Patellofemoral Pain Syndrome

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1 Certificate of Excellence (COE) Program Program delivered by the RMTAO Certificate of Excellence In Assessment Certificate of Excellence in Assessment CMTO and RMTAO member Complete 10 RMTAO run assessment courses over a 5 year period Pass each course s examination with a minimum 70% (multiple choice quiz) Patellofemoral Pain Syndrome Presented by Aaron Rutter PT, BScPT, FCAMPT Introduction Course Objectives Physiotherapist Manual and Manipulative Physiotherapist Acupuncture Queen s University RMTAO courses How do you recognize the signs and symptoms of patellofemoral pain? Does the patella actually track laterally or does the femur move medially to cause patellofemoral pain? How do you know someone has weak gluteus medius, gluteus maximus and quadriceps? Do you need to specifically strengthen vastus medialis oblique? What other dysfunctions can contribute to patellofemoral pain syndrome? 1

2 Anterior Knee Pain Patellofemoral Pain Syndrome Patellofemoral pain syndrome Fractures: femur, tibia, fibula, patella Muscle strains: quadriceps Tendinopathies: patellar, quadriceps, pes ancerinus ITB friction syndrome Meniscal: anterior horn (medial or lateral) Ligamentous sprains: MCL, LCL, PCL, ACL Bursitis: supra/infra/pre-patellar, pes ancerinus Plica syndrome Fat pad syndrome Loose bodies Synovitis OA, RA and other rheumatic diseases Referred Pain Hip OA, Lumbar disc or nerve root, SIJ, femoral nerve A syndrome, in medicine and psychology, is the collection of signs and symptoms that are observed in, and characteristic of, a single condition Anatomy Anatomy 2

3 Anatomy Anatomy Patellofemoral Joint Patellar Joint Surface Classification Synovial, compound, modified sellar Capsular Patterning Flexion > extension Closed Pack Position Full squat? Resting Position 25 degrees flex End Feel Capsular Largest sesamoid bone in body Modified sellar Convex: medial to lateral Trochlear groove: concave medial to lateral Concave: superior to inferior with a ridge in middle Trochlear groove: convex superior to inferior 3

4 Patellar Facets Contact Points of Patella The entire surface of the patella is never in contact with the femur at any given point in time Medial Odd Superior Middle Inferior Lateral 0 degrees Supra-patellar fat pad/bursa degrees Inferior facet of patella on trochlea degrees Middle facet of patella on trochlea degrees Superior facet of patella on trochlea 135 degrees Odd facet against medial femoral condyle 135 Medial Right Knee Lateral Right Knee Patellofemoral Pain Syndrome Non specific pain around or under the patella caused by poor tracking of the patella/femur Most common cause of anterior knee pain Patellar Pathologies 4

5 Chrondromalacia Patella Chondromalcia Patella Softening and degeneration of the cartilage under the patella Quite often used interchangeably with patellofemoral pain syndrome Usually occurs in adolescents, females greater than males 4 grades Grade I: softening and swelling, intact cartilage Grade II: fragmentation and fissuring of the articular surface within softened area Grade III: fibrillation or breakdown of the articular cartilage with a crap meat appearance Grade IV: erosive changes with exposure of the subchondral bone Normal patella Chondralmalcia patella Tendinopathies Osgood-Schlatter s Disease Quadriceps Patellar (Jumper s Knee) Irritation of the tibialtubercle growth plate in pre-teen or teens, caused by strong quadriceps contractions, causing excessive bone formation Tendinitis vs tendinosis Overuse vslack of use Tendinitis: inflammation Tendinosis: structural change (degeneration) in the tendon, decrease and disorientation of collagen, it has a decreased ability to take force (resisted, stretch, compression etc) 5

6 Sinding-Larson-Johannson Disease Osteoarthritis Boney fragmentation of the inferior pole of the patella in adolescence caused by a tendinitis of the proximal patellar tendon, leading to calcification and ossification Wear and tear of the cartilage Articular cartilage is about 5 mm thick Thickest in body Patellar Function Patellofemoral Pain Improve transmission of force from quadriceps to tibia especially in early ranges of flexion Increases mechanical advantage by up to 50% Lack of compression of the patellofemoraljoint is a source of pain Heino-BrechterJH, Powers CM. Patellofemoralstress during walking in persons with and without patellofemoralpain. Med SciSports Exerc. 2002;34:

7 Patellofemoral Braces Patellofemoral Braces Braces can increase the compression of the patellofemoraljoint by 30-40% and decrease patellofemoral stress by 27% and pain by 56% Braces do not improve the tracking of the patella PowersCM et al. Theeffectofbracingonpatellaalignment and patellofemoraljointcontactarea. MedSciSportsExerc. 2004;36: , PowersCM et al. Theeffectofbracingonpatellarkinematics in patientswithpatellofemoralpain. MedSciSportExerc. 1999:31: Powers CM et al. Theeffectofbracingonpatellofemoraljointstress during free and fast walking. Am J Sports Med. 2004;32: Brace/Taping McConnell Taping Using Hypafix and Leuko (brown) tape 1. Add compression Correct rotation Correct tilt Correct glide 2. Retest comparable sign (squat, stairs) 7

8 Patellofemoral Joint Stress Quadriceps Strengthening Posterior, superior, lateral Patellofemoral Pain Diminished contact area Elevated joint reaction forces Walking 0.5 body weight Up stairs 2.5 times body weight Down stairs 3.5 times body weight Squat to 90 degrees 7.5 times body weight Does vastus medialis oblique exist? Still controversy over if vastusmedialisis a single anatomical structure Smith TO et al. Do the vastusmedialisoblique and vastusmedialis longus really exist? A systematic review. Clin Anat 2009; 22(2): Quadriceps Strengthening Quadriceps Strengthening Can vastus medialis be preferentially activated? Altering lower limb orientation or the addition of co-contractions does not preferentially activate vastus medialis oblique. Smith TO et al. Can vastusmedialisoblique be preferentially activated? A systemic review of electromyographicstudies. Physiother Theory Pract. 2009; 25(2): Is isolated vastus medialis strengthening better than global quadricep strengthening? No. Both had similar improvements after an 8 week program as compared to a control group Symeet al. Disability in patients with chronic patellofemoralpain syndrome: a randomised controlled trial of VMO selective training versus general quadriceps strengthening. Man Ther 2009; 14(3):

9 Quadriceps Strengthening New Concept in the Research One issue with quadriceps strengthening is that the vector of force for the quads will always pull the patella laterally (Q angle) Even though you have improved compression through the patellofemoraljoint which will improve tracking, you may have to address other biomechanical problems that will effect the tracking Souza RB et al. Femur rotation and patellofemoral joint kinematics: A weight-bearing MRI analysis. J Orthop Sports Phys Ther. 2010;40: Historically, the patella was assumed to move on a fixed femur so most research was done in non weight bearing with the femur fixed Current research has been done in weight bearing and the conclusions being drawn are that the femur moves underneath a fixed patella If the femur internally rotates and adducts, this will cause relative laterally tracking of the patella What muscles control the position of the femur? SERF Bracing SERF: stabilization into external rotation of the femur ($85) Helps prevent lateral translation of the patella by preventing the femur from adducting and internally rotating Use for patellar dislocation and persistent patellofemoralpain and/or athletes that want to continue to play through their symptoms Observations 9

10 Genu Varus Genu Valgus Femeral Anteversion Tibial Torsion/Genu Valgus 10

11 Pre-patellar Bursitis Infra-patellar Bursitis Supra-patellar Bursitis & Quadricep Atrophy Dislocated Patella 11

12 Camel Sign (Fat Pad Irritation) Patellar Tendon Rupture Patellar Alignment Patella Alta Patella Alta High riding patella Patella Baja Low riding patella Frog-eyed Patella Patella high riding and lateral Squinting Patella Patella positioned medially Tilted Patella Translated Patella Rotated Patella 12

13 Patella Baja Frog Eyed Patellae Squinting Patellae Lateral Tilt and Translation Merchant s View X-ray taken from above when knee in 45 degrees of flexion 13

14 Subjective Complaints Pain Location Diffuse/specific ache around and/or underneath the patella Gradual onset Weight bearing activities aggravate Stairs, squatting, kneeling, running, jumping Movie goers knee Prolonged sitting in knee flexion Crepitus No/mild swelling Pain is always underneath (retropatellar) or around the knee cap (peripatellar) It does not refer to any other part of the leg Observations Static Posture Muscle bulk: quads, hams, gluts, add, gastroc Swelling Capsular, bursitis, tibial tubercle Femoral anteversion Femoral or tibial torsion Genu varus, valgus Patellar position Alta, baja, squinting, frog eyed Tilted, translated, rotated Observations Dynamic Walking Single Leg Stance Squat (sit to stand off chair) Step down off 8-9 inch step Athletes Lateral shuffle Deceleration Triple jump on 1 leg Side cut 14

15 What to look for Ankle/Knee Strategy Squat Trunk Upright Initiate movement through ankle and knee instead of the hip (eccentric gastroc) Trunk stays upright instead of forward trunk lean Trunk lean to weight bearing side (compensated Trendelenburg) Pelvic drop (uncompensated Trendelenburg) Internal rotation and adduction of the femur (valgus of the knee) Compensated Trendelenburg Uncompensated Trendelenburg Lateral trunk lean towards the stance (weight bearing) side When bring center of gravity closer to the hip the hip abductors don t have to work as hard to maintain balance Loss of hip abductor strength Pelvis on opposite side drops due to hip abductor insufficiency in single leg stance Hip (femur) adducts and internally rotates 15

16 Valgus of the knee Common Causes of Patellofemoral Pain 1. Femoral anteversion 2. Increased Q angle 3. Tight lateral retinaculum 4. Tensor fascia latae tightness 5. Vastus lateralis tightness 6. Biceps femoris tightness 7. Weak iliacus 8. Tight Gastrocnemius/Soleus 9. Weak Gluteus Medius, Gluteus Maximus and Quadriceps 1. Femoral Anteversion Femoral Anteversion Angle between the neck of femur and the posterior femoral condyles Craig s Test Trochantericprominence angle test Normal Birth: 30 degrees Adult: 8-12 degrees >12 degrees = femoral anteversion IR and ER rotate hip until the greater trochanteris most prominent If hip in more than 12 degrees of IR, then the patient has femoral anteversion 16

17 2. Increased Q angle Q Angle 2 lines ASIS to mid patella Mid patella to tibial tubercle Difference between these 2 lines is the Q angle Normal degrees Quads are always pulling the patella laterally Increased Q angle 3. Tight Lateral Retinaculum Femoral anteversion External tibial torsion Lateral displacement of tibial tubercle Broad pelvis (females) Supinated feet (tibial external rotation) Medial glide of patella restricted May bias when in Ober stest, as lateral retinaculumand ITB are interconnected 17

18 ITB Tension Tension vs Tightness 1. Gluteus maximus Direct attachment 2. Tensor fascia latae Direct attachment 3. Biceps femoris(short & long) Fascial attachment 4. Vastus lateralis Fascial attachment 1 2 ITB 3 4 Tension/Hypertonicity Increased elastic/viscoelastic stiffness in the absence of contractile activity DO NOT ASSUME THE MUSCLE IS TIGHT Must check muscle length/flexibility Quite often it is normal or overlengthened Tension will be relieved by strengthening, shortening or unloading the tissue (eg massage, taping, acupuncture) TRY TO FIND THE SOURCE OF THE TENSION Tightness Muscle length/flexibility is decreased Tightness will be relieved by stretching Netter Patient complaints will be the same for both Pain, stiffness, tightness, spasm, trigger points ITB Tension ITB Tension Common Causes The ITB is put on tension by the muscles attaching into it. These are what should be addressed first. Rarely will you have to treat the ITB directly The ITB is such a thick fascia, the muscles attaching into the band is what will stretch more effectively when you treat it Muscle Tightness TFL Gluteus maximus Biceps femoris Vastus lateralis Muscle Weakness Gluteus medius (overuse TFL as a hip abductor) 18

19 4. Tensor Fascia Latae Tightness Tensor Fascia Latae Tightness Stretching Modified Thomas in hip ER Ober s Home Stretch Lunge position ER back leg Posterior pelvic tilt Tensor Fascia Latae Tightness 5. Vastus Lateralis Tightness Home Stretching Knee flexion Does hip and pelvic position matter? 19

20 6. Biceps Femoris Tightness Home Stretching Tibial internal rotation Anterior pelvic tilt, lean forward through groin 7. Weak iliacus Test double straight leg raise with femur in some external rotation Arab AM et al. Sensitivity, specificity and predictive value of the clinical trunk muscle endurance tests in low back pain. Clinical Rehabilitation 2007; 21: Can they hold 28 seconds 8. Gastroc/Soleus Tightness Decreased dorsiflexion can cause the foot to turn out during gait causing tibial ER Increased Q angle Normal DF ROM? Foot pointing straight to wall Heel must stay on ground 9. Weak Gluteus Medius, Maximus and Quadriceps Prins MR et al. Females with patellofemoral pain syndrome have weak hip muscles:a systematic review. Aust J Physiother. 2009;55:9-15. Souza RB, PowersCM. Differencesinhipkinematics, musclestrength, and muscle activation between subjects with and without patellofemoral pain. J Orthop Sports Phys Ther. 2009;39: NoehrenB, DavisI. Theeffectofreal-timegaitretrainingonhip kinematics, pain and function in subjects with patellofemoral pain syndrome. Br J Sports Med. 2011;45:

21 Hip Kinematics Stage 1 Chris Powers Physiotherapist and researcher from California 8 stages for strengthening progression Non weight bearing activation Therabandmust always be above the knee Must hold the femur towards abduction and external rotation Clinically most patients are symptom free by stage 5 Clam Hip Abduction Hold 60 sec Theraband above the knee Hold 60 sec Theraband above the knee 21

22 Fire Hydrant Side Plank Hold 60 sec McGill SM et al. Endurance times for low back stabilization exercises: clinical targets for testing and training from a normal database. Arch Phys Med Rehabil 1999; 80: Males 95 sec Females 75 sec Side Plank Modified Side Planks 22

23 Stage 2 Weight bearing activation Double limb static Squat (Quads:Glut = 1:1) Hold 60 sec When do quads start to work more than gluts? Belt or band around the knees Surfer s Squat Stage 3 Hold 60 sec When do quads start to work more than gluts? Weight bear activation Single leg static 23

24 Wall Push Standing Fire Hydrant Hold 60 sec Prevents compensated Trendelenburg Hold 60 sec Kneeling Bosu Stage 4 Hold 60 sec Weight bearing Double limb dynamic 24

25 Resisted Squats Kettle Bell Squats Crab/Monster Walking Forward Lunge 25

26 Stage 5 Single Leg Squat with Bench Assist Weight bearing Single limb dynamic Single Leg Squat Romanian Deadlift 26

27 Step Ups Step Downs Hip Hikes Stage 6 Weight bearing Double limb ballistic 27

28 Box Jumping Lateral Jumping Bad Good Stage 7 1 Leg Jumping and Cutting Weight bearing Single limb ballistic Focus on variability Agility ladders Jumping forwards Jumping sideways (45 degrees) Jumping laterally Cutting at different angles Box jumping and landing External focus of attention during function movements 28

29 Agility Ladder 1 Leg Jump Stage 8 Review Return to sport Avoid contact Sport specific drills After many practices (up to 1 month), then add contact FIND THE SOURCE OF FEMORAL INTERNAL ROTATION AND ADDUCTION Strengthen Gluts, gluts, gluts, gluts, and more gluts Strengthen Quads 29

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