3 things you can do NOW for patello femoral pain...

Recalcitrant PFP? In addition to your treatment regiment AND getting to THE CAUSE of the patello femoral pain (often but not always gluteus medius function), have you tried?

• forefoot-strike running

• increasing step rate by 10% (ie cadence)

• "running softer"

according to this article:

"all modifications were associated with reduced patellofemoral joint force during running, compared with the participants’ normal running gait. But the modifications were also associated with immediate symptom improvement of at least one point out of 10; 62.5% of runners in the study experienced a positive symptomatic response to at least one of the gait modifications."

Easy to do, easy to implement

 

Esculier J-F, Bouyer LJ, Roy J-S. Immediate effects of gait retraining on symptoms and running mechanics of runners with patellofemoral pain. J Orthop Sports Phys Ther 2017;47(suppl 1):A9.

All that creaks may not be pathological...

image source: https://commons.wikimedia.org/wiki/File:Runners-knee_SAG.jpg

Gal with creaky knees? Patellar crepitus? Does all that noise mean something?

Well, it means that knee function is suboptimal and more than likely, there is abnormal patellar tracking. But is that clinically significant? The answer is ....maybe.

This study (1) looked at over 300 women, about 1/2 with patellofemoral pain and half without looking at the following outcomes: 

• the knee crepitis test
• anterior knee pain scale
• self reported knee pain in the last month
• knee pain after 10 squats 
• knee pain after climbing 10 stairs

They found that if you had patello femoral pain, you were 4 times more likely to have crepitus than not, but there was no correlation of crepitus with  Knee crepitus had no relationship with function, physical activity level , worst pain, pain climbing stairs or pain squatting. 

We would have loved to have seen any correlation in this group with knee valgus angles (i.e. "Q" angles 2 ) and how much tibial or femoral torsion was present (as these things change pressure and contact area 3), but that will hopefully be found in the literature elsewhere. 

1. , Pazzinatto MF, Priore LBD, Ferreira AS, Briani RV, Ferrari D, Bazett-Jones D, Azevedo FM. Knee crepitus is prevalent in women with patellofemoral pain, but is not related with function, physical activity and pain. Phys Ther Sport. 2018 Sep;33:7-11. doi: 10.1016/j.ptsp.2018.06.002. Epub 2018 Jun 6.

2. Emami MJ1, Ghahramani MH, Abdinejad F, Namazi H. Q-angle: an invaluable parameter for evaluation of anterior knee pain. Arch Iran Med. 2007 Jan;10(1):24-6.

3. Thay Q. Lee, PhD, Garrett Morris, BS, Rick P. Csintalan, MDThe Influence of Tibial and Femoral Rotation on Patellofemoral Contact Area and Pressure Orthop Sports Phys Ther 2003;33:686-693.

wider, flatter, less mobile feet

If you have patella femoral pain, the older you get, the wider (probably for increased proprioception), flatter (possibly due to loss of intrinsic strength and extensor tone) and less mobile (for stability) you feet become. 

"This study observed that in individuals with PFP, those aged 40–50 years had less foot mobility than younger adults aged 18–29 years, as evidenced by measures of midfoot height mobility and foot mobility magnitude. These differences represented a moderate effect size, and exceed the intra-rater minimal detectable change (MDC 95%) associated with these measures (midfoot height mobility 2 mm; foot mobility magnitude 3.1 mm). The differences between age groups were specific to both midfoot height mobility and foot mobility magnitude; however, there were no differences in midfoot width mobility."

Tan JM, Crossley KM, Vicenzino B, Menz HB, Munteanu SE, Collins NJ. Age-related differences in foot mobility in individuals with patellofemoral pain. Journal of Foot and Ankle Research. 2018;11:5. doi:10.1186/s13047-018-0249-2.

free full text: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5815185/

QL and Patellofemoral Pain?

photo credit: https://www.t-nation.com/training/training-disasters

"Subjects with PFP(patello femoral pain) have a higher prevalence of MTrPs (Myofascial trigger points) in bilateral GMe (gluteus medius)) and QL (quadratus lumborum) muscles. They demonstrate less hip abduction strength compared with controls, but the TPPRT (trigger point pressure release therapy, AKA ischemic compression) did not result in an increase in hip abduction strength. "

It is not surprising that when the hip is involved, the knee will be involved. As Dr. Allen often likes to say "the knee is basically in joint between 2 ball and socket joints ".

The gluteus medius and quadratus lumborum, along with the adductors are coronal plane stabilizers of the pelvis. They both have rotational components to their function as well affecting the hip directly for the former and lumbar spine for the latter. You can see our other QL articles about this here and here.

It is not much of a stretch to imagine that dysfunction of these muscles could result in trigger points and/or dysfunction of the knee (or foot for that matter ) could cause trigger points in these muscles.

Here is an article (1) examining trigger points in the gluteus medius and quadratus lumborum which, if you are familiar with Porterfield and DeRosa's work (2), are intimately linked during gait. We found it interesting that skin nick compression did not increase hip abduction strength where we find dry needling and intramuscular therapy often do.

Don't overlook these muscles and this important relationship.

1. Roach, Sean et al.Prevalence of Myofascial Trigger Points in the Hip in Patellofemoral Pain Archives of Physical Medicine and Rehabilitation , Volume 94 , Issue 3 , 522 - 526link to free full text article: http://www.archives-pmr.org/article/S0003-9993(12)01079-9/fulltexthttp://www.archives-pmr.org/article/S0003-9993(12)01079-9/fulltext

2. J. Porterfield, C. DeRosa (Eds.) Mechanical low back pain. 2nd ed. WB Saunders, Philadelphia; 1991

Varus anyone?

Varus anyone?

Does patello femoral pain have anything to do with rearfoot varus? Perhaps, according to this study:

" A small but significant increase in rearfoot varus was found in the patellofemoral pain group compared with the control group (8.9 vs. 6.8 degrees; p = .0002). These results suggest that increased rearfoot varus may be a contributing factor in patellofemoral pain and should be assessed when evaluating the events at the subtalar joint and the lower extremity. In addition, it has been demonstrated that consistent rearfoot measurements can be obtained by an individual clinician."

Powers CM, Maffucci R, Hampton S. Rearfoot posture in subjects with patellofemoral pain. J Orthop Sports Phys Ther. 1995 Oct;22(4):155-60.

Unless you have ownership....

Compliance is often the issue ...especially in younger folks

Just say no to the exercise video. You need:

• understanding on the patients part of the pathology and the importance of the rehab
• buy in on the patients part
• a way to monitor progress with objective outcomes

a nice review article in LER, full text here

additionally, this was covered in a great PODcast by David Pope here: http://physioedge.com.au/physio-edge-039-patellofemoral-pain-adolescents-dr-michael-rathleff/

What are we listening to this week? 

The Physio edge podcast with David pope. This week they interview Kurt Lisle about anterior knee pain. Here is our synopsis:

One of the things they empahasized right off the bat was that patellofemoral pain not only refers about the knee but also below or most importantly posterior to the knee. The fat pad had a tendency to refer more locally where is other structures can refer to other areas.

Aggravating factors for patello femoral dysfunctional pain tends to be flexion or activities involving flexion as well as compression of the knee and rest is in alleviating factor.

The fat pad pain tends to be to either side of the patellar tendon and sometimes directly under it. This can be aggravated by standing, particularly with the knee and hyperextension, which compresses the fat pad.

Patellar tendon pain tends to remain at the inferior pole of the patella on the tendon whereas patellofemoral pain has a tendency to refer more.

Physical examination pearls:

• Patellar tendonopathy alone generally does not have effusion present where as the patellofemoral or fat pad injury may.
  
• Is there pain in passive hyperextension? This generally can mean fat pad injury or potential he ligamentous injury.
  
• Visually you may palpate a thickened fat pad, particularly in females.
  
• Pain with passive motions generally points away from patellar tendon.
  
• Dialing in as to where and when they are having their pain is an important part of the functional evaluation.

Kurt likes to do a table top examination first to ensure functional integrity of the knee before jumping right to functional tasks. His concerns are (which are valid) is the knee up to the task you’re about to ask it to do? Good advice here.
He emphasizes the need to be systematic and consistent in your examination, no matter how you examine them. Develop a routine that you follow each and every time. He recommends passively looking at the knee in extension and 90° flexion.

There is a discussion on functional movement about the hip and pelvis, knee, and foot and ankle. Emphasis is made, for example at the knee, as to “is the knee moving medially and laterally or are the femur and tibia rotating mediately or laterally” in which is precipitating the pain?

“Catching” of the patella is often due to patellofemoral pathology such as a subchondral defect, slap tear of the chondral surface, or abnormalities of the trochlea of the femur.

Advanced imaging strategies are also discussed with a brief overview of some of the things to look for.

Finally treatment strategies were discussed. It is emphasized that identifying the specific activity or change activities that’s causing any pain he’s made as well as activity modification. We were happy to hear that footwear and its role in knee as well as hepatology was discussed as well as looking at occupational contributions to the pain.

There was emphasis on exercise specificity particularly with respect to if the problem was unilateral not giving “blanket” exercises for both knees but rather concentrating on the symptomatic side.

A discussion on the use of EMG and activation patterns was also entertained with some good clinical pearls here. More marked rather than subtle changes and activation side to side seem to be more clinically significant. In other words, with respect training, can they achieve similar levels of activation on each side with a similar activity (for example isometric knee extension with the leg bent 60°).

The judicious use of tape from a functional testing standpoint was interesting. Emphasis was made that tape is not a cure and will merely a tool.

All in all and informative, concise podcast with some great clinical pearls and a nice review of the knee and patellofemoral pain.

link to PODcast: http://physioedge.com.au/pe-029-acute-knee-injuries-with-kurt-lisle/