Knee Cap Pain Simon Kelly

Mark: Hi, it's Mark from Top Local. I'm here with Simon Kelly of Insync Physio in Vancouver. They're award-winning physiotherapists multi time award-winning best physiotherapists in Vancouver as voted by their customers. And we're going to talk about knee pain from kneeling. How are you doing today, Simon? 

Simon: How are you doing, Mark? Thanks for dialling in, sir. I'm doing really good today. So yeah, we're just going to talk a little bit about that kneeling pain. The umbrella term we use is patellofemoral pain syndrome, PFPS for short. 

Like you so rightly said, a lot of people get pain when they kneel directly on the knee from direct compression of the kneecap against the femur. Someone like a tiler, there are someone who's working on their knees a lot in their job or your occupation. Other times people have a going up and down stairs. Particularly on the way down, actually, because it lowers that joint more. Coming down the Grouse Grind or any of the hikes we have here around Vancouver, especially would be sore.

Generally, it's more gradual in onset, not a very specific event. And then you get a lot of swelling and a lot of pain and it just tends to get worse if you don't know exactly how to treat it. 

Mark: So do you have a specific case example that you could kind of walk us through  what the presenting problem looked like? What the treatment was and then the result?

Simon: Absolutely Mark. I had a guy come in, he was a 28 year old. He's actually a mountain biker. So I think it was at the start of the Covid time actually, just before he came in, he was doing a lot of mountain biking and he said he went in a seven hour mountain biking ride there and started to feel a lot of discomfort in the knee. Now mind you, seven hours is a pretty long time. And that was a bit more than he was used to doing. So that could be part of the reason why his knee started to become sore. But also we had to decide what it was first. 

So like I said earlier, you know, we look at the different diagnosis. The fact that it was nonspecific. And what I mean by that is, you know, his foot wasn't stocking the ground and he changed direction. There wasn't a lot of swelling on presentation in the clinic. Sometimes with patellofemoral pain syndrome, you can have a minor bit of swelling. And he couldn't remember a specific event. This was what he was tying it to the seven hours of mountain biking. 

So for us, we have to build a picture off that you know that kind of excludes or includes a lot of differential diagnosis, like I said. So he did say that the pain was sort of in behind the kneecap and a bit more to the inside of the knee cap or the medial aspect I would say of the knee. Usually when it's on the outside, you might've heard of ITB band or runners pain. So that kind of excluded that just based off his subjective and what he was saying.

So basically when I actually asked him a few more questions, there kind of intrinsic factors. And then we asked him about his bike and bike size and biomechanics of his bike. And he actually said that his suspension system, which is filled with air, I believe I'm not an avid mountain biker, but he said that his saddle was quite low. Which meant that the knee angle was, his kneecap was being forced off his femur, a lot more on the ride than it usually would have been. So usually a higher saddle decreases the force of the kneecaps. So I really feel that that kind of factored in to why his knee really got aggravated on the mountain bike on the way down especially. So that was kind of his initial presentation, I suppose. 

Mark: And then what was the treatment course? What kind of torture did you put him through? 

Simon: Yeah, exactly, torture is right Mark. So a lot of the time, like I spoke about there, you know there's intrinsic factors. So generally with patellofemoral pain syndrome, you know, the structures on the outside of the knee, you know, your outside quad and your ITB band that I spoke earlier, are a lot tighter especially in, in cyclists. So the inside knee is weak, which is the inside quad call your VMO and the outside is your lateral vasteralis. So we kind of do a lot of soft tissue work down along the outside of the leg. And we do a lot of IMS, which is intramuscular stimulation. It's called dry needling because you're not actually injecting anything. It's just needling. So basically we do a lot of needling into the muscle called your tensor fasciae latae. Now, that joins onto the band that goes down outside your leg and joins  just below your knee. So a lot of times those structures can become sort of short and tight. 

So the whole goal of the treatment is to needle the muscle on the top. Deep, soft tissue massage down the outside leg. And that has just released all the outside aspect of knee. And then we strengthened the muscle on the inside of the leg. So this theory will allow the kneecap to come more to the inside or towards your other knee. But the knee cap travels in a groove and under in your femur.

So in other words, you're strengthened the inside of the knee. You rule out the outside of the knee and in then the kneecap travels, that's the intrinsic factors. The factors associated with this, are kind of a knee in position. So if your knee is coming very close to the bar, as you're cycling up and down, if the saddle is actually too low, like I spoke about earlier, that all increases the force of the kneecap on the back of the femur.

So you can do all the treatments you want intrinsically, but you really have to fix the extrinsic factors for more longer term results and relief. That's why it's very important to take a good, subjective examination. And that's kind of treatment that we would start to do far and sorry, the exercises under the knee coming in, you generally with a knee in position, you have weak hip. What we call external rotators or abductors. So keeping the knee away from the other knee. 

So a lot of strengthening exercises to get that knee into correct bio-mechanical position, along with satellites and key position. Even though he's a mountain biker, he probably wouldn't need key position, but they're all the kind of factors that we have to factor in when we're dealing with a client like this.

Mark: And so what kind of result, what was the prognosis and how did it work out for this client? 

Simon: Absolutely Mark. Yeah. So when he first arrived in, I forgot to mention it actually, you know, he was feeling pain after 10 or 15 minutes mountain biking, up and down. So by the time I finished with him a couple of weeks ago, he was up to like three or four hours again, pain free.

So I think most of it, like I said, it's a combination. He definitely had tight outside structures or lateral structures. We eased off all that. We strengthened the inside of his leg. I spoke to him a lot about the biomechanics and exactly how his knee can go up and down. So he was very, very pleased. He had no pain obviously, and obviously, initially you have to get rid of some of the aggravating factors like avoiding kneeling on his knee. Sometimes even seated positions can push the kneecap away. So he was doing a lot of sitting at a desk job as well. So when it's very, very irritated that can even be painful without direct compression, like kneeling on the knee, like I spoke about. And avoiding deep, deep positions at the knee like deep squats, they were all implemented.

So we got them back to pain-free, but obviously he wasn't back mountain bike. And so by the end of it, we just increased gradually fixed his satellite, fixed his foot position and then he gradually got better and better till he was up to three or four hours. So he was very, very pleased with the outcome. As was I. 

Mark: Great. So if you have some knee pain that you need expert diagnosis, and then a proper training program that will relieve the pain for good and the knowledge for yourself so that you know how to prevent it in the future, because these things can go on for a long time. I can speak from experience on this. Insync Physio. You can get ahold of Simon Kelly at the Cambie Street office, which is at (604) 566-9716. Or check out You can book online there. It's very simple, very easy to use. Or if you're in North Burnaby, they have a Burnaby location. You can reach them at (604) 298-4878. Again, you can book Thanks Simon. 

Simon: Cheers, Mark. Thanks very much.