Patellofemoral pain syndrome (pfps)

Patellofemoral pain syndrome (pfps):
Introduction
Anatomy of Patellofemoral Complex
Epidemiology
Aetiological Risk factors
Pathogenesis
Clinical Features 
Assessment
Differential Diagnosis
Management
The Patellofemoral Foundation

1. Assessment and Management of Patellofemoral pain syndrome Dr. Venus Pagare (PT) MPT, KMC Mangalore SEHA EMIRATES HOSPITAL Abu Dhabi, UAE 1 ASSESSMENT AND MANAGEMENT OF PFPS

2. Introduction Anatomy of Patellofemoral Complex Epidemiology Aetiological Risk factors Pathogenesis Clinical Features  Assessment Differential Diagnosis Management The Patellofemoral Foundation ASSESSMENT AND MANAGEMENT OF PFPS 2 CONTENTS

3. ASSESSMENT AND MANAGEMENT OF PFPS 3 INTRODUCTION

4. ASSESSMENT AND MANAGEMENT OF PFPS 4 IT Band Syndrome Articular cartilage injury Hoffa’s disease Patellar instability subluxation Patellofemoral arthritis Pre –patellar bursitis Sinding -Larsen- Johannson - Syndrome Quadriceps Tendinopathy Referred pain from hip Neuromas Osgood- schlatter Plica synovialis Patellar Tendinopathy Symptomatic bipartite patella Patellofemoral Pain Syndrome Pes anserine bursitis Osteochondritis Dissecans Chondromalacia patellae Bone Tumors Loose-Bodies

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7. ASSESSMENT AND MANAGEMENT OF PFPS 7 Anatomy and Biomechanics of Patellofemoral Complex

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10. ASSESSMENT AND MANAGEMENT OF PFPS 10 Patellofemoral joint reaction forces depend upon the knee flexion angle and a s the knee is flexed, the patellofemoral compressive load is increased .

11. Activity Patellofemoral compressive force Stance phase of walking (peak knee flexion is about 20°) 25 - 50% body weight Ascending stairs 2 – 3 times body weight Running 5 – 6 times body weight Flexion greater than 90° 8 times the body weight Squatting 20 times the body weight ASSESSMENT AND MANAGEMENT OF PFPS 11

12. ASSESSMENT AND MANAGEMENT OF PFPS 12 Factors affecting Patellar Tracking Flat Trochlea Lax medial structures

13. ASSESSMENT AND MANAGEMENT OF PFPS 13 Excessive Subtalar Pronation

14. ASSESSMENT AND MANAGEMENT OF PFPS 14 INCIDENCE

15. ASSESSMENT AND MANAGEMENT OF PFPS 15 ETIOLOGY 2. Extrinsic Factors 3. Others

16. ASSESSMENT AND MANAGEMENT OF PFPS 16 1. Altered Biomechanics of leg

17. ASSESSMENT AND MANAGEMENT OF PFPS 17 2. Altered Biomechanics of the foot

18. ASSESSMENT AND MANAGEMENT OF PFPS 18 3. Anatomic Anomalies

19. ASSESSMENT AND MANAGEMENT OF PFPS 19 4. Medial- Lateral Mobility

20. ASSESSMENT AND MANAGEMENT OF PFPS 20 5. Soft Tissue Tightness

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22. ASSESSMENT AND MANAGEMENT OF PFPS 22 6. Muscle Imbalance

23. ASSESSMENT AND MANAGEMENT OF PFPS 23 Extrinsic Factors Excessive duration or frequency of physical Errors in training such as sudden increase in mileage Activities change of training surface Inappropriate foot wear such as high heels

24. ASSESSMENT AND MANAGEMENT OF PFPS 24 Others

25. ASSESSMENT AND MANAGEMENT OF PFPS 25 A study has identified 4 factors that have predictive values for the development of patellofemoral pain, which included: Tightness of the gastrocnemius and quadriceps Delayed reflex of vastus medialis obliquus Hypermobility of patella Decreased power of the quadriceps muscle.

26. ASSESSMENT AND MANAGEMENT OF PFPS 26 PATHOGENESIS

27. ASSESSMENT AND MANAGEMENT OF PFPS 27 Factors inducing patellofemoral nociceptive output

28. ASSESSMENT AND MANAGEMENT OF PFPS 28 1. Theory of Homeostasis

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33. ASSESSMENT AND MANAGEMENT OF PFPS 33 CLINICAL FEATURES

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35. ASSESSMENT AND MANAGEMENT OF PFPS 35 ASSESSMENT

36. ASSESSMENT AND MANAGEMENT OF PFPS 36 Pain History

37. ASSESSMENT AND MANAGEMENT OF PFPS 37

38. ASSESSMENT AND MANAGEMENT OF PFPS 38 Functional status, Activity Level, Sports Specific Questions

39. ASSESSMENT AND MANAGEMENT OF PFPS 39 Objective Examination Observation: Posture- Standing Anterior View

40. ASSESSMENT AND MANAGEMENT OF PFPS 40 Lateral View

41. ASSESSMENT AND MANAGEMENT OF PFPS 41 Posterior View Sitting: Anterior and Lateral View

42. ASSESSMENT AND MANAGEMENT OF PFPS 42 GAIT ASSESSMENT

43. ASSESSMENT AND MANAGEMENT OF PFPS 43

44. ASSESSMENT AND MANAGEMENT OF PFPS 44 EXAMINATION Movement testing

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49. ASSESSMENT AND MANAGEMENT OF PFPS 49 Functional Performance Testing Vertical Jump Performance Antero-medial Lunge

50. ASSESSMENT AND MANAGEMENT OF PFPS 50 Single Leg Press Step Down

51. ASSESSMENT AND MANAGEMENT OF PFPS 51 Balance and Reach Test Bilateral Squatting

52. ASSESSMENT AND MANAGEMENT OF PFPS 52 Special Tests

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59. ASSESSMENT AND MANAGEMENT OF PFPS 59 In patients presenting with knee pain, a positive outcome on either the vastus medialis coordination test, the patellar apprehension test, or the eccentric step test increases the probability of PFPS.

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63. ASSESSMENT AND MANAGEMENT OF PFPS 63 Investigations

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66. ASSESSMENT AND MANAGEMENT OF PFPS 66 DIFFERENTIAL DIAGNOSIS Chondromalacia Patallae Pes anserine bursitis Ilio - tibial Tenonitis Patellar subluxation / dislocation Plica syndrome Osteochondritis dissecans Patellar tendinitis Sinding-larsen - Johannson syndrome Patellofemoral osteoarthritis Osgood- schlatter lesion Symptomatic bipartite patella Prepatellar bursiis Hoffa’s Disease Quadriceps tendinopathy Patellar stress fracture Referred pain from hip and lumbar pathology Loose bodies Saphenous neuritis

67. ASSESSMENT AND MANAGEMENT OF PFPS 67 MANAGEMENT OF PFPS

68. ASSESSMENT AND MANAGEMENT OF PFPS 68 Clinical Classification of

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73. ASSESSMENT AND MANAGEMENT OF PFPS 73 Open v/s Closed Kinetic Chain Exercises

74. ASSESSMENT AND MANAGEMENT OF PFPS 74 ISOKINETIC TRAINING

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76. ASSESSMENT AND MANAGEMENT OF PFPS 76 Strengthening exercise : Hip Muscles

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80. ASSESSMENT AND MANAGEMENT OF PFPS 80 Centering Effect

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83. ASSESSMENT AND MANAGEMENT OF PFPS 83 Clinical Prediction Rule to identify those patients who would immediately receive a 50% reduction in patellofemoral pain with a medial patellar taping, four variables were identified: Degree of tibial angulation Soleus muscle length Patellar tilt test Relaxed calcaneal stance Positive patellar tilt test and tibial angulation greater than 5° of varus : best predicted success with taping.

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85. ASSESSMENT AND MANAGEMENT OF PFPS 85 The Palumbo dynamic patellar brace consists of a lateral pad that ’floats’ over the patella, maintaining effective position during knee motion. Cho-Pat knee strap functions dynamically , improves patellar tracking and spreads pressure uniformly over the surface area. Over prolonged periods, bracing can lead to atrophy in the quadriceps, and should be avoided.

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87. ASSESSMENT AND MANAGEMENT OF PFPS 87 The Clinical Prediction Rule for use of off-the –shelf orthotic insert for patients with PFPS: Forefoot valgus alignment (2° of valgus ) Limited passive extension of the first MTP joint (78°) Minimal motion on the navicular drop test (3 mm) Evidence indicates that combining physiotherapy with prefabricated foot orthoses may be superior to prefabricated foot orthoses used alone.

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92. ASSESSMENT AND MANAGEMENT OF PFPS 92 MEDICAL MANAGEMENT

93. ASSESSMENT AND MANAGEMENT OF PFPS 93 SURGICAL INTERVENTION If symptoms persist despite completing 6 – 12 months of thorough rehabilitation

94. ASSESSMENT AND MANAGEMENT OF PFPS 94 PRE & POST OPERATIVE REHABILITATION

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96. REFERENCES Brotzman SB, Manske RC. Clinical orthopaedic rehabilitation. 3 rd ed. Philadelphia: Elsevier Mosby; 2011 Levangie PK, Norkin CC. joint Structure & Function: A comprehensive Analysis. 4 th ed. Philadelphia: JAYPEE Brothers; 2006 Neumann DA. Kinesiology of the Musculoskeletal System: Foundations for rehabilitation. 2 nd ed. Mosby; 2009 Magee DJ. Orthopedic Physical Assessment. 5 th ed. Delhi: Saunders Elsevier; 2008 Brunker P, Khan K. Clinical Sports Medicine. 3 rd ed. Noida : Tata McGraw Hill Companies; 2008 ASSESSMENT AND MANAGEMENT OF PFPS 96

97. 6. Hertling D, Kessler RM. Management of Common Musculoskeletal Disorders. 4 th ed. United States of America: Lippincott; 2006 7. Zaffagnini S, Dejour D, Arendt EA. Patellofemoral Instability, pain and arthritis: clinical presentation, Imaging and Treatment. Springer; 2010 8. Zuluaga M. Sports Physiotherapy: Applied Science and practice. Churchill Livingstone; 1995 9. Waryasz GR, and McDermott AY. Patellofemoral pain syndrome (PFPS): a systematic review of anatomy and potential risk factors. Dyn Med 2008; 7 : 9 10. Millera D, Tumiab N and Maffulli N. Anterior Knee Pain. TRAUMA 2005; 7 : 11–18 ASSESSMENT AND MANAGEMENT OF PFPS 97

98. 11. Calmbach WL, Hutchens M. Evaluation of patients presenting with Knee Pain : Part II. Differential Diagnosis. Am Fam  Physician 2003; 68: 917 – 922 12. Nijs J, Geel CV, Cindy Van der auwera , Bart Van de Velde . Diagnostic value of five clinical tests in patellofemoral pain syndrome. Man Ther 2006; 69 – 77 13. Fulkerson JP. Diagnosis and Treatment of Patients with Patellofemoral Pain. Am J Sports Med 2002; 30: 447 – 456 14. Price JL. Patellofemoral syndrome: how to perform a basic knee evaluation. JAAPA 2008; 21: 39 – 43 15. Fredericson M, Yoon K. Physical Examination and Patellofemoral Pain Syndrome. Am J Phys Med Rehabil 2006; 85: 234 –243 ASSESSMENT AND MANAGEMENT OF PFPS 98

99. 16. Dixit S, Difiori JP, Burton M, Mines B. Management of Patellofemoral Pain Syndrome. Am Fam  Physician 2007; 75: 194 – 202 17. Green ST. Patellofemoral syndrome. J Bodyw Mov Ther 2005; 9 : 16 – 26 18. Post WR. Patellofemoral Pain: Let the Physical Exam Define Treatment. Phys Sports med 1998; 26: 135 – 141 19. Piva SR, Fitzgerald K, Irrgang JJ, Jones S, Hando BR, Browder DA et al. Reliability of measures of impairments associated with patellofemoral pain syndrome. BMC  Musculoskelet Disord 2007; 7:33 20. Juhn MS. Patellofemoral Pain Syndrome: A Review and Guidelines for Treatment. Am Fam  Physician 1999 ;60(7): 2012-2018 ASSESSMENT AND MANAGEMENT OF PFPS 99

100. 21. Witvrouw E, Danneels L, Tiggelen DV, Willems TM, Dirk Cambier . Open Versus Closed Kinetic Chain Exercises in Patellofemoral Pain: A 5-Year Prospective Randomized Study. Am J Sports Med 2004; 32: 1122- 1130 22. Whittingham M, Palmer S, Macmillan F. Effects of Taping on Pain and Function in Patellofemoral Pain Syndrome: A Randomized Controlled Trial. J Orthop  Sports Phys Ther 2004; 34 : 504-514 23. Witvrouw E, Werner, Mikkelsen C, Van Tiggelen D, Vanden Berghe L, Cerulli G. Clinical classification of patellofemoral pain syndrome: guidelines for non-operative treatment. Knee Surg Sports Traumatol Arthrosc 2005; 13: 122–130 ASSESSMENT AND MANAGEMENT OF PFPS 100

101. 25. Barton CJ, Munteanu SE, Menz HB, Crossley KM. The Efficacy of Foot Orthoses in the Treatment of Individuals with Patellofemoral Pain Syndrome: A Systematic Review. Sports Med 2010; 40: 377-395 26. Iverson CA, Sultive TG, Crowell MS, Morrell RL, Perkins MW, Garber MB. Lumbopelvic Manipulation for the Treatment of Patients With Patellofemoral Pain Syndrome: Development of a Clinical Prediction Rule. J Orthop  Sports Phys Ther 2008; 38 : 297 – 312 27. Sutlive TG, Mitchell DS, Maxfeild SA, McLean CL, Neumann JC, Swiecki CR. Identification of individuals with patellofemoral pain whose symptoms improved after a combined program of foot orthosis use and modified activity: A preliminary investigation. Phys Ther 2004; 84:49-61 ASSESSMENT AND MANAGEMENT OF PFPS 101

102. 28. Tsung -Yu Lan , Wei- Peng Lin, Ching -Chuan Jiang, Hongsen Chiang. Immediate Effect and Predictors of Effectiveness of Taping for Patellofemoral Pain Syndrome : A Prospective Cohort Study. Am J Sports Med 2010; 38: 1626 – 1630 29. Dye SF. The Pathophysiology of Patellofemoral Pain: A Tissue Homeostasis Perspective. Clin Orthop Relat Res 2005; 436: 100 – 110 30. Bolin M, Padua D, Marshall S, Guskiewicz K, Pyne S, Beutler A. Gender differences in the incidence and prevalence of patellofemoral pain syndrome. Scand J Med Sci Sports. 2010 October ; 20: 725–730 31. Barby , Singer K. Anterior Knee Pain Scale. Aust J Physiother 2009; 55: 140 ASSESSMENT AND MANAGEMENT OF PFPS 102

103. 32. D’hondt NE, Struijs PAA, Kerkhoffs GMMJ, Verheul C, Lysens R, Aufdemkampe G, Van Dijk CN. Orthotic devices for treating patellofemoral pain syndrome. Cochrane Database Syst Rev [Internet]. 2008. Available from: http ://onlinelibrary.wiley.com/doi/10.1002/14651858.CD002267/pdf 33. Heintjes EM, Berger M, Bierma-Zeinstra SMA, Bernsen RMD, Verhaar JAN, Koes BW. Exercise therapy for patellofemoral pain syndrome (Review). Cochrane Database Syst Rev [Internet]. 2009. Available from: http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD003472/pdf ASSESSMENT AND MANAGEMENT OF PFPS 103

104. 34. Naslund J. Patellofemoral Pain Syndrome: Clinical and Pathophysiological conditions [dissertation]. Stockholm: Karolinska institute; 2006. 35. Function, pain and psychological parameters [dissertation]. Norway: University of Norway; 2008 ASSESSMENT AND MANAGEMENT OF PFPS 104

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