The Problem of Patellofemoral Pain. The Low Back Pain of the Lower Extremity. Objectives. Christopher M. Powers, PhD, PT, FACSM, FAPTA

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1 Mechanisms Underlying Patellofemoral Joint Pain: What have we learned over the last 20 years? Professor Co Director, Musculoskeletal Biomechanics Research Laboratory Objectives 1. Highlight recent research that sheds light on the possible underlying cause(s) of patellofemoral pain 2. Illustrate how this information may integrated into clinical practice to improve clinical outcomes The Problem of Patellofemoral Pain The Low Back Pain of the Lower Extremity

2 Most common knee disorder seen in orthopaedic practice Wood et al., Prim Health Care Res Dev, times more common in women compared to men Boling et al., Scand J Med Sci Sports, 2009 Most common overuse injury in runners Taunton et al, Br J Sports Med, 2002 Individuals with PFP typically have long term symptoms (4 16 years) Price et al. Injury, 2000 Stathopulu & Baildam, Rheumatology, 2003 Previous history of PFP has been to be a risk factor related to patellofemoral arthritis Utting et al., Knee, 2005 An Update for the Conservative Management of PFP: A Systematic Review of the Literature Bolgla & Boling, Int J Sports Phys Ther, 2011 Inconclusive evidence for many of the common interventions used to treat patellofemoral pain

3 A multi disciplinary approach to understand mechanisms of patellofemoral pain In vitro studies Evaluating intrinsic PFJ mechanics Multi planar loading approach Powers et al, Clin Biomech, 1999 Biomechanical studies: Evaluating movement behavior

4 Imaging studies: Evaluating subject specific morphology & mechanics Modeling studies: Evaluating joint PFJ forces & stresses Clinical studies: Evaluating assessment & intervention methods

5 So.What have we learned? Proximal Factors Local Factors Distal Factors

6 PFP can arise from a variety of innervated tissue sources Subchondral bone Infrapatellar fat pad Synovium Retinaculum Patella tendon Consensus statement, International PFP Research Retreat (2009) Abnormal loading as a potential factor in the genesis of PFP Dye, Sports Med Arthroscopy Rev, 2001 Pain readily reproduced with activities that require quadriceps contraction Subchondral Bone Conclusions Overload Theory PFJ Stress Cartilage Stress Bone Stress Patella Water Content Intraosseus pressure Patellofemoral Pain

7 Patellofemoral joint stress PFJ reaction force PFJ contact area Patellofemoral joint susceptible to the highest stresses in the body High forces Small contact area Patella Articular Cartilage Thickest in the human body (4 5 mm)

8 Is patellofemoral joint stress elevated in persons with PFP? Patellofemoral Joint Model Algorithm Net Knee Joint Moment Knee Joint Angle Patellofemoral Joint Contact Area Quadriceps Force (QF) Patellofemoral Joint Reaction Force (PFJRF) Quadriceps Effective Lever Arm Patellofemoral Joint Stress Relationship between QF and PFJRF Heino & Powers, Med Sci Sports Exerc, 2002 Heino & Powers, Gait & Posture, 2002 Patellofemoral Joint Stress * Heino & Powers, Med Sci Sports Exerc, 2002

9 PF Joint Reaction Force * Heino & Powers, Med Sci Sports Exerc, 2002 Utilized Contact Area Heino & Powers, Med Sci Sports Exerc, 2002 Patellofemoral joint stress PFJ reaction force PFJ contact area

10 Quadriceps Weakness/Atrophy in Persons with Patellofemoral Pain: Cause of pain?? or A result of pain?? Subchondral Bone Conclusions Overload Theory PFJ Stress Cartilage Stress Farrokhi et al., 2011 Bone Stress Patella Water Content Intraosseus pressure Patellofemoral Pain Evaluate of PFJ Cartilage Stress Using Finite Element Modeling Farrokhi et al., Osteoarthritis & Cartilage, 2011

11 Patellofemoral Cartilage Stress Farrokhi et al., Osteoarthritis & Cartilage, 2011 Possible changes in cartilage in response to abnormal and/or prolonged stress Decreased cartilage thickness Decreased cartilage volume Loss of proteoglycans Increased water content Thickness Measurements Mean: 2.48 SD: 0.74 Mean: 2.02 SD: 0.54

12 Patella Cartilage Thickness mm PFP Control Farrokhi et al, Am J Sports Med, 2011 Subchondral Bone Conclusions Overload Theory PFJ Stress Cartilage Stress Ho et al., 2014 Bone Stress Patella Water Content Intraosseus pressure Patellofemoral Pain Estimating Voxel Specific Elastic Modulus of Patella Using IDEAL (Iterative Decomposition of water and fat with Echo Asymmetry and Least squares estimation) IP CHA (0.4 g/ml) IP MAX (0 g/ml) Ho et al., JMRI, 2013

13 MPa Medial Anterior Posterior Elastic Modulus Assignment for Heterogeneous Patella Model Lateral 3.5 Peak Patella Bone Stress MPa 1.5 PFP Control Ho & Powers, J Biomech, 2014 patellofemoral joint, cartilage, and bone stress is greater in persons with PFP Consensus statement, International PFP Research Retreat (2009 & 2011)

14 Possible changes in bone in response to abnormal and/or prolonged stress Increased stiffness of subchondral bone layer Elevated water content (edema) Bone marrow lesions Subchondral Bone Conclusions Overload Theory PFJ Stress Cartilage Stress Bone Stress Patella Water Content Intraosseus pressure Ho et al., 2014 Patellofemoral Pain Water, Fat, and Fat fraction Images Using IDEAL Protocol Water Fat Fat/(Fat+Water) Water fraction= 100% fat fraction

15 Patella Water Content % PFP Ho & Powers, Magn Res Imag (in press) Control Subchondral Bone Conclusions Overload Theory PFJ Stress Cartilage Stress Bone Stress Patella Water Content Intraosseus pressure Ho et al., 2014 Patellofemoral Pain The Influence of Repetitive Loading on Patella Water Content & Pain Ho et al. Eur J Sports Med, 2014

16 Procedures Visual Analog Scale (VAS) Pre running MR IDEAL scan VAS VAS Running Post running MR IDEAL scan 48 hrs post running MR IDEAL scan GE 3.0 T MR scanner IDEAL 0 of knee flexion TR= 20.2 ms TE= { } ms slice thickness= 2 mm FOV= 160*160 mm matrix= 256*256 BW= 125 khz Visual Analog Scale Pre running Immediately post running 48 Hours post running Patella Water Fraction PFP Control % 10% % Pre Running Immediately post running 48 hours post running

17 Conclusions PFJ Stress Cartilage Stress Bone Stress Bone Marrow Lesions Patella Water Content Intraosseus pressure Patellofemoral Pain Patellofemoral joint stress PFJ reaction force PFJ contact area Patella Malalignment/Maltracking Decreases Available Contact Area Powers et al, MSSE, 2004

18 Femoral Morphology Dictates Lateral Patella Tracking Femoral Morphology is Correlated with Lateral Patella Tilt & Displacement Powers, Phys Ther, 2000 Sulcus Angle Carrillon, et al. Radiology, 2000 Lateral Trochlear Inclination Harbaugh et al. J Orthop Res, 2010 Lateral Trochlear Inclination Teng & powers. Knee, 2013 Lateral Trochlear Inclination Measures of Femoral Morphology Sulcus Angle Lateral Trochlear Inclination Teng & Powers, Knee, 2013

19 Patella Alta Patella Alta Decreases Available Contact Area Control Lp Lpl Lpl/Lp > 1.2 Ward & Powers, Clin Biomech, 2004 patella tracking is largely influenced by bony geometry and position of the patella within the trochlear groove Consensus statement, International PFP Research Retreat (2009 & 2011) the presence of patella alta or abnormal trochlea morphology is associated with cartilage damage and bone marrow lesions Stefanik et al., Arthritis Care & Res, 2010 Stefanik et al., J Orthop Res, 2012 Consensus statement, International PFP Research Retreat (2013)

20 Relationship Between Patellofemoral Pain & PFJ Arthritis? Individuals with PFP typically have long term symptoms (4 16 years) Price et al. Injury, 2000 Stathopulu & Baildam, Rheumatology, 2003 Sandow & Goodfellow, JBJS, 1985 Previous history of PFP has been to be a risk factor related to patellofemoral arthritis (Utting et al., Knee, 2005) patella tracking is influenced by weight bearing status Consensus statement, International PFP Research Retreat (2009 & 2011) Open Chain Closed Chain Powers et al., JOSPT, 2003, Souza & Powers, JOSPT, 2009

21 Excessive femoral internal rotation increases lateral patella displacement/tilt & PFJ joint stress Liao et al. Med Sci Sports Exerc, 2015 Excessive Hip Rotation and PFP Souza & Powers, 2009 Increased hip internal rotation in females with PFP while running Boling et al., 2009 Increased hip internal was found to be a risk factor for the development of PFP Wirtz et al, 2011 Increased hip internal rotation in females with PFP while running Noehren et al., 2011 Increased hip internal in female runners with PFP What about the VMO???

22 The Great Debate: Is abnormal patella tracking more a function of VMO insufficiency or poor hip control? Patellofemoral joint stress PFJ reaction force PFJ contact area Hip Adduction Contributes to Increased Lateral Forces Acting on the Patellofemoral Joint

23 Lower limb alignment & lateral forces on the patella Q angle: 15 Lateral Force vector Dynamic Q angle & PFP Dynamic Q angle & PFP

24 How much of a change in the Q angle is relevant? Huberti & Hayes., JBJS, degree change in the Q angle increased peak pressures by 45%. A decrease in the Q angle decreased stress on the lateral facet and median ridge Hip Adduction and PFP Willson & Davis, 2008 Increased hip adduction with single leg squats, jump and running Noehren et al., 2011 Reported increased hip adduction in female runners with PFP Noehren et al., 2013 Females who developed PFP exhibited greater hip adductions than those who did not (prospective) Hip Kinematics are Associated with Pain and Function in Males & Females with PFP Nakagawa et al., Int J Sports Med, 2013 Peak internal rotation and hip adduction during a step down test were significant predictors of pain Peak hip adduction was a significant predictor of function

25 What about the foot??? Foot pronation contributes to tibia internal rotation Tibia internal rotation decreases the Q Angle 15 6

26 Very limited evidence that a pronated foot posture is a risk factor for PFP Limited evidence dynamic foot function during walking & running is a risk factor Consensus statement, International PFP Research Retreat (2015) Treatment Implications Historic Treatment Approach for PFP

27 Paradigm shift in the treatment of PFP Hip Control to Improve Patella Tracking & Minimize the Dynamic Q Angle What Muscle Would You Strengthen? Gluteus Maximus: The Tri planar Muscle Extensor Abductor External Rotator

28 Females with PFP Have Weak Hip Muscles: A Systematic Review Prins & van der Wurf, Austr J Physiother, studies evaluated Conclusion: Strong evidence that females with PFP have impaired strength of the hip extensors, abductors and external rotators Positive Clinical Outcomes Associated with Hip Strengthening for PFP Mascal et al. JOSPT, 2003 Nakagawa et al. Clin Rehab, 2009 Fukuda et al. JOSPT, 2010 Earl & Hoch, Am J Sports Med, 2011 Khayambashi et al. JOSPT, 2012 Khayambashi et al, Arch Phys Med Rehabil, 2014 Ferber et al, J Athl Train, 2015 Hip vs. Quadriceps Strengthening for PFP

29 Journal of Athletic Training, 2015 Archives Physical Medicine & Rehabilitation, 2014 Summary Patellofemoral stress appears to be an important biomechanical parameter associated with PFP The combination of reduced contact area and elevated joint reaction forces is most detrimental to the PFJ Summary The lateral forces acting on the patella are largely influenced by abnormal motions of the lower extremity (particularly in the frontal plane). Abnormal trochlear morphology and/or excessive femur rotation appear to influence patellofemoral stress by reducing contact area

30 Summary From a clinical standpoint, hip strength/control may be important than quadriceps strengthening What about the VMO??? Is it time to retire the quadriceps imbalance theory? Questions?

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