Patellofemoral Pain Syndrome

By Terri Milner Tarquini


August 1, 2017
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When it comes to common sports-related injuries in figure skating, Patellofemoral Pain Syndrome (PFPS) is a biggie.

“It’s not necessarily more common in skating than other sports, but it tends to be more common in female athletes so we see a lot of it in skating,” said Ellen Geminiani, primary sport doctor at Boston Children’s Hospital and chair of the sports science and medicine committee for U.S. Figure Skating. “Running sports have it as well, but it’s the jump landings and take-offs in skating that can be a real problem. It is an overuse injury - and there is a high volume of demanding jump landings and take-offs in a typical day of skating. Not to mention that we are placing these stresses on younger bodies, which is difficult on developing structures.”

PFPS is characterized by dull, aching pain at the front of the knee or around the kneecap. The pain can become more pronounced with walking or sitting for long periods of time, as well as going up or down stairs, kneeling or squatting. Sometimes those suffering from PFPS will report a grinding feeling.

“It happens when the structure is not prepared to do what is being asked of it,” Geminiani said. “There’s a groove at the end of the femur (thigh bone) where the knee cap has to be able to glide into that track in order to straighten. If the knee cap tracking is off due to tightness or anatomy, then the knee cap has to shift to get into that track. The more it has to work to do that the more times a day, the worse it can get. It’s like a car that is having trouble staying in its lane on the highway.”

Coaches are in the unique position to be able to assess a potential problem with an athlete and do something about it.

“Coaches are watching their skaters all of the time and they really need to be aware so they can act on it,” Geminiani said. “If they can see what’s going on, they can take steps to prevent the pain and keep their skaters on the ice.”

First up: stretching, stretching and more stretching. In a sport filled with muscles needing to contract to maintain balance, control and tightness, it’s imperative.

“Proper stretching needs to be a priority,” Geminiani said. “Muscles tend to tighten easily in athletes so the hip flexors, hamstrings and IT band need to be worked on to keep them loose.”

An eagle-eyed coach can spot when alignment is off - a huge indicator that problems are on the horizon.

“Alignment over the skating side is the best thing to prevent PFPS,” Geminiani said. “The knee needs to be over the toe like it’s supposed to be; don’t let the knee fall in. The body develops a memory for that, then the muscles develop to adapt and then it only gets worse. You might be able to keep going for a while with bad alignment, but eventually it will cause significant problems.”

Physical therapy is a fantastic route to, ideally, get ahead of the problem.

“About 15 or 20 years ago there was somewhat of a breakthrough regarding the importance of hip-stabilizing strength and increasing stability in the lower core, which can make a huge difference,” Geminiani said. “With PFPS, often the outer thigh is over-developed and we need to make the inside quad and inner thigh stronger. Those muscles need to be worked to build up while other muscles need to be stretched out. It’s important to come at it from more than one angle.”

In short, this is not a problem that can be ignored and that will right itself. Pain will be ongoing and increase. A kneecap that continuously needs to keep shifting in order to track properly can even begin to wear down and break down the cartilage on the back of the kneecap, resulting in surgery in extreme cases.

“Once an athlete is suffering from PFPS, we can manage it, be we don’t cure it,” Geminiani said. “Once there’s a tendency to have a tracking problem, the skater will continue to have it. The issues of alignment or flexibility or strength need to be addressed as soon as possible. The body can compensate for a while, but left unaddressed, it will eventually bite you.”

Getting out ahead of the problem is inarguably the best route possible. The thought in the medical community is that female athletes struggle more with PFPS because the female pelvis is wider and, as such, puts greater stress on the knees.

Geminiani said there are body types that have a greater likelihood of having the injury, such as athletes with flat feet or high arches or those with pronated hips or knees.

“Bodies are unique so everybody usually has something,” she said. “After they get injured is not the time to start treating them like an athlete and doing off-ice training that compliments their sport. The time to do that is before the injury. Coaches need to be active proponents of that. A skater cannot become a well-trained athlete simply by skating alone. There has to be the off-ice stretching and strength training and addressing of alignment that compliment skating.

That’s how a skater becomes a well-trained, healthy athlete. Period.”