A picture is not always worth a thousand words…

Great article illustrating how scans can be more harmful than helpful for those in pain.

The Sports Physio

The saying “a picture is worth a thousand words” is often used to explain how a complex situation, idea, or thought can be conveyed with a single still picture. There are many examples of when this is true, such as in the media when a poignant photograph expresses some joyful, or unfortunately more often some heartbreaking situation much better than any article could.


A perfect example of a heartbreaking picture expressing a 1000+ words

And there are many examples when pictures can convey an idea or information effectively and easily within healthcare, such as the use of an info-graphic to help disseminate scientific literature and research just like Yann Le Meur @YLMSportScience and Chris Beardsley @SandCResearchdo so very well. Then there are other images that can get across a message or an idea simpler, quicker, easier than a blog or an article could such as my recent ‘physio…

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As mentioned in previous posts, Hofa’s fat pad, along with the knee capsule is the MOST PAIN SENSITIVE STRUCTURE IN THE KNEE JOINT.

The Fat Pad is found just below the kneecap, directly behind the patellar tendon. It acts as a cushiom between the kneecap and the thigh bone behind.

Causes of Hofa’s Fat Pad Pain:

1. Direct blow to the knee.

2. Poor Biomechanics – a large Q angle, pes planus, increased internal rotation of the shin bone, instability of the knee.

3. History of knee hyperextension.

Signs and Symptoms of Hofa’s Fat Pad Pain:

• Banana shaped swelling and pain at the front of the knee below the kneecap

• Worse for full extension of the knee or full bending of the knee

• Squatting, running and going upstairs can make it worse

How to test your knee for this Syndrome:

• Lie down with the knee bent

• Therapist presses firmly on either side of the patellar tendon

• Patient straightens the knee as much as possible or the therapist extends the knee with their other hand while maintaining the pressure either side of the tendon

We hope you found this post helpful. The next post will be on PATELLAR TENDINOPATHY. Stay tuned!


Front of the Knee Pain: Bursitis


Bursae are sacs of fluid found between structures like bones and tendon to reduce friction between the structures as they move by one another.

There are many around the knee. #INFLAMMATION of a bursa –> BURSITIS. The main bursae are labelled🔝


Common Causes of Bursitis:

• Trauma
• Overuse
• Infection


Important History Questions:

1. Occupation? carpenters or plumbers on their knees a lot

2. Red and Swollen? Very local and well defined. Not widespread.

3. Trauma? Fall or Hurt

4. Worse for fully BENDING the knee?

5. Pain on prolonged sitting in a low chair?

Then it could be a bursitis


Most Commonly Affected Bursae:

1. HOUSEMAID’S KNEE i.e. Prepatellar Bursa – Common in professions who spend a lot of time on their knees eg carpenters and plumbers. Due ti chronic stress on bursa.

2. CLERGYMAN’S KNEE i.e. Superficial Infrapatellar Bursa – commonly occurs with JUMPER’S KNEE due to repetitive strain on patella ligament in jumping activities.


4. SUPRAPATELLAR BURSITIS (above kneecap) – trauma or repetitive trauma from kneeling or overuse for example.


Hope that was helpful. If that is you, you may benefit from treatment. Don’t hesitate to contact or DM us. Stay tuned for the next knee pain post!


Kneecap Pain Causes: Part 2


The #Qangle (above left image) aka the Quadricep angle is formerd by:

1. A vertical imaginary line running from the tibial tuberosity (bone at the top of the shin bone under the kneecap) through the middle of the kneecap.

2. A line from the ASIS (Bone sticking out at the top of the leg on the hip bone) through the middle of the kneecap.

The normal Q angle is said to be between 14 (males) to 17 (females) degrees. An angle of 18 degrees or more increases risk of knee pain and anterior cruciate ligament injury . This is because:

1. It increases the angle between the #patella and #quadricep #tendons –> potential injury.

2. The kneecap itself does not move in its groove as smoothly and there is am increased rate if degeneration and #sublux or #dislocation.

There are many factors that can increase the size of the Q angle. They are:

1. Females – have a wider #pelvis –> larger q angle. Anterior knee pain is very common in women <30 especially runners. #Osteoarthritis of the knee is also more common in females.

2. Hip Joint – #anterversion or #retroversion of the hip, coxa vara, osteoarthritis all INCREASE the Q angle.
3. Knee Joint – ‘Knock Knees’ and outward rotation of the shin bone aka Footballer’s Legs also INCREASES the Q angle.

4. Foot – #Overpronation or a flat arch also INCREASES the Q angle.

5. Muscle weakness or #Imbalance – Weak #glute muscles and deep leg muscles INCREASE the Q angle. A SHORTENED INCIDENTS calf head and #POPLITEUS also turn the shin bone inwards INCREASING the Q angle.
Some of these factors can be resolved with treatment and #rehabilitation.

Stay tuned for more on anterior knee pain.


Kneecap Pain Causes: Part 1




#Patella Alta – above left diagram. Generally kneecaps sit in the groove and the bottom of the kneecap is about level with the joint line. However, people born with an unusually high knee cap or those left with one after surgery are susceptible to much faster degeneration of the back of the kneecap as it doesn’t sit in the groove well.

If the bottom angle of the #kneecap is line with or below the joint line (imaginary line where the knee bends) this is considered to be ‘normal’ or less likely for #cartilage damage to occur as quickly as when it is high.

#Trochlear Dysplasia – see above bottom right. This is when instead of having a stable groove to sit in. The kneecap sits in a shallow or flat groove. This allows excessive movement particularly right and left and decreases stability of the patella. It can lead to increased incidences of #dislocation and faster degeneration. When moving the kneecap side to side in a stable trochlear, the kneecap should rise a little when pushing to the outside of the leg.

Test for a shallow groove is done using the inverted J sign

– Patella Tilt – see above top right. If the patella is tilted one side more than the other, there is more chance of wearing on the side closer to the thigh bone. One tests this by springing the kneecap on the right and left sides.

Patella Testing:

1. Inverted J Sign – sit on high surface knees dangling of the side. Extend and flex knees, watch for patella moving excessively up and out as the knee extends or see link below.


Then with the legs completely extended on a couch:

2. Check lowest angle of kneecap is in line with the joint line

3. Spring the kneecap on either side to test the tilt

4. Palpate behind kneecap when sliding it to the side for pain

5. Holding the kneecap to the left and then to the right, contract the quads. Test for apprehension or pain.

6. Lift kneecap and contract quads. See if pain disappears.

More to come!


Front Of The Knee Pain: Part 2


Above is a picture of the patella/kneecap. #Patellofemoral pain is a range of pains or disorders that can be anything from mild discomfort to severe pain. The pain is thought to originate from contact between the back of the knee cap and the thigh bone.

The pain source of the cartilage is controversial. Many studies indicate it is not the #cartilage on the back of the kneecap but the soft tissues around the knee or the bone underneath the cartilage (subchondral bone) that causes the pain.

There are various causes, these can include:

1. Overuse/Repetitive Strain/Over loading
2. Arthritis
3. Trauma/Injury
4. Excessive Weight
6. Imbalance of structures around the knee cap

To name a few causes.


1. Females <30 (to be explained) 2. >50s in combination with #Arthritis
3. Sporty adolescents and young adults


1. Pain around the kneecap, usually hard to pinpoint and can feel deep or behind it.
2. Clicking in the knee while flexing and extending it.
3. A feeling of giving way.
4. Catching or locking.
5. Worse after sitting for a long time, known as a positive cinema sign.
6. Worsens after repeated squatting. Especially very low ones past 90 degrees.
7. Worse after increased loading in the knee after the following activities where the knee is flexed and the quads have to contract forcefully): (Loading through the knee is mentioned in number of times of your bodyweight (BW) going through the knee) – Upstairs –> 3x BW
– Downstairs –> 5x BW
– Jumping –> 5x BW
– #Squatting –> 5x BW
– Running
8. Swelling

Stay tuned for a more detailed look at the causes.


Front of Knee Pain: Part 1


So that you have an idea of the function of the patella aka kneecap, I have drawn 3 images above that I hope will help.

As the knee bends from a totally straight position to a totally flexed position there are different structures that come into contact with the kneecap, which help in diagnosis of knee pain. So…
In full extension (straight leg) there is minimal compression on the back of the kneecap. However HOFA’S FAT PAD can be caught, so banana shaped pain in full extension under the knee cap may be due to the fat pad (also pinches in full flexion). See diagram.

As the knee begins to bend, the kneecap gradually gets more and more compressed from behind by the thigh bone.
At 20 – 30 degrees –> it begins to come into contact with the groove it sits in between the condyles shown in the bottom left picture and it keeps sliding down as the knee flexes more.

At 90 degrees flexion – most of the back of the knee cap has come into contact with the thigh bone behind.
Between 0 and 90 degrees the compression force on the kneecap increases. This combined with the large contact area helps to DECREASE the load on the kneecap.

But 90 degrees flexion – a SMALLER contact area on the back of the kneecap and INCREASED quadriceps compression on the kneecap INCREASES the load on the knee cap.

This is why squatting, >90 degrees may not be the best idea given that at least 6 times your bodyweight if not more
is going through the area.

The top image shows how the kneecap is influenced by muscles and other soft tissue.

The forces on the inside of the kneecap that help control its movement are:

1. VMO – The inner most quadricep muscle

2. Retinaculum

The forces on the outside of the kneecap:

1. ITB – Iliotibial band, popular area thats a common cause of pain in runners and an area people love foam rolling.

2. VML – the outside quadriceps muscle.

3. Retinaculum

Any weakness or wasting in these muscles can lead to poor movement of the patella and pain. Muscle tone and strength of the quadriceps is therefore important.

The Straight Leg raise is great way to strengthen without impacting the kneecap.