Could weak muscles cause front of kneecap pain? , fsf, Query, 4/2009

[JimStanmore]

04-27-2009, 05:34 PM
Query
        
Could weak muscles cause front of kneecap pain?
When I squat, especially on one leg, I experience mild pain in two places, not immediately, but after several seconds:

(1) In the quads, a bit above the knee. I am pretty certain this is just muscle soreness.

(2) The entire area in front of the kneecap (patella). I wish to know whether this is the result of inadequate hamstring strength, or if it is a problem with the joint.

Could poor hamstring strength create a pain in front of the kneecap? This is what I want to believe, in which case strength training - e.g., doing more squats -- will fix it. But if my knees are wearing out (I'm over 50, and my mother had knee problems) I worry that too many squats could be bad for them.

The pain increases if I hold the position, increasing significantly at the point my muscles are out of strength to support my weight, and goes away within a few seconds after I come out of the squat. It occurs in either knee.

I have generally low strength in my legs and core. E.g., I cannot shoot the duck in a normal, right angle knee position, but must drop lower until my butt cheek almost contacts my heel. I can not rise out of that on one knee, unless I first shoot my free leg backwards for momentum. I cannot jump high. I skate forwards fairly fast, but not backwards. I don't do good power pulls. E.g., I can not begin gliding using a power pull, an exercise a coach recently provided in a group lesson.

I also have very poor muscle flexibility. E.g., I can't come anywhere near a split with straight legs, but if I bend one knee (which I guess releases hamstring tension), my hip can almost come to a full (forward or sideways) split position (which suggests the hip bones, ligaments and joint capsule). Nor can I go into a proper spiral with a fully straight skating leg. Likewise I cannot touch my toes with straight knees, and on the floor with legs in front of me, I can not bend forward past about 90 degrees (though with knees bent, I can go into child pose or fetal position without feeling the stretch), and have virtually no spinal back-bend (especially in the lower spine), and relatively poor side-bend.

In short, I should give up on skating, but I'm stubborn.

If this requires a medical diagnosis, financial issues make it necessary to see as few specialists as possible, as cheap as possible. Could a physical therapist or certified physical trainer diagnose this, or do I need someone more expensive? What type of specialist do I need to see?
Last edited by Query; 04-27-2009 at 05:42 PM.


Old 04-27-2009, 07:07 PM
TreSk8sAZ
        
A physical therapist or orthopedist could diagnose something like this. You have to be very careful just doing squats, however, because it could be something other than weak hamstrings and could inflame a problem in your actual knee from the repetitive motion.

I had pain in my knee for a number of reasons, had trouble getting low in sit spins, etc. While I had an injury, a large cause of the pain once the injury was no longer the issue was an inequality between my inner and outer quad. Apparently my IT band and outer quad had taken over and essentially my inner quad died. This caused pain in the kneecap area because one side was pulling without me being aware of it. I felt no inequality, other than just a bit of weakness.

So it may be something more than just poor hamstring strength because it could be an inequality or it could be a completely different mucles that is pulling one side out of alignment. You want to make sure you're working the right area while taking care not to further inflame or injure the sore parts.
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04-27-2009, 09:04 PM
NCSkater02
        
Yes. Skip squats, lunges, and stairs until you can see an orthopod. I've had knee pain for years--skating strengthened my muscles so it quit hurting. Now that I've missed most of the last year, my knee is hurting again.

Get it checked out before it turns into something major.


04-27-2009, 11:57 PM
TiggerTooSkates
        
If you have a medical school in your area, call up their sports med/orthopedics division and see if they can help. Sometimes you get lucky.

I understand about the finance thing - I've been there too.


04-28-2009, 08:21 AM
RachelSk8er
        
I had patellar femoral syndrome in my knees, same kneecap area pain you describe. Balancing out strength in my hamstrings (which were noticably weaker) and my quads, strengthening my calves/shins and ovrall core strength got rid of it completely. I worked with a trainer for 12 weeks earlier this year to make sure I was doing things correctly before going off on my own. Need to get my butt back in the gym before the problems come back, I've been BAD all semester with the gym....

Romanian deadlifts with a medicine ball were a great exercise for me not only for hamstring strength, but balance and getting a good stretch behind the knee. You can google how to do them, they're easy. I did a lot of exercises with the Bosu ball, too.

I also have a friend who is a PT and she said a lot of problems come from some muscle in the butt that on skaters actually tends to be weak and other muscles overcompensate for it causing pain (she tested mine, Stormy's and a few other people at ANs and when she does it, if it's weak you pretty much fall over, it's funny). You'd never think a butt muscle in a skater would be weak.
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04-28-2009, 03:33 PM
doubletoe
        
Absolutely yes. I had the same symptoms and was diagnosed with this problem a few years ago. It is very common among skaters because we use our outer quads more than we use our inner quads or hamstrings, creating an imbalance in the pull on the knee. In my case, my inner quads were fine, but my hamstrings were under-developed compared to my quads. I was asked to stop doing sitspins, salchows and axels for 6 weeks and do hamstring exercises every day. It worked. My physical therapist was a figure skater herself, so she was great at explaining how each figure skating movement affects the muscles and knees!
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04-28-2009, 04:46 PM
Skate@Delaware
        
Just be sure, if you see someone, that you tell them you are an athlete (you train, don't you?). Try to find a SPORTS physiotherapist. That's what I did when i went through my 2nd round of therapy and it made 200% difference compared to the first round.
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04-28-2009, 08:32 PM
Query
        
Thanks guys/gals, for all your help.

Since this isn't anything sudden, and it is equal in both knees (so it can't be an acute injury), I'll try to get some data before panicking.

So I measured the effect - determined how many seconds I can stand with one foot on a specific stair and reach the other foot down to almost the next step before I start to feel pain around the kneecap. Then I'll try some moderate strength training exercises (but with no weight bearing deep knee bends) every day for a couple weeks. If it doesn't get better (done at a fixed time, say, in the morning, before the exercise), that will perhaps prove strength isn't the problem.

Then I can see a sports PT or an ATC, and give him or her the additional data to work with. Wonder if I can find a PT who is also an ATC, who I was told athletes should seek.
Last edited by Query; 04-28-2009 at 08:49 PM.
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Query


04-28-2009, 09:55 PM
rsk8d
        
Hi Query.

The type of knee pain around the kneecap can be caused by several things:

1) mis-alignment of the kneecap, causing too much friction behind the kneecap as it tracks in a groove from the femur to the tibia bone. This will refer pain in several directions around the kneecap. Some times kinesiotaping of the kneecap to improve its position will decrease the pain.

2)Tightness of the ITBand muscle, which runs down the outer side of the thigh. It attaches to the lateral retinaculum, which pulls the kneecap laterally. Deep tissue massage, foam rolling, and a lot of stretching will alleviate the tightness.

3) an imbalance of flexibility and/or strength between the hamstrings and quadriceps. There is typically a 2/1 ratio between quad and hamstring strength. Improving strength of the hamstrings will even the strength ratio. Flexibility factors in if one or both of the muscles are tight.

4) lastly: arthritis (which hopefully isn't the case)

Recommendation: get evaluated by a PT (agree with previous poster about sports PT, as there are many different specialties). Ask MD about an x-ray, and it will tell you if you hav arthritis or if it is fixable with PT.

Hope that helps! I will send you an article I wrote on the topic.


04-28-2009, 10:14 PM
Isk8NYC
        
Quote:
Originally Posted by RachelSk8er View Post
I had patellar femoral syndrome in my knees, same kneecap area pain you describe.
Interesting. I went to a sports orthopedist who ordered xrays and MRIs before diagnosing Patellar Femoral Syndrome. (Maybe it's a catch-all diagnosis?)

However, my pain is not in front of the kneecap, it's actually inside/behind the kneecap where the femor slides up and down. He said that the back of my kneecaps were developing burrs or rough spots that were preventing free movement without "catching." (Probably from falling on my knees while figure skating, btw.)

He recommended Elliptical exercise machines to build up the knee muscles without the impact of jogging or running. There were some other exercises as well, which escape me just now. (I'm better, so I've been slacking off, lol.)
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04-30-2009, 05:14 AM
Andy02
        
Regular exercise can keep inflammation down as well. One way to try to exercise the joints is by first taking a pain reliever. A pain reliever along with inflammatory will help to reduce the inflammation and therefore the pain, at least temporarily.


04-30-2009, 07:14 PM
doubletoe
        
Quote:
Originally Posted by Isk8NYC
Interesting. I went to a sports orthopedist who ordered xrays and MRIs before diagnosing Patellar Femoral Syndrome. (Maybe it's a catch-all diagnosis?)

However, my pain is not in front of the kneecap, it's actually inside/behind the kneecap where the femor slides up and down. He said that the back of my kneecaps were developing burrs or rough spots that were preventing free movement without "catching." (Probably from falling on my knees while figure skating, btw.)

He recommended Elliptical exercise machines to build up the knee muscles without the impact of jogging or running. There were some other exercises as well, which escape me just now. (I'm better, so I've been slacking off, lol.)
The diagnosis I got from the sports orthopaedist was actually chondromalacia patella (very much like what you just described). I was also told I had "tight kneecaps." But my PT said that was one of those catch-all diagnoses she heard a lot and she wasn't convinced. So the first thing my PT did was to test the relative strength of my quads vs. hamstrings and of course she found the imbalance she had suspected. I was so grateful that she was a skater because the first PT I'd gone to gave my quad exercises and it just made it worse!
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05-01-2009, 10:12 PM
rsk8d
        
Patellofemoral syndrome and chondromalacia patella are interchangeable diagnoses, usually what we see on a physical therapy prescription if MRIs are negative and there is pain around the kneecap. Referring to the previous post, a good PT would recognize a muscular imbalance. The old 'strengthen the quads' treatment is from over 15 years ago. Now, skilled PTs are trained to look at muscular strength and flexibility imbalances, patellar alignment, lower extremity alignment, and foot positioning. PF syndrome is kind of like a puzzle that the PT has to figure out. That's the fun of my job, not everyone presents the same.....
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05-07-2009, 02:48 PM
rlichtefeld
        
Quote:
Originally Posted by rsk8d
Patellofemoral syndrome and chondromalacia patella are interchangeable diagnoses, usually what we see on a physical therapy prescription if MRIs are negative and there is pain around the kneecap. Referring to the previous post, a good PT would recognize a muscular imbalance. The old 'strengthen the quads' treatment is from over 15 years ago. Now, skilled PTs are trained to look at muscular strength and flexibility imbalances, patellar alignment, lower extremity alignment, and foot positioning. PF syndrome is kind of like a puzzle that the PT has to figure out. That's the fun of my job, not everyone presents the same.....
I already had an ITB diagnosis, and had done some PT for that. But, the pain remained. Went back to the MD and he ordered an MRI and they gave me the chondromalacia patella diagnosis. I went to an orthopod, and he gave me a cortisone shot in my knee and told me to get to a gym.

I talked with several of the coaches and others in the skating community and they suggested a personal trainer that had worked with several of the upper level skaters at my rink. The gym is very close to the rink.

I have been doing 30 minutes a week with him primarily focusing on strengthening the knee as well as upper body and core for my pairs skating. I've also started taking a yoga class. Both seem to be helping. I also take quite a bit if ibuprofen every day due to Morton's Neuroma's in both feet.

So between the anti-inflammatories, and the exercises my knee feels the best it has in about 4-5 years. And, my jumps are much, much bigger!!!

So, yes try exercise, but try the correct exercises.

Rob
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05-07-2009, 05:26 PM
ibreakhearts66
        
I'm another one who has been diagnosed with chondromalacia/patellofemoral pain syndrome. I've also had other knee injuries; torn meniscus and MCL in one knee from soccer that I had surgery on, as well as a partial ACL tear and degenerative meniscus tear in my left knee that a doctor missed years ago and was found more recently (no surgery but I did get a nice Terminator-esque DonJoy brace), and a plica in the left knee. But the chondromalica/PFPS came way before and I've had lots of physical therapy for that. I did strengthening exercises for the inner part of my quads and hamstrings. The biggest problem was my outer quads being too strong and pulling my knee cap to the outside. Through a bunch of different exercises and soccer/skating, the inner quad eventually developed and you can actually see the muscle run down near my kneecap bulge when I flex. The muscle I'm describing is the one that is really really evident in professional soccer players. I'll look for a picture if I can.

Sorry I don't really remember the exercises. I do remember doing one-legged leg presses at a low weight and pretty small range of motion (no where near 90 degress).

I'll look for a picture of a soccer player where you can really see the muscle I'm talking about.
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05-07-2009, 09:32 PM
rsk8d
        
Lack of core strength, especially in an athlete, can factor in as well. If the core is weak, the knees become overloaded.

If anyone wants an article written on the subject, PM me with your email address, and I'll send it to you.....
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05-08-2009, 10:03 AM
Query
        
FWIIW, as the O.P., I've talked to a number of people about my problems. I'm told arthritus is unlikely, though I still intend to get an x-ray, because my pain only occurs a few seconds after single leg bent-knee weight bearing, and goes away in a few seconds after I straighten the knee as well.

One person I spoke to in a non-professional manner (A PT who brings arthritic people to a hot whirlpool bath at a local pool I frequent) said most arthritic pain lasts longer, and often shows up in the morning before exercise. She says the bath seems to be good for her arthritic patients, which I could take as a bad sign since I like them too, but I've always felt warm baths felt good after exercise intense enough to create muscle soreness - the whole ice and cold water thing never worked well for me.

In addition, though my mom had arthritic knees (and a knee replacement surgery her PT said she could have avoided if she had come to him), which indicates a family history, she never felt pain over her kneecap.

A ballet (which I don't do) teacher who taught a course in dance kineseology said different people do identical motions using completely different combinations of muscles. It never occurred to me that some combinations might produce unhealthy muscle strength imbalances, or might limit strength, but it seems obvious in retrospect.

So I've started paying attention to how I use my muscles. When I skate or bear weight with bent knees or jog (I deliberately use a low and long, low impact, almost race-walk style), I primarally use one small part of my quads, diagonally above and outside the knee - which is where the pain starts, before it spreads to the kneecap. Stroking I use them both to pull the leg forward into a bent knee, and to straighten the leg afterwards. That kind of very selective muscle use is probably dumb, in terms of pulling the kneecap in one direction, and might limit how strong I can get and high I can jump as well. Perhaps as a result, my quads seem 2 or 3 times stronger than my hamstrings, by a very unscientific measurement; neither are at all strong by the standards of people who use machines.

Realistically, most hamstring exercises look boring. Not sure I could stand to use a machine, or to do unexciting things like leg raises, for very long.

I am now playing with another type of running style that still stays pretty low impact, but mostly uses my hamstrings. (Still don't understand how quads and hamstrings could do some of the same things, but it works.) A runner told me one should sometimes run for short distances with a bouncy half-jumping gait for training purposes - perhaps he meant to balance muscle development. Am consciously trying distribute usage to more of my muscles, and do more kinds of activity. Am loosing weight too (from 150 to 129 pounds in the past couple years, at my slightly under 5'4" height, most of it in the last few months), just in case that is a contributing factor. I was 115 in college, and would like to get there in a several more months.

I'm not willing to give up skating, even jumping, yet.
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05-08-2009, 02:42 PM
Skate@Delaware
        
Quote:
Originally Posted by Query
I'm not willing to give up skating, even jumping, yet.
Nor should you, unless the pain becomes unbearable, then you should seek medical help.

some exercises are boring. I vary them so they don't get tooooo boring. Lunges, wall squats using a ball, walking lunges, etc. There are only so many variations you can do. I don't use the machines (my son and I work out together and he isn't allowed so out of fairness we use bodyweight only).

Since you are outside running/jogging, are you on the same side of the road all the time? Or do you run on a track? I was once advised to switch sides of the road, as the angle of the pavement can cause muscular imbalance (it slants and running on the same side causes your legs to adapt to that particular angle, which can eventually cause problems). Something I just remembered (I don't run on the road anymore).
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05-08-2009, 03:52 PM
rlichtefeld
        
Runner's frequently develop ITB (Illio-tibial band syndrome) by running on a roadway with a crown. It's the same thing that happens with skaters doing a lot of public sessions going always in the same direction.

There are several exercises for ITB. They aren't boring, don't take up a lot of time, and work well for both skating and running.

Also, try yoga to balance the over-development of the muscles that skaters develop.

Rob
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05-08-2009, 04:39 PM
looplover
        
I'm late to this but I am sure weak muscles can cause it! I've been having knee pain not from skating so much as impact from trying to jog with my dog. I'd fallen on both of my knees once while skating and was sure I'd dislodged something in there.

Well, I went to a knee specialist and she took x-rays - knees perfectly normal - she wants me to do strengthening exercises. There was apparently nothing wrong with my knees at all and I think they thought I was nuts.
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05-09-2009, 08:12 AM
sk8pics
        
I went to a sports medicine for women lecture once a long time ago, and I recall talk about knee pain in women athletes being often due to muscle imbalance, most commonly the hamstrings being too weak compared to the quads. I know I get occasional knee pain if I am not faithful about doing my leg curls and leg extensions.

Yes, the exercises can be boring, but it doesn't take long to do those two exercises. It may just be something you have to do in order to be pain free and able to do the things you want to do. But by all means, see a doctor-- one who will listen to you and work with you, rather than dismiss your pain-- rather than just waiting to see what happens or trying sort of random things.
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05-09-2009, 03:41 PM
rsk8d
        
"Realistically, most hamstring exercises look boring. Not sure I could stand to use a machine, or to do unexciting things like leg raises, for very long."- by Query


Single leg dead lifts (reach downs) and single leg bridges are pure hamstrings exercises. When progressed to doing either on something to challenge balance, they become 'unboring'.
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05-30-2009, 10:44 AM
Query
        
I wanted to see a physical therapist to help me evaluate whether or not my knee pain was caused by arthritus. Specifically, rsk8d at this forum, because she sounds very knowledgeable, and because she published the materials at sk8strong.com, some of which I have bought. (Including some very clear DVDs and a book on exercises for skaters.)

But I was going to have to travel fairly far to get to her, which would have added a lot of time and money to the process.

I am visiting Ithaca, NY, where there is a sports PT/ATC called Dave McCune who several people had told me was good. So I visited him.

He watched me move, especially the knee. He also felt my muscles and tissues while I did various things, and tested how strong I was doing various types of things.

He was able to essentially eliminate the posibility of arthritus and cartilage damage, without needing an x-ray. rsk8d talked about Quad/Hamstring strength imbalance as a frequent cause of such problem. He says I do use my quads too much. But he said in my particular case, I only support my weight with my quads. And my kneecap moves wrongly because of this. He gave me a bunch of exercises to try to bring in more muscles, around my hip and rear end. He says this will improve my skating balance and performance too. He also wants me to strengthen everything - quads, hamstrings, core, hip, rear end.

He says a lot of skaters (as well as dancers and gymnasts, who have similar problems) come into his practice, and he seems fairly knowledgeable about skating, though I don't know if he skates.

He mentioned that quad dominance is common in the US because we sit in western style chairs. In cultures where people squat, it is less common, because that uses more of ones muscles, where as chairs use mostly quads to sit and stand, and almost nothing while one is sitting.

Maybe squatting is a good exercise too.
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05-30-2009, 04:25 PM
rsk8d
        
Hi Mitch. I'm glad you were able to see a PT! Let me know if you need any more advice.
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rsk8d


05-31-2009, 11:37 AM
Query
        
Quote:
Originally Posted by rsk8d View Post
I'm glad you were able to see a PT! Let me know if you need any more advice.
I showed him the book you sell. He liked the diagrams, and pointed out similarities between what he prescribed and your exercises.

He has tried publishing books about PT through publishing houses. Says that by the time they get to print, they become out of date, and better exercises are available. Your way, self-published, may be more efficient.
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