Management of Patellofemoral Pain Syndrome João Barroso Orthopaedic department ULS Matosinhos Portugal
Introduction Anterior Knee Pain affects 1 in 4 athletes very common! (Knowles et al) Patellofemoral pain syndrome (PFPS) is one of the most common problems (DeHaven & Lintner), mostly between the ages of 15 and 30. Females athletes are 2.23 times more likely to develop PFPS compared with males 2
Anathomy and Biomechanic Dynamic Stabilizers: - Quadriceps tendon, Patellar tendon, Vastus medialis obliquus (VMO), Vastus lateralis, and Ilio=bial band. Sta1c Stabilizers: - Ar=cular capsule, the medial and lateral patella re=naculum, special configura=on between the femoral trochlea and =bial plates. 3
Definition, Anatomy and Biomechanics Strengths over patellofemoral complex: - 1/3 body weight during walking - 3x body weight when climbing stairs / inclined plane - 7x body weight when doing squatting / "Squatting body! One of the most highly loaded joint in the human 4
Risk Factors Alterations in patellar tracking Increase of load and tension on patellofemoral apparatus 6
Muscular Risk Factors Weakness, < muscular flexibility; Anatomical Femoral trochlea dysplasia, Patella position (patella alta/baja or subluxation) General ligamentous laxity Malalingment of the lower extremity Subtalar Pronation, Valgus knee, external tibial torsion, Angle Q> 15º; Femoral anteversion Overuse, Trauma
Risk Factors 7
Diagnosis Clinical history Physical exam In the majority of cases are enough to do diagnoses of PFPS
Diagnosis Pain - Insidious onset; - Anterior knee pain behind or around patella; - Exacerbated after long periods in sitting position with flexed leg and/or with activities that increase load on patella. 8
Diagnosis SWELLING LOCKING INSTABILITY Not characteristic. Not characteristic; Loose body or meniscal lesion. Not characteristic; When exists it s reflex of the painful arch that inhibits quadricipital contraction false instability. 8
Diagnosis INSPECTION Alignment, Lateral patellar tracking - J Sign?, compare with contralateral quadriceps; PALPATION Pain on the patellar retinaculum; Patella is unusual! +++ OA, trauma or bipartite patella, tendinopathies; MOBILITY Complete passive and active knee mobilization, symptomatic or not. 8
Diagnosis Patellar Glide >3 lateral quadrants medial weakness <1lateral quadrant lateral thickening Patellar Tilt Test Pressure medial facet Elevation <15º - lateral thickening Patellar Grind Test Pain + test. 8
Diagnosis RX mandatory if: - History of trauma; - > 50 years; - Knee swollen.
Differential Diagnosis Meniscal and cartilage lesion Bone tumor Patellar instability Hoffa Syndrome Patellar and quadricipital tendinopathy Osgood-Schlatter Syndrome Iliotibial Treatment Syndrome OA Patelofemoral Pre-patellar bursitis Symptomatic bipartite patella.
Relative Rest and activity modification Cryotherapy TREATMENT 1ST LINE Identification and correction of precipitating events Rehabilitation program
Relative Rest and activity modification Cryotherapy TREATMENT 1ST LINE Identification and correction of precipitating events Rehabilitation program
Treatment Relative rest and activity modification Resistance training exercises have been identified as playing a role in causing the injury, so cessation of specific exercises such as full squats and lunges is indicated; Runners should reduce mileage to a level that does not provoke pain; Alternative activities: bicycling, swimming, or the use of an elliptical trainer
Relative Rest and activity modification Cryotherapy TREATMENT 1ST LINE Identification and correction of precipitating events Rehabilitation program
Treatment Identification and correction of precipitating events A careful history will identify a precipitating event
Relative Rest and activity modification Cryotherapy TREATMENT 1ST LINE Identification and correction of precipitating events Rehabilitation program
Treatment Criotherapy for pain and edema reduction Reduce the pain in a short time but without pain improvement 4 months later
Relative Rest and activity modification Cryotherapy TREATMENT 1ST LINE Identification and correction of precipitating events Rehabilitation program
Rehabilitation Program Treatment Focus on correcting maltracking of the patella; Some patients may require significant strengthening of the quadriceps; Others may have excessively tight lateral structures or poor quadriceps flexibility. Soft tissue techniques and flexibility exercises can be helpful for these patients.
NSAIDs OTHER TREATMENTS Foot ortho1cs Patellar taping and bracin
NSAIDs OTHER TREATMENTS Foot ortho1cs Patellar taping and bracin
Other Treatments NSAIDs When alter native approaches have been unsuccessful, or when pain management is essential for participation in rehabilitation.
NSAIDs OTHER TREATMENTS Foot ortho1cs Patellar taping and bracing
Other Treatments Patellar taping and bracing controversial Some evidence in short-term treatment to enable patients to perform pain-free exercise.
NSAIDs OTHER TREATMENTS Foot orthotics Patellar taping and bracin
Other Treatments Foot orthotics No evidence
Treatment - Surgical For those whose symptoms persist despite their completing at least 6 to 12 months of rehabilitation program, and in whom other causes of anterior knee pain have been excluded.
Treatment - Surgical Release of thickened lateral retinaculum; Proximal realignment, and distal realignment; Antero-medialization of the tibial tuberosity; Tibial valgization osteotomy.
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