William Cote PT/s

9-28-15

Patellofemoral pain syndrome, also called retropatellar and peripatellar pain, is a common pain disorder experienced by young adults (10-35 y/o) and adolescent athletes who participate in jumping and pivoting sports.1,2

Incidence ranges from 10-40% of clinical visits for knee problems for the general population and people with high physical activity levels.1,2

Pain is often reported at the anterior compartment of the knee and is aggraveted by sports activities, stair climbing, kneeling/squatting, and prologned sitting with the knee flexed.1,3

Often due to weakness of the vastus medialis obliquus (VMO) resulting in abnormal tracking of the patella, resulting in increased work for the vastus lateralis.2

http://physioworks.com.au/images/Injuries-Conditions/patellofemoral_pain.jpg

Causes range from subluxation and dislocation to patellar malalignment, or simply overuse as a

causative factor.4

Causes are generally seperated into two categories:4

◦ First includes problems with static structures such as the shape of the osseous surfaces or length of

the fascia.

◦ Second category includes issues related to the dynamic structures surrounding the knee, including

the VML, VMO, and VL muscles’ function in the development of PFPS.

Treatment options are widespread and include: general and specific hip/knee strengthening, surface

EMG biofeedback, stretching, acupuncture, low level laser, patellar mobilizations, corrective foot

orthoses, patellar taping, and external patellar bracing.

Q-angle appears to be discriminate between runners with and without

PFPS, with a greater Q-angle thought to be associated with an increased

lateral force on the patella.

A more shallow trochlear groove associated with a laterally tilted patella.

Tibiofemoral rotation, along with patellar width, may be one of the factors

leading to a decrease of contact area in the PF joint, which can increase

anterior knee pain.

Stability of the patellofemoral joint (PFJ) is largely maintained by soft

tissues, in particular, the dynamic balance of medial and lateral quad

muscles.2

Evidence suggests that an increase in VML muscle EMG is associated with

greater lateral patellar displacement and tilt.5

Looking for 1:1 VMO/VL ratio.

http://www.aafp.org/afp/2007/0115/afp20070115p194-f1.jpg

Important to question whether etiology appears to be due to trauma,

congenital structural problems, or overuse.

Assessment of patient’s static alignment can provide clues to presence of

abnormal mechanical stress on the knee.

Important to perform a careful assessment of muscle function of the lower

kinetic chain, specifically between the pelvis, hip, foot, and ankle.

Rehabilitation may include a period of rest, followed by activity

modification.

Appropriate management plan for PFPS is based on evaluation of collected

data, and includes:

◦ Strengthening, stretching, and manual interventions to address ROM impairments and

motor deficits

◦ Movement reeducation to address habitual movement patterns

◦ Rehabilitation of the extensor mechanism and control of proper lower extremity

alignment.

Recovery time is variable and often occurs in stages.

http://www.bidmc.org/CentersandDepartments/Departments/OrthopaedicSurgery/ServicesandPrograms/SportsMedicine/ForPatients/RehabilitationProtocols.aspx

Phases include acute, sub-acute, and return to

activity/sports phase.

Main goals include:

• strengthening,

• stretching of tight structures

• stretching of shortened muscles

stabilization of the knee

• patient and family education

• Typical rehab time: 2-3wk/ 8-12 weeks6

Goals of treatment are patient dependent and are based on thorough

evaluation.

General guidelines include:

http://www.brighamandwomens.org/patients_visitors/pcs/rehabilitationservices/physical%20therapy%20standards%20of%20care%20and%20protocols/knee%20-%20patellofemoral%20pain%20syndrome.pdf

Main focus is to minimize pain, reduce edema, establish quad activation,

and reach full ROM.

Exercises include: quad sets, SAQ, SLR, heel slides, and targeted hip

exercises for flexion, extension, ER, and abduction.

Flexibility focus is on quads, HS, glutes, abd/adductors, IT band, and

piriformis

Reduction of swelling and pain is crucial to restoring normal activity of the

quadriceps, and includes medications, cryotherapy, e-stim, and joint

compression.

Restoring volitional muscle control is another early principal that must be

accomplished and can include electrical stim and biofeedback.2

Further goals here include focus on the quadriceps, through basic open

chain exercises, and improving soft tissue mobilty.

Reduction of valgus postural alignment at knees and ankles seen after PT

treatment.

◦ Treatment includes stretching of the HS, quad, IT band, and stregthening of the quad

femoris with squatting exercise.

Very controversial subject as many do not believe it to have effect.

Results from orthopedic study show that lateral taping, causing increased

tension on the skin over the VMO, results in increased VMO surface EMG

amplitude.

Based on the fact that VMO taping increases stimulation of cutaneous

afferents, thus producing this positive effect.

Goal is to: increase strength, proprioception, flexibility, and continue to

reduce edema and maintain ROM.

Exercises include CKC strenghening: leg press, TKEs, step ups, wall sits,

squats, HS curls, and proprioceptive exercises.

Continue with stretching as needed with ROM levels, and add in

cardiovascular training.

Very little evidence of effects of aerobic exercise on quadriceps torque and EMG activation of VMO, VL, and glute med (GM).

High pain PFPS subjects showed decrease in both VMO (25%) and VL (12%) following aerobic exercise with reaching exercise.◦ Increased activation of glute med shown

Must consider the glute med. as potential

source of altered neuromuscular

function of the quadriceps muscle

in PFPS patients.

http://images.slideplayer.com/12/3539698/slides/slide_40.jpg

Step up exercise is shown to be effective in increasing muscle activation in

both the VMO and VL after PT treatment.

Benefit also seen with the step down (eccentric) exercise as there was

reduced quad activation, suggesting higher efficiency of motor control and

coordination, with reduced energy consume by the VMO.

◦ Specifically in VL comparisons between CG and Post-PF group

General exercises, such as squats and knee extension, stress the whole

quadriceps and can regarded as a global approach for targeting the VMO.

Use of the these two exercises, in groups of weight training for strength and

for muscle hypertrophy showed: improved VL/VMO amplitude ratio,

VMO/VL onset difference, knee extension torque, and better knee joint

position.

Improvements were seen for both the strength and hypertrophy groups in

comparison to the CG.

Knee extensor activities help to improve VMO/VL amplitude ratio in both

open and close chain exercises.

Adding in EMG biofeedback has proven to enhance the amplitude ratio of

the VMO/VL, thus providing an ajdunct to therapeutic exercise to help

reduce PFP symptoms.

With increased in VMO/VL ratio there is a reduction in lateral pull on the

patella as the VMO starts to activate first during the extension mechanism.

The addition of biofeedback with this treatment helps as it provides real

time feedback during training, which facilitates integration of sensory cues

and motor recruitment of the muscles.

Study shows significant increase in VMO/VLL muscle during double leg

squat with addition of hip adduction for both healthy and PFPS patients.

Results showed a more balanced activity level between the VMO and VLL

as compared to normal DL squat.

Goal is to return to prior level of activity/sports with no pain/limitation and

maintain flexibility.

Add in sports specific exercises where indiciated along with cardio

progression to increase endurance.

Provide and witness patient independence with individualized HEP.

Large body of work supporting abnormal hip function and PFPS.

With higher level activities, including running, SLS, and single leg jumps,

it has been demonstrated that PFPS patients present with more hip

adduction.

◦ Increased hip adduction associated with increased valgus nature of LE

Restrictions seen with these high level activities are believed to be

observed with weakness of both the glute medius and maximus.

When compared to CG, PFPS patients

had increased hip IR, adduction,

reduced hip torque during isometric

strength testing, and reduced glute

max activity during all activities.

Example:SLS with poor control

It is seen that these exercises are appropriate as they replicate sports related

activities, and being able to tolerate without increased hip adduction and IR

is necessary for return to sport.

Experimenting shows the need for glute strengthening in previous stages to

help improve knee and ankle stability during high level activities.

Box jumps, or vertical jumps, are another important exercise to perform in

order for return to normal/sports activities in young adults.

Seen that PFPS patients have a increase in knee abduction at moment of

initial contact with these activities.

◦ With this still present it is highly likely that the patient will have a reoccurance of PFP

symptoms with return to sports

http://www.lf.k12.de.us/wp-content/uploads/2015/03/Sports.png

• With these symptoms still

present at this stage, the

clinical focus must be on

improving muscular

performance and hip motor

control strategies to decrease

valgus postures and knee

abduction loads.

• This in turn can help to

decrease abnormal

patellofemral loading

mechanics during future

sports maneuvers.

Commonly expected outcomes include:

◦ Improved or normalized muscle length

◦ Normal patella mobility

◦ Normal VMO density

◦ Normalized muscle imbalances at hip and knee

◦ Correct shoe wear

◦ Complete reduction in knee pain

◦ Painless performance of sport related activities

◦ Independence with provided HEP

http://mvpsc.com/wp-content/uploads/next-step-538x218.jpg

PFPS is a very common disorder, up to 40% of knee visits, and can be

treated in a multitude of different ways.

Spotlight turning to preventative care for younger adults.

Early focus on hip strengthening should not be overlooked.

Return to sport must be done gradually and with exercises that help to

mimic daily life or sport related activities.

Questions?

1. Myer GD, Ford KR, Barber Foss KD, et al. The incidence and potential pathomechanics of patellofemoral pain in female athletes. Clin Biomech.

2010;25(7):700-707.

2. Ng GYF, Zhang AQ, Li CK. Biofeedback exercise improved the EMG activity ration of the medial and lateral vasti muscles in subjects with

patellofemoral pain syndrome. J Electromyorg Kinesiol. 2008;18(1):128-133.

3. Coqueiro KRR, Bevilaqua-Grossi D, Berzin F, Soares AB, Candolo C, Monteiro-Pedro V. Analysis on the activation of the VMO and VLL muscles during

semisquat exercises with and without hip adduction in individuals with patellofemoral pain syndrome. J Electromyorg Kinesiol. 2005;15(6):596-603.

4. Brody LT, Hall CM. Therapeutic Exercise: Moving Toward Function. Baltimore, MD: Lippincott Williams & Wilkins; 2011.

5. MacGreogor K, Gerlach S, Mellor R, Hodges PW. Cutaneous stimulation from patella tape causes a differential increase in vasti muscle activity in people

with patellofemoral pain. J Orthop Red. 2005;23(2):351-358.

6. Reinold M. Feel better, move better, perform better website. http://www.mikereinold.com/2009/05/10-principles-of-patellofemoral.html. Accessed

September 18, 2015.

7. Ott B, Cosby NL, Grindstaff TL, Hart JM. Hip and knee muscle fucntion following aerobic exercise in individuals with patellofemoral pain syndrome. J

Electromyogr Kinesiol. 2011;21(4):631-637.

8. Sacco IC, Konno GK, Rojas GB, et al. Functional and EMG response to a physical therapy treatment in patellofemoral syndrome patients. J Electromyogr

Kinesiol. 2006;16(2):167-174.

9. Wong YM, Ng G. Resistance training alters the sensiomotor control of vasti muscles. J Electromyogr Kinesiol. 2010;20(1):180-184.

10. Souza RB, Powers CM. Differences in hip kinematics, muscle strength, and muscle activation between subjects with and without patellofemoral pain. J

Orthop Sports Phys Ther. 2009;39(1):12-19.