Patellofemoral Pain Syndrome: A Case Study

Transcription

1 University of North Dakota UND Scholarly Commons Physical Therapy Scholarly Projects Department of Physical Therapy 2015 Patellofemoral Pain Syndrome: A Case Study Alexandra Jares University of North Dakota Follow this and additional works at: Recommended Citation Jares, Alexandra, "Patellofemoral Pain Syndrome: A Case Study" (2015). Physical Therapy Scholarly Projects This Scholarly Project is brought to you for free and open access by the Department of Physical Therapy at UND Scholarly Commons. It has been accepted for inclusion in Physical Therapy Scholarly Projects by an authorized administrator of UND Scholarly Commons. For more information, please contact zeineb.yousif@library.und.edu.

2 Patellofemoral Pain Syndrome: A Case Study by Alexandra Jares Bachelor of Science in Honoribus Northern State University, 2012 A Scholarly Project Submitted to the Graduate Faculty of the Department of Physical Therapy School of Medicine and Health Sciences University of North Dakota in partial fulfillment of the requirements for the degree of Doctor of Physical Therapy Grand Forks, North Dakota May, 2015

3 Tills Scholarly Project, submitted by Alexandra Jares in partial fulfillment ofthe requirements for the Degree of Doctor of Physical Therapy from the University of North Dakota, has been read by the Advisor and Chairperson of Physical Therapy under whom the work has been done and is hereby approved. ~R'$~\L-- (Graduate School Advisor) 11

4 PERMISSION Title Patellofemoral Pain Syndrome: A Case Study Department Physical Therapy Degree Doctor of Physical Therapy In presenting this Scholarly Project in partial fulfillment of the requirements for a graduate degree from the University ofn orth Dakota, I agree that the Department of Physical Therapy shall make it freely available for inspection. I further agree that permission for extensive copying for scholarly purposes may be granted by the professor who supervised my work or, in his absence, by the Chairperson of the department. It is understood that any copying or publication or other use of this Scholarly Project or part thereof for financial gain shall not be allowed without my written permission. It is also understood that due recognition shall be given to me and the University of North Dakota in any scholarly use which may be made of any material in this Scholarly Project. Signature Date 111

5 TABLE OF CONTENTS LIST OF TABLES... v ACKNOWLEDGEMENTS... vi ABSTRACT... vii CHAPTER I. BACKGROUND AND PURPOSE....1 II. CASE DESCRIPTION....4 Examination....4 EvaluationiDiagnosislPrognosis... 6 Interventions... 6 Outcomes... 8 III. DISCUSSION... 9 Reflective Practice Conclusion... l 0 REFERENCES iv

6 LIST OF TABLES 1. Table 1: Initial Circumferential Measurements Table 2: Therapy Interventions Table 3: Discharge Circumferential Measurements... 8 v

7 ACKNOWLEDGEMENTS I would like to thank my scholarly project advisor, Dr. Tom Mohr, for his assistance and corrections on my case stndy. Also, thanks to the University of North Dakota Physical Therapy professors for the education they have provided, allowing me to increase my skill and clinical decision making when working with patients in the clinical setting. VI

8 ABSTRACT Background and Purpose: Patellofemoral Pain Syndrome (PFPS) is one of the most common lower extremity disorders reported, with a higher prevalence among females and in active individuals. While quadriceps strengthening has generally been the chosen treatment approach, some studies have pointed to the importance and influence of the hip musculature. Patients with PFPS commonly present with decreased posterolateral strength, specifically in the hip abductors, hip extensors, and hip external rotators. Case Description: The patient was a 13-year-old thin-framed female who was referred to physical therapy after dislocating her right patella during a twisting motion in dance class. Interventions: Based on the patient's diagnosis and examination fmdings, a plan of care was developed to address the patient's impairments and functional limitations with a focus on proximal hip musculature strengthening. Outcomes: The patient demonstrated improvements in clinically meaningful impairments, including knee ROM, lower extremity strength and flexibility, proprioceptive awareness, and overall function. Discussion/Conclusion: This case report describes the rehabilitation process of a young female patient with PFPS who responded well to a strengthening program with the primary focus on hip musculature strengthening. Positive results were achieved in this case without focus on commonly used intervention strategies. These results support recent research that has shown proximal hip musculature strengthening in patients with PFPS to be superior and more efficient than historically used treatment approaches. vii

9 CHAPTER I BACKGROUND AND PURPOSE Patellofemoral Pain Syndrome (PFPS) is one of the most common lower extremity disorders reported, with a higher prevalence among females and in active individuals, 1,2 PFPS may be defined as "peripatellar or retropatellar pain resulting from physical and biomechanical changes in the patellofemoral joint.,,3 Due to the increase of pressure observed between the patella and the femur during knee flexion, PFPS is often classified as an overuse or overload injury,3 Patients with this condition may present with dysfunctional patellar tracking, decreased flexibility of the lower extremity, and decreased strength or atrophy of the quadriceps and hamstrings, particularly the vastus medialis oblique,4 Other attributing biomechanical factors include increased supination or pronation at the foot and a large Q angle of the femur? Patients with PFPS generally present with peri-patellar pain that is aggravated by activities that stress the patellofemoral joint. Common contributing activities include stair climbing, ambulation on uneven sur f ' aces, squattmg, 'd' an smg I e-i eg movements, 13 ' Historically, the etiology ofpfps has been linked to dysfunctional patellar tracking secondary to quadriceps impairments.z,5 Conservative management has often been the treatment of choice, with interventions consisting of patellar taping, exercise associated with vastus medialis oblique strengthening, bracing, biofeedback, and foot orthoses,l,2 Although conservative treatment of PFPS has been shown to be beneficial for some patients, others continue to experience pain and dysfunction with knee movement. 6 1

10 As such, recent research has been conducted with a focus on the influence of the proximal hip musculature at the knee joint. While quadriceps strengthening has generally been the chosen treatment approach, some studies have pointed to the importance and influence of the hip musculature. Patients with PFPS commonly present with decreased posterolateral strength, specifically in the hip abductors, hip extensors, and hip external rotators? Excessive hip internal rotation and adduction during functional activities uncontrolled by weakness in these muscles can lead to dysfunctional lower extremity joint alignment and the onset ofpfps 5 Research has shown initial hip strengthening of the abductors and external rotators may provide earlier reduction in pain and improvements in function in t h IS patient popu I' atlon.. 57 In a systematic review of the effectiveness of proximal exercises compared to knee exercises in improving pain and function in patients with PFPS, Peters et all reported improvements in pain and function in all proximal exercise participants, with only variable outcomes in those patients who perfomied knee exercises. I In a randomized clinical trial, Dolak et al 5 investigated the benefits of hip strengthening prior to functional exercises versus quadriceps strengthening prior to functional exercises in thirty-three females with PFPS to detemiine if either treatment approach demonstrated greater improvements 5 The researchers reported that both approaches led to improvements in self-reported function, objective function, and hip strength, with initial hip strengthening showing earlier pain reduction than that of quadriceps strengthening. Dolak et al 5 2

11 suggested initial hip strengthening may provide a more efficient treatment approach, allowing muscle training while reducing PFPS symptoms and load on the patellofemoral joint. 5 This case report describes the physical therapy plan of care for a young female with patellofemoral pain syndrome utilizing hip muscle strengthening as the primary intervention. The purpose of this report is to show that posterolateral hip strengthening combined with lower extremity exercise and stretching can lead to improvements in pain and functional status in a patient presenting with PFPS. 3

12 CHAPTER II CASE DESCRIPTION Examination The patient was a 13-year-old thin-framed female who was referred to physical therapy after dislocating her right patella during a twisting motion in dance class. Paramedics were able to reduce her patella at the scene and the patient was given a knee immobilizer until she could be examined by a medical doctor a few days later. The patient had also experienced a previous patellar dislocation on the same leg approximately one year prior while at ballet. Previous treatment included physical therapy and the use of a knee brace during activities that was later discontinued. MRI findings of the present condition showed evidence of a patellar dislocation and relocation, bone contusions of the lateral femoral condyle and medial patella, and a tear of the medial patellofemoralligament patellar attachment. The patient was instructed by her doctor to wear a knee brace at all times, begin a rehabilitation program, and defer from dance at this time. The patient's chief complaint upon entering physical therapy was pain and weakness of the right knee. She stated her pain as a 4/10 about the right patella that began after her prior dislocation in dance class. The patient was currently ambulating with the use of a knee immobilizer and displayed a slight antalgic gait pattern favoring her right side. Upon observation, significant atrophy of the right quadriceps, edema and swelling 4

13 about the right knee, and slight genu val gum were visualized. The patient stated her pain as worse with stairs and when ambulating long distances, specifically in the hallways at school. Patient goals were to decrease pain and increase strength and range of motion about the right knee to allow pain-free ambulation at home and school and a return to athletic activities within 8-12 weeks. Examination and special testing of the patient's lower extremities revealed significant range of motion loss and atrophy at the right knee. Range of motion measured 0-59 degrees at the right knee with fear and apprehension displayed during movement. Motions were within normal limits at left knee. Quadriceps and hamstrings testing were deferred at the right knee due to pain and apprehension. Hip flexion, extension, abduction, adduction, external rotation, and internal rotation all 4-/5 at right and left hip. Quadriceps and hamstrings strength were both 415 on left. Special testing from the initial doctor visit revealed anterior drawer and Lachman's both positive + 1. The patient reported sensation as normal, with tenderness along medial and lateral patella. Table 1 shows the results of circumferential measurements at both the right and left knee taken at the initial examination. Table 1: Initial Circumferential Measurements 5

14 Evaluation/Diagnosis/Prognosis Based on the patient's clinical presentation and exam findings, the patient was detennined an appropriate candidate for physical therapy services due to impairments and functional limitations. A plan of care was developed to address the current patellofemoral instability and the patient's goals. The patient was to attend therapy two times per week for six to eight weeks, continue use of her knee brace for daily activities, and refrain from recreational activities. The following goals were implemented by the student physical therapist and patient: Increased range of motion at the right knee to equivalent of opposite lower extremity, increased strength to 5/5 at bilateral lower extremity, decreased pain to 0/10 with activity, ability to ambulate without a knee brace, and ability to return to all activities of daily living and athletic activities at level prior to injury within eight to twelve weeks. Iuterventions An intervention plan and home exercise program were developed to address the plan of care and therapy goals set by the patient and student physical therapist. Interventions were focused on hip abductor and external rotator strengthening, along with quadriceps strengthening, edema reduction, and lower extremity stretching. Table 2 outlines the exercises perfonned throughout the duration of therapy. Thera-band strength was progressed from yellow to green during therapy and weights and repetitions/sets were increased as tolerated. The patient's knee brace was worn as needed during therapy for stabilization. 6

15 Table 2: Therapy Interventions Week I Exercise/Treatments Passive range of motion (PROM) and gentle manual stretching at right knee. Soft tissue mobilization for pain and swelling reduction about right quadriceps and knee joint. Gait training in parallel bars. Seated leg extension. 2 PROM and manual stretching at right knee. Seated leg extension. Mini-lunges. Leg press machine. Mini-squats. Prone hip extension. Supine straight leg raise. 3 Continuation of exercises from week 2. Increase in ROM and repetitions/sets. 4 Supine lower extremity bridging, double and single leg. Leg press machine, double and single leg. Seated leg extension. Monster walks (forward) and side stepping with Thera-band around knees. Gluteal raises (hip extension, knee bent) in quadruped position. 5 Continuation of exercises from week 4. Gluteal raises and hip abduction combination in quadruped position. Standing hip abduction. 6 Continuation of exercises from week 5. Bridging performed with Thera-band around thighs. Mini-lunges with weights in hand. Standing calf raises. Knee extension and flexion machines. Standing hip abduction with Thera-band. 7 Continuation of exercises from week 6. Mini-squats with isometric adduction with small therapeutic ball between knees. Standing hip extension with Theraband. 7

16 Outcomes The patient was seen for physical therapy services two to three times per week for a total of seven weeks in our clinic. At discharge the patient was transferred to the Sanford Power Center with emphasis on return to sport rehabilitation. At the termination of physical therapy, the patient reported decreased pain to 1110 with activity and 0/1 0 at rest in her right knee. Inflammation and tenderness to palpation were both absent. Special tests to evaluate ligament integrity and patellar tracking at the right knee were all negative. Range of motion returned to degrees at bilateral knee. Strength increased to 4+/5 at bilateral lower extremity hip and knee. Increased lateral translation of the right patella could be visualized, but there was a check reign and endpoint. Slight atrophy was still present at right quadriceps. Circumferential measurements of the left and right knee at the discharge of physical therapy can be found in table 3. The patient had no complaints of instability, but was instructed to continue with the use of a knee brace by her doctor for physical activity. Table 3: Discharge Circumferential Measurements 8

17 CHAPTER III DISCUSSION This case report describes the rehabilitation process of a young female patient who responded well to a strengthening program with the primary focus on hip musculature strengthening. Hip weakness has commonly been linked to patellofemoral tracking problems, resulting in pain and dysfunctional lower extremity joint alignment during functional activities. 5,8 Positive results were achieved in this case without focus on common intervention strategies, such as vastus medialis oblique strengthening and patellar taping. These results support recent research that has shown proximal hip musculature strengthening in patients with PFPS to be superior and more efficient than historically used treatment approaches. Prior research has discussed the relevance of dysfunction in the lower extremity kinetic chain when evaluating and developing a plan of care for patients with PFPS. 9,lO Weakness in the hip external rotators and abductors allows uncontrolled internal rotation and adduction during functional activities, which can lead to pain and dysfunction. 5 In addition, research has shown that proximal weakness often accompanies distal lower extremity impairments and injuries. I I,ll Although recent research has demonstrated the superior benefits of proximal hip muscle strengthening in patients with PFPS, this patient's rehabilitation program also incorporated quadriceps and overall lower extremity strengthening, as well as lower extremity stretching. Rixe et alb found that quadriceps and hip strengthening combined 9

18 with stretching comprised the most effective treatment for reducing knee pain symptoms and improving function in patients with PFPS. 13 As such, the most beneficial treatment modality recommended for patients experiencing PFPS is a combined physiotherapy program which includes strength training of the proximal hip musculature and quadriceps, and stretching of the quadriceps muscle group.13 Reflective Practice Neuromuscular reeducation may have been a beneficial treatment approach to incorporate into the intervention plan for this patient. Baker et al 14 discuss the existence of abnormal knee joint proprioception in patients demonstrating PFPS. Results from this study and others support the addition of neuromuscular/proprioceptive reeducation in the treatment of PFPS and abnormal patellar tracking due to dysfunctional lower extremity joint aligmnent The patient in this case study may have achieved additional positive results from this treatment approach as she demonstrated decreased muscle control with exercises and lower extremity movements during therapy and had a history of injury reoccurrence. Conclusiou This case study reinforces the importance of hip strengthening along with quadriceps strengthening and stretching in patients with PFPS. Proximal exercises may be more efficient at decreasing pain and decreasing the chance of reoccurrence in patients experiencing PFPS due to overuse or patellar dislocation. The incorporation of proximal hip musculature strengthening should be considered when building a plan of care and 10

19 ~--- intervention program for patients with PFPS. Further research on the relationship between hip musculature weakness and PFPS may be beneficial in treating PFPS and identifying the patients who will best benefit from this treatment approach. 11

20 REFERENCES 1. Peters J, Tyson N. Proximal exercises are effective in treating patellofemoral pain syndrome: a systematic review.1jspt 2013; 8(5): Khayambashi K, Fallah A, Movahedi A, et al. Posterolateral hip muscle strengthening versus quadriceps strengthening for patellofemoral pain: a comparitive control trial. Archives 0/ Physical Medicine and Rehabilitation Juhn M. Patellofemoral pain syndrome: A review and guidelines for treatment. Am Fam Physician. 1999; 60(7): Meira E, Brumitt J. Influence of the hip on patients with patellofemoral pain syndrome: a systematic review. Sports Health. 2011; 3(5): Dolak K, Silkman C, Medina McKeon J, et al. Hip strengthening prior to functional exercises reduces pain sooner than quadriceps strengthening in females with patellofemoral pain syndrome: a randomized clinical trial. J Orthop Sports Phys Ther. 2011; 41 : Collins NJ, Bisset LM, Crossley KM, Vicenzino B. Efficacy of nonsurgical interventions for anterior knee pain: systematic review and meta-analysis of randomized trials. Sports Med 2012;42(1): Nakagawa T, Muniz T, Baldon R, et al. The effect of additional strengthening of hip abductor and lateral rotator muscles in patellofemoral pain syndrome: a randomized controlled pilot study. Clin Rehabil. 2008; 22: Khayambashi K, Mohammadkhani Z, Ghaznavi K, et al. The Effects ofisolated Hip Abductor and External Rotator Muscle Strengthening on Pain, Health Status, and Hip Strength in Females With Patellofemoral Pain: A Randomized Controlled Trial. Journal O/Orthopaedic & Sports Physical Therapy. 2012;42(1): Carson WG, Jr., James SL, Larson RL, Singer KM, Winternitz WW. Patellofemoral disorders: physical and radiographic evaluation. Part I: Physical examination. Clin Orthop. 1984; James SL, Bates BT, Osternig LR. Injuries to runners. Am J Sports Med 1978;6: Bullock-Saxton JE. Local sensation changes and altered hip muscle function following severe ankle sprain. Phys Ther. 1994;74:17-28; discussion

21 12. Jaramillo J, Worrell TW, Ingersoll CD. Hip isometric strength following knee surgery. J Orthop Sports Phys Ther. 1994;20: Rixe J, Glick J, Brady J, et al. A review of the management of pat ell of em oral pain syndrome. Phys Sports Med 2013; 41(3): Baker, V., Bermel!, K., Stillman, B., Cowan, S., and Crossley, K. Abnormal knee joint position sense in individuals with patellofemoral pain syndrome. J Orthop Res. 2002; 20: David Hryvniak, Eric Magrum, Robert Wilder, Patellofemoral Pain Syndrome: An Updat. Current Physical Medicine and Rehabilitation Reports, 2014:2(1):