Rehabilitation of Anterior Knee Pain in the Pregnant Athlete

Pregnancy may be a risk factor for ligamentous laxity in the lumbopelvic and peripheral joints, leading to patellofemoral pain and related symptoms. According to previous research at Massachusetts General Hospital, 26% of pregnant individuals reported severe knee dysfunction, the prevalence increased from the first to third trimesters, and a high level of physical activity was among the risk factors.

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Now, a Mass General team has developed guidelines for offering physical therapy to recreational and competitive athletes with anterior knee pain during a healthy pregnancy. For each trimester of pregnancy, they explain the physiologic changes relevant to sports medicine, specify rehabilitation goals, and present guidance about interventions.

Researchers from the Mass General Brigham Women's Sports Medicine Program, including Jamie A. Preszler, DPT, a senior physical therapist in the Department of Sports Physical Therapy, Kelly C. McInnis, DO, a physiatrist who co-directs Mass General Brigham Program as well as the Women's Sports Injury and Performance Clinic at Mass General, Lisa Baute, MD, an obstetrician/gynecologist in the Department of Obstetrics and Gynecology, and Miho J. Tanaka, MD, PhD, orthopedic surgeon and program co-director, published the recommendations in Physical Therapy in Sport.

First Trimester

The hormone relaxin increases through week 12 of gestation, modifying ligament structure and affecting the knee directly and indirectly. It's important to establish lumbopelvic, hip, and knee muscle strength and control. Soft tissue mobilization is recommended to reduce myofascial stiffness that may contribute to pain and limited range of motion.

External support, including patella taping and orthotic inserts, can temporarily relieve acute and subacute patellofemoral pain.

Second Trimester

Beginning in the second trimester, anterior pelvic tilt increases and the center of gravity shifts anteriorly as the fetus and gravid uterus grow. The authors recommend positional modifications to common patellofemoral pain rehabilitation exercises that will allow the athlete to accommodate these postural changes.

Combining hip- and knee-targeted exercises with lower quadrant manual therapy may be indicated for patellofemoral pain. The new guidance also suggests specific core stability and foot strengthening exercises to maximize knee function during pregnancy.

Third Trimester

During the third trimester, weight gain is accelerated, soft tissue edema becomes notable, and the growing fetus and uterus displace the diaphragm superiorly, affecting the cardiovascular and pulmonary systems. As these demands on the musculature progress, preventing an increase in patellofemoral pain is important so physical activity can continue.

Precautions

Because physical therapists may hesitate to treat pregnant athletes, the authors provide detailed advice about safe care:

• No specific positioning precautions are necessary for physical therapy during the first trimester
• Exercise in the prone and supine/hook-lying positions is not recommended during the second and third trimesters
• Avoid the Valsalva maneuver in the third trimester as it can decrease cardiac output, causing dizziness and other symptoms, and unduly strain the pelvic floor muscles
• Proper breathing should be a particular emphasis during strength training in the third trimester
• Isometric, concentric, and eccentric exercises do not compromise maternal or fetal well-being during healthy pregnancies in the third trimester when performed with rest periods and supervision

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