About Patellofemoral Pain Syndrome
There are many different conditions that can affect the structures of the knee, and we use the term “anterior knee pain” as a general way of describing all of them at once. Most cases of knee pain are caused by Patellofemoral Pain Syndrome, or PFPS. PFPS refers to an abnormal tracking of the patella on the femoral groove which is determined to be secondary to changes in lower extremity alignment, training errors or muscle imbalance (2). PFPS is the most commonly reported overuse injury in the active population. It’s also the most common lower extremity condition for runners who are seen in sports medicine practices. Overall, the condition occurs in 25% of runners (1). For females, there is a 2.2 times increased likelihood of developing PFPS when compared with males (3).
Diagnosing PFPS can be tricky, but recent studies have shown evidence that the strongest diagnostic test we have for the condition is resisted MMT of the quad (+ Likelihood ratio (TR) 2.2), but 2 of 3 positive tests within a single test cluster (quad pain upon contraction of the quad, pain upon squatting, and pain with manipulation) showed a (+) LR of 4.0 (7).
Additionally, the eccentric step down test (+ LR 2.34, – LR .70) offers value for identifying precipitating or perpetuating impairments, or for differential diagnosis (20).
How is PFPS treated?
The standard recommendation for treating those with PFPS maintains a conservative approach. The leading medical journals for physical therapy also recommend adding relative rest (and decreasing the amount of aggressive activities that are performed), modifying current activities (changing shoe style, type of terrain and volume of training), and controlling the inflammation process (2).
Overall, the recommendations that have come out from many different studies have noted that a solid amount of consistent, high quality evidence exists that shows physical therapy interventions to be highly effective in the early management of PFPS. Specifically, many authors recommend using customized rehabilitation treatment plans that are focused on reducing those forces that cross the patellofermoral joint (2).
For PFPS, physical therapists typically combine interventions that are specifically tailored to the symptoms that an individual patient is experiencing. The types of physical therapy interventions typically used include therapeutic exercise, manual therapy, proprioception training, orthoses and taping.
What does the evidence say?
A recent study found Level B evidence for using manual therapy in patients with PFPS (4).
Crossley showed improved stair climbing ability after manual therapy had been performed on the patellofemoral and tibiofemoral joints (9).
In patents with PFPS, there was an immediate decrease in quadricep inhabitation following lumbo-pevlic manipulation (25,26).
A study by Iverson, et al, demonstrated a 50% reduction in pain with functional activities following a lumbopelvic manipulation in a subgroup of patients with PFPS. One of the variables associated with success for this group included a side-to-side difference in hip IR >16 degrees which improves the probability of success from 45% to 80% (+ LR 4.5)(15).
In a recent study by Lowry et al, there was demonstrable improvement in pain and disability using manual therapy to the lower quarter, exercise, orthotics and taping in a series of patients with PFPS (17).
Herrington look at the benefits of utilizing open chain compared to closed chain strengthening in those with PFPS. While each group had improved short-term strength and function, there was no statistical different found between the groups. (13)
A randomized, controlled trial demonstrated less pain and better function in a group of female PFPS patients performing knee and hip strengthening, compared to a group with just knee strengthening and a control group (11).
Mascal et al. showed less pain and better function in two females with PFPs using a proximal and distal lower quarter strengthening program (18).
Clark et al. examined the efficacy of the individual components of physiotherapy in patients with anterior knee pain. Patients within a subgroup that also included exercise were significantly more likely to be discharged at three months than non-exercising patients (5).
Patellar taping has shown a clinically important change in chronic knee pain, but there have been conflicting results that could indicate a subgroup of patents might be most beneficial for this type of intervention (29).
Lescher, et al. developed a clinical prediction rule to determine which patients with PFPS might most likely benefit from using patellar taping in treatment. Two variables, (+) patellar tilt test and >5 degree tibia var, increased the probability of success from 52 to 83% (16).
In Derasari, et al., results showed an inferior glide of patella produced with taping increased patellofemoral joint surface contact area and lessened pressure across the joint during functional activities in patents with chronic PFPS. (9)
Altered foot positing that changes the knee mechanics and leads to increased pain with activity has been associated with PPFS. Using orthotics has been shown to be useful in improving the position of the foot and reducing knee pain for the short term (19).
In a randomized study that evaluated the effects of using custom orthotics to reduce knee pain, it was found that using custom orthotics was effective in decreasing pain and improve tolerance to running (14).
Wearing specialized foot orthotics alone was not superior to utilizing physical therapy, and there were no other improvements shown by adding orthotics to a patient’s physical therapy program (6).
There was support in a recent systematic review that using foot orthoses to prevent the first episode of overuse conditions showed no difference between custom and prefabricated foot orthoses. There was insufficient evidence to recommend foot orthoses for the treatment of lower limb overuse conditions (23).
Are you suffering from PFPS?
Those with anterior knee pain show noted improvements in pain and in disability when they have worked with a licensed Physical Therapist with advanced training in manual therapy and exercise program development. Interested in learning more? Contact Total Motion Physical Therapy today.
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