Patellofemoral Joint Pain Syndrome

Patellofemoral Joint Pain Syndrome
What is it?
International Patellofemoral Study Group – www.ipsg.org
An orthopedic enigma that is probably best defined by what it’ss not
An orthopedic enigma that is probably best defined by what it
not
Diagnosis of Exclusion
IT’S NOT





Intra‐articular Pathology
Patellar Tendinopathy
Peripatellar Bursitis
Plica Syndrome
y
Apophysitis
Articular Cartilage
“a troublesome thing and once destroyed, it is not repaired”
Hunter W. On the structures and diseases of articulating cartilage. Hunter
W On the structures and diseases of articulating cartilage
Philos Trans R Soc Long B Biol Sci 1743; 9:267
“There are, I believe, NO instances in which a lost portion of cartilage has been restored or a wounded portion repaired with
cartilage has been restored, or a wounded portion repaired, with new and well formed permanent cartilage, in the human subject.”
Written in 1851
Paget J. The classics. Healing of cartilage. Clin Orthop 1969; 64:7‐8.
patellofemoral subjective symptoms
• Insidious or Traumatic Onset (Women > Men)
y
g
y
• Overuse syndrome where small variation magnified by high repetitions – violation of the rule of “2s”
• Adjectives used to describe dysfunction include
o catching, clicking, cracking, crunching, creaking, g,
g,
g,
g,
g,
and/or grating
o giving way ‐ (reflex inhibition by quads)
o psuedo locking ‐patient can actively "unlock" the knee
• Aching anterior knee pain
• Feeling of generalized lower extremity weakness • Increased pain with stair climbing and arising from a chair
patellofemoral subjective symptoms
•
•
•
Increased pain with prolonged sitting ( + movie sign)”
• “post‐inertia
post inertia dyskinesia
dyskinesia
Point tenderness to palpation of patellar facets and soft tissue stabilizers (VMO, retinaculum, etc.) Crepitation
p
–
High degree of asymptomatic crepitus present in patellofemoral function.

•
•
Abernathy; JBJS, 1978 study showed that 62% of patients had patellofemoral crepitus in absence of h d
ll f
l
b
f
pathology
Swelling or synovial thickening, but not true effusion
–
significance: produces asymmetrical quad wasting
significance: produces asymmetrical quad wasting
Often bilateral and/or family history
Prevalence of PFPS

Prevalence of 12‐13% females between 18‐35
Roush JR, et al, Int J Sports Phys Ther, 2012
A word about patellofemoral pain …

Changes in fear avoidance behaviors are an important predictor of outcome success
Piva SR, J Rehabil Med, 2009 Is it caused by the Foot, Knee, or Hip?



80’s – Foot (STJ pronation)
90’s – Knee (VMO)
00’s – Hip (gluteals)
Is it that the knee is a victim of being a slave to the forces
of being a slave to the forces generated by the two long bones above and below it?
What should be evaluated?

Alignment
–

Mobility
–

Capsular restrictions; LE flexibility; Patellar mobility
Contractile Status
–

Q Angle; Femoral/Tibial Torsions; Patellar Q
Angle Femoral/Tibial Torsions Patellar
Orientations; Foot Morphology
Quads and Hips
Quads and Hips
Functional Tasks/Gait
–
No “clinical special tests” of any significant value
What Works?
Systematic Review of the Quality of RCTs for PFPS
Bizzini, Childs, Piva, DeLitto. J Orthop Sports Phys Ther. 2003
Developed a grading scale for 20 RCTs on Patellofemoral Syndrome Intervention
PROVEN
PROVEN NOT
NOT PROVEN
 Accupunture
Laser
Bracing
Taping
Modalities
IA Injections
Orthotics ‐ Protonics
 Lateral Retinacular Stretching
 Viscosupplemenation
 SIJ Manipulation
 Strength Training Strength Training

(no specific type is superior)
 Combined interventions (tend to have better short than long term effect)
What Works?
Systematic Review of the Literature from 2000-2010
Effect size based on change in pain level
MODERATE TO STRONG EFFECT SIZE
SMALL TO MODERATE EFFECT SIZE
 Quad Training (WBing or NWBing)
Patellar Bracing
Neoprene Sleeve
Foot Orthotics
(all the above enhance exercise training)
Hip Strengthening
 Patellar Taping (short term)
Combined interventions 
Bolgla LA, et al, Int J Sports Phys Ther, 2011
Systematic review of RCTs supports the use of strengthening and flexibility exercises in the management of PFPS
Harvie D, et al, J Multidiscip Healthc, 2011 PFPS Exercise Intervention Systematic Review
Kujala Functional Scores




Exercise intervention (immediate)
Control, sham, alternative (3 month FU)
Exercise intervention (immediate)
Control, sham, alternative (3 month FU
VAS Pain Scale
Frye JL Sports Health 2012
Frye JL, Sports Health, 2012
APTA Orthopedic Section’s Clinical Practice Guidelines
Knee Pain and Mobility Impairments: Meniscal and Articular Cartilage Lesions
CLINICAL GUIDELINE
STRENGTH OF RECOMMENDATION
Clinical
Clinical Course
Course
C
Risk Factors
C
Progressive Weight Bearing
D
Early Knee Motion
C
Return to Activity Criteria
E
Therapeutic Exercise
B
NMES
B
Intervention Strategies to discuss








Education
Exercise Training
Exercise Training
Manual Therapy
Flexibility/Stretching
y
g
Orthotics/Bracing
Taping
M d liti
Modalities
Chondroprotective Agents – Neutraceuticals ‐ Medications
PFPS Education
Neutraceuticals (Nutritional Supplement)

Glucosamine Functions
–
–
–

Chondroitin Functions
–

Chondrocyte stimulation
y
Collagen and proteoglycan production
Anti‐inflammatory effect
Inhibits degradative enzymes
Dosage
–
1000‐2000 mg GA/day; 800‐1600 mg CS/day

Minimum of 2‐3 months usage is recommended to detect noticeable results
Generally considered to be better than NSAIDs with less side effects for
those with osteoarthritis Probably not that beneficial to acute traumas
those with osteoarthritis. Probably not that beneficial to acute traumas
Evidence
E
id
for
f Glucosamine
Gl
i
Chondroitin Sulfate

2‐year, double‐blind, placebo‐controlled study that enrolled 662 patients with knee OA
patients with knee OA
– Compared with placebo, the odds of achieving a 20% reduction in WOMAC pain were celecoxib: 1.21, GS: 1.16, combination GS/CS: 0.83 and CS alone: 0.69, and were not statistically significant
0.83 and CS alone: 0.69, and were not statistically significant
GAIT trial: Sawitzke AD, et al, Ann Rheum Dis, 2010

Meta‐analysis could not demonstrate significant pain relief or impact on joint space narrowing
Wendel S, et al, BMJ, 2010
However; placebo value may approach 50%
However; placebo value may approach 50%
Viscosupplementation (Super Goo)
Euflexxa – Hyalgan – Synvisc – Supartz – Orthovisc Injections

SSeries of injections of elastic and fluid to act as a shock absorber and i
fi j i
f l i
d fl id
h k b b
d
lubricant in the knee

Best symptom relief is usually and about 6 months

Measurable improvement in function as measured by SF‐36
Goorman SD, et al. Arch Phys Med Rehab. 2000

Safely and effectively relieves OA knee pain, Safely
and effectively relieves OA knee pain
facilitates an improved activity level, and decreases the need for pain medication, therapy, and assistive devices
Lee S, et al. J Knee Surgery, 2004
rehab rules – rule of
rds
1/3
Contributors to
y
Patellofemoral Syndrome
tissue threshold
Proximal
Control
Distal
Influences
Dosage
Mechanics
Knee Mechanics
& Quad Function
Structure
PFPS Exercise Training
…so, what kind of exercise is important?
NWB
vs.
WB
patella tilts on fixed femur vs. femur rotating on fixed patella
Both resulting in increased contact pressure on the lateral facet
Powers CM, et al. J Orthop Sports Phys Ther. 2003
Quadriceps Training
Patellofemoral Default Quad Exercise
Program based on limiting PFJRS
ROM
CKC PFJRF Contact Area
0‐45 Low
Low
45 90
45‐90
45‐0 Max
High
Max
Low
Weight Bearing
OKC Non Weight Bearing
Non‐Weight Bearing
90‐45 Mod

High 
Default Patellofemoral Protective Arcs
based on impairment
Exercise Leg Press
Wall Squat
S
Step Up
U
Squat
Lunge
Leg Extension
Leg Extension
Degenerative Instability Hypomobile Overconstrained
Hypermobile Underconstrained
0‐45 0‐45 painfree height
i f
h i h
0‐45 0‐45 45 0
45‐0
45‐120 45‐90 painfree range
i f
90‐20 90‐20 90 45
90‐45
CKC
OKC
G d News!!
Good
N
!!
Both 90-0° NWB leg extension and 0-90° WB leg press over 6 weeks of
training was effective as compared to a control group
Strength
Improved
Function
Improved
VAS Pain
Decreased
Step Down Pain
Decreased
Herrington L, et al. J Orthop Sports Phys Ther, 2007
Quadriceps Strength Deficits

In a systematic review with meta‐analysis the most significant prospective predictor of PFPS i ifi
i
di
f
was decreased knee extension strength
Forest plot of knee extension isometric torque as % of BW
Forest plot of knee extension isometric torque as % of BW
Bottom Line
Avoid those range of motions that 
painful crepitus. This range will change from patient hi
ill h
f
i
to patient and diagnosis to diagnosis
Quad vs. VM training

NO difference between specific VMO training and general quadricep training in patients with chronic PFPS
quadricep training in patients with chronic PFPS Syme G, et al, Man Ther, 2008

In both O/CKC all vasti muscles are recruited in similar proportion
Spairani I, et al, Int J Sports Phys Ther, 2012
Gluteal Exercise Training
Studies Indicating Hip Muscle Weakness
associated with PFPS
Jarmillo Mascal Ireland
JOSPT JOSPT JOSPT
Ext
1994
2003


2003
Leetun
Med Sci
Sport Exer
2004
Tyler
AJSM
Robinson
JOSPT
2006
2007
Cichanowski
Med Sci
Sports Exer
2007
Bolgla
JOSPT
Souza
AJSM
Baldon
JAT
Fukuda
JOSPT
Earl
AJSM
2008
2009
2009
2010
2011






Abd



ER



Flex









 SYSTEMATIC REVIEW Prins MR, et al, Aust J Physiother, 2009
 Control of femoral rotation is particularly true with females
Souza RB, et al, J Orthop Sports Phys Ther, 2010

poor proximal hip control allows
“Medial Collapse”

Femoral IR and adduction allowing i
increased knee valgus and Q angle
dk
l
d
l

Work the gluteus maximus to control the rotation and gluteus medius to control
rotation and gluteus medius to control the adduction

Excellent agreement on identifying Excellent
agreement on identifying
“poor” performance indicating a need for proximal hip attention
C
Crossley K, et al, Am J Sports Med, 2011
l K t l A J S t M d 2011
Clam 30˚
Clam 60˚
Sidelying Abd

Single Leg
Squat
S t
GLUTEUS MAXIMUS

Forward
Lunge
Single Leg
Deadlift

Lateral Band
Walk
Sideways
Lunge
Twisting
Lunge
> 50% MVIC EMG
> 50% MVIC EMG Hop
Landing
1. Single Leg Deadlift ‐ 59
2. Single Leg Squat ‐ 59
GLUTEUS MEDIUS
> 50% MVIC EMG
1. Sidelying Abd – 81
2 Single Leg Squat 2.
Single Leg Squat – 64
3. Lateral Band Walk – 61
4. Single Leg Deadlift – 58
5. Sideways Hop – 57
FYI ‐ Clam at 60/30˚ ‐
/
40/30
/
DiStefano LJ, et al, J Orthop Sports Phys Ther, 2009
Minimizing TFL substitution

Gluteus maximus and medius are more active than the TFL in –
–
–
–
–
il t l d bil t l b id i
unilateral and bilateral bridging quadruped hip extension (knee flexed and extending)
clam shells
squatting
side stepping Selkowitz DM, J Orthop Sports Phys Ther, 2013

Glut max activity can be increased by placing the band around the foot as opposed to the ankles
C b id ED t l Cli Bi
Cambridge ED, et al, Clin Biomech, 2012
h 2012
Glute Max Training Exercise Examples
Straight Leg Dead Lift Bent Knee Double Leg Dead Lift
Single Leg Straight
Leg Dead Lift
Glute Med Training Exercise Examples
NWB G. Med Progression
Easy
Harder
Sagittal
Coronal
Transverse
Hardest
Weight Bearing Gluteal Exercise in
all Cardinal Planes
Core Integration Exercises
PRONE PLANKS
SIDE PLANKS
Easier
Qaudruped
Harder
pod
Tripod
Plank Positions with Dynamic Hip Motion
S.E.R.F. Strap
http://www.donjoystore.com/ViewProducts/SERFStrap/156.aspx
6
50% Pain Reduction
no strap
3
2
0
Femoral Strap
14
12
Hip Rotation Angle (ER - / IR +)
femoral strap
4
1
No Strap
*
Maintain
Hip ER
*
10
8
Femoral Strap
No Strap
*
6
4
2
0
-2
-4
-6
6
p = .003
p = .001
p = .011
Step Down
Running
Drop Jump
-8
350
300
% change in EMG
G activity)
• patellofemoral brace designed to treat patellofemoral pain stemming from pain stemming from
abnormal or excessive hip internal rotation, adduction, and/or knee valgus motion(s)
valgus motion(s)
VAS Pain Score
V
5
250
Significant  Glut
Max EMG activity
200
150
100
50
0
Step Down
Running
Drop Jump
PFPS Manual Therapy
case series showing that concurrent anterior tibial translation
is effective in alleviating patellofemoral pain
Creighton D, et al, J Man Manipul Ther, 2007
Long arc assisted knee extension with tibial translation adequate to eliminate pain Rectus femoris stretching with manual anterior tibial translation adequate to eliminate pain
local manual therapy
Patellar Tilts and Glides
Expert consensus on the use p
of medial glides and tilts to improve patellar mobility if excessive lateral pressure
excessive lateral pressure syndrome is present
proximal manual therapy
Preliminary CPR for identifying PFPS patients who
will respond to lumbopelvic manipulation
1.
2
2.
3.
4.
5.
> 14 hip IR asymmetry*
> 16 ankle dorsiflexion asymmetry
> 16
ankle dorsiflexion asymmetry
Navicular drop > 3 mm
No stiffness with sitting > 20 minutes
S
Squatting is the most painful activity
i i h
i f l i i
* - most powerful predictor of success
•
•
IR deficit presence: + LR of 5 increasing probability of success from 45 to 80%
Any three present: increased probability to 94%
Iverson CA, et al, J Orthop Sports Phys Ther, 2008
PFPS Flexibility/Stretching
Inflexibility
•
tight hamstrings
•
•
tight ITB •
•
•
•
can lead to external rotation of tibia and increasing Q angle tethers the patella in a more lateral position from the lateral retinacular band running off the ITB
as the knee bends, the ITB is pulled posteriorly and if there is tightness of the ITB it will cause the patella to track laterally
the ITB it will cause the patella to track laterally
tight hip flexors •
•
increase necessary quadricep tension, tight internal rotators that alter Q increase
necessary quadricep tension, tight internal rotators that alter Q
angle, or increases need for df ROM at TCJ
inhibit full patellar excursion
tight gastroc/soleus
tight gastroc/soleus
•
increase compensatory pronation in midstance
Effect of improved hip mobility and strength
Tyler, et al, Am J Sports Med, 2006
93%
success
75%
success
27%
success
NO
success
The effect of a combination of (1) improved hip flexion strength, (2) normalized Ober test, and (3) normalized Thomas test on treatment success. The x‐axis refers to the number of factors (3/3 t 0/3)
(3/3 to 0/3) a patient achieved. The white bars represent successful outcomes; the black bars ti t hi d Th hit b
t
f l t
th bl k b
represent unsuccessful outcomes (P < .001) Effect of improved hip mobility and strength
Tyler, et al, Am J Sports Med, 2006
80%+ successful (> 1.5  on VAS) when Ober and Thomas tests normalized
further evidence for flexibility
Patients with patellofemoral
pain syndrome had less flexibility in the gastroc/soleus, quadriceps, and hamstrings
(but not ITB)
Piva, et al, J Orthop Sports Phys Ther, 2005
PFPS Orthotics/Bracing/Taping
biomechanical
bi
h i l factors
f t
causing
i
lower extremity malalignment
• Increased Q angle



femoral neck anteversion
external tibial torsion
laterally displaced tibial tubercle
• Tibia Vara
g
• Genu Valgus
• Pes Planus/Foot Pronation
great overview by
Powers CM in JOSPT 33(11):639‐646, 2003
Orthotic Usage



Decreases hip IR/adduction
D
Decreases knee valgus and Q angle k
l
dQ
l (2‐3°° immediate improvement in Q angle)
Decreases laterally directed forces on patella
Kuhn, et al, JMPT, 2002

Prefabricated orthoses provided immediate improvements in pain and function
B t CJ B J S t M d 2011
Barton CJ, Br J Sports Med, 2011

RCT indicates short term value in conjunction with physical therapy
p y
py
Collins N, et al, Brit J Sports Med, 2009
Who is likely to benefit from orthotics?
Preliminary CPRs
1. Forefoot valgus alignment > 2 (+LR = 4.0)
2. 1st MTP extension < 78 (+LR = 4.0)
3 Navicular drop < 3 mm (+LR = 2.4)
3.
N i l d
3
( LR 2 4)
1.
2
2.
3.
4.

Sutlive TG, J Orthop Sports Phys Ther, 2004
age > 25
Height < 5'5”
Height < 5
5
Worst Pain < 5/10 on VAS
>11 mm increase in midfoot width upon weight‐bearing +LR = 9 (40 to 86% chance of pre‐ to post‐test success) if 3 of the 4 above findings were present

1.
2.
3.
4.
Vinzenzino, et al, Br J of Sports Med, 2008
Vinzenzino, et al, Br J of Sports Med, 2008
Subjects who wear less supportive footwear
Pain < 2/10
Limited ankle dorsiflexion
Immediate improvement in pain during single leg squat
If 3 of 4 present likelihood of success increased from 25 to 78% Barton CJ, et al, Med Sci Sports Exer, 2011
What about taping?
Patellofemoral Taping Research Summary
Impact on Congruence: MINIMAL

t i
taping medialized patella prior to exercise but lost post‐exercise
di li d t ll
i t
i b tl t
t
i – Pfieffer, Am J Sports Med, 2004 
taping does not significantly modify patellar lateralization or tilt – Gigante, Am J Sports Med, 2001

no significant reduction (improvement) of patellofemoral congruence despite subject’s subjective pain relief – Bockrath, Med Sci Sports Exer, 1993 
taping did not improve patellar position (but bracing did) b b h
but both methods reduced pain on an 8” step down h d d d i
8”
d
–
Worrrell, J Sports Rehabilitation, 1994 
taping effective at medializing patella but unable to p
with exercise – Larsen, Am J Sports Med, 1995
maintain position What about taping?
Patellofemoral Taping Research Summary
Impact on the Knee Extensor Mechanism (timing and torque production)



systematic review revealed variable findings regarding vastus
systematic
review revealed variable findings regarding vastus medialis vs. vastus
vs vastus
lateralis timing – Aminka, J Athl Training, 2005
taping decreased vastus medialis demand – Ng, J Electromyo Kinesiol, 2002
taping increased extensor concentric and eccentric quad peak torque by 20‐25%
taping increased extensor concentric and eccentric quad peak torque by 20
25%
– Herrington, Man Ther, 2002


taping caused a mild decrease in jumping ability – Ernest, J Orthop Sports Phys Ther, 1999
taping of the patellofemoral joint changed the timing of VMO and VL activity in subjects with PFPS during step‐
up and step‐down tasks – Gilleard, Phys Ther, 1988
Overall Impression: Taping reduces neural inhibition and improves proprioception
d
l hb
d
What about taping?
Patellofemoral Taping Research Summary
Impact on Pain: effective at modulating pain






96% of patients had immediate and significant decrease in patellar pain with 96%
of patients had immediate and significant decrease in patellar pain with
corrective taping ‐ McConnel, 1987
increased patient satisfaction and decreased pain at one year post but no significant change in function as measured by the WOMAC – Clark, Ann Rheum Dis,
significant change in function as measured by the WOMAC Clark, Ann Rheum Dis, 2000
taping reduced pain on a NPRS at 2, 3, and 4 weeks and decreased pain with step down activities – Whittingham, J Orthop Sports Phys Ther, 2004
taping decreased pain – Ng, J Electromyo Kinesiol, 2002 taping decreased pain – Cowan, Med Sci Sports Exerc, 2002
both taping and placebo taping decreased pain – Christian, J Electromyo Kinesiol, 2004

taping decreased pain with stair ambulation – Salsich, J Orthop Sports Phys Ther, 2002
certainly no agreement on orientation

.10 ‐ .36 kappa values ‐ Fitzgerald, Phys Ther, 1995

intratester kappa ‐0
intratester kappa 0.06 06 ‐ .35 and intertester kappa 35 and intertester kappa ‐0
0.03 03 ‐ .19 19 – Watson, JOSPT, 1999
Watson JOSPT 1999

visual, goniometric, & caliper assessment agreement unacceptable – Tomisch, JOSPT, 1996, 
kappa agreement on medial, neutral, lateral only .29 – Lesher, JOSPT, 2006, taping technique no longer determined by clinical assessment of
patellar position
Who Benefits from Taping?
Overall, 66% had at least a 20 mm change on a 100 mm pain VAS
 Those who responded best:
Those who responded best
–
–
–

Higher levels of pre‐taping pain
Less lateral patellofemoral tilt
Larger Q angle
Those who responded least:
– High BMI
High BMI
– More lateral patellofemoral tilt
– Smaller Q Angle
Lan Ty, et al, Am J Sports Med, 2010

Placebo effect?

Psychological influence
–
“Putting a band‐aid on a 2‐year old’ss boo‐boo
old
boo boo”
Neurological influence
–
–
Cutaneous receptors may alter neural input
Tape/braces stimulate receptors in proprioceptive p
,
deficient knee to improve recruitment, increase function, and decrease pain
No personal experience with kinesiotaping …but
I’ve heard a lot of positive anecdotal results
Type “kinesio taping” in search box at PubMed, Cochrane,
PEDro, or Hooked and you get 8 relevant results for the knee
PEDro or Hooked and you get 8 relevant results for the knee
Kinesio Taping Research

Kinesio taping revealed no difference in muscle power in healthy non‐injured athletes
Fu TC, et al (Taiwan), J Sci Med Sport, 2007

Preliminary report that questions the effect of kinesio taping on bioelectrical activity of vastus medialis muscle Stupik A, et al, Ortop Traumatol Rehabil, 2008

Kinesio tape did not alter the muscle peak torque generation and total work
Wong OM, et al, Phys Ther Sport, 2012

Kinesio® taping and E. Stim have similar effects on decreasing pain, improving functional condition, increasing muscle strength and improving quality of life and neither are superior in the treatment of patellofemoral pain syndrome.
Kuru T, et al, Acta
T et al Acta Orthop Traumatol
Orthop Traumatol Turc, 2012
Turc 2012
Kinesio Taping Research

Similar value to lumbopevlic manipulation with gluteal kinesio taping (pretty low bar)
Miller J, et al, Sports Health, 2013

Reduction below MDC change in pain level during stair climbing
Campolo M, Int J Sports Phys Ther, 2013 
The addition of kinesio taping to a conventional exercise program does not improve results in patients with PFPS
Akbas E, Acta Orthop Traumatol Turc, 2011

Systematic review concluded there was little quality evidence to support the use of kinesio taping in the management or prevention of sports injuries
Williams S, Sports Med, 2012
of course, who needs evidence when
you have celebrity endorsements
Pathology
Classifications
• Over/Under Constrained Patellas
• Articular Cartilage Lesions
− Traumatic
− Atraumatic
− Osteochondral Lesions
− Osteochondritis Dissecans
• Plicae Syndrome
• Fat Pad Syndrome
Overconstrained PFPS
CLASSIFICATION
DIAGNOSIS
TREATMENT
Excessive Lateral
Pressure
Lateral Pressure Syndrome
• Lateral Tilt
• Decreased Medial Glide
• VMO dysplasia or atrophy
• Medial
glides/tilts
Medial glides/tilts
• Patellar taping (LLPD
effect)
• LE stretching
• Quad and Hip training
Quad and Hip training
• Avoid biking and resistive OKC quad training
Global Patellar Pressure Syndrome
Patellar mobility decreased y
in all planes (usually
secondary to trauma or immobilization
• Patellar Mobs
• QS, SLR, Mini‐Squats in available patellar range
• Cautions: same as ELPS and NO taping
and NO taping
Underconstrained PFPS
CLASSIFICATION
DIAGNOSIS
TREATMENT
Acute
• Significant swelling
• Adductor tubercle tenderness
• + apprehension sign
• Conservative vs. Surgical
• Restoration of function following immobilization in full extension
Chronic
Recurrent
• > 2 Quadrant Glide
• Extensor mechanism Extensor mechanism
imbalance
• Patellar maltracking
• Bracing/Taping
• 90‐40
90 40° quad training
quad training
• Hip frontal and transverse plane training
• Correct LE alignment
Non-Operative
p
Summary
rehabilitation pearls
“stretch lateral, strengthen medial, and straighten top to bottom”








Do not train through pain
M t
Must control swelling/edema
t l
lli / d
Normalize LQ biomechanics
Medial patellar tilts/glides
Medial patellar tilts/glides
Proximal Hip Control
Flexibility training
Flexibility training
Taping (non‐elastic) if indicated
Minimize PFJ stress with appropriate pp p
arc motion
PFPS Prognosis

Long standing symptoms and lower scores on the Kujala Outcome Measure predict a poorer h
j l
di
prognosis (irrespective of gender and morpho‐
metry (BMI and arch height)
metry (BMI and arch height)
Collins NJ, et al, BMC Musculoskeletal Disord, 2010
Does PFPS require a referral to PT?

Odds Ratio for recovery (slight, strong, or full recovery) was 4.07 for a supervised therapy vs.
recovery) was 4.07 for a supervised therapy vs. usual care group in regards to Kujala functional score and pain scores at 3 months (but not 12 months)
Hart L. Clin J Sport Med, 2010

A higher proportion of subjects in the supervised therapy vs usual care group
supervised therapy vs. usual care group reported recovery at 3 (42 vs. 35%) and 12 (62
vs. 51%) month follow‐ups.
Van Linschoten R, et al, BMJ, 2009
Van Linschoten R, et al, BMJ, 2009
rehabilitation perspective
the knee is subject to what happens above and below it
From the Hip Down
“
“core
to
t the
th floor”
fl ”
Femoropatellar Syndrome
TREAT the
th KNEE
Patellofemoral Syndrome
From the Foot Up
“ground reaction”
Tibiopatellar Syndrome
Surgical
S
gi l Management
M
g
t
of Articular Lesions
Alford JW and Cole BJ. Cartilage Restoration: Parts 1‐2. Am J Sport Med. 33:2 and 33:3, 2005
Alford
JW and Cole BJ Cartilage Restoration: Parts 1‐2 Am J Sport Med 33:2 and 33:3 2005
JOSPT Theme Issue – Volume 36:10; October 2006
Surgical Techniques
Debridement and Lavage
• 1st line palliative treatment indicated in low demand patients with < 2 cm lesions
line palliative treatment indicated in low demand patients with < 2 cm lesions
Abrasion Chondroplasty
• Motorized burring of subchondral bone
Microfracture
i f
Drilling illi (marrow stimulation)
• “picking” with drill (not burring) to cause bleeding and formation of “pseudo” cartilage OA S
OATS
• Osteochondral autograft transfer
ACI
• Autologous articular cartilage implant
Overlapping treatment options ranging from
palliative, to reparative, to restorative objectives
MST: marrow stimulation
ACI: autologous chondrocyte implantation
OCG: osteochondral grafting
Lower Demand
Higher Demand
Higher Demand/Larger Lesion
Surgical Algorithm
Decision making b d
based upon: 


Lesion Site
Lesion Size
Physical Demand
Tetteh ES, et al, J Orthop Sports Phys Ther, 2012
Rehab Influences

Individual variables that will influence the rehabilitation design and progression
rehabilitation design and progression include:
–
Lesion location, size, depth, and ,
, p ,
containment
–
Patient age, size, cartilage health, goals, and motivation
l
d
i i
–
Concomitant surgical interventions
Articular Cartilage Rehab Considerations
Mithoeffer K, et al, J Orthop Sports Phys Ther, 2012
FACTORS
IMPLICATIONS
INDIVIDUAL Age
Slower cartilage repair with increased age BMI
Slower progression with BMI > 30
Sport Goal
Higher demand for impact sports LESION DEFECT
Defect Size
Faster improvement with smaller defects
Surgical Technique
g
q
More rapid improvement with restorative techniques
p
p
q
Defect Location
Immediate WBing for PF defects (Knee locked in full extension)
Symptom Duration
Slower recovery in injury > one year old
CONCMITANT INJURIES
CONCMITANT INJURIES
Concurrent Surgeries
Modified protocol if ACL, osteotomy, meniscal repair, etc
Meniscal Health
Slower rehab after menisectomy (especially lateral)
Prognostic Indicators
1.
2.
3.
4.
5.
Body Size (< 30 BMI)
Symptom Duration (< 12 months)
Age (< 40)
Number of Previous Surgeries
(
)
Lesion Size (< 2‐3 cm) and subsequent amount of lesion “fill”
Mithoefer K, et al, 2006 Am J Sports Med and
Mithoefer
K et al 2006 Am J Sports Med and
2005, J Bone Joint Surg
Microfracture

Drill picking to produce a fibrin “superclot”
fibrin superclot for for
smaller, focal lesions that are surrounded by normal cartilage

This psuedocartilage is less durable and resilient than normal cartilage
Osteochondral Autograft Transfer Surgery
Osteocartilaginous Transfer Surgery

Cylindrical osteocartilaginous grafts are taken from peripheral and NWB portions of the knee and transferred to the prepared damaged area under arthroscopic control

Most common osteocartilaginous Most
common osteocartilaginous
procedures • MosaicPlasty (Smith Nephew)
• COR Systems (Innovasive Devices)
y
(
)
• OATS (Arthrex).
• Allografts can be used for larger lesions
Autologous Articular Cartilage Implant
Cartilage Implant
Autologous Articular Cartilage Implant
use of Carticel (autologous cultured chondrocytes) to repair clinically signi‐
ficant symptomatic cartilage defects of the femoral condyles or trochlea
ficant, symptomatic cartilage defects of the femoral condyles or trochlea
Recommended Indications
P i
Patient Age A
15 55
15‐55 years old
ld
Defect Location preferably femoral condyles (not bipolar lesions)
Defect Size 1 to 10cm2
Number of Defects preferably one
Defect type
Defect type Grade IV
Grade IV
General Rehab Trends


Acute Proliferation Phase
– First 4‐6 weeks
– Immediate, controlled A/PROM (CPM)
• Range limiting or unloading brace prn
– NWB to PWB • NWB if condyle/plateau lesion; WBAT if trochlear lesion
– Regain Quad Control
– Build Hip/Trunk strength
SubAcute Transitional Phase
– First 1‐3 months
– Gentle, gradual PREs
– Progress to FWB by 4‐8 weeks
P
FWB b 4 8
k
General Rehab Trends
Remodeling Phase
• 3‐6 months
36
h
• Maximizing strength ‐ hips/thighs
Low impact activities tolerated
• Low impact activities tolerated
Terminal Maturation Phase
• May last for another 6‐12 months
y
• Return to premobid levels of activity as tolerated
Important Considerations

Load protect affected area
– Grass football field analogy
G
f tb ll fi ld
l

Restore passive knee extension ASAP and gradually regain flexion
ASAP and gradually regain flexion ROM as tolerated

Gentle progression

Careful with mobilizations?
ACI Education
Patient must understand the maturation consistency f h “
”
il
of the “new” cartilage
After 1 week
Like WATER
After 3 months
Like YOGURT
After 6 months
Like DOUGH
After 9 months
Like CHEESE
y
After one year
Like RUBBER
Protocol Resources


Microfracture
– J Ortho Sports Phys Ther. 2006; 36(10):784‐86
O t h d lA t
Osteochondral Autograft Transfer
ft T
f
–
–

J Ortho Sports Phys Ther. 2006; 36(10):742‐43
• Includes considerations and alterations based on concomitant surgeries
J Ortho Sports Phys Ther 2006; 36(10):787 89
J Ortho Sports Phys Ther. 2006; 36(10):787‐89
Autologous Articular Cartilage Implant
–
–
–
–
–
J Ortho Sports Phys Ther. 2006; 36(10):758‐60
 Includes considerations and alterations based on concomitant surgeries
J Ortho Sports Phys Ther. 2006; 36(10):790‐92
Bailey A. Rehab after Oswestry ACI: The OsCell Protocol. J Sports Rehabil. 12:104‐118, 2003
http://www.carticel.com/pdfs/carticel
p //
/p /
_rehabilitation_gguide.pdf
p
http://www.oscell.enta.net/patients.htm
One Additional ACI Resource
Hambly K,
K et al.
al Am J Sports
Med. 2006; 34(6): 1020-38
Evidence-based Review
Long Term Outcomes for Chronic Patellofemoral Pain
Surgery vs. Rehab

Prospective RCT with 28 subjects in each group
–
–
Surgery and HEP vs. HEP alone
At 5‐year follow‐up both groups improved but no difference in function (Kujala outcome score) or pain (Kujala outcome score)
or pain (VAS)
Kettunen JA, Br J Sports Med, 2011
vs.
Extensor Mechanism Injuries
two conditions of the immature extensor mechanism
Larsen‐Johannson Disease
IP Tendinopathy “Jumper’s Knee”
Osgood‐Schlatter’s Disease Tibial Apophysitis
Tendinitis or Tendinosis?
Inflammation or collagen degradation?
collagen degradation?
Rarely does condition have inflammatory mediators
fl
d
Patellar Tendon Palpation

Mild tenderness in patellar tendons in asymptomatic
tendons in asymptomatic jumping athletes should be considered normal
Cook JL, Khan KM. Br J Sports Med, 2001

In active individuals SN is very In
active individuals SN is very
high (98%) but SP is only moderate
Ramos LS, Clinics, 2009
Pathognomic Sign of Patellar Tendinopathy
Much higher level of pain when palpating inferior pole in extension than flexion
l i
i
h fl i
NPRS = 5/10
Rath E, et al, Indian J Orthop, 2010
NPRS = 2/10
Palpation Rationale



Pathogenesis is impingement between deep fibers of proximal patellar tendon on the inferior pole of the patella
patellar tendon on the inferior pole of the patella. These fibers are easily deformed with A to P palpation pressure. In 90° of flexion or with active tension as in a mini‐squat, the anterior fibers stretched fibers protect the posterior fibers for pressure deformation
> pain
< pain
> pain
< pain
Infrapatellar Tendinopathy
Acute Care
 Ice massage and Tylenol
d l
l
 Nitric Oxide Patches
 Address hip, knee, ankle joint dd
h k
kl
restrictions
 Address LE malalignments Address LE malalignments
 LLD, foot abnormalities
 Correct flexibility deficits (quads and hams)
Modality Care

Low‐level laser treatment –
–

Iontophoresis/phonophoresis
–

6 randomized controlled studies: 2 = improvement; 4 = no improvement Deep friction massage
Deep friction massage –
–

p
;
p
25 randomized controlled clinical trials: 12 = improvement; 13 = no improvement mixed results due to non‐standardized treatment dose/regimen?? 9 studies and one Cochrane review No significant evidence of added benefit over standard PT
Ultrasound –
–
randomized controlled studies Mild benefit shown with elbow “osis”
CONCLUSION: Modalities do not currently have enough research to recom‐
mend their use for the treatment of tendinopathy.
Infrapatellar Tendinopathy Terminal Care
•
•
Use of infrapatellar strap
Restore tensile abilities through eccentric training after 1‐2 weeks of pain free ADLs
f i f
ADL
―
Nice Overview in Hale, SA, J Sport Rehabil, 2005
Fluk
u
Strap
ChoPat
C
o at
Strap
Eccentric Training


Patient satisfaction in 9/10 for eccentric training and 0/9 for concentric training
concentric training
3 x 15 BID/daily x 12 wks
Froham A, Br J Sports Med 2005
p
Purdham CR, Br J Sports Med, 2004
Jonnson, Br J Sports Med 2005

Decline eccentric training as effective as surgical tenotomy for chronic tendinosis
Bahr R, J Bone Joint Surg, 2006
Can we prevent it?

36.5˚ dorsiflexion should be used as a cutoff point in prognostic screening to identify and elevated risk for ti
i t id tif
d l t d i kf
developing IP tendinopathy in HS basketball players
p y
–
–
–
–
20‐30% risk in those with < 36.5˚
1 2% i k i th
1‐2% risk in those with > 36.5˚
ith > 36 5˚
+ LR of ̴ 4.5
‐ LR of ̴ .30
Questions-Discussion
Thank you