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
- Patellar and Quad 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.
Athletes who are involved in sports that include sudden explosive and repetitive movements of the knee can develop pain and tenderness at these tendons. Of the two, patellar tendon pain is usually the more common injury especially in sports such as basketball and volleyball due to the excessive jumping (this is where the term “jumpers knee” was coined). However, patellar and quadriceps tendon pain are both very prevalent in sports such as weightlifting, powerlifting and CrossFit due to the high forces that are sustained during the repetitive strength and ballistic movements.
Classically, those with patellar tendinopathy will complain of tenderness and pain at the connection point of the kneecap and patellar tendon (called the inferior pole of the patella). You may even experience pain where the patellar tendon attaches to the tibia (a small bump on the front of your shin called your tibial tuberosity). Usually you won’t have pain directly in the center of your patellar tendon unless you’ve sustained a direct blow to the knee (like hitting your knee into a corner of a desk).
Those with quadriceps tendinopathy will have pain and tenderness at the connection point of the kneecap and the quad tendon (called the superior pole of the patella).
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
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