The document provides an orthopedic presentation on physiotherapy management of patellofemoral pain syndrome (PFPS). PFPS is characterized by anterior knee pain that is aggravated by activities involving the patellofemoral joint. Treatment involves a multimodal physiotherapy approach including joint mobilization, therapeutic exercises to strengthen the quadriceps and hips, electrotherapy such as neuromuscular electrical stimulation, and cryotherapy. The goal of rehabilitation is to reduce pain and improve function through strengthening, stretching, and knee stabilization exercises.

1. AN ORTHOPEADIC POSTING PRESENTATION ON:
PHYSIOTHERAPY MANAGEMENT OF PATELLOFEMORAL
PAIN SYNDROME
PRESENTED BY
SHARAFADEEN HAMZA
AT
PHYSIOTHERAPY UNIT
MAITAMA DISTRICT HOSPITAL ABUJA
ON
16TH JULY, 2020
1

2. OUTLINE
☼ Introduction
☼ Clinical relevant anatomy of (PFPS)/Anatomy
☼ Etiology
☼ Risk factor
☼ Clinical presentation
☼ Differential Diagnoses
☼ Diagnosis/Diagnostic test
☼ Outcome Measure
☼ Medical Management
☼ Other Interventions
☼ Physiotherapy Management
☼ References
2

3. INTRODUCTION
DEFINITION:
 Patellofemoral Pain Syndrome (PFPS) is an umbrella term
used for pain arising from the patellofemoral joint itself, or
adjacent soft tissues.
 It is characterised by anterior knee pain but can be felt in
other areas of the knee.
(Physiopedia)
3

4. INTRODUCTION CONT’D
 Often due to weakness of the vastus medialis obliquus (VMO)
resulting in abnormal tracking of the patella, with in increased
work for the vastus lateralis.
4
(Myer GD et al., 2010; Ng GYF et al., 2008)

5. CLINICALLY RELEVANT ANATOMY OF PATELLOFEMORAL PAIN
SYNDROME
Figure :Depiction of the patella (kneecap) and the structures related to it
5

6. PATELLOFEMORAL JOINT
6

7. STATISTICS/EPIDEMIOLOGY
 PFPS is the most common cause of anterior knee pain
syndrome in the out patient.
 PFPS account for up to 20% of all injuries in runners.
 More common in athletes
 Female: Male 2:1
7
(Harrington et al., 2013)

8. JOINT ARTICULATING SURFACES
The knee consist of two major joint: the tibiofemoral joint and
patellofemoral joint.
PATELLA
 The patella is a triangular shaped seasmoid bone, the posterior
surface of the patella is covered with articular cartilage.
 Patella has much smaller articular surface than its femoral
counterpart.
LIGAMENT
 Medial patellofemoral ligament
 Lateral patellofemoral ligament
MUSCLES
 Quadriceps muscles
(Physiopedia)
8

9. AETIOLOGY
Non-traumatic causes can be intrinsic or extrinsic:
 Intrinsic factors include: improper alignment of the leg or the
joint.
 Extrinsic factors include: type of physical activity, repetitive
activity, or changes in the intensity of a physical activity
 Main aggravating factors are weight bearing activities :
 Squatting
 Running
 Stairs
8
(Pivotalphysio.com)

10. RISK FACTORS
 Age.Patellofemoral pain syndrome typically affects
adolescents and young adults.
 Sex. Women are twice as likely as men are to develop
patellofemoral pain. This may be because a woman's wider
pelvis increases the Q- angle.
 Certain sports. Participation in running and jumping sports
can put extra stress on your knees, especially when you
increase your training level.
.
10

11. Q-ANGLE FOR MALE AND FEMALE
 The average angle is:
 15.8 ± 4.5 for females
 11.2 ± 3.0 for men
 Above 15 is considered much in men
 Above 17 is much in female
(Sportsinjury.net; Pivotalphysio.com)
11

12. CLINICAL PRESENTATIONS
 Patient's usually present with the complaint of anterior knee
pain that is aggravated by activities that increase
patellofemoral compressive forces such as:
ascending/descending stairs,
sitting with knees bent,
kneeling,
squatting.
12

13. DIFFERENTIAL DIAGNOSES
 Patella tendinopathy
 Ligament Sprain/Rupture
 Patellar subluxation or instability
 Meniscal tears
13
(Nunes et al., 2013)

14. DIAGNOSES/DIAGNOSTIC TEST
 X-ray may be needed for further evaluation of the knee joint.
(cook et al., 2010).
 Step test: it involve standing on a 15cm block with hands on
hips and using the involved limb to “slowly” and “smoothly”
eccentrically lower the body until the contra lateral heel
touches the floor (Nijs et al., 2006)
 A positive result is the reproduction of patient pain, which is
prevalent in 74% of individuals PFPS (Selfe J et al., 2001).
14

15. (The patients stand on the uninvolved limb on a 15-cm box)
15

16. SPECIAL TESTS TO RULE OUT COMPETING
DIAGNOSES
 Meniscal injury- Apley’s compression test, joint line
tenderness
 ACL injury - Lachman’s test
 PCL injury - Posterior drawer test
 MCL and LCL – valgus and varus stress tests
16

17. SPECIAL TESTS
 Apley’s Compression Test
 + knee pain, clicking
17

18. SPECIAL CONT’D
 Joint line tenderness
 + pain with palpation
18

19. SPECIAL CONT’D
 Posterior drawer test
 + excessive posterior translation of the tibia on the femur
19

20. SPECIAL CONT’D
 Valgus and Varus stress tests at 0° and 30° knee flexion
 + excessive movement, pain
20

21. SPECIFIC AREAS TO ASSESS FOR PFPS
• Strength
• Flexibility
• Patellar malalignments
• Foot mechanics
• Determine what is weak…
• MMT:
– Quadriceps
– Hip external rotators
– Hip abductors
– Gluteal muscles
21

22. OUTCOME MEASURES FOR PFPS
 Visual Analog Scale or Numeric Pain Rating Scale
 Anterior Knee Pain Scale
Also known as the Kujala Scale
 Lower Extremity Functional Scale
22

23. MANAGEMENT
 MEDICAL
Over –the – counter pain relievers such as ,
acetaminpphen, ibuprofen (Advil, Motrin others).
 Arthroscopy
 Realignment
(Mayoclinic.org)
23

24. PHYSIOTHERAPY MANAGEMENT
Subjective Assessment
 Biodata
 Pateint Hx
 Occupation and level of activity or sport
 Location and onset of the pain
 Duration of the pain
 Level of the pain
 Aggravating and alleviating factor
24

25. Objective Assessment
 General and local observations
 Test of ROM
 Test for individual muscles strength on the (on the affected LL
and unaffected LL)
 Palpation
 Test for sensation
 Special tests to rule out other knee pain conditions
25

26. MANAGEMENT PLAN
 Joint mobilization
 Therapeutic exercises
 Electrotherapy (NMES)
 Cryotherapy
 Main goals include:
 Pain management and strengthening,
• stretching of tight structures
• stretching of shortened muscles
• stabilization of the knee
• patient and family education
26

27. JOINT MOBILIZATION
Teys p et al., 2008;Hall T et al.,2001 27

28. THERAPEUTIC EXERCISES
 Quadriceps – front of thigh stretch
Procedure:
 Place your foot on a chair behind you.
 Gently tighten your buttocks and feel the stretch on the
front of the thigh. Hold 30-60 seconds, 3-4 times per day.
28

29. 29

30. EXERCISE CONT’D
• Wall Squat: Stand with your back to the wall and your feet
about 12 inches away.
• Perform a small squat, making sure your knees stay over your
ankles.
• Hold the position for 5-10 seconds. Return to standing and
repeat 10-20 times.
(Health guideline.net)
30

31. EXERCISE CONT’D
 Straight leg raising: Lie on your back with your affected leg
straight and your other leg bent. Tighten your thigh muscles
then lift your leg no higher than the other knee. Keep your
knee fully straight while you lift and lower your leg. Keep
your thigh muscles tight while you lower your leg. Repeat 10-
20 times, 3-4 times per day.
(Healthguideline.net)
31

32. EXERCISE CONT’D
 Exercise therapy should include both hip and knee
strengthening using both open (non-weight-bearing) and
closed (weight-bearing) kinetic chain exercises .
(Lack S. et al., 2015 ; Crossely KM et al., 2016)
32

33. (Healthguideline.net) 33

34. NEUROMUSCULAR ELECTRICAL STIMULATION
ELECTRICAL MUSCLE STIMULATION
Mode : Continuous
Pad : 10.2 × 12.7 on vastus medialis and
proximal vastus lateralis 75 burst/sec.
Time : 15 mins for 3-12 wks.
(Synder –Mackler et al., 1994; Capin Jj et al., 2012)
34

35. CRYOTHERAPY
Type : Ice towel
Temperature : 10-15 ͦ
Time : 15- 20 mins
35

36. CONCLUSION
 Early, appropriate rehabilitation may be critical to preventing
poor outcomes and optimizing function for individuals with
PFPS.
 It was strongly recommended that exercise therapy, including
hip and knee strengthening and stretching, should be done to
patient with PFPS to improve short-, medium-, and long-term
outcomes in individuals with PFP.
 Rehabilitation program should be designed to target the
patient’s specific impairments and functional limitations
identified during the evaluation.
 Patients may gradually return to sport or activity over a period
of 4-6 weeks
36
(Matthews M et al., 2017)

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