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Patellofemoral Pain Syndrome

///Patellofemoral Pain Syndrome
Patellofemoral Pain Syndrome2019-08-26T14:03:13-05:00

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?

patellofemoral-1-webManual Therapy

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).

 

Exercise

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).

patellofemoral-2-web

Taping

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)

Using Orthotics

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.

References

  1. Bizzine, M. et al. A systematic review of the quality of randomized controlled trials for patellofemoral pain syndrome. JOSPT. 2003; 33(1):4-20.
  2. Bolga, L. et al. An update for the conservative management of patellofemoral pain syndrome: A systematic review of the literature. The International Journal of Sports Physical Therapy. 2011; 6(2):112-125.
  3. Boling, M. Gender differences in the incidence and prevalence of patellofemoral pain syndrome. Scann J Med Sci Sports. 2010; 20(5):720-725.
  4. Brantingham, J. Manipulative therapy for lower extremity conditions. Expansion of iterative review. Journal of Manipulative and Physiological Therapeutics. 2009; 32(1):52-71.
  5. Clark D, Downing N. Mitchell J, et al. Physiotherapy for anterior knee pain: a randomized controlled trial. Ann Rheum Dis. 2000;59: 700-704
  6. Collins N, Crossley K, Beller E, Darnell R, McPoil T, Vincenzino B, et al. Foot orthoses and physiotherapy in the treatment of patellofemoral pain syndrome: randomized clinical trials. BR J Sports Med 2009; 42(3):163-168.
  7. Cook, C. et al. Best tests/clinical findings for screening and diagnosis of patellofemoral pain syndrome: a systematic review. Physiotherapy. 2001;1-8.
  8. Creighton, D. et al. Use of Anterior Tibial Translation in the Management of Patellofemiral Pain Syndrome in Older Patients: A Case Series. J Man Manip Ther. 2007; 15(4): 216-224
  9. Crossley, K. et al. Physical Therapy improves knee flexion during stair ambulating in patellofemoral pain. Med Sci Sp Ex. 2005; 37:176-183.
  10. Derasari A, et al. McDoconnell taping shifts the patella inferiorly in patients with patellofemoral pain: a dynamic magnetic resonance imaging study. Phys Ther. 2010; 90(3):411-419
  11. Fukuda, T. et al. Short-Term Effects of Hip Abductors and Lateral Rotator Strengthening in Females with Patellofemoral Pain Syndrome: A Randomized Controlled Clinical Trial. JOSPT. 2010; 40(11):736-742
  12. Gross MT, Foxworth JL. The role of foot orthoses as an intervention for patellofemoral pain. JOSPT. 2003; 33:661-670.
  13. Herrington L, Al-Sherhi A. A controlled trial of weight bearing versus non-weight-bearing exercises for patellofemoral pain. JOSPT. 2007;37:155-160.
  14. HIrschmuller A, Baur H, Muller S, Helwig P, Dickhuth HH, Mayer F, et al. Clinical effectiveness of customized sport shoe orthoses for overuse injuries in runners: a randomized controlled study. Br J Sports Med 2001; 45(12):959-965
  15. Iverson CA, et al. Lumbopelvic manipulation for the treatment of patients with patellofemoral pain syndrome who respond to patellar taping. J Orthop Sports Phys Ther. 2006; 36:854-866.
  16. Lesher J, et al. A clinical prediction rule for classifying patients with patellofemoral pain syndrome who respond to patellar taping. J Orhop Sports Phys Ther. 2006; 36:854-866.
  17. Lowry, C. et al. Management of Patellofemoral Pain Syndrome Using a Multimodal Approach: A Case Series. JOSPT. 2008; 38(11):691-702
  18. Mascal CL, Landel R, Powers C. Management of patellofemoral pain targeting hip, pelvis, and trunk muscle function: 2 case reports. JOSPT. 2003; 33:647-660.
  19. Munuera PV, Mazoteras-Pardo, R. Benefits of custom-made foot othorses in treating patellofemoral pain. Prostet Orthot Int 2011; 35(4):342-349.
  20. Nijs, J. et al. Diagnostic value of five clinical tests in patellofemoral pain syndrome. Man Ther. 2006; 11:69-77
  21. Powers, C. et al. Patellofemoral kinematics during weight-bearing and non-weight-bearing knee extension in persons with lateral subluxation of the patella: a preliminary study. JOSPT. 2003; 33:677-685.
  22. Rabin, A. et al. Measures of Range of Motion and Strength Among Healthy Women with Differing Quality of Lower Extremely Movement During the Lateral Step-Down Test. JOSPT. 2010; 40(12):792-800
  23. Souza, R. eta l. Differences in Hip Knematics, Muscle Strength, and Muscle Activation Between Subjects With and Without Patellofemoral Pain. JOSPT. 2009; 39(1):12-19.
  24. Suter, E. et al. Conservative lower back treatment reduces inhibition n knee extensor muscles: a randomized controlled trial. J Manipulative Physiol Ther. 2000; 23;76-80.
  25. Suter, E. et al. Decrease in quadriceps inhibition in knee extensor muscle : a randomized controlled trial. J Maniputalive Physiol ther. 1999; 22:149-153.
  26. Taunton, J. et al. A Retrospective case control analysis on 2002 running injuries. Br J Sports Med 2002; 39:95-101.
  27. Tiggelen D.V. et al. Effect of bracing on the prevention of anterior knee pain – a prospective randomized study.
  28. Warden S. J et al. Patellar taping and bracing for the Treatment of Chronic Knee Pain: A Systematic review and Meta-Analysis. Arthritis and Thaumatology A Systematic review and Meta-Analysis. Arthritis and Rheumatology(Arthritis Case & Research). Vol. 59, NO.1, January 15, 2008, pp73-83. DOI 10, 1002/art.23242. 2008 American College of Rheumatology.
  29. Wilk KE, George JD, Mangine RE and Malone TR. Patellofemoral disorders: a classification system and clinical guidelines for nonoperative rehabilitation. Journal of Ortho and Sports Phys Ther. 1998; 28(5): 307-322