CREAKY KNEES - a patient's guide
Dr Ruth Highet - Sports Physician

What are creaky knees?

Do your knees creak going up or down stairs, get irritable after being in a bent position for long periods, ache when you go to the movies or sit in the car a long time? Do they Sometimes they look a bit puffy when they're sore but they don't ever get "really swollen"?

If the pain is felt just to the inside or outside of the front of the knee and gets worse with running (particularly on hills or stairs) then most likely you have what is termed "patellofemoral pain" or "anterior knee pain". Many athletes will self diagnose themselves with 'runners knee" and much of this is patellofemoral but there are many other causes and types of knee pain in runners.

What can be done to help?

So if it is patellofemoral, there is good news and bad news. The good news is that it usually is very treatable. The bad news is that it will require a lot of time and effort on your part, doing a lot of specific exercises. Rest assured though, it is one of the most common syndromes to present in a sports medicine clinic.

In the early stages it is important to avoid activities which bring on symptoms. Fortunately, in most cases after a period of rehabilitation the sufferer can get on with the activities they enjoy. Surgery is very rarely indicated in this condition but good physiotherapy is essential. Usually the patient's major worry about their condition is that they are developing arthritis in their knee joint. We can usually reassure them that their "knee" joint is fine but their "kneecap" joint (patello femoral joint) is the culprit. Not very long ago all knees that presented with these symptoms were diagnosed as "chondromalacia patellae" (C.P). C.P really shouldn't be diagnosed however unless a surgeon has viewed the back of the kneecap at operation and visualised significant "wear and tear" there. Probably only about 1% of all the cases of kneecap pain that we see have got this far.

What is the cause?

The common denominator is that the kneecap doesn't track correctly on the front of the knee. Problems may start in the hip and pelvis. Weak buttock muscles (gluteals) resulting in poor pelvic stability are very commonly associated and require specific strengthening to correct. It will help to consciously and constantly throughout the day think about squeezing your "butt" muscles e.g. standing in the supermarket queue, talking on the phone etc. Tight hamstrings (back of thigh muscles) and tight lateral thigh muscular structures can also upset the normal mechanics of the kneecap on bending and need to be stretched out.

The biomechanics of your feet are extremely important when it comes to kneecap pain. This is particularly so when repetitive-motion high-impact sports are involved such as running, hopping, jumping and skipping activities. Excessive pronation, rolling in of the joints below the ankle joints may occur for a wide variety of reasons but this may frequently need to be controlled with orthotics (insoles inside the shoe) to help correct patellofemoral pain.

The muscles at the inside front of the knee which form part of the quadriceps muscle (the VMO) are very frequently wasted in this condition. If you try and fully straighten your knee and flex your foot up toward the shin, this muscle should form a bulge on the inside of the knee just above the kneecap. Sometimes these muscles may be present but not fire at the right time and patients have to be instructed on how to fire them. Correct firing of this muscle is very important for normal patellofemoral joint mechanics.

This muscle wastes away very quickly following surgery or after a knee injury especially if the knee joint swells up. We often see patients who have had a knee operation for a different condition and subsequently developed anterior knee pain. This is usually remedied with strengthening up the VMO again.

An Australian physiotherapist, named Jenny McConnell, became famous in the sports medicine world for her treatment programme for this condition. Most New Zealand physiotherapists are able to carry out this "McConnell" programme. Taping is used to help correct the kneecap position by correcting the glide and the tilt of the kneecap and stretching tight structures on the outside of the kneecap. Because the knee feels less painful strapped the muscles will fire off better. Specific strengthening exercises are carried out for the VMO with the knees strapped in the correct position.

I sometimes see young athletes who have been denied Phys-Ed sometimes for years on the basis of a diagnosis of "chondromalacia". This shouldn't happen as true "chondromalacia" almost never occurs at this age. Rest if anything makes the condition worse by allowing further weakening of the key muscles and not altering the biomechanics of the lower limb. Rehabilitation in this group may be very rewarding. Children and adolescents with parental encouragement are usually happy to do their exercises knowing that they can become active and painfree again.

Summary

If you have "movie-goers knee" and are apprehensive about your knee going up or down stairs with or without pain or clicking, then don't assume you have knee joint arthritis. Get along to a sports physician or sports physio. A visit to a sports podiatrist to checkout your footwear and gait might be very relevant too.