VADEMECUM Patellofemoral Pain Syndrome (PFPS)

Transcription

1 Hogeschool van Amsterdam Amsterdam School for Health Professional European School of Physiotherapy VADEMECUM Patellofemoral Pain Syndrome (PFPS) AUTHORS: Hyacinth Nwosu: HVA, 24 January 2008 Odile Saurat:

2 Table of contents: Pages 1. Introduction 3 2. Definition 3 3. Aetiology 4 4. Signs and Symptoms 4 5. Epidemiology 4 6. Patient History 4 7. Assessment 5 8. Policy 5 9. What is proven Refer to Prevention and information Conclusion Literature 7 2

3 1. INTRODUCTION Patellofemoral pain syndrome (PFPS) is an important clinical problem and the most prevalent disorder of the knee. (Sultive et al 2004). It is a common source of anterior knee pain in active individuals between the age of years old. Several names has been giving to this disorder such as patellar malalignments, patellofemoral arthralgia, chondromalacia and anterior knee pain. We use PFPS here to describe the type of patients who have pain over the anterior aspect of the knee without other identifiable causative pathology (patella tendonitis or tendinopathy, osteoarthritis, patella subluxation or dislocation, traumatic injuries, plica syndrome, Osgood Schatter syndrome, bursitis). Most patients who have PFPS can be successfully treated once contributed factors are identified during history taking and physical examination. The following provides an update on the best clinical evaluation and treatment of patients with PFPS. 2. DEFINITION Patellofemoral Pain refers to all disorders associated with discomfort on the anterior aspect of the knee joint and may include a diverse range of injury. It describes a continuum of articular cartilage changes affecting the under surface of the patella (Brukner and Khan 2002). It is characterised by retropatelar pain (behind the kneecap) or peripatellar (around the kneecap) when ascending or descending stairs, squatting or sitting with flexed knees (Heintjes 2007). To understand PFPS we first need to understand the anatomy. Anatomy.and biomechanics The patellofemoral joint comprises the patella and the femoral trochlea. The patella acts as a lever and also increases the moment arm of the patellofemoral joint, the quadriceps and patellar tendons (Dixit 2007). The patella moves within the patellofemoral grove of the femur. Several forces act on the patella to provide stability and keep it tracking properly.(figure1, 2). Stability of the patellofemoral joint involves dynamic and static stabilizers (table 1, figure1), which control movement of the patella within the trochlea, referred to as patellar tracking. Patellar tracking can be altered by imbalances in these stabilizing forces affecting the distribution of forces laterally and medially along the patellofemoral articular surface, the patellar and quadriceps tendons, and the adjacent soft tissues. Pain may result from malfunctioning of any of these forces. Table 1 Dynamic and static stabilizers of patellar joint Dynamic stabilizers Quadriceps tendon, Patellar tendon, Vastus medialis obliquus (VMO) Vastus lateralis, Iliotibial band (ITB) Static stabilizers Articular capsule, Femoral trochlea, Medial and lateral retinacula, Patellofemoral ligaments. 3

4 3. AETIOLOGY According to Heintjes (2007) and Sultive (2004)) the aetiology of PFPS is considered as multiple factors and not yet understood. Aetiology, structures causing the pain and treatment methods are all debated in literature, but consensus has not been reached so far (Heintjes 2006). However several opinions suggested that the following may be the cause. Table 2 Possible causes of patellofemoral pain. Soft tissue tightness and muscle weakness (Lower extremities Training like distance running, hills, stairs Patellar malalignement Increasing Q angle Overuse and over load Structural and postural alteration Abnormal biochemical like excessive pronation, femoral anteversion (internal femoral torsion), High small patella (patella alta) Muscle dysfunction caused by VMO, hip abductors/external rotators( Gluteus medius) 4. SIGNS & SYMPTOMS Usually of gradual onset Stiffness or pain, or both, on prolonged sitting with the knees flexed often called Theatre sign. Feeling of knee swelling or fullness, especially over the infrapatellar area. Pain with activities that load the patellofemoral joint, such as climbing or descending stairs, squatting, or running. Difficulty for the patient to localize pain. Patient draw circle with their fingers around the patella circle sign. Achy pain, can be sharp at times. Complaint of knee giving way as a result of transient inhibition of the quadriceps because of pain or deconditioning but not true patellar instability. Other common symptoms Popping or crepitus. 5. EPIDEMIOLOGY Of those affected, the condition occurs more frequently in females (Taunton et al, 2002), also athlete of both sex and elderly people. It accounts for 25% to 40% of all knee problems seen in sports medicine centres (Bizzini et al 2003). Incidence rates of 7% and 10% have been reported in young male and female athletes respectively (Houghton 2007). 6. PATIENT HISTORY Before assessing patient with PFPS, it is important to have a thorough general overview of the characteristic of the pain. Patient with PFPS often complain of diffuse and poorly localised pain over anterior aspect of the knee. Pain seems to be from "behind the kneecap underneath, or around the patella. The clinical history should include a thorough description of Pain characteristics (location, character, onset, duration, change with activity or rest, aggravating and alleviating factors, night pain) Trauma (acute macrotrauma, repetitive microtrauma, recent/remote) Mechanical symptoms (locking or extension block, instability, worse during or after activity) Inflammatory symptoms (morning stiffness, swelling) Effects of previous treatments and the current level of function of the patient Previous injury or knee surgery chronic (inflammatory joint disease or bleeding diathesis, is significant, especially if knee swelling is present. Type of activity producing pain (runners, long sitting and kneeling) 4

5 7. ASSESSMENT An extensive search of the literature revealed no single golden standard tests. This is because of the multiple forces affecting the patellofemoral joint. However, the basic assessment have to be performed thoroughly with particular attention to extensor mechanism function. The primary purpose of assessment is to look for possible source of pathology and to assess for correctable factors that can be addressed with rehabilitation. Studies have shown that the following sequence could be used during examination of the lower extremities: 1. General low extremities Inspection (for overall impression of lower-limb alignment and possible cause of patellar pain and functional abnormalities) 2. Palpation ( for tenderness, muscle tone, effusion) 3. Range of motion (AROM and PROM in Knee and hip is usually normal) 4. Resistant test for weakness of quads especially VMO and hip abd and ext rotators -- patellar maltracking, > knee valgus 5. Flexibility ( for tightness ) Poor flexibility in these areas may contribute to stress across the patellofemoral joint 6. Functional test (Single leg squat or Step-down) reduced balance and strength 7. Clinical tests: for patellar mobility and position to be performed as a routine: Table 3; clinical or special tests for assessing PFPS. Tests Assessment Procedure Outcome effect Patellar glide (apprehension&tilt) test LaBotz et al(2004) Dixit et al (2007) Mobility, pain & lateral structure tightness Patella Lat Pressure flexion -Displacement of less than 1 quadrant:tight lateral structures; -Displacement of more than 3 quadrants: patellar hyper mobility Compression test: Houghton et al(2007) Final step Retropatellar tenderness Direct compression of posterior part of patella into trochlea at different knee flexion Pain Pain Note; Cochrane review (2007) the specificity and sensitivity of these tests is debated in literature, but validation studies are absent 8. POLICY Several studies have shown physical therapy to be effective in treating PFPS. However, according to Dixit et al (2007) and Juhn (1999) there is no singular treatment program that will be effective for all patients. Therefore, definitive treatment should be individualized. It is important to educate patient Table 4; shows different treatment methods and the goals of the treatments. Goals of treatment Treatment tools Reduce pain and inflammation Reduce Patellofemoral Joint Reaction Forces joint Strengthening of lower extremities and improving alignment Stabilization/balance/proprioceptive exercises hip and knee Rest, ice, NSAID, reduced loading exercise Stretching of tight structures and shortened muscles Exercise Therapy - Open and closed chain - Quadriceps strengthening exercises 1 st : isometric contraction, inner range (non weightbearing) contractions and progressive and straight leg raising, increase resistance, with or without taping (Mc Connell) while retraining VMO Wobble-board, progress to running, jumping, landing, ball throwing on wobble-board Other Therapies such as bracing, ultrasound, massage, electro muscular Stimulation, foot orthoses, could be used as adjunctive. 5

6 9. WHAT IS PROVEN There is a lack of consensus in the literature regarding the reliability of therapists in assessing the specific components of the tilt, glide and pronation of the patella, which taping is purported to alter (Whittingham et al 2004) According to Hing (2006) the confirmation of specific diagnose of PFPS is difficult because of a paucity of valid clinical test. Particular attention should be paid to illiotibial band, hamstring, rectus femoris and gastrocnemius and soleus flexibility (LaBotz 2004). According to Australian physiotherapy Association 2005 (Evidence based Clinical Statement) exercise therapy (quadriceps strengthening exercises) is recommended and there is insufficient evidence to support or refute the use of patellar bracing or taping. If successful, taping should immediately reduce pain during aggravating activity by at least 50 %. (Brukner et al 2006). Also other treatments tools such as ultrasound, massage, Electro Muscular Stimulation, foot orthoses, Biofeedback, acupuncture need further trials to clarify their specific effect on PFPS. According to Cochrane Review (randomised clinical trials level 1 ie high quality articles) Heintjes et al 2007, Van Linschoten et al(2006),medline, CINAHL, Web for scientific databases for RCT, Australian Physiotherapy Associations (APA)(2005) and our findings, there is strong evidence that exercise therapy ( open and closed kinetic chain exercises) might help to reduce knee pain associated PFPS with a treatment frequency/ duration/ 2-3x/weeks for 6 to 12 weeks, but further trials are needed Multimodal physiotherapy interventions( such exercise McConnell taping, foot orthosis,etc or combination) are effective in the treatment of patellofemoral pain syndrome (Heintjes et al (2003), Bizzini et al (2003), Crossley et al (2001). 10. REFERRED TO If symptoms persist after 6 to 12 weeks despite an appropriate rehabilitation program, a physiotherapist should refer the patient to an orthopaedist. (LaBotz 2004, Dixit et al 2007) 11. PREVENTION AND INFORMING Varying the types of activity that patient participate Avoiding excessive worn and inappropriate footwear Avoiding unnecessary forces across the knee like cross-leg sitting, prolonged squatting Taking care of injuries immediately (first aid, rest) If running, choosing an even, clear surface Boudreau (2004), Nwosu and Saurat (2008) 12. CONCLUSION Based on the reviewed articles and expert opinions, we concluded that: in patients presenting with PFPS, there is no strong evidence to support the validity and reliability of assessment tools. We suggest that physiotherapists should perform a thorough patient history for differential diagnosis. However a positive outcome on palpation of the patellae, functional tests, patellae mobility or glide test, apprehension and compression test is recommended. Therefore there is no golden standard rules for assessing PFPS. Addition, there is also no strong evidence that clearly indicate that one treatment is seen as the best. Based on this limited evidence we can expect therefore that physiotherapists use a combination of various interventions in respect to individual patient's symptoms and causes. Further research is needed to come up with the best physiotherapy assessment and treatment tools for PFPS. 6

7 13. LITERATURE Articles: 1. Aminaka, N., Gribble, P. A. (2005) A systematic review of the effects of therapeutic taping on patellofemoral pain syndrome. Journal of Athletic Training. Vol.40, (4) pp Bruckner, P. & Khan, K. (2002) Revised 2nd edn Clinical Sports Medicine. Sidney: McGraw-Hill Australia Pty Limited 3. Brukner, P.D., Crossley, K.M., Morris, H., Bartold, S.J., Elliot, B. (2006) Recent advances in Sports Medecine. MJA Practice essentials-sports Medecine, Vol. 184 (4) pp Bizzini, M., Chitds, J.D., Piva, S R., Delitto, A. (2003) Systematic Review of the Quality of Randomized Controlled Trials for Patellofemoral Pain. Syndrome. Journal of Orthopaedic & Sports Physical Therapy, Vol. 33 (I) pp Boudreau, E. (2004) Standard of Care: Patellofemoral Pain Syndrome (PFS) Physical therapy for the patient with PFS. Department of Rehabilitation Services, Brigham & Women s Hospital, Boston, MA pp Crossley, K. (2005) Physiotherapy treatment for patellofemoral pain. APA Evidenced-Based Clinical statement, Australien Physiotherapy Association E.M. pp Crossley, K., Dip, G., Bennell, K., Green, S., Cowan, S., Mc Connell, J. (2002) physical Therapy for patellofemoral pain: a randomized, double-blinded, placebo controlled trial. American Journal of Sports medicine, Vol. 30, (6) pp Dixit, S., Difiori, J.P., Burton, M. & Mines, B. (2007) Management of Patellofemoral Pain Syndrome. Am Fam Physician; Vol. 75, pp Fulkerson, JP. (2004) Patellofemoral symposium. View summary: orthopedic [online] Vol. 27, (12) pp. 27:12. Available from, < > [19 November 2007] 9. Fulkerson, JP. (2002) Current Concepts: Diagnosis and Treatment of Patients with Patellofemoral Pain. The American Journal of Sport Medecine. Vol. 30, ( 3) pp Hing, W., Overgton, M., Goddard, D., (2006) A critical appraisal and literature critique on the effect of patellar taping is patellar taping effective in the treatment of patellofemoral pain syndrome? New Zealand Journal of Physiotherapy 34 (2) pp Heintjes, E., Berger, M.Y., Bierma-Zeinstra, S.M.A., Bernsen, R.M.D., Verhaar, J.A.N., Koes, B.W. (2007) Exercise therapy for patellofemoral pain syndrome. Cochrane Database of Systematic Review, in The Cochrane Library (issue 4).pp Houghton, K.M. (2007) Review for the generalist: evaluation of anterior knee pain. Pediatr Rheumatol Online J.; Vol. 5: 8.pp Juhn, M.S. (1999) Patellofemoral Pain Syndrome: A Review and Guidelines for Treatment. American Family of Physician [online] Vol. 6 (7) Available from < [19 November 2007] 14. Van Linschoten, R., van Middelkoop, M., Berger, M.Y., Heintjes, E.M., Koopmanschap, M.A., Verhaar, J.A., Koes, B.W. & Bierma-Zeinstra, S. MA. (2006) The PEX study Exercise therapy for patellofemoral pain syndrome: design of a randomized clinical trial in general practice and sports medicine. BMC Musculosckelet. Disord. Vol. 7: LaBotz, M. (2004) Practical essentials: Patellofemoral Syndrome. The physician and sports medicine, Vol. 32 (7) pp Loudon, J.K., Wiesner, D., Goist-Foley, H.L., Asjes, C., & Loudon, K.L. (2002) Intratrater Reliability of Functional Performance Tests for Subjects With Patellofemoral Pain Syndrome. J Athl Train. Vol. 37 (3) pp Nijs, J., Van Geela, C., Van der auweraa, C., Van de Veldea B. (2006) Diagnostic value of five clinical tests in patellofemoral pain syndrome. Manual Therapy, Vol.11, pp Piva, S.R., Fitzgerald, K., Irrgang, J.J., Jones, S., Hando, B.R., Browder, D.A. & Childs, J.D. (2006) Reliability of measures of impairments associated with patellofemoral pain syndrome. BMC Musculoskeletal Disorders 7:33 pp Sutlive, T.G., Mitchell, S.D., Maxfield, S.N., McLean, C.L., Neumann, J.C, Swiecki, C.R., Hall, R.C., Bare, A.C. & Flynn, T.W. (2004) 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, Vol. 84, pp Withrow, E., Lysen, R., Bellemans, J., Peers, K. & Vanderstraeten, G. (2000) Open Versus Closed Kinetic Chain Exercises for Patellofemoral Pain: A Prospective, Randomised study. The American Journal of Sports Medecine, Vol.28 (5) pp

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