Patellofemoral Pain Syndrome

Cameron Bulluss www.newcastle-physio.com.au

Aim of Session
Understand patellofemoral pain syndrome Quick tests that can be used in a general practice setting (full assessment 45mins) (How to examine the knee) How to differentiate it from patellar tendinopathy and tibiofemoral pathology and fat pad impingement How to treat PFPS

Patellofemoral Pain
Rewarding to treat Usually easy to diagnose Model required

Definition and Causes

PFPS

is the term used to embrace all retropatellar and peripatellar pain in the absence of other pathologies Patellofemoral pain is caused by overload or injury to the joint secondary to
Bony

malalignment/morphology hip and knee Overuse Trauma Muscle imbalance hip or quadriceps Poor lower limb biomechanics Combination of these

Patella Articular Cartilage

Functions of the Patella

Acts as a fulcrum to increase the leverage of the quadriceps musculature Protects the anterior part of the knee from external force Reduces stress in the tibio-femoral joint by reducing quadriceps force

What is the Pain Generator

Articular cartilage is aneural But articular cartilage overstress or damage can lead to chemical irritation of the synovium or chemical or mechanical irritation of subchondral bone Increased venous pressure Fibrosis of nerves in the lateral retinaculum

Not to be Missed
Slipped Capital Femoral Epiphysis

Referred Pain from the Hip

Osteochondrits Dissecans

Perthes Disease

Tumor

History

Anterior knee pain but not always

Sometimes

joint line and rarely popliteal

Often accompanied by giving way (quadriceps inhibition) Aggravated by

Stairs

(up and down) Sometimes walking and particularly hills Prolonged sitting

? Value of X-Rays

Imaging

Doesnt prove diagnosis Malalignment on films is a risk factor but not diagnostic proof Frequently misses OCD Doesnt change conservative management Usual views of AP, lateral and Skyline not sensitive to early changes or tracking Tracking is a dynamic thing and a single image is a poor representation CT with contracted quadriceps more useful

Practical Session

Quick tests
Squat

or repetitive squat try to reproduce symptoms Hip assessment Palpation

Patellofemoral

joint, fat pad, patellar tendon

Tests

for effusion Passive movement of the knee Resisted leg extension at 0, 20,45,90,120 Differentiation

Practical Session

Hip assessment Leg Length assessment Knee examination Patella biomechanics Functional tests Observation/measurement of thigh girth/vmo bulk/vmo emg/vl emg testing of quadriceps throughout examination Palpation for tenderness/effusion Ligaments collaterals, cruciates, patellofemoral Range of motion Patellofemoral tests medial tilt and medial glide, lateral glide Response to tape

Treatment

(8-12 week program)

Settle pain

Medication Taping, Bracing, activity modification, Correction of quadriceps imbalance (Neptune et al 2000
Clinical Biomechanics)

Correction of biomechanics

Body mass index optimisation

Lateral retinacular stretches (NHMRC guidelines) ?Hamstring and Gastrocnemius stretches Orthotics (Clinical Journal of Sports Medicine. 11(2) 103 -110 April 2001) footwear

Nisha J. et.al Twin Research and Genetic Epidemiology Unit, St. Thomas' Hospital, London, UK

Orthotics
Excessive foot pronation shown to increase internal rotation of the knee and is common with patellofemoral pain Biomecanical modelling supports the notion that they reduce patellofemoral pain in many subjects (Newton 2002) Correction of overpronation improve outcomes in the treatment of patellofemoral pain (Clinical Journal

of Sports Medicine. 11(2) 103 -110 April 2001)

VMO strengthening

VMO strengthening as a treatment for PFPS is supported by biomechanical studies which show lower PFJ force with stronger VMO and clinical studies which show that it is an effective treatment.
(Neptune et al 2000 Clinical Biomechanics)

Must be comfortable, closed chain where possible or open chain towards terminal extension

Strength of Gluteus Medius/Minimus

Weakness of these muscles will lead to an increase in femoral internal rotation and increased patellofemoral stress Studies on women with patellofemoral pain show that those with PF pain are more likely to have poor hip strength (Ireland,

J Ortho Sports Physical Therapy 2003)

Tape

Shown to
Reduce

pain (Crossley etal 2002) Alter position of patella (Crossley et al 2002, Larssen et al 1995) in most people Alters vastii function Improve quadriceps strength

Problems Associated with Taping

Friction Allergic reaction Tape also is difficult to apply if the patient needs to squat down fully

What factors contribute?

Remote Factors Increased femoral internal rotation Increased knee valgus Foot overpronation Muscle flexibility

Local Factors Volume of activity Sub-optimal patella position

Structural factors Dynamic factors ie vmo activity

Patellofemoral Bracing

NHMRC Guidelines for Anterior Knee Pain Syndrome

See handout