As a personal trainer, you may encounter clients who experience patellofemoral pain (PFP), a common cause of knee pain that can significantly impact their quality of life. This is often considered an overuse injury, and the lack of long-term evidence can leave you wondering about the best management options for your clients with PFP. Here are some tips based on the current evidence to help your clients achieve their goals.
Before we dive in, it's important to note that you should refer clients with PFP to a physiotherapist or medical professional for proper diagnosis and treatment. As a personal trainer, your role is to work in collaboration with the physiotherapist or medical professional to design exercise programs that complement their treatment plan. I have “bolded” the areas which can be provided by you, the personal trainer to help, regardless!
Combination treatment over stand-alone treatment: Recent studies have identified six treatment modalities that were effective in reducing pain and improving knee function at three months (1).
They include:
Knee-targeted exercise*
Combined interventions
Lower quadrant manual therapy
Knee-targeted exercises combined with perineural dextrose injection
Hip-and-knee-targeted exercise: Knee-targeted exercises combined with perineural dextrose injection, as well as hip-and-knee-targeted exercise, were found to be superior to knee-targeted exercises alone for pain and function.
As a personal trainer, it's important to work in collaboration with the physiotherapist or medical professional to design an individualized treatment plan for your client that includes a multi-modal approach. Here are my tips.
Educate, educate, educate. Education is a crucial aspect of any rehabilitation intervention. It's essential to have a solid understanding of the condition to empower the client to self-manage with performing their rehabilitation without you. So do your research on the injury, then make sure to use your knowledge (within your lane) to help your client! Some examples of what you can help with is education on load management strategies, positioning, and graded activity can be useful in pain management and increasing the client's self-efficacy. Additionally, a transparent discussion regarding expectations for how injuries heal can be useful. I often send the client the research that was easy to understand for them to also have a read!
It's also important to address the client's concerns and provide reassurance regarding the healing time, and how healing isn't linear in nature, i.e. it doesn't get better on a continuum of painful to be completely gone!
Treat the whole person: Research suggests a high prevalence of anxiety, depression, and kinesiophobia among patients with PFP (3, 4). As a personal trainer, it's essential to consider the range of factors that may influence the client's pain, function, and quality of life. Asking questions about sleep habits, mood changes, coping strategies, and knee confidence can help paint a picture of the impact PFP has on the client's life. For some clients, interventions such as sleep strategies and mindfulness may have a positive influence on their pain and function.
Additionally, kinesiophobia can influence movement patterns and has been linked to pain and disability in stair ascent for women (5). Therefore, assessment and management of kinesiophobia to avoid counterproductive movement strategies could be valuable. For example, pain-free exercises similar to the client's aggravating factor may help increase their confidence in their knee, reduce kinesiophobia, and improve function.
Address biomechanical factors: While addressing the psychosocial factors is important, it's also essential to address the biomechanical factors that may be contributing to the patient's PFP. The physio will perform thorough assessment of the patient's knee joint mechanics, lower extremity alignment, and foot posture, which can help identify any malalignments or muscle imbalances that need to be addressed. They might suggest customized orthotics, bracing, taping, and shoe inserts may be necessary to help reduce the load on the patellofemoral joint and improve joint mechanics. Where you come in, is adding any extra information that the physio might find helpful (which you may know from training the client for a while or from having more access to the client). For example one of my clients with shoulder pain told they physio she slept on her back. However I know (from seeing the tiredness in her eyes and from previous interactions) that she was a side sleeper, and this is important for recovery options in terms of injury management.
Progress exercises gradually Progression of exercises is essential in the management of PFP. Gradual loading and progression of exercises can help increase the patient's tolerance to activity, improve muscle strength and flexibility, and reduce pain. It's essential to individualize the exercise program and progress it based on the patient's pain and function. Encouraging the patient to continue with the exercise program even after their symptoms have improved can help prevent the recurrence of PFP. This is actually really important because there is a reason that the person became injured! And just because there is no pain doesnt mean they never need to do the exercises that got them pain free again!
In conclusion, patellofemoral pain is a common condition that can significantly impact the patient's quality of life. Personal trainers need to take a patient-centered approach and collaborate with the patient and physiotherapist to select the most appropriate training options. A multi-modal approach, active rehabilitation, education, addressing psychosocial and biomechanical factors, and gradual progression of exercises are essential in the management of PFP. By addressing all of these factors, personal trainers can help their patients with PFP achieve their goals and improve their quality of life.
If you know you need to start working with Physiotherapists and allied health but dont know where to start to get clients to their best outcomes, check out my exercise rehabilitation courses, or reach out if you aren’t sure.
P.S. With my courses, my hope for you is to not be "that trainer" who avoids training any area with a previous injury: I once had a client who started with me because when she got a hip injury, the personal trainer was out of ideas because the person also had a shoulder injury where for years they just worked lower body. When their hip was injured, they were out of areas to train and out of a job.
*The specific exercises and parameters should be provided by the physiotherapist, and then you can work within these limits.