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Current Concepts  in  Patellofemoral Pain Syndrome: Treatment and Rehabilitation Dale J. Buchberger, MS, PT, DC, CSCS, DAC...
Thank you Dr. Winterstein and Shawna McDonough for the invitation to present
<ul><li>Discuss the prevalence and consequences of common lower extremity (LE) injuries. </li></ul><ul><li>Review Patho-an...
Patello-femoral Pain Syndrome (PFPS)
Where do we start?
<ul><li>Iliotibial Band Friction Syndrome (ITBFS) </li></ul><ul><ul><li>Most common cause of lateral knee pain in runners ...
<ul><li>ACL Sprains </li></ul><ul><ul><li>More common in female athletes compared to males </li></ul></ul><ul><ul><li>~70-...
<ul><li>Patellofemoral Pain Syndrome (PFPS) </li></ul><ul><ul><li>Diagnosed more frequently in females than males </li></u...
<ul><li>Lateral Ankle Sprains </li></ul><ul><ul><li>Most frequently injured joint in athletics and daily life </li></ul></...
<ul><li>Pain </li></ul><ul><li>Short- term and long-term disability </li></ul><ul><li>Decreased exercise participation </l...
<ul><li>ITBFS  </li></ul><ul><ul><li>↓   hip abductor strength results in </li></ul></ul><ul><ul><ul><li>↑ peak femoral ad...
<ul><li>ACL Sprains & PFPS </li></ul><ul><ul><li>Predisposition to injury due to LE alignment: </li></ul></ul><ul><ul><ul>...
<ul><li>ACL Sprains & PFPS  (continued) </li></ul><ul><ul><li>↑ hip abductor strength  =  ↓  knee valgus when landing from...
<ul><li>Chronic Lateral Ankle Sprains </li></ul><ul><ul><li>Weakness in hip abductors on the involved side </li></ul></ul>...
<ul><li>The lower extremity kinematic chain </li></ul>Relationship of LE Injury to  Hip and Knee Stability
Functional Squat Exam
Common Patterns <ul><li>-Tight posterior leg (Correct this fault then reassess) </li></ul><ul><ul><li>Achilles tendon, gas...
<ul><li>FOOT/ANKLE </li></ul><ul><li>Pes planus  </li></ul><ul><ul><li>Structural  </li></ul></ul><ul><ul><li>Functional-c...
<ul><li>KNEES </li></ul><ul><li>Dynamic valgus </li></ul><ul><ul><li>uncorrected </li></ul></ul><ul><li>Dynamic varus </li...
<ul><li>HIPS/PELVIS </li></ul><ul><li>Thighs parallel </li></ul><ul><li>Thighs non parallel </li></ul><ul><li>LUMBAR SPINE...
Additional Patterns  <ul><li>Foot Pronation </li></ul><ul><ul><li>Hip, foot or both? </li></ul></ul><ul><ul><li>Structural...
What’s wrong with this squat?
Alignment for the Assessment <ul><li>Line the medial malleolus with the lateral edge of the acromion </li></ul><ul><li>No ...
Location of patellofemoral pain <ul><li>Anterior </li></ul><ul><li>Posterior </li></ul><ul><li>Medial </li></ul><ul><li>La...
Traditional Hypothesis <ul><li>The patella tracks laterally </li></ul><ul><li>Patella malaligned </li></ul><ul><li>Increas...
Presentation <ul><li>Usually anterior or anterolateral knee pain </li></ul><ul><li>worse with going up and down steps </li...
Etiology <ul><li>Once thought to be primarily a soft tissue disorder secondary to patellar tracking disorder </li></ul><ul...
Anatomical etiologies of PFPS <ul><li>Pinching or irritation of the infrapatellar fat pad </li></ul><ul><li>Plicae Syndrom...
Synovial Plica
Predisposing factors v. etiologies <ul><li>Increased Q (quadriceps) angle </li></ul><ul><li>Underdevelopment of the femora...
Patellar Orthopedic tests <ul><li>Waldron's - chondromalacia </li></ul><ul><li>Clarke’s Patellar grind - retropatellar irr...
Current thoughts  <ul><li>Patellofemoral syndrome or femoralpatellar syndrome??? </li></ul><ul><li>Kinetic chain breakdown...
Suggested Program of Management  for  Patellofemoral Pain Syndrome (PFPS)
Management  Interventions <ul><li>Goals </li></ul><ul><ul><li>Reduce pain </li></ul></ul><ul><ul><li>Restore ROM:  </li></...
Manual Therapy <ul><li>Directed to the:   </li></ul><ul><ul><li>Psoas, Iliacus </li></ul></ul><ul><ul><li>Lateral Patellar...
Kinetic chain <ul><li>Joint Mobilization and HVLA </li></ul><ul><ul><li>peripheral joints </li></ul></ul><ul><ul><ul><li>a...
VMO? <ul><li>Progression </li></ul><ul><ul><li>Open chain </li></ul></ul><ul><ul><ul><li>Hip Series (6 moves) </li></ul></...
Flat Bridge <ul><li>Feet closer to the buttocks increase Gluteus </li></ul><ul><ul><li>As comfortable ROM in the knee impr...
Clam Shell <ul><li>Always consider  three points of contact  for side posture exercises </li></ul><ul><ul><li>Head </li></...
Elevated (Couch) Bridge
BOSU Bridge
Straight knee bridge Lift bum Depress abdomen Toes pointed to ceiling, can vary for chosen affect Vary arm position for st...
Bent Knee Ball Bridge
6-Move Hip Series: Open chain <ul><li>Short arc abduction (SAABD) </li></ul><ul><li>Hip flexion/extension </li></ul><ul><l...
Short arc abduction <ul><li>Strengthen Hip Abductors </li></ul><ul><li>Open chain proprioception and pelvic control </li><...
Hip Flexion/ Extension Knee to 90 degrees of hip/knee flexion Extend hip/knee 3 points of contact Keep Femur and Tibia par...
Long Arc Hip Abduction <ul><li>Hip abductors </li></ul><ul><ul><li>+30 degrees </li></ul></ul><ul><li>Pelvic control </li>...
Bicycle Hip/knee flexion Extend knee BEFORE extending hip Extend hip last in a long lever sweeping motion Maintain 3 point...
Circles: Clockwise/counterclockwise Point toe Perform CW/CCW circles as though you are drawing circles with a pen attached...
Ball Table Shoulders in center of ball Head resting on ball Knees forward Feet straight ahead Squeeze bum Depress abdomen ...
Side to side walks Watch shoulder movements Patient will have the tendency to move the contralateral shoulder in the oppos...
Ball Squat <ul><li>Gluts </li></ul><ul><li>Lumbar and thoracic extensors </li></ul><ul><li>Good if patient has limited ank...
Ball squat with band Add the band to ball squat to increase stimulation of hip abductors and reduce dynamic valgus at the ...
Balance Lunge or Split Squat <ul><li>Quad/Gluteus strength </li></ul><ul><li>Quad/Psoas Flexibility </li></ul><ul><li>Prop...
What’s wrong with this patient?
Conclusions <ul><li>The hip is gaining acceptance as a functional etiology of PFPS </li></ul><ul><li>Both open and closed ...
Questions
Thank You! 2006-2007 and 2008-2009 Stingray Sportsmanship award recipient; 2010-2011 High-point trophy winner
In Loving Memory  of Lyle J. Buchberger Thanks for everything! Love ya dad! May 30, 1928 - January 12, 2009
Shoulder Made Simple ®  <ul><li>Dale J. Buchberger, MS, PT, DC, CSCS, DACBSP® </li></ul><ul><li>Active Physical Therapy So...
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Current Concepts in Patellofemoral Pain Syndrome: Treatment and Rehabilitation - Dale J. Buchberger

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Current Concepts in Patellofemoral Pain Syndrome: Treatment and Rehabilitation by Dale J. Buchberger, MS, PT, DC, CSCS, DACBSP.

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Current Concepts in Patellofemoral Pain Syndrome: Treatment and Rehabilitation - Dale J. Buchberger

  1. 1. Current Concepts in Patellofemoral Pain Syndrome: Treatment and Rehabilitation Dale J. Buchberger, MS, PT, DC, CSCS, DACBSP Vice-President, American Chiropractic Board of Sports Physicians Chiropractic Consultant, Auburn Doubleday's (Single-A affiliate Washington Nationals) Chiropractic consultant, Syracuse University Athletics Chiropractic consultant, New York Jets Football Strength and Conditioning Coordinator Auburn Stingrays Swim Team NUHS Homecoming Oakbrook, Il USA June 11, 2011
  2. 2. Thank you Dr. Winterstein and Shawna McDonough for the invitation to present
  3. 3. <ul><li>Discuss the prevalence and consequences of common lower extremity (LE) injuries. </li></ul><ul><li>Review Patho-anatomy of Patellofemoral pain syndrome (PFPS) </li></ul><ul><li>Review the LE kinematic chain. </li></ul><ul><li>Summarize the results of research regarding PFPS and its relationship to hip and knee function. </li></ul><ul><li>Describe how a functional squat can be used as an assessment tool. </li></ul>Objectives
  4. 4. Patello-femoral Pain Syndrome (PFPS)
  5. 5. Where do we start?
  6. 6. <ul><li>Iliotibial Band Friction Syndrome (ITBFS) </li></ul><ul><ul><li>Most common cause of lateral knee pain in runners </li></ul></ul><ul><ul><li>Incidence rate as high as 22.2% </li></ul></ul>Prevalence of Common LE Injuries Fredericson M, Weir A. Practical management of iliotibial band friction syndrome in runners. Clinical journal of Sports Medicine. 2006; 16: 261-268.
  7. 7. <ul><li>ACL Sprains </li></ul><ul><ul><li>More common in female athletes compared to males </li></ul></ul><ul><ul><li>~70-80% of ACL injuries result from non-contact mechanisms </li></ul></ul>Prevalence of Common LE Injuries <ul><ul><li>Jacobs CA, Uhl TL, Mattacola CG, Shapiro R, Rayens WS. Hip abductor function and lower extremity </li></ul></ul><ul><ul><li>landing kinematics: Sex differences. Journal of Athletic Training. 2007; 42: 76-83. </li></ul></ul>
  8. 8. <ul><li>Patellofemoral Pain Syndrome (PFPS) </li></ul><ul><ul><li>Diagnosed more frequently in females than males </li></ul></ul><ul><ul><li>~25% of knee pain evaluated in a sports injury clinic </li></ul></ul>Prevalence of Common LE Injuries <ul><ul><li>Robinson RL, Nee RJ. Analysis of hip strength in females seeking physical therapy treatment for unilateral patellofemoral pain syndrome. Journal of Orthopedic & Sports Physical Therapy. 2007; 37: 232-238. </li></ul></ul>
  9. 9. <ul><li>Lateral Ankle Sprains </li></ul><ul><ul><li>Most frequently injured joint in athletics and daily life </li></ul></ul><ul><ul><li>70-80% of ankle sprains are inversion-type sprains </li></ul></ul>Prevalence of Common LE Injuries <ul><ul><li>Friel K, McLean N, Myers C, Caceres M. Ipsilateral hip abductor weakness after inversion ankle sprain. Journal of Athletic Training . 2006; 41: 74-78. </li></ul></ul><ul><ul><li>Hootman JM, Dick R, Agel J. Epidemiology of collegiate injuries for 15 sports: summary and recommendations for injury prevention initiatives. Journal of Athletic Training . 2007; 42: 311-9. </li></ul></ul>
  10. 10. <ul><li>Pain </li></ul><ul><li>Short- term and long-term disability </li></ul><ul><li>Decreased exercise participation </li></ul><ul><li>Leading cause of osteoarthritis </li></ul><ul><li>Significant public health cost </li></ul>Consequences of LE Injuries <ul><ul><li>Emery CA, Rose SM, McAllister JR, Meeuwisse WH. A prevention strategy to reduce the incidence of injury in high school basketball: A cluster randomized controlled trial. Clinical Journal of Sports Medicine. 2007; 17:17-24. </li></ul></ul>
  11. 11. <ul><li>ITBFS </li></ul><ul><ul><li>↓ hip abductor strength results in </li></ul></ul><ul><ul><ul><li>↑ peak femoral adduction moments </li></ul></ul></ul><ul><ul><ul><li>↓ pelvic stability during stance phase </li></ul></ul></ul><ul><ul><li>Overtraining + weakness of hip abductors = ITBFS </li></ul></ul>What the Evidence Shows Fredericson M, Weir A. Practical management of iliotibial band friction syndrome in runners. Clinical journal of Sports Medicine. 2006; 16: 261-268
  12. 12. <ul><li>ACL Sprains & PFPS </li></ul><ul><ul><li>Predisposition to injury due to LE alignment: </li></ul></ul><ul><ul><ul><li>Wide pelvis </li></ul></ul></ul><ul><ul><ul><li>↑ femoral anteversion </li></ul></ul></ul><ul><ul><ul><li>↑ genu recurvatum </li></ul></ul></ul><ul><ul><ul><li>↑ genu valgum </li></ul></ul></ul><ul><ul><ul><li>External tibial rotation </li></ul></ul></ul><ul><ul><ul><li>Forefoot pronation </li></ul></ul></ul>What the Evidence Shows <ul><ul><li>Bonci CM. Assessment and evaluation of predisposing factors to anterior cruciate ligament injury. Journal of Athletic Training. 1999; 34: 155-164. </li></ul></ul>
  13. 13. <ul><li>ACL Sprains & PFPS (continued) </li></ul><ul><ul><li>↑ hip abductor strength = ↓ knee valgus when landing from a jump </li></ul></ul><ul><ul><li>Activation of quadriceps and hamstrings is improved with ↑ hip muscle activity </li></ul></ul><ul><ul><ul><li>Big motor; no frame syndrome </li></ul></ul></ul>What the Evidence Shows <ul><ul><li>Jacobs CA, Uhl TL, Mattacola CG, Shapiro R, Rayens WS. Hip abductor function and lower extremity landing kinematics: Sex differences. Journal of Athletic Training. 2007; 42: 76-83. </li></ul></ul>
  14. 14. <ul><li>Chronic Lateral Ankle Sprains </li></ul><ul><ul><li>Weakness in hip abductors on the involved side </li></ul></ul><ul><ul><li>Rehab protocols need to address proximal stability </li></ul></ul>What the Evidence Shows <ul><ul><li>Friel K, McLean N, Myers C, Caceres M. Ipsilateral hip abductor weakness after inversion ankle sprain. Journal of Athletic Training . 2006; 41: 74-78. </li></ul></ul>
  15. 15. <ul><li>The lower extremity kinematic chain </li></ul>Relationship of LE Injury to Hip and Knee Stability
  16. 16. Functional Squat Exam
  17. 17. Common Patterns <ul><li>-Tight posterior leg (Correct this fault then reassess) </li></ul><ul><ul><li>Achilles tendon, gastroc-soleus complex </li></ul></ul><ul><ul><li>Tib post, flexor digitorum, flexor hallicus lg </li></ul></ul><ul><li>-Weak lumbar extensors with contracted hip flexors. </li></ul><ul><li>-Strong gluts with weak lumbar extensors and contracted hip flexors ( athletic presentation ) </li></ul><ul><ul><li>*Complete Kinetic chain dysfunction: tight lower leg, tight hip flexors, weak lumbar extensors and weak gluteus maximus/medius </li></ul></ul><ul><ul><li>Harding FV, et al. Significant side to side differences in Joint Moments During Squatting. MSSE 2002; 34:5, S215 </li></ul></ul>
  18. 18. <ul><li>FOOT/ANKLE </li></ul><ul><li>Pes planus </li></ul><ul><ul><li>Structural </li></ul></ul><ul><ul><li>Functional-correctable </li></ul></ul><ul><li>Heels up </li></ul><ul><li>Heels down </li></ul><ul><li>Tight achilles </li></ul><ul><li>Normal achilles tendon </li></ul><ul><ul><li>* Adequate DF of the ankle </li></ul></ul>Functional Squat as an Assessment Tool Buchberger DJ . Functional assessment and management of the lower extremity in clinical practice . Presented at: A Somatic Senses Ltd event; February 17-18, 2007; Victoria, British Columbia, Canada
  19. 19. <ul><li>KNEES </li></ul><ul><li>Dynamic valgus </li></ul><ul><ul><li>uncorrected </li></ul></ul><ul><li>Dynamic varus </li></ul><ul><ul><li>Over correction </li></ul></ul><ul><li>Femoral internal rotation </li></ul><ul><ul><li>uncorrected </li></ul></ul><ul><li>Femoral external rotation </li></ul><ul><ul><li>Consider retroversion </li></ul></ul>Functional Squat as an Assessment Tool Buchberger DJ . Functional assessment and management of the lower extremity in clinical practice . Presented at: A Somatic Senses Ltd event; February 17-18, 2007; Victoria, British Columbia, Canada
  20. 20. <ul><li>HIPS/PELVIS </li></ul><ul><li>Thighs parallel </li></ul><ul><li>Thighs non parallel </li></ul><ul><li>LUMBAR SPINE </li></ul><ul><li>Flexed </li></ul><ul><li>Extended </li></ul><ul><li>SHOULDERS </li></ul><ul><li>Forward </li></ul><ul><li>Neutral </li></ul><ul><li>Back </li></ul>Functional Squat as an Assessment Tool Buchberger DJ . Functional assessment and management of the lower extremity in clinical practice . Presented at: A Somatic Senses Ltd event; February 17-18, 2007; Victoria, British Columbia, Canada
  21. 21. Additional Patterns <ul><li>Foot Pronation </li></ul><ul><ul><li>Hip, foot or both? </li></ul></ul><ul><ul><li>Structural pes planus </li></ul></ul><ul><li>Valgus knee motion </li></ul><ul><ul><li>Dynamic Knee Valgus </li></ul></ul><ul><ul><ul><li>Weak abductors </li></ul></ul></ul><ul><ul><ul><li>Poor eccentric control of adductors </li></ul></ul></ul>
  22. 22. What’s wrong with this squat?
  23. 23. Alignment for the Assessment <ul><li>Line the medial malleolus with the lateral edge of the acromion </li></ul><ul><li>No verbal or tactile cueing on the initial squat </li></ul><ul><ul><li>If the heels come up; VC to keep them down </li></ul></ul><ul><ul><li>If dynamic valgus TC to correct alignment </li></ul></ul><ul><ul><ul><li>If pes planus corrects with correction of dynamic valgus=functional pes planus </li></ul></ul></ul>
  24. 24. Location of patellofemoral pain <ul><li>Anterior </li></ul><ul><li>Posterior </li></ul><ul><li>Medial </li></ul><ul><li>Lateral </li></ul>
  25. 25. Traditional Hypothesis <ul><li>The patella tracks laterally </li></ul><ul><li>Patella malaligned </li></ul><ul><li>Increased patellofemoral joint (PFJ) compression and shear forces during movement </li></ul><ul><li>May or may not result in abrasion of the retropatellar cartilage </li></ul><ul><ul><li>Primarily a functional diagnosis </li></ul></ul><ul><ul><li>Excludes anatomical obstruction such as synovial plicae, OA, etc. </li></ul></ul><ul><ul><li>Powers JOSPT 1998 </li></ul></ul><ul><ul><li>Lee JOSPT 2003 </li></ul></ul>
  26. 26. Presentation <ul><li>Usually anterior or anterolateral knee pain </li></ul><ul><li>worse with going up and down steps </li></ul><ul><li>worse with sitting for long periods </li></ul><ul><li>crepitus more than not </li></ul><ul><li>difficulty coming out of a squatting maneuver </li></ul><ul><ul><li>21-40% of the population (possibly more today) </li></ul></ul><ul><ul><li>Brody and Thein JOSPT 1998 </li></ul></ul>
  27. 27. Etiology <ul><li>Once thought to be primarily a soft tissue disorder secondary to patellar tracking disorder </li></ul><ul><ul><li>Contracture of the lateral retinaculum </li></ul></ul><ul><ul><li>Weakness of the VMO </li></ul></ul><ul><ul><li>Increased Q-angle </li></ul></ul><ul><ul><li>Pes Planus </li></ul></ul><ul><ul><li>Brody and Thein JOSPT 1998 </li></ul></ul>Brier 1998
  28. 28. Anatomical etiologies of PFPS <ul><li>Pinching or irritation of the infrapatellar fat pad </li></ul><ul><li>Plicae Syndrome </li></ul><ul><li>Chondromalacia patella secondary to degeneration of the patellar hyaline cartilage </li></ul><ul><li>Degeneration secondary to instability </li></ul><ul><li>Powers JOSPT 1998 </li></ul>
  29. 29. Synovial Plica
  30. 30. Predisposing factors v. etiologies <ul><li>Increased Q (quadriceps) angle </li></ul><ul><li>Underdevelopment of the femoral condyles or patella </li></ul><ul><li>Patella alta (high riding) </li></ul><ul><li>Weak VMO; poor timing with VL </li></ul><ul><li>Tight lateral retinaculum, vastus lateralis and/or ITB </li></ul><ul><li>Hip weakness </li></ul><ul><ul><li>Dynamic valgus </li></ul></ul><ul><ul><li>Femoral IR </li></ul></ul><ul><ul><li>Functional pes planus </li></ul></ul><ul><li>Structural pes planus </li></ul><ul><li>Changes in intensity level of training </li></ul><ul><li>Training error </li></ul>Souza and Powers AJSM 2009, Robinson JOSPT 2007, Lee JOSPT 2003, Lloyd-Ireland JOSPT 2003
  31. 31. Patellar Orthopedic tests <ul><li>Waldron's - chondromalacia </li></ul><ul><li>Clarke’s Patellar grind - retropatellar irritation </li></ul><ul><li>Figure 4 - popliteus tendon </li></ul><ul><li>Medial plicae test - plica </li></ul><ul><li>Plicae stutter - advanced plica </li></ul><ul><li>Patellar Apprehension - instability </li></ul>
  32. 32. Current thoughts <ul><li>Patellofemoral syndrome or femoralpatellar syndrome??? </li></ul><ul><li>Kinetic chain breakdown starts in the hip </li></ul><ul><ul><li>Weakness of the hip extensors, abductors and external rotators </li></ul></ul><ul><ul><ul><li>Allows for dynamic femoral valgus and IR </li></ul></ul></ul><ul><ul><ul><ul><li>The femoral groove moves medially as the patella “appears” to move laterally </li></ul></ul></ul></ul>Lloyd-Ireland JOSPT 2003, Powers JOSPT 2003, Robinson and Nee JOSPT 2007, Souza AJSM 2009
  33. 33. Suggested Program of Management for Patellofemoral Pain Syndrome (PFPS)
  34. 34. Management Interventions <ul><li>Goals </li></ul><ul><ul><li>Reduce pain </li></ul></ul><ul><ul><li>Restore ROM: </li></ul></ul><ul><ul><ul><li>Quads and Hip flexors </li></ul></ul></ul><ul><ul><ul><li>DF of the ankle </li></ul></ul></ul><ul><ul><li>Functional strength </li></ul></ul><ul><ul><ul><li>Open chain: hip </li></ul></ul></ul><ul><ul><ul><li>Closed chain: hip/knee </li></ul></ul></ul><ul><ul><li>Functional control </li></ul></ul><ul><ul><ul><li>kinetic chain reduce dynamic valgus in SLS </li></ul></ul></ul><ul><ul><ul><li>ADL’s, IADL’s, recreational, occupational, athletic </li></ul></ul></ul>
  35. 35. Manual Therapy <ul><li>Directed to the: </li></ul><ul><ul><li>Psoas, Iliacus </li></ul></ul><ul><ul><li>Lateral Patellar Retinaculum </li></ul></ul><ul><ul><li>VMO and Sartorius </li></ul></ul><ul><ul><li>ITB (TFL and Glut med/min) </li></ul></ul><ul><ul><li>Biceps Femoris (Myofascial kinetic chain through the STL/DSL and piriformis muscle) </li></ul></ul><ul><ul><ul><li>Various manual techniques are available: </li></ul></ul></ul><ul><ul><ul><ul><li>ART ® , SASTM ® , GISTM ® , F.A.S.T. ® , MET, MFR, etc </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Rollers for home/supportive care </li></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Various density foam rollers, PVC Pipe </li></ul></ul></ul></ul></ul>
  36. 36. Kinetic chain <ul><li>Joint Mobilization and HVLA </li></ul><ul><ul><li>peripheral joints </li></ul></ul><ul><ul><ul><li>ankle, foot </li></ul></ul></ul><ul><ul><ul><li>SI joints </li></ul></ul></ul><ul><li>Orthotics </li></ul><ul><ul><li>pes planus </li></ul></ul><ul><ul><ul><li>Functional versus structural </li></ul></ul></ul>Sports Illustrated 2005 Cliborne JOSPT 2004
  37. 37. VMO? <ul><li>Progression </li></ul><ul><ul><li>Open chain </li></ul></ul><ul><ul><ul><li>Hip Series (6 moves) </li></ul></ul></ul><ul><ul><ul><li>Clam shells </li></ul></ul></ul><ul><ul><ul><li>Straight knee ball bridges </li></ul></ul></ul><ul><ul><li>Closed chain </li></ul></ul><ul><ul><ul><li>Bridging </li></ul></ul></ul><ul><ul><ul><li>Ball Tables </li></ul></ul></ul><ul><ul><ul><li>Side walks </li></ul></ul></ul><ul><ul><ul><ul><li>w/wo band </li></ul></ul></ul></ul><ul><ul><ul><li>Ball Squats with band </li></ul></ul></ul><ul><ul><ul><li>Balance Lunges </li></ul></ul></ul><ul><ul><ul><li>Butcher, et al JOSPT 2007 </li></ul></ul></ul>
  38. 38. Flat Bridge <ul><li>Feet closer to the buttocks increase Gluteus </li></ul><ul><ul><li>As comfortable ROM in the knee improves move the feet closer to the buttocks. </li></ul></ul><ul><li>Good early PWB activity with functional application </li></ul><ul><li>Regain knee F/E </li></ul>
  39. 39. Clam Shell <ul><li>Always consider three points of contact for side posture exercises </li></ul><ul><ul><li>Head </li></ul></ul><ul><ul><li>Back </li></ul></ul><ul><ul><li>Sacrum </li></ul></ul>
  40. 40. Elevated (Couch) Bridge
  41. 41. BOSU Bridge
  42. 42. Straight knee bridge Lift bum Depress abdomen Toes pointed to ceiling, can vary for chosen affect Vary arm position for stability -Can add HS curl later Hold 3-6 seconds
  43. 43. Bent Knee Ball Bridge
  44. 44. 6-Move Hip Series: Open chain <ul><li>Short arc abduction (SAABD) </li></ul><ul><li>Hip flexion/extension </li></ul><ul><li>Long arc abduction (LAABD) </li></ul><ul><li>Bicycle </li></ul><ul><li>Circles: clockwise/counterclockwise </li></ul><ul><ul><li>Perform all 6 motions consecutively </li></ul></ul><ul><ul><li>Start with 5 reps of each (30 total) and progress to 30 reps of each (180 total) </li></ul></ul>
  45. 45. Short arc abduction <ul><li>Strengthen Hip Abductors </li></ul><ul><li>Open chain proprioception and pelvic control </li></ul><ul><ul><li>Three points of contact </li></ul></ul><ul><li>Femoral acetabular motion </li></ul><ul><ul><li>Avoid lumbar lateral flexion </li></ul></ul>
  46. 46. Hip Flexion/ Extension Knee to 90 degrees of hip/knee flexion Extend hip/knee 3 points of contact Keep Femur and Tibia parallel to floor during all motion Hip/knee Flexion Hip/knee Extension
  47. 47. Long Arc Hip Abduction <ul><li>Hip abductors </li></ul><ul><ul><li>+30 degrees </li></ul></ul><ul><li>Pelvic control </li></ul><ul><ul><li>Avoid lumbar lateral flexion </li></ul></ul><ul><li>CORE stability </li></ul><ul><li>Dynamic flexibility of Hip Adductors </li></ul>
  48. 48. Bicycle Hip/knee flexion Extend knee BEFORE extending hip Extend hip last in a long lever sweeping motion Maintain 3 points of contact Keep femur and tibia parallel to the floor
  49. 49. Circles: Clockwise/counterclockwise Point toe Perform CW/CCW circles as though you are drawing circles with a pen attached to you big toe Perform motions as smooth as possible Maintain 3-points of contact
  50. 50. Ball Table Shoulders in center of ball Head resting on ball Knees forward Feet straight ahead Squeeze bum Depress abdomen Hold 3-6 sec
  51. 51. Side to side walks Watch shoulder movements Patient will have the tendency to move the contralateral shoulder in the opposite direction of the lead leg. Ex: left leg moves to the left stretching the band and the right shoulder dips down to the right Shoulder should stay parallel to the floor and move in the same direction as the lead leg.
  52. 52. Ball Squat <ul><li>Gluts </li></ul><ul><li>Lumbar and thoracic extensors </li></ul><ul><li>Good if patient has limited ankle DF </li></ul><ul><ul><li>Teaches form and technique </li></ul></ul>
  53. 53. Ball squat with band Add the band to ball squat to increase stimulation of hip abductors and reduce dynamic valgus at the knees
  54. 54. Balance Lunge or Split Squat <ul><li>Quad/Gluteus strength </li></ul><ul><li>Quad/Psoas Flexibility </li></ul><ul><li>Proprioception </li></ul><ul><li>Pelvic control </li></ul><ul><li>Promote balance in SLS </li></ul>
  55. 55. What’s wrong with this patient?
  56. 56. Conclusions <ul><li>The hip is gaining acceptance as a functional etiology of PFPS </li></ul><ul><li>Both open and closed chain exercise programs maybe effective in the rehabilitation of patients with PFPS </li></ul><ul><li>If a passive structure is restricted there is usually an active tissue not keeping up with it’s end of the bargain </li></ul><ul><li>SAQ/LAQ only used in cases of quadriceps deficiency (either elderly, TKA, etc.) </li></ul><ul><li>Souza AJSM 2010, Robinson JOSPT 2007, Witvrouw AJSM 2004 </li></ul>
  57. 57. Questions
  58. 58. Thank You! 2006-2007 and 2008-2009 Stingray Sportsmanship award recipient; 2010-2011 High-point trophy winner
  59. 59. In Loving Memory of Lyle J. Buchberger Thanks for everything! Love ya dad! May 30, 1928 - January 12, 2009
  60. 60. Shoulder Made Simple ® <ul><li>Dale J. Buchberger, MS, PT, DC, CSCS, DACBSP® </li></ul><ul><li>Active Physical Therapy Solutions PC </li></ul><ul><li>Active Chiropractic Solutions </li></ul><ul><li>40 Westlake Ave. </li></ul><ul><li>Auburn, NY 13021 </li></ul><ul><li>315-515-3117 </li></ul><ul><li>For more information about the Buchberger-12 ® or Shoulder Made Simple ® programs please visit our website at: </li></ul><ul><li>www.rotatorcuff.net </li></ul><ul><li>If you have any questions you can email Dr. Buchberger at: </li></ul><ul><li>[email_address] </li></ul>

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