Clinical Evaluation of the Patellofemoral Joint

Transcription

1 Clinical Evaluation of the Patellofemoral Joint Robert C. Manske, MPT, MEd, SCS, ATC, CSCS Wichita State University Department of Physical Therapy Via Christi Health Wichita, Kansas Common Condition 25-40% of all knee problems presenting to sports medicine centers Bizzini M, et al. Systematic review of the quality of randomized controlled trails for patellofemoral pain syndrome. J Orthop Sports Phys Ther. 2003;33:4-20. Chesworth BM, et al. Validation of outcome measures in patients with patellofemoral pain syndrome. J Orthop Sports Phys Ther. 1989;10: Rubin B, Collins R. Runner s knee. Phys Sportsmed : Common Terms PF Arthrosis: true wear and tear PF Chondrosis: wear of the chondrocytes PF Arthralgia: PF pain Anterior Knee Pain Syndrome Excessive Lateral Pressure Syndrome (ELPS): articular cartilage on lateral region causing pain Extension subluxation: VMO imbalance 1

2 PF Maltracking PF Malalignment PF Compression Common Terms Non Operative Treatment Successful in 75-90% of Patients Busch MT et al., Clin Sports Med, 8: , 1989 DeHaven KE et al, Chondromalacia patella in athletes: Clinical presentation and conservative management. Am J Sports Med, 1979;7:5-11. Fulkerson J and Hungerford DS. Disorders of the Patellofemoral Joint, 1990 Insall J. Current concepts review: Patellar pain. J Bone Joint Surg, 1982;64A: Micheli LJ et al., Am J Sports Med, 9: , 1981 Radin EL, A rational approach to the treatment of patellofemoral pain. Clin Orthop, 1979; 144: Sandow MJ et al, The natural history of anterior knee pain in adolescents. J Bone Joint Surg, 1985;67B: Stougard J, Acta Orthop Scand, 46: , 1975 Yates C et al., Orthopedics, 9: , 1986 What About the Other 10-25%? 2

3 The Key to Treating PFP is to treat the CAUSE not the SYMPTOM(S) Patellofemoral Pain Syndrome is Very Vague! There needs to be a classification system for patients with PF problems Wilk KE, Davies GJ, Mangine RE, Malone TR. Patellofemoral Disorders: A Classification System and Clinical Guidelines for Non-Operative Rehabilitation. Journal of Orthopedic and Sports Physical Therapy 1998; 28:

4 Classification System Patellar Compressive Syndromes Patellar Instability Biomechanical Dysfunction Direct patella Trauma Soft Tissue Lesions Overuse Syndromes Osteochondritis Dissecans Neurologic Disorders Primary c/o pain PF Pain Symptoms Complain of giving way, due to reflex inhibition, swelling or weakness Crepitus snap/crackles/pops Pain with stairs Very slight effusion from synovial response PAIN Pain at rest Nerve-related pain Neuroma RSD/CRPS Radiculopathy Tumor Infection Stress fracture Grelsamer RP, Stein DA. Patellofemoral Arthritis. J Bone Joint Surg 2006;88A(8):

5 Activities that increase loading across the PF joint Ascending or descending stairs Squatting Jumping Sitting with knee flexed for long periods of time (+ Movie goers sign) PF Signs Passive patellar hypo mobility (global) Passive patellar hypermobility Primarily lateral glide Patellar Malposition Patella Alta, patella baja, patellar tilt VMO Atrophy VMO atrophy or dysplasia Measure for VMO atrophy 10cm proximal to joint line 5

6 PF Signs Patella Alta High riding patella Length of infrapatellar tendon > height of patella Hypermobility Usually a congenital problem Predisposition to subluxation grasshopper eyes sup/lat deviation Rx lateral subluxation brace VMO rehab PF Signs Patella baja (infera) Congenital or iatrogenically produced secondary to PT autograph ACL reconstruction Scarring down of IPT Hypomobility Development of chondromalicia secondary to increased PFJRF Insall and Salvati Normal Height of superior pole of patella and length of the IPT should have 1:1 relationship PF Signs 6

7 Positive Apprehension Test/Fairbanks Sign Facet tenderness upon palpation PF Signs Facet Tenderness Muscular imbalances Flexibility deficits Quadriceps tightness Hamstring Tightness PF Signs 7

8 Hypertrophied VL VL:VMO timing LE malalignment PF Signs Patellar Compression Test Clark s Patellar Grind (Compression) Test 8

9 Clark s Patellar Grind (Compression) Test The Diagnostic Value of the Clarke Sign in Assessing Chondromalacia Patellae Doberstein ST, Romeyn RL. J Athlet Train. 43(2): , Doberstein and Romeyn Purpose to evaluate CS ability to detect CP in patients undergoing arthroscopic knee surgery 106 patients; none with complaints of PFP Doberstein ST, Romeyn RL. The Diagnostic Value of the Clark Sign in Assessing Chondromalacia Patellae. J Athl Train. 2008;43(2):

10 Doberstein and Romeyn In 106 patients (36) had + CS; only 23 actually had significant CP (27) false positives Doberstein ST, Romeyn RL. The Diagnostic Value of the Clark Sign in Assessing Chondromalacia Patellae. J Athl Train. 2008;43(2): Doberstein and Romeyn 67.5% specific meaning only (56 of 83) who were tested - actually did not have pathology. 9 patients actually had CP, thus 39% (9 of 23) sensitive meaning only 9 patients + CS actually had CP Clarke s Sign is an invalid and unreliable method to detect CP Doberstein ST, Romeyn RL. The Diagnostic Value of the Clark Sign in Assessing Chondromalacia Patellae. J Athl Train. 2008;43(2): PF Crepitus Grading of crepitus will only evaluate the PF joint Position in 90/90 Grade most severe sounds Loudest ROM should be documented If present is it painful or painless 1+ Mildly palpable 2+ Moderately palpable 3+ Severely palpable and audible 10

11 PF Crepitus Tactile Friction Sound Grading scale None Smooth motion no sound Mild Fine grade sandpaper - no sound Moderate Medium grade sandpaper squeaky floorboard Severe Bone-on-bone grinding popping-cracking-crunching Lancaster AR, Nyland J, Roberts CS. The validity of the motion palpation test for determining patellofemoral joint articular cartilage damage. Phys Ther Sport 2007;8: PF Crepitus 188 consecutive patients with suspected PF joint articular cartilage damage. Clinical examination followed by arthroscopic surgery Motion Palpation Test Patient edge of table, knee at 90º, passively moving knee between 100-0º while applying ~5 lb compression force with index finger distal to inferior patellar pole Lancaster AR, Nyland J, Roberts CS. The validity of the motion palpation test for determining patellofemoral joint articular cartilage damage. Phys Ther Sport 2007;8: PF Crepitus Motion palpation test: sensitive (87%) positive predictive value (97%) Accuracy (85%) Lancaster AR, Nyland J, Roberts CS. The validity of the motion palpation test for determining patellofemoral joint articular cartilage damage. Phys Ther Sport 2007;8:

12 PF Crepitus Low in: Specificity (33%) Negative predictive value (10%) This indicates a large number of people without pathology tested positive **Findings indicate that MPT is only useful as PE tool for identifying PF joint articular cartilage damage when crepitation grade is listed as severe! Lancaster AR, Nyland J, Roberts CS. The validity of the motion palpation test for determining patellofemoral joint articular cartilage damage. Phys Ther Sport 2007;8: Muscle Flexibility Specific Flexibility Tests Hamstrings in 90/90 Tight hamstrings may pull tibia posterior Pulls IPT inferior/posterior Increase PFJRF secondary to adaptive shortening of the retinaculum Creates hamstrung knee 12

13 Specific Flexibility Tests Gastrocnemius/Soleus Lumbar spine Hip flexors Thomas Test Specific Flexibility Tests Quadriceps Femoris Ely s Test Specific Flexibility Tests ITB/TFL Obers Test (knee extended) Modified Obers (knee flexed) isolates TFL 13

14 Specific Flexibility Tests Hip IR/ER The primary goal in treating patients with anterior knee pain is identifying the cause and treating the causative factors Normal position PF Orientation: Glide Component 14

15 PF Orientation: Glide Component Lateral glide: midline of the patella is lateral to the midline of the femur PF Orientation: Glide Component Lateral glide: midline of the patella is lateral to the midline of the femur PF Orientation: Glide Component Medial glide: midline of the patella is medial to the midline of the femur. Medial glide is very rare and may be present with an overextensive post-op lateral release. 15

16 Passive Mobility of PFJ Has been described in full extension Fulkerson JP, Hungerford DS. Disorders of the patellofemoral joint. 2 nd ed. Baltimore, MD: Williams and Wilkins; Kujala UM, Kvist M, Osterman K, et al. Factors predisposing army conscripts to knee exertion injuries incurred in a physical training program. Clin Orthop 1986;210: And 30 knee flexion. Fithian DC, Mishra DK, Balen, et al. Instrumented measurement of patellar mobility. Am J Sports Med (5): Skalley TC, Terry GC, Teitge RA. The quantitative measurement of normal passive medial and lateral patellar motion limits Am J Sports Med 1993;21: Patellar Passive Mobility When done in full extension is more purely a test of peripatellar soft-tissue compliance because there is less resistance from engagement of patella in trochlea Passive Medial and Lateral Glide Test 16

17 Patellar Passive Mobility Measurement done by dividing the knee into quadrants 3 quadrants of lateral glide suggest incompetent medial restraint Medial glide of 1 or less tight lateral retinaculum Medial glide greater than 3 quadrants indicates hyper mobility Kolowich PA, Paulos LE, Rosenberg TD, et al. Lateral release of the patella:indications and contraindications Am J Sports Med 1990;18(4): Patellar Passive Mobility Medial translation 9.5 mm Lateral translation 5.4 mm Ranges for each direction 3-15 mm Must therefore examine for bilateral symmetry not just overall mobility Skalley TC, Terry GC, Teitge RA. The quantitative measurement of normal passive medial and lateral patellar motion limits Am J Sports Med 1993;21: Patellar Passive Mobility Lateral passive patellar displacement with 6# force 14 +/- 1.8 mm Range of 8-20 mm Joshi RP, Heatley FW. Measurement of coronal plane patellar mobility in normal subjects. Knee Sports Surg Tramatol Arthrosc 2000;8:

18 Patellar Passive Mobility 22 females with PFP 22 females without Measured with special apparatus Ota S, et al. Comparison of patellar mobility in female adults with and without patellofemoral pain. J Orthop Sports Phys Ther 2008;38(7): Ota S, et al. Comparison of patellar mobility in female adults with and without patellofemoral pain. J Orthop Sports Phys Ther 2008;38(7): Passive Patellar Mobility No significant differences in lateral or medial patellar mobility in females with and without PFP Ota S, et al. Comparison of patellar mobility in female adults with and without patellofemoral pain. J Orthop Sports Phys Ther 2008;38(7):

19 Apprehension Test Image from: Stanitski CL: Patellofemoral Mechanism, in: Stanitski et al. Pediatric and Adolescent Sports Medicine, Vol 3. W.B. Saunders, Philadelphia, Patellar Maltracking Continues to be the subject of much debate! Usually patella follows a Concave Lateral C-Shaped curve moving from flexion to extension. PF Orientation: Passive Tracking Component 19

20 PF Orientation: Active Tracking Component Active Resisted Range of Motion PF Orientation: Active CKC Tracking Component 20

21 PF Orientation: Tilt Component Normal position Lateral tilt: lateral border is lower than medial border. PF Orientation: Tilt Component Lateral tilt: lateral border is lower than medial border. PF Orientation: Tilt Component Medial tilt: medial border is lower than lateral border. Rare. Usually only present after post-op lateral release. 21

22 Patellar Tilt Test Should be done in full extension with quads relaxed so that soft tissues are in their most relaxed position Push posteriorly on the medial border of the patella while lifting on the lateral side Patella should correct to at least neutral or beyond by about 15 Patellar Tilt Test PF Orientation: Rotation Component Normal position. 22

23 PF Orientation: Rotation Component External Rotation: inferior pole lateral to superior pole or most medial point is inferior to the most lateral point. PF Orientation: Rotation Component Internal Rotation: inferior pole medial to superior pole or most medial point is superior to the most lateral point. PF Orientation: Anteroposterior Component Normal 23

24 PF Orientation: Anteroposterior Component Depression: inferior pole to superior pole PF Orientation: Anteroposterior Component Elevation: inferior pole anterior to superior pole. Leg Length Measurements 24

25 Leg Length Differences Result in abnormal gait and may be associated with either short or long leg Short limb results in pelvic drop on ipsilateral side causing a increased valgus force at knee in terminal swing Perry J. Gait Analysis, Normal and Pathological Gait. Thorofare, NJ: Slack; Leg Length No studies yet have implicated direct relationship between leg length differences and PF pain Clinically seems relevant. Assess iliac crest height ASIS PSIS Pelvic Symmetry 25

26 Supine to Long Sitting Test Supine to long sit leg length test Direct Measurements Measure from ASIS to medial malleolus Anatomical Supine non weight bearing Functional Standing weight bearing Knee Ligament Instability 26

27 Knee ligament Instability Always rule out each of the four major knee ligaments for instability Parolie and Bergfeld reported that 48% of their chronic PCL deficient patients had stiffness following prolonged sitting (+ movie sign). Parolie JM, Bergfeld JA. Long-term results of nonoperative treatment of isolated posterior cruciate ligament injuries in the athlete. Am J Sports Med 1986;14: Knee ligament Instability Posterior cruciate ligament tears increase patellofemoral joint reaction forces by posterior displacement of the tibial tuberosity. Kinetic Chain Exercises Need to monitored very carefully. Limited ankle dorsiflexion Excessive subtalar pronation Hip external rotator weakness 27

28 Limited Ankle Dorsiflexion Tibiofemoral joint required to extend during mid-stance of gait. Excessive pronation (causing tibial internal rotation) may prevent knee from fully extending. This can ultimately affect patellar tracking. Reid DC. Anterior knee pain and the patellofemoral pain syndrome. In: Reid DC ed. Sports Injury Assessment and Rehabilitation, NY Churchill Livingstone; 1992: Lack of Ankle Dorsi Flexion Squat requires hip and knee flexion and ankle dorsiflexion. If dorsiflexion limited the subtalar joint will pronate to compensate for this lack of motion. Irrgang JJ, Rivera J. Closed Kinetic Chain Exercises for the Lower Extremity: Theory and Application. Sports Physical Therapy Section Home Study Course: Current Concepts in Rehabilitation of the Knee. LaCrosse WI: SPTS; Tiberio D. The effect of excessive subtalar joint pronation on patellofemoral mechanics: a theoretical model. J Orthop Sports Phys Ther 1987;9: Ankle Joint Pronation This increased pronation, coupled with internal tibial rotation will increase the functional Q-angle and may contribute to patellofemoral pain. Irrgang JJ, Rivera J. Closed Kinetic Chain Exercises for the Lower Extremity: Theory and Application. Sports Physical Therapy Section Home Study Course: Current Concepts in Rehabilitation of the Knee. LaCrosse WI: SPTS;

29 Hip External Rotator Weakness Hip weakness may allow uncontrolled hip internal rotation, allowing excessive foot pronation, both of which contribute to increased Q-angle Pease BJ, Cortese M. Anterior knee pain: Differential diagnosis and physical therapy management. In Orthopedic Physical Therapy Home Study Course LaCrosse WI: Orthopedic Section, American Physical Therapy Association; Thank You! Robert C. Manske, PT, DPT, MEd, SCS, ATC, LAT, SCS, CSCS Wichita State University Dept. Physical Therapy 1845 North Fairmount Wichita, Kansas