I started playing squash in 2008 but, within a few months, I developed a minor pain on the flip side of my left knee, which progressively grew to a painful niggle every time I bent it. Eventually I underwent a diagnostic arthroscopy, which revealed my condition to be a “softening of articular cartilage over medial femoral condyle”. I recently started playing squash again, but despite a conscious effort to not overdo it, my knee has started hurting again. What should I do? Please help!
Squash is an effective way to keep fit but it definitely takes a toll on the body, especially the knees. But that’s no reason to stop. Let’s focus on getting your body strong enough to play the game injury-free.
The most likely diagnosis based on the symptoms you’ve mentioned would be patellofemoral joint syndrome, which means the kneecap (patella) does not track properly in the groove provided to it by the thighbone (femur). The kneecap is controlled by the thigh muscles (quadriceps) and gets stability from the Illiotibial band (which starts at the hip and goes down the outside of the thigh to end alongside the knee), buttocks (glutes) and core. If these structures do not apply force properly to the knee there will be a change in the knee’s alignment, so every time you bend and straighten your leg, the back of the kneecap will rub against the femur and create inflammation. Excessive loading of the inner-side of the knee joint leads to eventual degeneration of the femoral condyle as mentioned in your arthroscopy.
Recognise the symptoms
Just in case there is something more sinister like a cartilage tear, ask yourself a few more questions. If your answer to at least three is yes, go see a good clinician before starting a rehabilitation routine.
- Does the knee give way on you?
- Do you get sudden catching pain or locking in your knee?
- Do you tend away from twisting movements, not trusting your knee?
- Is there swelling that just doesn’t ease off no matter what you do?
You’ll need to focus on the stability, flexibility, strength and endurance of the muscles associated with keeping your knee healthy. Also, if you have a dropped arch, you’ll be more prone to loading the inner side of the knee joint with weight-bearing activity. A good pair of shoes as well as arch supports would help here.
For flexibility, stretch your glutes, hamstrings (muscle behind your knee) and quads daily. The stretch should last 30 seconds and be repeated thrice. Do this thrice a day.
A leg injury affects your balance on that leg, which makes you prone to more injury. To improve stability and strength, stand only on the injured leg. Gradually decrease the stability of the platform on which you are standing, and add activities like throwing a ball in the air or bounce a squash ball on the racket. As your pain eases you can start adding sport-specific exercises like single leg squats and lunges in the pain-free zone with your knee aligned over your middle toe and your pelvis straight with your core engaged.
To improve the stability of your pelvis and knee, you’ll need to strengthen your glutes and quads. Lunges are great for this but if you are really sore, start with a gym routine without weights and progress to a sport-specific regime like squats and lunges after three weeks. Stick to the leg press and calf machines rather than the knee extension machine for strength training to protect your kneecap.
To improve your endurance, keep the reps high and the weights low. Start with three sets of 10 progressing to four sets of 15 over a six-week period. Start with cycling for cardio, slowly introducing running by the third week. It takes three months to develop good muscle firing patterns, so don’t rush it. You can start getting back on the squash court after six weeks of strength and stability training, doing drills at first, looking to compete by the third month.
Listen to your body and progress steadily. If you overdo things, ice is good but never exercise through your pain. Good luck!
Claudia is a physiotherapist with Elite Athlete Performance.