2. Patellofemoral pain syndrome, also called retropatellar and peripatellar pain, is a common pain disorder
experienced by young adults (10-35 y/o) and adolescent athletes who participate in jumping and pivoting
sports.1,2
Incidence ranges from 10-40% of clinical visits for knee problems for the general population and people
with high physical activity levels.1,2
Pain is often reported at the anterior compartment of the knee and is aggraveted by sports activities, stair
climbing, kneeling/squatting, and prologned sitting with the knee flexed.1,3
Often due to weakness of the vastus medialis obliquus (VMO) resulting in
abnormal tracking of the patella, resulting in increased work for the vastus lateralis.2
http://physioworks.com.au/images/Injuries-Conditions/patellofemoral_pain.jpg
3. Causes range from subluxation and dislocation to patellar malalignment, or simply overuse as a
causative factor.4
Causes are generally seperated into two categories:4
◦ First includes problems with static structures such as the shape of the osseous surfaces or length of
the fascia.
◦ Second category includes issues related to the dynamic structures surrounding the knee, including
the VML, VMO, and VL muscles’ function in the development of PFPS.
Treatment options are widespread and include: general and specific hip/knee strengthening, surface
EMG biofeedback, stretching, acupuncture, low level laser, patellar mobilizations, corrective foot
orthoses, patellar taping, and external patellar bracing.
4. Q-angle appears to be discriminate between runners with and without
PFPS, with a greater Q-angle thought to be associated with an increased
lateral force on the patella.
A more shallow trochlear groove associated with a laterally tilted patella.
Tibiofemoral rotation, along with patellar width, may be one of the factors
leading to a decrease of contact area in the PF joint, which can increase
anterior knee pain.
5. Stability of the patellofemoral joint (PFJ) is largely maintained by soft
tissues, in particular, the dynamic balance of medial and lateral quad
muscles.2
Evidence suggests that an increase in VML muscle EMG is associated with
greater lateral patellar displacement and tilt.5
Looking for 1:1 VMO/VL ratio.
http://www.aafp.org/afp/2007/0115/afp20070115p194-f1.jpg
6. Important to question whether etiology appears to be due to trauma,
congenital structural problems, or overuse.
Assessment of patient’s static alignment can provide clues to presence of
abnormal mechanical stress on the knee.
Important to perform a careful assessment of muscle function of the lower
kinetic chain, specifically between the pelvis, hip, foot, and ankle.
7. Rehabilitation may include a period of rest, followed by activity
modification.
Appropriate management plan for PFPS is based on evaluation of collected
data, and includes:
◦ Strengthening, stretching, and manual interventions to address ROM impairments and
motor deficits
◦ Movement reeducation to address habitual movement patterns
◦ Rehabilitation of the extensor mechanism and control of proper lower extremity
alignment.
Recovery time is variable and often occurs in stages.
9. Goals of treatment are patient dependent and are based on thorough
evaluation.
General guidelines include:
http://www.brighamandwomens.org/patients_visitors/pcs/rehabilitationservices/physical%20therapy%20standards%20of
%20care%20and%20protocols/knee%20-%20patellofemoral%20pain%20syndrome.pdf
10. Main focus is to minimize pain, reduce edema, establish quad activation,
and reach full ROM.
Exercises include: quad sets, SAQ, SLR, heel slides, and targeted hip
exercises for flexion, extension, ER, and abduction.
Flexibility focus is on quads, HS, glutes, abd/adductors, IT band, and
piriformis
11. Reduction of swelling and pain is crucial to restoring normal activity of the
quadriceps, and includes medications, cryotherapy, e-stim, and joint
compression.
Restoring volitional muscle control is another early principal that must be
accomplished and can include electrical stim and biofeedback.2
Further goals here include focus on the quadriceps, through basic open
chain exercises, and improving soft tissue mobilty.
12. Reduction of valgus postural alignment at knees and ankles seen after PT
treatment.
◦ Treatment includes stretching of the HS, quad, IT band, and stregthening of the quad
femoris with squatting exercise.
13. Very controversial subject as many do not believe it to have effect.
Results from orthopedic study show that lateral taping, causing increased
tension on the skin over the VMO, results in increased VMO surface EMG
amplitude.
Based on the fact that VMO taping increases stimulation of cutaneous
afferents, thus producing this positive effect.
14. Goal is to: increase strength, proprioception, flexibility, and continue to
reduce edema and maintain ROM.
Exercises include CKC strenghening: leg press, TKEs, step ups, wall sits,
squats, HS curls, and proprioceptive exercises.
Continue with stretching as needed with ROM levels, and add in
cardiovascular training.
15. Very little evidence of effects of aerobic exercise on quadriceps torque and
EMG activation of VMO, VL, and glute med (GM).
High pain PFPS subjects showed decrease in both VMO (25%) and VL
(12%) following aerobic exercise with reaching exercise.
◦ Increased activation of glute med shown
Must consider the glute med. as potential
source of altered neuromuscular
function of the quadriceps muscle
in PFPS patients.
http://images.slideplayer.com/12/3539698/slides/slide_4
0.jpg
16. Step up exercise is shown to be effective in increasing muscle activation in
both the VMO and VL after PT treatment.
Benefit also seen with the step down (eccentric) exercise as there was
reduced quad activation, suggesting higher efficiency of motor control and
coordination, with reduced energy consume by the VMO.
◦ Specifically in VL comparisons between CG and Post-PF group
17. General exercises, such as squats and knee extension, stress the whole
quadriceps and can regarded as a global approach for targeting the VMO.
Use of the these two exercises, in groups of weight training for strength and
for muscle hypertrophy showed: improved VL/VMO amplitude ratio,
VMO/VL onset difference, knee extension torque, and better knee joint
position.
18. Improvements were seen for both the strength and hypertrophy groups in
comparison to the CG.
19. Knee extensor activities help to improve VMO/VL amplitude ratio in both
open and close chain exercises.
Adding in EMG biofeedback has proven to enhance the amplitude ratio of
the VMO/VL, thus providing an ajdunct to therapeutic exercise to help
reduce PFP symptoms.
20. With increased in VMO/VL ratio there is a reduction in lateral pull on the
patella as the VMO starts to activate first during the extension mechanism.
The addition of biofeedback with this treatment helps as it provides real
time feedback during training, which facilitates integration of sensory cues
and motor recruitment of the muscles.
21. Study shows significant increase in VMO/VLL muscle during double leg
squat with addition of hip adduction for both healthy and PFPS patients.
Results showed a more balanced activity level between the VMO and VLL
as compared to normal DL squat.
22. Goal is to return to prior level of activity/sports with no pain/limitation and
maintain flexibility.
Add in sports specific exercises where indiciated along with cardio
progression to increase endurance.
Provide and witness patient independence with individualized HEP.
23. Large body of work supporting abnormal hip function and PFPS.
With higher level activities, including running, SLS, and single leg jumps,
it has been demonstrated that PFPS patients present with more hip
adduction.
◦ Increased hip adduction associated with increased valgus nature of LE
Restrictions seen with these high level activities are believed to be
observed with weakness of both the glute medius and maximus.
24. When compared to CG, PFPS patients
had increased hip IR, adduction,
reduced hip torque during isometric
strength testing, and reduced glute
max activity during all activities.
Example:
SLS with poor control
25. It is seen that these exercises are appropriate as they replicate sports related
activities, and being able to tolerate without increased hip adduction and IR
is necessary for return to sport.
Experimenting shows the need for glute strengthening in previous stages to
help improve knee and ankle stability during high level activities.
26. Box jumps, or vertical jumps, are another important exercise to perform in
order for return to normal/sports activities in young adults.
Seen that PFPS patients have a increase in knee abduction at moment of
initial contact with these activities.
◦ With this still present it is highly likely that the patient will have a reoccurance of PFP
symptoms with return to sports
http://www.lf.k12.de.us/wp-content/uploads/2015/03/Sports.png
27. • With these symptoms still
present at this stage, the
clinical focus must be on
improving muscular
performance and hip motor
control strategies to decrease
valgus postures and knee
abduction loads.
• This in turn can help to
decrease abnormal
patellofemral loading
mechanics during future
sports maneuvers.
28. Commonly expected outcomes include:
◦ Improved or normalized muscle length
◦ Normal patella mobility
◦ Normal VMO density
◦ Normalized muscle imbalances at hip and knee
◦ Correct shoe wear
◦ Complete reduction in knee pain
◦ Painless performance of sport related activities
◦ Independence with provided HEP
http://mvpsc.com/wp-content/uploads/next-step-538x218.jpg
29. PFPS is a very common disorder, up to 40% of knee visits, and can be
treated in a multitude of different ways.
Spotlight turning to preventative care for younger adults.
Early focus on hip strengthening should not be overlooked.
Return to sport must be done gradually and with exercises that help to
mimic daily life or sport related activities.
31. 1. Myer GD, Ford KR, Barber Foss KD, et al. The incidence and potential pathomechanics of patellofemoral pain in female athletes. Clin Biomech.
2010;25(7):700-707.
2. Ng GYF, Zhang AQ, Li CK. Biofeedback exercise improved the EMG activity ration of the medial and lateral vasti muscles in subjects with
patellofemoral pain syndrome. J Electromyorg Kinesiol. 2008;18(1):128-133.
3. Coqueiro KRR, Bevilaqua-Grossi D, Berzin F, Soares AB, Candolo C, Monteiro-Pedro V. Analysis on the activation of the VMO and VLL muscles during
semisquat exercises with and without hip adduction in individuals with patellofemoral pain syndrome. J Electromyorg Kinesiol. 2005;15(6):596-603.
4. Brody LT, Hall CM. Therapeutic Exercise: Moving Toward Function. Baltimore, MD: Lippincott Williams & Wilkins; 2011.
5. MacGreogor K, Gerlach S, Mellor R, Hodges PW. Cutaneous stimulation from patella tape causes a differential increase in vasti muscle activity in people
with patellofemoral pain. J Orthop Red. 2005;23(2):351-358.
6. Reinold M. Feel better, move better, perform better website. http://www.mikereinold.com/2009/05/10-principles-of-patellofemoral.html. Accessed
September 18, 2015.
7. Ott B, Cosby NL, Grindstaff TL, Hart JM. Hip and knee muscle fucntion following aerobic exercise in individuals with patellofemoral pain syndrome. J
Electromyogr Kinesiol. 2011;21(4):631-637.
8. Sacco IC, Konno GK, Rojas GB, et al. Functional and EMG response to a physical therapy treatment in patellofemoral syndrome patients. J Electromyogr
Kinesiol. 2006;16(2):167-174.
9. Wong YM, Ng G. Resistance training alters the sensiomotor control of vasti muscles. J Electromyogr Kinesiol. 2010;20(1):180-184.
10. Souza RB, Powers CM. Differences in hip kinematics, muscle strength, and muscle activation between subjects with and without patellofemoral pain. J
Orthop Sports Phys Ther. 2009;39(1):12-19.
Editor's Notes
-With this lateral movement patients often have increased pain as the patella is mis-aligned within in the groove.
In turn, this promotes excessive or abnormal contact of the articular surface with the femoral condyles, thus changing the articular cartilage undersurface of the patella.5
Strengthening includes both OKC and CKC, with OKC coming first to help monitor pain and reduce strain on the knee.
Etiology includes valgus knee, shortening of the HS, increased Q angles, and patellar malalignment.
Increased lateral force causes an increase in lateral tracking of the patella. Higher Q angle is associated with reduced VMO/VL ratio as compared to normal Q angles.
Increased genu valgus, IR of femur relative to the tibia, and a wide pelvis all increase the q angle. Both hip rotation and genu valgus can both be influenced by hip, foot, and ankle mechanics.
Tilted patella is seen from 30-0 terminal extension, with lateral displacement in last 9 degrees. Laterally displaced patella significantly associated with higher incidence of PFP.
Rotation examined with MRI and in PFP group 46% of variance was explained by rotation and width, with pain free subjects showing only width as a factor.
Atrophy of VMO also associated with increased rates of PFPS, as this muscle helps to maintain a medial pull on the patella and reduce lateral tracking.
Other muscles seen to play a part inlcude the glut med. Weak here can cause more adduction and IR of the femur, thus putting more stress on the PF joint. Increased valgus force causes increased lateral pull on the patella.
Need a 1:1 ratio of VMO and VL to function properly. VMO coming first to balance VL lateral force. VMO is most important dynamic structure of the PF joint. VMO musct activate first to get medial pull of patella.
Attention should be paid to what motions reproduce the patient’s pain, as these can be used to monitor progress and efficacy of applied intervention.
Question info about painful movements, limp, pain, running, climbing stairs, and prolonged sitting with knees flexed between asymptomatic and patients with subluxation, ant knee pain, and dislocation.
With look at posture you can alter with ther ex.
Alignment problems can be caused by structural deformities, habitual usage patterns, impaired motor control or performance, or ROM limitations.
Asymmetry or excessive weight shift on SLS may be from hip abductor weakness/lack of control and can cause increased adduction, causing an increase in lateral forces on the patella and lateral tracking.
Good ex to look at this is step down; maintain knee over 2nd toe. Excessive lateral shift suggests hip abd, ER, and ext weakness along with poor motor control. This is couple with poor control of foot pronation. All in all this leads to increased hip adduction and lateral pull on the patella.
Patellar compression test also a good tool as a + sign here is highly indicitive of PFPS. – posterior compress and quad contraction, along with ober, faber, patella apprehension, grind test, and lateral tilt test.
Rehab of extensor mechanism is foundation of treatment for PFPS
Pool as appropriate treatment for someone with PFPS, especially if they have other issues at other joints. Can mix land and aqua txs.
-Protocol taken from Beth Isreal Deconess Medical Center. Coupled this infor with other protocols from Beth Isreal and South Shore Hospital.
-Strengthening of glute med and max, quadriceps (VMO), and HS. Strengthening ER will help with gait and stability. Strengthen quads needs to be in pain free ROM (lateral steps and mini squats)
-strcutures include IT band and lateral retinaculum
-Strech muscles include HS, wuads, hip flexors, and gastroc soleus complex
-stability for both the hip and knee
-education includes HEP, flexibility training, strengthe training, proper footwear for support, and patell taping if possible.
-Approx 70% recover with conservative tx and time.
-Also includes hands on therapy to reduce edema, promote increased tissue flexibility, and to increase PROM of both the hip and knee. Joint mobilizations are also helpful to increase the mobilty of the knee joitn, both posterior for knee flexion and anteriorly for knee extension.
-Modalities such as ESTIM may also be beneficial as this help promote activation of inhibited quad muscles, such as the VMO.
Bio helps with the real time data for improved activation.
OKC can include quad sets, SAQ, LAQ, SLR, stretching, and exercises that also focus on not only knee extension, but hip flexion also
(STRECTCHING)
6 exercises: stretching HS in suine and sitting / stretch quad in SL / strengthen quad femoris while squatting in hip adduction / stretching IT band it sitting and standing. Up and down stair walking was performed on patients both after PT and without PT, control group.
With increased strength and tissue flexibility we begin to see improved LE posture and can progress on to a secon phase that focuses more on cintuned strengthening.
Protocol included 5 weeks of sessions, with 5 supervised and 20 unsupervised.
Mike Reinold doesn’t have much faith in the idea
Worry about compression effect on patella
Taping was done horizontally as the fibers run in the VMO, unlike VL which run more vertically. Only affected VMO with this direction.
forward and lateral step ups appropriate here, but step downs not because increased load on the patella. Want to watch the medial drift of the knee here.
DL and progress to SL leg press. Squats to 90 degrees here, as long as pain free. Stress pain free range to the patient. Also add in pain free CKC hip strengthening.
proprioceptivr exercises here can include balance training, bosu board, and patella taping, weight shifting side-to-side, weight shifting diagonally, mini-squats, and mini-squats on an unstable surface such as a tilt board. As the patient advances, tilt board squats can be progressed from double leg to single leg.
Cardio: cycle with progressive resistance, ellptical if pain free, walking on treadmill or swimming
(CARDIO)
Modified Balke-Ware treadmill protocol used for cardio testing on PFPS patients. Walk for self selected speed for 3mph for at least 20 minutes. During first 15 mins inclines goes up 1% per minute. Last 5 min they adjusted % so they stay in 15-17 Rpe range. Only stop if intolerable pain noted by the patient.
Pts showed increased in glute med activity, thus showing that they may be adapting compensatory muscle activity strategies to avoid positions that will load the joint and increase their pain. Glute med helps to control ER and abduction thus reducing pain in the knee from increased lateral load.
Low pain subjects and control group did not see changes in VMO/VL activation. Thus they had the qud strength to control medial movement and did not need the glut med to fire more, as the high patients did. With high level pain pts strengthening the glute med is crucial along with the VMO/VL.
(STAIR CLIMBING)
Shows need for PT rehab in PFPS
Use fo EMG on surface of control group and PF group with stair walking, up and down 4 stairs at 15cm high, 25 sessions for 5 weeks. 5 supervised and 20 unsupervised.
6 exercises: stretching HS in suine and sitting / stretch quad in SL / strengthen quad femoris while squatting in hip adduction / stretching IT band it sitting and standing. Up and down stair walking was performed on patients both after PT and without PT, control group.
Clear improvement seen after PT treatment. Larger increase in VMO activation with step ups compared to VL
(WEIGHT TRAINING)
PFPS pts have a reduced knee joint position, thus making it difficult to repicate a knee position after change, thus improved jt proprioception at the knee. Shows improved jt capsule receptors, improved motor control at the knee joint, and improved CNS closed loop efferent response.
Amplitude ratio shows improved activation of the qud muscles
Onset time is important as for proper control of the PF joint we want to the VMO to fire before the VL and it can be seen that after the exercise program the VMO is firing first, thus allowing better control of lateral tracking of patella and reducing symptoms.
Extensor torque shows the strength of the VMO/VL and it was shown that both groups had a significant and similar improvement over the CG.
Better joint sense of proprioception seen with the tx group in comparison to the CG. Major problem for PFPS pts.
This type of training is helpful for reducing symptoms, but overall helpful in the PREVENTION of PFPS.
Biofeedback
Warm up, sit to stand single leg, and proprioception drills.
Action of adductors is crucial to selectively strengthening thee VMO
Can inluce normal squats, wall sits, semi squats, or wall slides
-Return to running/plyometic exercise training.
-Possiblre addition of step down exercises but must monitot patella pain tolerance. Not recommended.
-Progress to SL strengthening – SLS, split squat, and SL dead lift with weight most likely.
(RUNNING, STEP DOWN, AND DROP DOWN EX – FEMALES – HIP KINEMATICS)
Increased valgus nature increased lateral pull on the patella
EMGs place of glute med and max for experiment, these 2 help to control hip adduction and IR.
Exercises help to increase improve glute med and max strength and provide stabilty at the kne before returning to normal activities.
These exercises target the glute med and max, which help to improve ER and hip abdcution, this reducing valgus force at the knee and ankle.
Look at control group, as this is a level where you want to be at this stage to return to normal sports activities.
Box jumping/vertical jumping exercise
Once again, with this information it makes it clear just how much work needs to put on the hip musculature in previous stages to be able to perform these activities well and return to sports without hesitation and an increased risk for re-injury.
