Patellofemoral pain syndrome (PFPS) is a common musculoskeletal disorder that causes anterior knee pain. It affects 15-33% of the active adult population and is more prevalent in females. PFPS has multiple potential causes including poor lower extremity biomechanics, muscle weakness/imbalances, and excessive tightness. Treatment focuses on strengthening the vastus medialis oblique muscle, correcting biomechanical faults, and using patellar taping. Patellar taping may help reduce pain by improving patellar tracking and altering quadriceps muscle activation patterns. While studies show taping can improve muscle function and decrease pain, its effects on knee biomechanics and long term outcomes require further research.

1. PT

3.  One of the most commonest musculoskeletal
disorders (Murray et al, 2005)
 Accounts for 25% of all knee injuries seen in
sports medicine clinic (Devereaux et al, 1984)
PATELLOFEMORAL PAIN SYNDROME
(PFPS)

4.  Reported to affect 15% - 33% of active adult
population
 21%-45% of adolescents (Lindberg, 1986)
 Highest among females
 Diverse in physical expression & functional
limitation
 Although common among active individuals, it is a
term without universally accepted definition

5.  Often used interchangeably with
 Patellofemoral Syndrome
 Patellofemoral Stress Syndrome
 Patellofemoral Dysfunction
 Anterior Knee Pain
 Runner’s knee

6. Symptoms are associated with common conditions
 Articular Cartilage Injury
 Chondromalacia Patella
 IT band syndrome
 Osgood-Schlatter Disease
 Osteochondritis Dissecans
 Patellar Instability
 Patellar subluxation
 Patellar Stress fracture
 PatellarTendinopathy
 Patellofemoral athritis
 Pes Anserine Bursitis
 Pre Patellar Bursitis
 Quadriceps tendinopathy
Witvrouw et la , 2005

7. PAIN AGGRAVATING FACTORS
 Activities associated with flexed knee
 Running (Powers CM, 1998)
 Stair walking (Crossley et al, 2002)
• Ascending & descending
 Inclined walking (Levine J, 1979 & Mc Connell, 1996)
 Squatting
 Prolonged sitting (Movie Goer’s knee) (Mc Connell J, 2002)

8. PATELLOFEMORAL PAIN
Increased PF joint forces
Continued forces across knee
Overuse
Acute Injury

9. CAUSES
 Multi factorial in origin
 Variety of pathologies or anatomical abnormalities
• Product of morphological changes in joint structure
oInternal & external stressors
• Result of both mal alignment & muscle dysfunction

10.  Poor biomechanics at the foot, knee &/or hip
 Poor muscle strength & imbalance
 Excessive muscle tightness
 Improper patellar motion during quadriceps
contraction

11.  Mechanical Factor contributing to PF pain
 Patellar Tracking (Hvid et al, 1981)
 Magnitude of forces acting around knee
• Result in higher Patello Femoral Joint Reaction
Forces (PFJRF) (Railey et al, 1972)
 Patellofemoral pressure
 Increased PFJ stress (Wallace et al, 2002)

13.  Common theory
 Maltracking
• Result of Vastus Medialis Oblique (VMO) weakness
relative to Vastus Lateralis (VL)
• Atrophy of VMO (LaBrier & O’Neil, 1993)
• Lateral tracking

14.  VMO
 Core stabilizer (Host et al, 1995)
 Only muscle that can move patella medially (Grabiner &
Westfall, 1992)
 Works in tonic fashion throughout entire ROM of knee
(Mc Connell, 1986 & Gaffney et al, 1992)
 Centralizes patella in the trochlear groove (LaBrier &
O’Neil, 1993)

15.  In PFPS
 VMO insufficiency have been frequently associated
(Hudson et al, 2010)
• VMO changes from functioning in a tonic to a phasic
manner (Richardson, 1987; Cowen et al, 2001)
• Response time of VMO relative to VL is decreased &
reversed (Voight & Wieder, 1991; Kannus & Nittymaki, 1994; Souza &
Gross, 1991)

16. ASSESSMENT
 Patellar alignment
 Forms the key to determine magnitude &
direction of force to be applied to patella
 Assessed in relation to
 Tilt
 Glide
 Rotation
 Anterior – posterior position

17.  Medial or lateral displacement of patella
 Knee flexed to 200
 5 mm lateral displacement of patella laterally (Ahmed et
al, 1988)
• 50% reduction in tension
 Medial or lateral tilt
 Mild if more than 50% of lateral border palpable
 Severe if less than 50% of lateral border palpable
(Collado & Fredericson, 2010)

18.  Rotation
 Internal
 External
 Anterior - posterior alignment
 Irritation of fat pad with posterior tilt

21.  Patellar mobility
 4 longitudinal quadrants
 Patella displaced medially & laterally

22. Tight lateral retinaculum &/or ITB
Incompetent medial restraint
Dislocatable patella
Globally hypermobile
1 quadrant of medial displacement
3 quadrants lateral displacement
4 quadrants lateral displacement
3 or 4 quadrant medial displacement
(Collado & Fredericson, 2010)

23. STRENGTHENING OF VMO
Shelton & Thigpen, 1991

24.  Pure VMO strengthening programs without
addressing specific activation & recruitment
problems

25.  Significantly moves patella medially (Larsen et al,
1995)
 Increase VMO contraction strength
• Concentrically
• Eccentrically
• Isometrically
 Increases VMO : VL ratio (Westfall & Worell, 1992)
 Earlier & prolonged contraction of VMO (Mc Connell, 1987)
(Mc Connell 1987; Hilyard, 1990; Crome et al, 1987)

26.  Mechanism of action of patellar tape
 Pain inhibition
 Reduction of reflex inhibition of Quadriceps
• Increase in force
 Altered quadriceps recruitment
 Improved patellar tracking
• Decreased load on PFJ
Gresalmer & Mc Connell, 1998

27.  Four main mal alignments of patella;
 Excessive
• Lateral glide
• Lateral tilt
• Posterior tilt of inferior pole
• Rotation
Mc Connell, 1986 & 1996

32. THERAPEUTIC EFFECTS
 Pain
 Neuromuscular control
 VMO/VL activity
 LE kinematics
 PFJRFs
Balachandar, Barton, Morrissey (2011)

33.  Clinical Prediction Rule
 Patients with PFPS who would respond to
taping
 +ve patellar tilt test
 Tibial varum > 50
Lesher et al, (2006)

34. EVIDENCE BASED TAPING
 VMO/VL activity (Gilleard; Mc Connell & Parsons 1998)
 Activation during step up & down tasks
 Earlier activation of VMO on step up
 No change in VL activation
 Decrease in mean values of VMO-VL onset time
(Mostamand; Bader & Hudson, 2011)
 Immediately after taping than before & after a prolonged
period

35.  Review & meta analyses
 Reduction in perceived pain
 4 weeks following medial taping + exercise
 Reduction in pain during functional tasks
 Immediately after medial taping
 Reduction in VMO / VL onset ratio
 Earlier VMO activation
Balachandar et al, (2011)

36.  sEMG studies on onset timing of VMO/VL
 Seated knee extension
 Squat
 Significant reduction in pain score & increase in
functional level
 Post treatment
 12 month follow-up
 79.5% achieved normal sEMG onset timing
Paoloni et al, (2012)

37.  VMO / VL activity compared between 15
asymptomatic & 13 symptomatic subjects (Collado &
Fredericson, 2010)
 No significant difference
 Effect on PFJRF during squatting
 Motion analysis system using force plate
 Significant reduction in PFJRF
 Mechanism responsible for reduction in pain

38.  Effect on lower extremity kinematics &
dynamic postural control
 Star Excursion Balance Test (SEBT)
 Perceived pain
 Reach distance
 Significant reduction in pain
 Significant increase in reach distance
Aminaka & Gribble, 2008

39.  Effects on knee joint proprioception (Callaghan;
Selfe, 2008)
 Joint position sense (JPS) using Biodex
 No enhancement in JPS
 Worsened in some cases

40.  Kinematic source for pain reduction (Derasari; Brindle; Alter;
Sheehan, 2010)
 Full fast-phase contrast MRI
 Significant PF inferior shift
 Increased contact area

41.  Systematic review (Aminaka & Gribble, 2005)
 Positive results after taping on
 Neuromuscular control
 Muscle activity
 Pain
 Mechanism of effects
 Not clear
 Various neural & mechanical hypothesis & theories postulated

42.  Major limitation in investigating efficacy of
patellar taping
 Very few RCTs
 Lack of randomization
 Inability to blind subjects, therapists &/or
assessors
 Standardization of employed technique
 Length
 Angle
 Force of application
 Material used

43. SUMMARY & TAKE HOME MESSAGE
 Significant reduction in perceived pain
 Improvement in functional tasks
 Clinical evidence for the success of taping technique
 Unclear
 None of the reviews demonstrated detrimental
effects of taping
Low cost, non invasive & effective tool in treating
PFPS

44. Tightness of muscle-tendon units VMO dysfunction
PF mal alignment
 PF contact area
 Concentration of PF force/
unit contact area
Tissue overload / injury
Patello Femoral Pain
 Concentration of PF
force/ unit contact area
Hypo pressure, disuse &
early degeneration