VH. Biomechanics of the ankle: a kinematic study. Orthop Clin North Am. 1973; 4(1):75-96