What/Where is the true source of PFP? What theories do we use for diagnosing PFP and how does literature support the theories? How can we better treat “PFPS” patients through a more thorough evaluation and the developing classifications of PF disorders?

1. Erik Nason, MS, ATC, LAT, CSCS
RehabWorks, Kennedy Space Center, FL
Xtreme Action Sports Medicine Services, Inc. (Owner)

2. One of the most common musculoskeletal disorders
11% of musculoskeletal complaints in the office setting
are anterior knee pain
Commonly called:
Anterior Knee Pain
Chondromalacia
Derangement of Knee
Patellofemoral Pain Syndrome
Dr. Scott Dye refers to PFPS as
“The Black Hole of Orthopedics”

3. What/Where is the true source of PFP?
What theories do we use for diagnosising PFP and
how does literature support the theories?
How can we better treat “PFPS” patients through a
more thorough evaluation and the developing
classifications of PF disorders?

4. Clear understanding of the underlying
pathophysiology?
Junk Term Diagnosis
Similar to Impingement Syndrome
Anterior knee pain is more of a symptom than dx.
There is no specific protocol for Patellofemoral Pain
Understanding the source of pain and being able to
classify it can produce a more successful outcome in
rehabilitation.

5. Vague responses from patients
Complain of diffuse patellofemoral pain
Hard to pinpoint location of pain during evaluation
Pain behind or around the patella (usually with flexion)
Imaging can help but is not always necessary at first
History
MOI
Usually gradual onset, no specific MOI

6. Is the source of pain.…
Bone
Articular Cartilage
Meniscus
Soft Tissue
Fat Pad
Capsule
Ligamentous
The cause of pain is..
Malalignment
Neurological
Dysfunction
Weight
Biomechanics
Structural
Dynamic/Activity

7.  Examined the mapping of pain and sensations of the author’s own
knee without anesthesia.
 Measurement of no sensation to severe pain
 Severe pain found
 Anterior Synovial Tissues
 Retinaculum
 Fat Pad
 Capsule
 Moderate to Severe pain found
 Insertion points of the cruciate ligaments
 Slight to Moderate pain found
 Capsule margins
 No sensations were detected on patellar articular surface
 Even though pt had asymptomatic Grade II and III chondromalacia.

8.  Historic research findings-
Fulkerson et al – 1985
 He biopsied the lateral
retinaculum and underlying
synovial tissue of
patellofemoral patients during
lateral releases to treat PFPS.
Found enlarged with
moderate lose of
myelinated fibers
compared to asymptomatic
cadaver
Evidence of the source of
pain
 Sanchis-Alfonso -1998
 Neuromas were found within
the biopsied tissues
 Reported a direct relationship
between the severity of pain and
the severity of neural damage in
the lateral retinaculum.
 A follow up study showed
increased levels of substance P
within the lateral retinaculum
 Increased pain transmission

9. Sameer Dixit, M., Monique Burton, M., & Brandon Mines, M. (2007). Management of patellofemoral pain syndrome.
American Family Physician, 75(2), 195- 202.

10. Suggested theories of the underlying source of PFPS
Chondromalacia
Pathology of Lateral Retinaculum
Peripatellar synovitis
Excessive Lateral Patellar Pressure
VMO Dysplasia
Patella Malalignment
Limited Contractile Tissue Flexibility

11. Chondromalacia
Research has weaken the theory of chondromalacia being
the source of PFPS
Articular cartilage lacks nociceptive output through
substance-P fibers like other articular tissues of the knee
VMO Dysplasia
Current literature has suggested changes in neuromuscular
activity throughout the lower extremity might be associated
with PFPS
Patellar Malalignment
There is little biomechanical evidence that supports the
hypothesis that translation or tilt of the patella alone is
responsible for patella pain

12. Although PFPS may be caused from maltracking of
the patella through the trochlear grove, the cause of
this poor tracking may not be due to a malalignment
(such as a Q-angle) as much as a neuromechacial
failure.
Decreased functional strength
Decreased proprioception skills
Decreased neuromotor skills
Adversely affects the biomechanics of the articular tissues of
the PFJ

14. Go one step further in your evaluation
Stop using “Patellofemoral Pain” as a diagnosis
Separate the symptoms into classifications:
Classification should:
Clearly define diagnostic categories
Aid in the selection of appropriate interventions
Allow the comparison of treatment approaches for a
specific diagnosis.

15. Patellar Compression Syndromes
Patellar Instability
Biomechanical Dysfunction
Direct Patella Trauma
Soft Tissue Lesions
Overuse Syndromes

16. Excessive Lateral Pressure Syndrome (ELPS)
Patella is over-constrained by soft tissue tightness
Usually the lateral retinaculum
Pt will have decreased medial glide
Some soreness medially with more acute cases
Pain with palpation of medial patellofemoral ligaments
Global Patellar Pressure Syndrome (GPPS)
Bilateral tightness surrounding patella
Causing an excessive compression within the trochlea
More common with direct trauma or fractures

17. Chronic patella subluxation
Often associated with shallow trochlea
Medial tissues are scarred over…poor medial sensitivity
Acute patellar dislocation
Possible rupture of medial patellofemoral ligament
Look for medial pain
Recurrent patellar dislocation
What is the common factor
Location of pain

18. Alterations that can impact the forces of the PFJ
Foot and Ankle mechanics
Hip Strength
Leg Length Discrepancy
Flexibility deficiencies
Take thorough Hx.
Any past ankle injuries, any muscular imbalances, etc.
Biomechanical dysfunction can lead to chronic
adaptations over time
For Example: Weak hip ER = Femur to IR = mimic ELPS

19. Articular cartilage lesion (isolated)
Fracture
Fracture/Dislocation
Articular cartilage lesion with associated
malalignment
May need to rule out soft tissue irritation such as fat
pad or tendon injury

20. Suprapatellar plica
Hard to evaluate, but easy to forget
Fat pad syndrome
Highly vascularized and rich nerve fibers
Typical in direct trauma
Medial patellofemoral ligament pain
Result of ELPS
Illiotibial band friction syndrome
Typical in runners, physically active individuals
Bursitis
More acute, direct trauma, repetitive stress

21. Tendinitis
Most commonly patellar tendinitis
Occasionally but rarely quadriceps tendinitis
Apophysitis
Most common is Osgood-Schlatter
Common in the adolescent
Sindig-Larsen-Johansson – inferior patellar pole

22. Use these classifications to identify the sources of pain
Fine tune your evaluation to establish the root cause of
the source of pain
DON’T RUSH THE EVAL.
Evals can last two, three or more visits.
While you’re implementing acute care, the evaluation
window needs to be open to change
Evaluation is also built upon how the patient responds.
Don’t get locked into a PFPS protocol…everyone is
different.

23. Stop using Patellofemoral Pain Syndrome as a
diagnosis.
Evaluate deeper to find the source of pain and the
cause of pain
Place the PF disorder into a classification to better
label the source of pain
Create a more injury specific rehabilitation protocol to
help treat the source of pain and not the general dx
Implement proprioception exercises ASAP to stimulate
and recruit all available neuro elements to strengthen
the neuromotor loop.

24. Thank You!
Discovery Launch Thursday Feb 24th
@ 4:50pm