Lecture 9 Patellofemoral Dysfunction.pdf

Patellofemoral dysfunction

1. Patellofemoral
Dysfunction

2. NonoperativeManagement
Related Patellofemoral Pathologies
•Chondromalacia patellae
•Patellofemoral pain syndrome (PFPS)
•PF Instability

3. CHONDROMALACIA PATELLAE
•Chondromalacia patellae, also known as “runner’s knee,” is a
condition where the cartilage on the undersurfaceof the patella
(kneecap) deteriorates and softens. This condition is common
among young, athletic individuals, but may also occur in older
adults who have arthritis of the knee.
•SYMPTOM
Dull, aching pain in the front of your knee, behind your kneecap.
This pain can get worse when you go up or down stairs.

4. PF Instability
•Instability includes subluxation or dislocation of a single or recurrent episode
•There may be an abnormal Q-angle, dysplastic trochlea (shallow groove or flat
lateral femoral condyle), patella alta, tight lateral retinaculum, and inadequate
medial stabilizers (vastusmedialisoblique muscle [VMO] and medial
patellofemoral ligament [MPFL]).
•There may be associated fractures. Usually the instability is in a lateral
direction
•The dislocation may derive from direct trauma to the patella or from a forceful
quadriceps contraction while the foot is planted and the femur is externally
rotating while the knee is flexed.
•Recurrent dislocation is usually an indication for surgery to redirect the forces
through the patella.

5. Q-ANGLE
•The quadriceps or the patellofemoral angle, is the angle between
the quadriceps muscles and the patellar tendon. Both the hip and
foot must be placed in neutral positions.
•The Q-angle is the angle between the quadriceps tendon and the
patellar tendon.
•An increased Q-angle is a risk factor for patellar subluxation.
•the normal Q-angle for males is usually 14 degrees, and in females
it is approximately 17 degrees. A wider pelvis and increased Q-
angle in females is linked to knee pain, patellofemoral pain, and
ACL injury.

7. PF Pain with Malalignment or Biomechanical
Dysfunction
CAUSES
•Femoral anteversion
•External tibialtorsion
•Genu valgum,
•Foot hyperpronation
•A tight lateral retinaculum
•Weak VMO muscle
•Neuromuscular deficits in the hip musculature
•Incompetent MPFL
•Patella alta
•Patella baja
•Generalized laxity
•Dysplastic femoral trochlea
•Abnormal patellar tracking

8. PF Pain Without Malalignment
•Patellofemoral pain without malalignment includes many
subcategories of lesions that cause anterior knee pain.
•Soft tissue lesions. Soft tissue lesions include plica syndrome, fat
pad syndrome, tendonitis, IT band friction syndrome, and bursitis.

9. PLICA SYNDROME
•Irritation of remnants of embryological synovial tissue around the
patella.
•Chronic irritation, the tissue becomes an inelastic, fibrotic band
that is tender during palpation.
•Acute, the tissue is painful during palpation.
•The band is usually palpable medial to the patella,

11. Fat pad syndrome/Hoffa's disease
•Irritation of the infrapatellar fat
pad from trauma or overuse.

13. Tendonitis
•Tendonitis of the patellar or quadriceps tendons, sometimes also
•Also called jumper’s knee, typically
•occurs from overuse as the result of repetitive jumping
•Tenderness occurs along the attachment of the tendon to the
patella
•Symptoms may be exacerbated secondary to tightness quadriceps.

15. IT band friction syndrome
•irritation of the IT band as it passes over the lateral femoral
condyle.
•Contributing factors could be tight tensor fasciae lataeor gluteus
maximus. Because the IT band attaches to the patella and lateral
retinaculum, it may cause anterior knee pain.

17. Prepatellarbursitis
•Also known as housemaid’s knee,
•It is the result of prolonged kneeling or recurrent minor trauma to
the anterior knee.
•When inflamed, there may be restricted motion due to swelling
and pain caused by direct pressure or pressure from the patellar
tendon.

19. Tight medial and lateral retinacula/Patellar
pressure syndrome
•Increased contact pressure of the patella in the trochlear groove.
•.

20. Osteochondritisdissecansof the patella or femoral
trochlea
•Pain on the retro surface of the patella that is worse during
squatting, stooping, ambulating, and descending steps. The knee
may give way or lock. There may be loose bodies within the joint.
•Lesion of the subchondral bone that can involve the articular
cartilage

22. •Traumatic patellar chondromalacia
•PF osteoarthritis
•Apophysitis
•Symptomatic bipartite patella
•Trauma

23. Etiologyof Symptoms
•Direct trauma
•Overuse
•Faulty patellar tracking from malalignment due to anatomical
variations or soft tissue length and strength imbalances in the hip
•Knee, or ankle/foot
•Degeneration

24. Common Impairments, Activity Limitations,
and Participation Restrictions
•Pain in the retropatellarregion
•Pain along the patellar tendon or at the subpatellarfat pads due to irritation
•Patellar crepitus; swelling or locking of the knee
•Altered lower extremity alignment, specifically increased hip adduction and internal
rotation and dynamic knee valgus (valgus collapse) that occurs during weightbearing
activities, such as ascending and descending stairs, squatting, or landing after a
jump.
•Weakness of the hip abductor, external rotator, and/or extensor muscles
•Weakness, inhibition, or altered recruitment or timing of firing of the VMO muscle
•Decreased flexibility of the tensor fasciae latae, hamstrings, quadriceps, or
gastrocnemius and soleus muscles
•Overstretched medial retinaculum
•Restricted lateral retinaculum, IT band, or fascial structures around the patella
•Decreased medial gliding or medial tipping of the patella ■Pronated foot

26. Activity limitations and participation
restrictions
•Limited performance of basic ADL as the result of pain or poor
knee control (valgus collapse)
•Pain-related limitations of functional mobility (e.g., reduced
ability to get in or out of a chair or car, ascend and descend stairs,
walk, jump, or run) that are necessary to carry out ADL and IADL,
work, and community, recreational, or sport activities
•Inability to maintain prolonged flexed knee postures, such as
sitting or squatting, as the result of pain and stiffness in the knee

27. Management
PROTECTION PHASE
•Modalities
•Rest
•gentle motion
•Muscle setting exercises in pain-free positions
•Splinting the patella with a brace or tape may unload the joint
and relieve the irritating stress.

28. CONTROLLED MOTION AND RETURN TO FUNCTION PHASES
•modifying the biomechanical factors that may be contributing to
the impairment
•Management during the controlled motion and return to function
phases of rehabilitation typically emphasizes increasing strength,
dynamic control, and pain-free mobility of the knee and hip;
modifying abnormal movement strategies that may contribute to
impairments and improving stability of the pelvis and trunk,
balance, and functional abilities.
•Improve Muscle Performance and Neuromuscular Control
•Modify Biomechanical Stresses

29. Surgical and Postoperative Management

30. Proximal Extensor Mechanism
Realignment: Medial Patellofemoral
Ligament Repair or Reconstruction
and Related Procedures
•MPFL repair or tightening
•MPFL reconstruction
•VMO imbrication (advancement)

34. Clarke’s Sign (Patellar Grind Test)
•The examiner presses down slightly
proximal to the upper pole or base of
the patella with the web of the hand as
the patient lies relaxed with the knee
extended
•The patient is then asked to contract the
quadriceps muscles while the examiner
pushes down.
•If the test causes retropatellarpain and
the patient cannot hold a contraction,
the test is considered positive.
•https://www.youtube.com/watch?v=pRq
nODPqxFs

35. McConnell Test for Chondromalacia Patellae
•The patient is sitting with the femur laterally rotated. The patient
performs isometric quadriceps contractions at 120°, 90°, 60°,
30°, and 0°with each contraction held for 10 seconds
•If pain is produced during any of the contractions, the patient’s
leg is passively returned to full extension by the examiner.
•The patient’s leg is then fully supported on the examiner’s knee,
and the examiner pushes the patella medially.
•The medial glide is maintained while the knee is returned to the
painful angle, and the patient performs an isometric contraction,
again with the patella held medially. If the pain is decreased, the
pain is patellofemoral in origin. Each angle is tested in a similar
fashion
•https://www.youtube.com/watch?v=25gGcJS_Pec

37. THANK YOU