Musculoskeletal Case Study

Josh de Rooy Musculoskeletal Analysis, Prescription and Rehabilitation S00164793
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Patello-Femoral Pain Syndrome – Clinical Review
Client
A 21 year old female who is a marathon runner has started experiencing knee pain around
the patella. She has recently changed her training location to an area with more hill climbs
and descents, and has increased her training from twice per week to 4-5 times per week to
prepare for a marathon.
Title/Condition:
Patello-Femoral Pain Syndrome
Differential Diagnosis:
With the main symptom of PFPS being pain around/posterior kneecap, this is also a
symptom similar to many other knee related injuries. These include:
 Pes anserine bursitis
 Articular cartilage injury
 Iliotibial band syndrome
 Osgood-Schlatter
 Osteochondritis dissecans
 Patellar instability/subluxation
 Patellar stress fracture May have tenderness directly over patella
 Patellar tendinopathy
 Patellofemoral
 Patellar tendinopathy
 Plica synovialis
 Prepatellar bursitis
 Quadriceps tendinopathy
 Sinding-Larsen-Johansson syndrome (Dixit, Difiori, Burton & mines, 2007)

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Description:
Patello-femoral pain syndrome is a commonly suffered cause of knee pain, with high
prevalence in active adolescents, young adults and particularly woman (van Linschoten et
al., 2007). The patellofemoral joint consists of the patella and femoral trochlea, and relies on
medial and lateral forces to align the patella within the femur, called ‘patella tracking’.
Alterations in patella tracking causes rubbing of the articular cartilage that covers the
posterior patella against the femur, stimulating nociceptors within the joint, resulting in pain.
PFPS generally see’s pain reported as under and around the patella, and is exacerbated
upon loaded knee flexion and extension, alongside impaired lower limb functioning (Moyano
et al., 2013) Activities of daily life (ADL) which can be affected include: walking up and down
stairs (particularly down), jogging, sitting with knees flexed for prolonged periods of time,
squatting, and kneeling (Boling et al., 2010; Linschoten et al., 2012)
Forms of management differ between: resting until symptoms decrease, taping or bracing to
align the patella (for incorrect tracking), and exercise to correct gait biomechanics and
strengthen muscle weakness and imbalance, which are the suspected underlying issue
(Moyano et al., 2013)
Causes:
Although the pathology is not yet completely understood, there are many likely cause which
contribute to development of PFPS.
 Slowed activation of Vastus Medialis Obliquus compared with vastus lateralis is
evident, an imbalance between medial and lateral stabilizers occurs and force
distribution at the joint is compromised (Boling et al., 2010). Frequent, high intensity

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activity of malaligned extensor function causes increased irritation and debilitation, if
not treated, further degeneration and complications may occur (Fulkerson, 2002).
 It is also evident that weak hip musculature, particularly gluteus medius, causes
increased internal rotation of the femur and valgus force at the knee, which combined
can cause an increased Q-angle, leading to further lateral maltracking of the patella
(Boling et al., 2010; Ireland, Wilson, Ballantine & Davis, 2003).
Risk factors:
 Gender - difference in: q angle, internal rotation, hip adduction and knee valgus
(boling et al., 2010)
 Lack of physical conditioning
 Joint angles
 Increased navicular drop
 Increased patella mobility (Linschoten et al., 2012)
 Slowed activation of VMO compared with VL
 Decreased gastrocnemius flexibility
 Compressive and shearing forces to under surface of patella
 Excessive lateral pressure to patella (Lankhorst, Bierma-Zeinstra & Midelkoop,
2012)
 Tight musculature and attachments
 Weak hip abductors and external rotators
 Overuse
 Direct trauma (Dixit et al., 2007)

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Examination
Subjective
 Management: Has the client undertaken medical management in the past or
currently? Did this have any effect on knee pain?
 Medication: Is the client taking any anti-inflammatories or similar pain management
medication?
 Tests conducted: Has the client had any x-rays or imaging done?
 Alternative treatment: Has the client experimented with alternative options such as
acupuncture or remedial massage? Or management such as bracing or icing, and
their benefit?
 Previous treatment: Has the client undertaken physiotherapy or occupational
therapy for the current injury? Were these beneficial?
 Aggravating/Alleviating factors: Does the client experience pain in certain
activities? E.g. running, stair climbing/descending, squatting or sitting with knee
flexion? How long until pain onset?
 Chart: Ask client to circle/shade areas of pain on a body chart.
 Nature of symptoms: Ask the patient to describe symptoms e.g. pain, stiffness,
feeling of giving way? Or uncommon: catching, swelling, and clicking.
 VAS Pain Scale: On a scale of 0 – 10 (10 being severe) ask the client to rate their
pain best, worst, and currently, and occurences.
 Patterns: Does the client experience symptoms at certain times of day? E.g. night,
morning, mid-day.
 Sleep Problems: Does the client awake at night due to pain or discomfort? How
many times?

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 Other symptoms: Ensure it is noted any other symptoms that cause onset of pain or
unusual symptoms requiring medical attention.
 Footwear: Does client wear old or un-supportive footwear?
 Previous medical history – Notes previous knee conditions, comorbidities? List
previous conditions, and pain in places other than knee e.g. hip, ankle, and lower
back.
 Functional problems: Note any ADLs which have been affected.
Objective
 Gait abnormality: Observe clients lower limb alignment while walking, into to room
upon meeting and when asked .Identify excessive lateral tracking of patellar or
abnormal eversion of rear foot.
 Joint mobility: Passively examine mobility and tracking of patella and tightness of
surrounding structures.
 Palpate: Identify any atrophy, tone and activation at end point knee extension,
compared with vastus lateralis. Is there any tenderness of retinacula?
 Posture: Examine trunk, pelvic, and lower limb alignment. Examine alignment of the
leg and knee and identify patella positioning and Q angle size, via goniometer.
Check for over pronation at the subtalar joint via navicular drop test.
 Reflexes: Ensure standard reflex of calcaneal and patella tendons.
 Strength: Assess knee, ankle, and hip musculature strength with comparison of
sides, via single-leg squat, step down test, which would have minimal medial rotation
at the hip or adduction.

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Diagnostic Tests
 “J-sign” test: Ask patient to actively extend knee while standing, starting in 90
degree flexion, watch for lateral patella movement at end-point extension.
 Lateral pull test: Patient starting in supine, have them contract knee extensors,
observe patella movement (lateral = positive)
 Patella glide test: Examine mobility of patella by manually moving in all 4 directions.
 Patella tilt test: In supine, lift lateral patella border, if not horizontal, lateral
attachment are tight. Lift also the medial border to assess laxity (positive if tilt is
more than contralateral side).
 Ober’s test – Assess tightness in ITB and TFL
 Thomas test – Assess tightness in quadriceps and hip flexors.
 Range of motion: Observe active and passive ROM of the knee, hip and ankle
joints, along with ITB, quadriceps, hamstring, and gastrocnemius flexibility.
(Tyler et al., 2006)
Functional Testing
 Bilateral Squat – squat to 90o
flexion – as many as possible in 30 seconds
 Step Down – left and right, 8 inch box - as many as possible in 30 seconds (Louden
at al., 2002)
Desired Outcomes
• Decreased pain in ADL
• Increased strength of quadriceps
• Increased VMO strength, with improved activation patterns compared to vastus
lateralis

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• Increased hip abductor and external rotation strength
• Increased flexibility of surrounding structures and joints
• Reduced excessive rearfoot eversion in gait
• Decreased pain with prolonged sitting
• Improved ability to participate in sports Improved ability to ascend and descend stairs
• Improved awareness/self-management of aggravating factors
Outcome measures:
• The self-administered patellofemoral pain severity scale
• Kujala self-administered questionnaire – improved score
• Manual muscles tests – Negative Ober’s and Thomas test
• Patient satisfaction
• VAS pain scale – reduced pain
• Goniometry – Increased ROM of the hip, knee and ankle joints, also muscles:
gastrocnemius, hamstrings, quadriceps and ITB.
Assessment / Plan
Overall Contraindications/Precautions
 Avoid activities that cause excessive patellofemoral joint reaction forces.
 Avoid excessive knee flexion for around 4-6 weeks of rehabilitation.
 Reduced flexion ROM if pain occurs.
Prognosis
The prognosis of the client is determined based on history of injury and examination, which
will expose contributing factors to the condition. According to Kannus and Niittymaki et al.
(1994), atleast 70% can be rehabilitated with quadriceps strengthening, independent of age,
sex, biomechanical factors, and fitness level.

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It depends on comorbidities, but a poor outlook will present if the aggravating factors are not
altered or reduced. Identification of these factors and correct treatment as early as possible
will have an improved prognosis, but a worse prognosis is seen with symptoms present for
over a year in duration, before treatment (Collins et al., 2010).
Other considerations:
- Activity modification
- Anti-inflammatory medication and modalities
- Patellar taping and bracing (Patellar taping/mobilization)
- Orthotic management for subtalar joint pronation
- Open kinetic chain exercises—avoid terminal extension
- Closed kinetic chain exercises—avoid excessive flexion
These factors apply especially in early treatment.
Treatment Summary
Each phase to be performed 3 times per week, pending pain.
Goals week 1-4: increase strength, flexibility, retrain quadriceps activation, introduce
balance.
Week 1-2:
- Swiss ball squat – 40 degree knee flexion (quadriceps, gluteal, hamstring strength)
- Isometric contractions of VMO - seated with knees at 90° flexion (quadriceps activation)
- Theraband front pull - standing on uninjured leg, extend thigh with flexed knee – repetitions
(Hip flexors)
- Theraband isometric hold - standing on uninjured leg extend thigh with flexed knee – resist
adduction (using abductors/external rotators)
- Single leg calf raise

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Week 3-4:
- Wall slides – 40 degree knee flexion, with theraband around knees
- Mini Squat – 30 degree flexion
- Lateral step down – from 4 inch step
- Forward Lunges – onto 8 inch step with gentle push off.
- Single leg calf raise – on bosu ball
Goals week 5-8: increase functional strength, flexibility, quadriceps eccentric strength,
proprioception and balance training.
Week 5-6:
- Single Leg Mini Squat – 30 degree flexion.
- Lateral step down – from 6 inch step
- Side stepping – with theraband just below knees – slight knee flexion
- Forward Lunges – onto 8 inch step with regular push off.
- Single leg stance – catch and pass ball to partner, maintain balance (week 6 add bosu ball)
Week 7-8:
- Single Leg Squat – as deep as possible pain free.
- Side stepping – with theraband just below knees – slight knee flexion
- Forward lunges – as deep as possible, pain free.
- Straight leg, single leg deadlift – focus on hip and ankle stability.
- Single leg hopping (forward/back/side) – while catching and passing ball to partner.
After all sessions the following stretches will be performed:
- Standing quadriceps
- Seated hamstring
- Standing calf
- Figure 4 gluteal
- Foam roller on ITB and TFL

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Weeks 1-4 passive, 4-8 active (Boling, Bolgla, Mattacola, Uhl, & Hosey, 2006; Fredericson
and Powers,2002)
Maintenance and Prevention
Once rehabilitation is successfully completed, it’s vital to maintain strength and endurance
in: hip abductors and external rotators for pelvic stability, and quadriceps for patellar
stabilization. All stretches included in the above program are to be performed atleast 3 times
per week (specifically after exercise), to maintain active and passive ROM, particularly within
gastrocnemius, ITB/TFL, and hamstrings.
Exercises include:
- Isometric theraband hold
- Single leg squat
- Side stepping with theraband around knees

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References
Boling, M. C., Bolgla, L. A., Mattacola, C. G., Uhl, T. L., & Hosey, R. G. (2006). Outcomes of
a weight-bearing rehabilitation program for patients diagnosed with patellofemoral
pain syndrome. Archives of physical medicine and rehabilitation, 87(11), 1428-
1435.
Boling, M., Padua, D., Marshall, S., Guskiewicz, K., Pyne, S., & Beutler, A. (2010). Gender
differences in the incidence and prevalence of patellofemoral pain syndrome.
Scandinavian journal of medicine & science in sports, 20(5), 725-730.
Collins, N. J., Crossley, K. M., Darnell, R., & Vicenzino, B. (2010). Predictors of short and
long term outcome in patellofemoral pain syndrome: a prospective longitudinal
study. BMC musculoskeletal disorders, 11(1), 11.
Cowan, S. M., Bennell, K. L., Crossley, K. M., Hodges, P. W., & McConnell, J. (2002).
Physical therapy alters recruitment of the vasti in patellofemoral pain syndrome.
Medicine and science in sports and exercise, 34(12), 1879-1885.
Dixit, S., Difiori, J. P., Burton, M., & Mines, B. (2007). Management of patellofemoral pain
syndrome. American family physician, 75(2).
Fulkerson, J. P. (2002). Diagnosis and treatment of patients with patellofemoral pain. The
American journal of sports medicine, 30(3), 447-456.
Fredericson, M., & Powers, C. M. (2002). Practical management of patellofemoral pain.
Clinical Journal of Sport Medicine, 12(1), 36-38.
Ireland, M. L., Willson, J. D., Ballantyne, B. T., & Davis, I. M. (2003). Hip strength in females
with and without patellofemoral pain. Journal of orthopaedic & sports physical
therapy, 33(11), 671-676.

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Kannus, P., & Niittymäki, S. (1994). Which factors predict outcome in the nonoperative
treatment of patellofemoral pain syndrome? A prospective follow-up study. Medicine
& Science in Sports & Exercise.
Lankhorst, N. E., Bierma-Zeinstra, S. M., & van Middelkoop, M. (2012). Risk factors for
patellofemoral pain syndrome: a systematic review. journal of orthopaedic & sports
physical therapy, 42(2), 81-A12.
Loudon, J. K., Wiesner, D., Goist-Foley, H. L., Asjes, C., & Loudon, K. L. (2002). Intrarater
reliability of functional performance tests for subjects with patellofemoral pain
syndrome. Journal of athletic training, 37(3), 256.
Moyano, F. R., Valenza, M. C., Martin, L. M., Caballero, Y. C., Gonzalez-Jimenez, E., &
Demet, G. V. (2013). Effectiveness of different exercises and stretching
physiotherapy on pain and movement in patellofemoral pain syndrome: a
randomized controlled trial. Clinical rehabilitation, 27(5), 409-417.
Tyler, T. F., Nicholas, S. J., Mullaney, M. J., & McHugh, M. P. (2006). The role of hip muscle
function in the treatment of patellofemoral pain syndrome. The American journal of
sports medicine, 34(4), 630-636.
van Linschoten, R., van Middelkoop, M., Berger, M. Y., Heintjes, E. M., Verhaar, J. A.,
Willemsen, S. P., ... & Bierma-Zeinstra, S. M. (2009). Supervised exercise therapy
versus usual care for patellofemoral pain syndrome: an open label randomised
controlled trial. BMJ: British Medical Journal, 339.

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