Potential Risk Factors for Knee Pain:

• Poor quadriceps strength (particularly, the inner/medial quadriceps).
• Poor hip abductor and/or hip external rotator strength.
• Prior knee injury.
• Over use.
• Obesity.
• Poor foot biomechanics including overpronation (when the feet excessively roll inward, which causes the knee to roll inward during each step).
• A larger “Q-angle” which is the associated angle between the hip and knee.
• Even anomalies in the shape of one of the bones that make up the knee joint could predispose you to knee pain.

The most obvious (yet rarely talked about) reason for experiencing knee pain directly relates to your range of motion (ROM).  In its simplest form, the knee is a hinge joint.  It bends and straightens (flexes and extends).  If your knee isn’t able to fully bend or straighten because of either excessive quadriceps tightness and/or hamstring tightness, then you’re at an elevated risk for many common knee pain diagnoses including Patellar Femoral Pain Syndrome (PFPS) and Patellar Tendinitis.

Quadriceps Tightness

Poor range of motion in the quadriceps can be associated with a higher risk for developing knee pain.  One potential reason for this is that the quadriceps muscle blends into the quadriceps tendon.  Eventually it attaches to the patella (kneecap) before becoming the patellar tendon where it attaches to the tibial tubercle on the tibial bone (the main lower leg bone).

Excessive tightness will cause alterations in force and tracking of the patella.  This can lead to inflammation and ultimately, pain in or around the structures of the knee (including the patella, quadriceps tendon, patellar tendon, the patellar femoral joint or the infrapatellar fat pad).  The following four muscles make up the quadriceps:  vastus lateralis; vastus medialis; rectus femoris; and the vastus medialis.  The rectus femoris is most likely to be tight as it crosses two joints–both the hip joint and the knee joint.  The other muscles only cross one joint–the knee joint.

Normal range of motion in the quadriceps will vary from person to person (especially, the older you get or if you have a history of injury).  For most healthy and younger to middle aged people, normal range of motion could be defined as the ability to touch your heel to your buttocks with your hip and low back in a neutral (not flexed or extended) position (as demonstrated below).

Regular static stretching and mobilization will help you to improve your range of motion in the quadriceps and ultimately, avoid knee pain. 

Static Stretch

Static stretching is best performed post workouts.  (Static stretching prior to a work out or activity has been shown to decrease performance.)  Hold the following stretch for at least 60 seconds, and perform two to three repetitions.

Quadriceps “Tack and Floss” Mobilization

You can use a foam roller to help mobilize the quadriceps while working on your range of motion.  Position your upper thigh onto the foam roller.  Roll around until you locate a particularly tight and/or restricted area, and then very slowly bend your knee back and forth.  If this is painful, do not exceed more than a mild to moderate amount of pain.  Perform 1-2 minutes on each leg once per day.

Hamstring Tightness

Hamstring tightness can often restrict full knee extension (particularly, during functional activities).  The most common reason for poor hamstring mobility is chronic poor posture while sitting and standing.  Most of us sit for a good portion of the day.  This results in tight hamstrings and increases your risk for experiencing knee pain as well as low back pain.

Poor range of motion can also be a contributing factor to muscle imbalances.  A hamstring that is either too long (over stretched) or a hamstring that is too short and contracted will not generate as much force and strength as a hamstring within its optimal length.  The ability for a muscle to contract optimally is dependent on it being at an optimal length.  This is known as the length tension relationship.

Many people (women in particular) struggle with adequate hamstring strength in relationship to quadriceps strength.  This muscle imbalance can lead to pain and is a major risk factor in suffering an ACL tear.  Therefore, one way to insure proper hamstring strength is to insure proper hamstring length. 

Hamstring Stretch in Doorway 

Static stretching is best performed post workouts.  (Static stretching prior to a work out or activity has been shown to decrease performance.)  Find a doorway and place one leg on the frame and stretch the opposite leg through the doorway.  Try to keep your back with a neutral arch.  As your hamstring relaxes, slowly move closer to the wall or doorframe.  Hold for at least 1 minute per side, and preferably two repetitions per side. 

Hamstring Mobilization Using the Foam Roller 

Place your leg on the foam roller.  Roll your hamstring back and forth on the foam roll.  Move slowly and spend extra time on the more painful areas.  Be sure to mobilize the entire hamstring and feel free to work on other areas of the leg that feel tight or restricted.  If this is painful, do not exceed more than a mild to moderate amount of pain.  Perform for 1-2 minutes per leg.

Don’t forget the basics when it comes to self-treating knee pain.  Lack of range of motion could be the most simple and obvious reason for why you’re experiencing knee pain.  Implement my recommended exercises in order to address any tightness in the quadriceps and/or hamstrings.  Getting back to the basics can be an integral component to successfully treating your knee pain and preventing further injury.

If you’re experiencing knee pain, do you think either poor range of motion and/or tightness in your quadriceps and/or hamstrings are causing it?  Which strategy can you implement to alleviate your pain and prevent injury?  Please share below.

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A.  Excellent question, Lisa! A spondylolisthesis (spondy) is a certain kind of back injury that is associated with a pars interarticularis defect which is part of the vertebrae. It’s often called the “scotty dog” fracture because of its shape. This condition can be congenital (from birth) or happen from trauma. It’s diagnosed slightly more in males (5% of the male population versus 3% in the female population).

It is important to note if the fracture is stable or not. If the spondylolisthesis is unstable during active motion, such as bending forward or backward, the vertebrae can actually slip and move forward or backward.

Spondylolisthesis injuries are graded I, II, III, IV, and V.

• A Grade I defect occurs when 25% of the vertebral body has slipped forward.
• Grade II occurs when 50% of the vertebral body slips forward.
• Grade III occurs when 75% of the vertebral body slips forward.
• Grade IV occurs when 100% of the vertebral body slips forward.
• Grade V occurs when the vertebral body completely falls off which causes a spondyloptosis.

In many cases, you will never know if you have this particular condition unless an X-ray is taken. For most people, this condition is completely benign and painless (particularly, in Grade I defects).

If you have a Grade I or II spondylolisthesis and are experiencing pain, conservative treatment (including formal physical therapy) is usually the first form of treatment. Surgical intervention may be performed as needed in the case of a Grade II spondylolisthesis. Surgical intervention is almost always necessary in cases of Grade III or higher.

Exercise and Treatment Considerations

In case of a stable Grade I and some Grade II spondylolisthesis, exercise is an important part of the treatment strategy. There are a few items of consideration. First, obtain clearance from your medical physician. Often, a series of X-rays will be taken while you are standing and standing bending either forward or backward. This can determine if the area is stable. If so, then conservative treatment can be initiated.

When determining which motions to guide your treatment, always let pain and directional preference guide your movements. A directional preference is simply a method to identifying a pattern to the pain.  Does the pain get worse when you bend over or does it improve?  What happens when you repeat this movement?  Determine how your pain responds.  If it spreads away from the spine and down into the leg, beware that you are moving in the wrong direction.  Stop that particular movement.  If the pain improves then continue with exercises in that direction.  Never do anything that worsens your pain or symptoms.

On average, I tend to have my clients be less aggressive with lumbar range of motion, especially press-ups and backward bending. Although it’s not prohibited completely in the case of a stable injury, it’s merely a precaution as some research indicates that it may have the potential to cause more pain and worsen the pars defect.

It’s also entirely possible that the cause of pain has nothing to do with the spondylolisthesis. A thorough physical therapy evaluation should help to determine the actual cause of the pain (although, sometimes it is never truly known). The American Physical Therapy Association (APTA) offers a wonderful resource to help find a physical therapist in your area. In most states, you can seek physical therapy advice without a medical doctor’s referral (although it may be a good idea to hear your physician’s opinion as well).

The focus of the treatment and exercise is on the strengthening of the inner and outer core muscles and lumbar extensors. With the only caveat being that you may need to avoid excessive loading with the spine extended. In this instance, I recommend that you work with a highly qualified trainer or sports medicine professional to insure that you are performing your particular exercise and sport in a manner that will keep you safe and the fracture stable.

It is also important to insure proper hip and pelvic mobility so that the spine is not over worked. In cases of spondylolisthesis, insuring a normal amount of hip extension in addition to proper hamstring length and hip rotation is important. If the hip cannot fully extend during walking and running, it will cause excessive lumbar extension. You may even want to focus on having less of a lumbar curve (a posterior pelvic tilt) if your tendency is to hyper extend with an anterior pelvic tilt. Be sure to work on thoracic mobility to insure the entire vertebral chain can move freely.

Exercise is the critical component to the management of this condition. I would highly advise that you consult with a local physical therapist that has a Lumbar MedX exercise machine.  This particular machine can isolate the lumbar multifidus during exercise better than any other exercise that I am aware of.

Other exercises can be utilized to activate the multifidus. These Lumbar Extensor Exercises are designed to progressively activate the multifidus muscles (with the final exercise being the most challenging). Generally improving your core strength is a critical component to the overall treatment. My only caution is to once again avoid excessive loading in hyper extension and to take your strength progression more slowly while monitoring your symptoms.  If you perform an activity that causes worsening pain, then you will need to modify or eliminate that particular activity until it can be performed pain free.

In some cases, more flexion biased stretches would be indicated. This would be determined by the directional preference.  If extension biased exercises worsened the pain and flexion biased exercises improved the pain, then initially you would proceed with flexion biased exercises to help control pain while you progress into your core and lumbar stabilization program.  Examples of flexion biased stretches would be a single knee to chest (below left) or a double knee to chest exercise (below right).  Hold these for 20-30 seconds at a time and perform 4-5 repetitions each.

Good luck, Lisa! I hope you find this information to be helpful and provide some relief from the pain you’re experiencing.  For more information on treatment strategies for low back pain, please refer to How to Safely Self-Treat Low Back Pain.

Do you suffer from spondylolisthesis? Please share your best tips for pain management.

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Disclaimer:  The Physical Therapy Advisor blog is for general informational purposes only and does not constitute the practice of medicine or other professional health care services, including the giving of medical advice. No health care provider/patient relationship is formed.  The use of information on this blog or materials linked from this blog is at your own risk.  The content of this blog is not intended to be a substitute for professional medical advice, diagnosis, or treatment.  Do not disregard, or delay in obtaining, medical advice for any medical condition you may have.  Please seek the assistance of your health care professionals for any such conditions.

To safely self-treat your low back pain, first take a moment to assess your symptoms and pain level. What led to your pain and/or injury?  Did the pain come on suddenly or slowly?  Evaluate the severity of the injury. If you’re experiencing any of the following, please seek immediate medical attention:

• Loss of bowel/bladder function.
• Uncontrollable pain. The pain is so severe you cannot function or move.
• You are losing muscle function or control. The muscles in the legs will no longer work. (This is different than pain preventing the muscle from working.) This sensation of paralysis occurs when the muscles will not actually function.
• Significant loss of sensation in the leg or groin area. This is not a tingling sensation, but an actual loss of sensation. For example, you cannot feel the toilet paper when you wipe after using the toilet.
• Onset of pain without any known mechanism for the injury. (Thoroughly consider your activity. Many times, a slow onset of pain begins several hours after performing an activity.)

Fortunately, most LBP is mechanical–meaning it is from a physical or structural cause and isn’t related to conditions such as cancer or infections. Most LBP will have a directional preference for extension.  A majority of injuries occur when performing a forward biased (flexed movement) like chronic slouching or a spinal flexion biased movement.  For discussion purposes, I will be addressing an extension biased program.

You should be able to alter and change your LBP within a short period of time. First, establish a directional preference by identifying a pattern to the pain.   Does the pain get worse when you bend over or does it improve?  What happens when you repeat this movement?  Determine how your pain responds.  If it spreads away from the spine and down into the leg, beware that you are moving in the wrong direction.  Stop that particular movement, and instead try flexion biased movements.  In my experience, most episodes of LBP tend to respond better to extension biased movements.  If flexion or extension doesn’t help or change the pain in any way, then you may need assistance from a medical provider.

The rule of thumb for movement: If the pain worsens by spreading peripherally down the buttock and into the leg and/or foot, then the condition is worsening. We must stop that activity.  If the pain centralizes and returns back toward the spine (even if the pain worsens slightly), then keep moving as the condition is actually improving.  For a thorough discussion and an excellent treatment resource, please refer to Treat Your Own Back by Robin A. McKenzie.

Although most LBP isn’t considered serious, the pain tends to re-occur. One major reason for this is that the deep stabilizing muscles known as the multifidus muscles reflexively shrink, weaken, and lose function. Without proper rehabilitation, the muscles will not fully recover.  This increases the risk of future episodes because the spine no longer has the ability to stabilize itself normally.

How to Safely Self-Treat Low Back Pain:

• Perform Press-ups – Once you have injured your back, immediately start press-ups. Perform this exercise with high repetitions and frequently throughout the day as long as the pain does not periperalize down the buttock and into the leg and/or foot. Lie on your stomach and perform 10-20 press-ups. Move slow and easy, but work your way up to full motion multiple times a day.

• Perform Standing Back Extensions – After sitting, stand up and perform standing back extensions. Ideally, perform this exercise at least 10 repetitions each time you stand.

• Activate the Multifidus – Start exercises to activate the multifidus muscles as soon as possible. Think spine extensor muscle activation. Again, perform this exercise frequently during the day after the initial injury. The Lumbar Extensor Exercises are designed to progressively activate the multifidus muscles (with the final exercise being the most challenging). Once the pain subsides and muscle function improves, more advanced lumbar extension strengthening and stabilizing exercises should be performed to decrease your risk of re-current low back pain.
• Don’t Sit – Walking is critical to your recovery! It’s the number one way your spine receives nutrients and disposes of metabolic waste products. Walk frequently, and try to avoid any prolonged sitting.
• If you Sit, Use Good Posture – Use a McKenzie Lumbar Roll to help insure a good lumbar curve. If you can’t sit comfortably, listen to your body and don’t sit! Be sure to stand up and walk every 20-30 minutes. Make sure you stand with good posture as well.
• Stretch the Muscles of the Legs and Pelvis – Hamstring, Hip Flexor, and Piriformis Stretches for LBP help to reduce muscle spasms and tightness throughout pelvis area when performed daily. Stretch for at least 30 seconds at a time, 2-3 times each session.
• Reduce Inflammation and Support the Healing Response – I recommend starting a thirty day course of CapraFlex by Mt. Capra.  CapraFlex is an organic glucosamine and chondroitin supplement which also includes an herbal and spice formulation designed to naturally decrease inflammation and support healing.  I recommend it to anyone recovering from an injury or attempting to prevent injury when performing at a very high level. I personally use it, and in my practice, it has helped clients recover faster and prevent injury. It can interfere with some blood thinning medication, so if you are on this type of medication, please check with your physician.
• Ice as Needed for Pain – The rule for icing is to apply ice no more than twenty minutes per hour. Do not place the ice directly against the skin, especially if you are using a gel pack style. Individuals with poor circulation or impaired sensation should take particular care when icing.
• Use Topical Analgesics for Pain – There are many topical agents which can be used for pain. My two favorites to help manage pain and stiffness are Arnica Montana (an herbal rub) and Biofreeze.
• Be as Active as You Can – Don’t stop moving! It’s important that you remain as active as you can. You should taper certain activities that you know will increase your pain. This typically would be activities involving heavy loading of the spine such as squats with weight, deadlifts, and other activities that may cause forward flexion (particularly under a load). As you are able to, continue to work on cardiovascular conditioning and core muscle activation, particularly the lumbar extension exercises. Remember the concept of peripheralization and centralization. If your pain progresses from the area of the injury into your leg, then you need to stop that activity. If the pain remains constant or is progressing out of the leg, then continue with the activity as you are helping the body to heal.
• Ask for Help – Yes, even physical therapists have to ask for help sometimes! Many useful manual techniques can help to manage LBP. You just can’t perform them on yourself. If your pain is not improving, I highly suggest seeking a qualified and competent physical therapist who works with clients suffering from LBP. The American Physical Therapy Association offers a wonderful resource to help find a physical therapist in your area. In most states, you can seek physical therapy advice without a medical doctor’s referral (although it may be a good idea to seek your physician’s opinion as well).

Low back pain is a serious and debilitating condition. It will either most certainly affect you or someone close to you.  Be pro-active in maintaining a healthy back by incorporating these helpful methods for a speedy recovery.  Don’t let LBP affect your ability to stay active and keep enjoying your favorite activities!

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