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Painful Knee cap

I have painful and noisy knee cap! Do I have arthritis?

Many people who suffer with knee pain, complain of a nagging pain that seems to arise from behind the knee cap . They don’t recall any precipitating injury, only that the knee has go sore and, now, affects daily activities such as climbing stairs crouching or sitting with the knees bent for long periods and sometimes it develops this grinding noise. 

painful knee cap

The knee is composed mainly of 2 joints: one between the shin bone and thigh bone (tibio-femoral joint) and another one between the knee cap and the thigh bone (patella-femoral joint).As the knee cap moves quite freely when the knee is straight, the patella-femoral joint relies on structures that stabilise the knee cap centred in

the femoral groove as it moves up and down when you bend and straighten the knee (i.e. going up the stairs, squatting).

painful knee cap

Sometimes, due to imbalances on these structures, specific weakness and poor stability in the hip or ankle joints or even an imbalanced workout at the gym, this tracking of the kneecap on the thigh bone, just behind it, goes wrong and you can hear and feel the friction, which will sooner or later lead to discomfort in the front of the knee. As demonstrated, this tends to be purely dysfunctional, therefore an appropriate course of Physiotherapy will help you normalising the function and balance of the knee and other lower limb structures in order to improve your symptoms .

Now, answering the question, there may be some wear and tear (i.e. osteoarthritis) of these surfaces that slide on each other, but it doesn’t mean your pain arises from it, as even people with some level arthritis tend to respond well to Physiotherapy.

Image on the left - different components of muscles ac on the kneecap3

Image on the right - - Illustration and MRI image demonstrating outside maltracking of the kneecap and increased contact area (red arrows)4

1. Smith B, Selfe J, Thacker D, Hendrick P, Bateman M, Moffatt F, et al. Incidence and prevalence of
patellofemoral pain: a systematic review and meta-analysis. PLoS One. 2018; 13: e0190892. 10.1371/journal.pone.0190892 PMID: 29324820
2. Petersen W, Ellermann A, Gösele-Koppenburg A, et al. Patellofemoral pain syndrome. Knee Surg
Sports Traumatol Arthrosc 2014; 22(10):2264–2274
3. Kapandji ,I.A., The Physiology of the Joints, Volume 2: Lower Limb, 5Ed, Churchill Livingstone -
4. Norris, R. & Massey, D. (2018), Patellar Dislocation, The Knee Resource [WWW document] [accessed 9 th November 2018]


Dry needling to improve hamstring muscle flexibility in athletes

Hamstring muscle flexibility is important because it optimizes musculoskeletal function and may prevent injury to the muscle. The most common way of improving muscle flexibility is through stretching, which has been shown to bring about viscoelastic and neurophysiological changes in the muscle.

In the clinical setting, acupuncture is routinely used to treat myofascial trigger points, which are commonly found in tight muscles. The aim of this study was to investigate whether the acupuncture technique referred to as superficial dry needling could improve hamstring muscle flexibility.

The literature reports that the hamstring is the most commonly injured muscle during sporting activity (O’Hora et al. 2011). Hamstring muscle flexibility is considered to be important in preventative and clinical rehabilitation programmes (Schuback et al. 2004; O’Hora et al. 2011).
Stretching exercises are recommended on the basis that they may prevent injuries (Schuback et al. 2004; O’Hora et al. 2011), improve athletic performance (Thacker et al. 2004), and improve muscle and joint flexibility (Thacker et al. 2004).

Flexibility varies between individuals, and it has been suggested that muscles spanning more than one joint are more at risk of injury (Davis et al. 2008).

The acupuncture technique known as dry needling is commonly used to treat myofascial pain and dysfunction (Baldry 2002a, b; Huguenin 2004). It is known as “dry” needling because no substance is injected (Baldry 2002a).

Acupuncture point selection:


Acupuncture Point Selection

Bladder (BL) 37 was selected as the acupuncture point employed in the present
study. In traditional Chinese medicine, the indications for using BL37 are sciatica, low
back pain, occipital headaches, and paralysis and numbness of the lower extremities (Ding 1991).

Bladder 37 was chosen because of its location over the hamstring muscle, and also because
it shows some correlation with the common MTPs of the hamstrings described by Travell & Simons (1992).

Acupuncture technique:
The acupuncture technique known as superficial dry needling was used.

The results of this research provide statistically significant evidence to support the use of this technique to improve hamstring muscle flexibility with stretching.


Bradnam-Roberts L. (2007) A physiological underpinning or treatment progression of Western acupuncture. Journal of the Acupuncture Association of Chartered Physiotherapists 2007 (Autumn), 25–33.

Baldry P. (2002a) Management of myofascial trigger point pain. Acupuncture in Medicine 20 (1), 2–10.

O’Hora J., Cartwright A., Wade C. D., Hough A. D. & Shum G. L. K. (2011) Efficacy of static stretching and proprioceptive neuromuscular facilitation stretch on hamstrings length after a single session. The Journal of Strength and Conditioning Research 25 (6), 1586–1591.


Shockwave Therapy – Treatment of Musculoskeletal injuries

Extracorporeal Radial Shockwave Therapy is a series of high-energy impulses to the affected area.

It is used as a treatment for trigger points, myofascial pain and tendinopathies like shoulder impingement, tennis elbow, hip bursitis, patellar tendinitis (knee), Achilles tendinopathy (ankle) and plantar fasciitis (foot).

Pedro is a free database of over 28’000 randomised clinical trails (RCTs), systematic reviews and clinical practice guidelines in physiotherapy.

Clinical studies performed with the Swiss Dolorclast


‘Shock wave’ therapy is now extensively used in the treatment of musculoskeletal injuries. This systematic review summarises the evidence base for the use of these modality.


A thorough search of the literature was performed to identify studies of adequate quality to assess the evidence base for shockwave therapy on pain in specific soft tissue injuries.


23 appropriate studies were identified. There is evidence for the benefit oESWT in a number of soft tissue musculoskeletal conditions, and evidence the treatment modality is safe. There is evidence that ESWT is effective in the treatment of plantar fasciitis, calcific tendinitis and lateral epicondylitis. Where benefit is seen in ESWT, it appears to be dose dependent, with greater success seen with higher dose regimes. There is low level evidence for lack of benefit of low-dose ESWT and in non-calcific rotator cuff disease and mixed evidence in lateral epicondylitis.


Br J Sports Med. 2014 Nov;48(21):1538-42. doi: 10.1136/bjsports-2012-091961. Epub 2013 Aug 5.