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Patellofemoral Pain Syndrome

 

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Differential Diagnosis and Treatment of Patellofemoral Pain Syndrome

Developed by: Patrick McNamara

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Background

While at UNC I have worked in a sports medicine clinic on a military base as well as the campus recreation gym as a personal trainer. I started noticing a large proportion of my patients and clients had insidious onset knee pain, which had lasted for years in some cases. For some, their pain was so severe that it markedly changed their lifestyle and reduced their activity levels. Through the grapevine I had heard that quadriceps strengthening was the best option for individuals with patellofemoral pain syndrome (PFPS), though this seemed odd to me as this was often a pain provoker for the patients and clients I have had. In class and in clinic I had seen treatments with McConnell taping and orthotics, but I felt there may be some patients that would benefit from one or the other depending on their presentation. I saw a shotgun approach (throw everything you have at it) being taken towards treating PFPS and thought the literature may help focus our efforts as clinicians. My Capstone project was designed to give clinicians and students a toolbox that would refine their approach to treating PFPS.

 

Overview and Purpose

Patellofemoral pain syndrome is considered a diagnosis of exclusion for insidious onset retropatellar and/or anterior knee pain. (1) Some authors estimate that up to 25% of individuals seeking physical therapy for knee pain will be diagnosed with PFPS. (2) Individuals often complain of pain with functional and athletic activities such as: squatting, ascending/descending stairs, prolonged sitting, jumping, etc. (1) While a prevailing theory has long been that PFPS is caused by abnormal patellar tracking, recent evidence is suggesting other factors may be pertinent to the pathomechanics influencing the onset of symptoms. (1) In a rather famous and disturbing study Dr. Scott Dye underwent arthroscopic palpation of knee structures without anesthesia, and found that the fat pad, anterior synovium, and joint capsule were extraordinarily painful when compressed. (3) Posterior hip weakness, particularly of the hip extensors, abductors, and external rotators is a common theme among patients presenting to PT clinics. Weakness of these muscle groups would lead to adduction and internal rotation of the femur, which could lead to abnormal patellar compressive forces in and around the knee joint. (1,4-8)

Successful treatments have focused on the entire kinetic chain including stretching tight soft tissues (triceps surae, hamstrings, hip flexors, IT band), strengthening hip musculature (external rotators, extensors, and abductors), as well as trunkal stability and endurance. (6,9) However, it appears that incorporating multiple treatment techniques may be more beneficial for successful resolution of the pain episode. (10) Lumbopelvic manipulations, orthotics, and/or taping may be indicated and provide immediate relief when applied appropriately. Clinical prediction rules have been established to determine individuals most likely to benefit from these techniques based upon their clinical presentation. (11-13)

This project was designed to help clinicians focus their interventions, and provide evidence for alternative treatment techniques if one approach is not eliciting the desired response. I incorporated case studies at the end of the presentation to provide ideas for timelines and progressions of treatments. I also compared taping alone to exercise or a combination of the two for my Critically Appraised Topic in the fall of 2014 for my Evidence Based Practice course.

Products

  1. In order to convey the current literature in a relatively concise fashion I created a Powerpoint (PatelloFemoral Pain Syndrome) presentation to walk through diagnostics/assessments, outcome measures, and different treatment approaches for PFPS.
  2. I also created a YouTube channel (https://www.youtube.com/playlist?list=PLcGyWKr297nHxr-l_iERLmiq60GYo3zl2)  to provide visual and verbal feedback for exercises. Some of these exercises will be important in home exercise programs, while others are more appropriate for clinic. I will continue to add exercises to the channel over time. You can select different topics by looking at the “tag” that the video is listed under. Currently I have made a “PFPS exercises” tab for this project.
  3. In the fall of 2014 I created a Critically Appraised Topic (McNamara_CAT) addressing the question “For a recreational runner with chronic unilateral patellofemoral pain syndrome, is knee and hip musculature strengthening more effective when compared to McConnell taping in decreasing patient-reported pain and increasing patient-reported function at 1-year follow-up?”

Evaluation

Feedback from my committee members focused primarily on developing exercise progressions that can be used both in the clinic and for a home exercise program. To this end, I have incorporated several ideas both with and without equipment onto the above listed YouTube site as well as images on the PowerPoint. I have also created a feedback form (Capstone Questionnaire) for the presentation, which includes questions for how clinicians can use the information provided to change their clinical practice.

Acknowledgements

This project was a real joy to complete as I was able to discuss physical therapy topics with current clinicians and students alike. I would like to thank Nick Mang for his stellar camera work and Sabina and Tyler Beckler for their feedback on my powerpoint. Jen Anderson and Tyler Goode were my committee members and provided positive support and critical evaluation of the project, and helped guide me to the finished product. Thanks to Mike Gross for his input on the presentation as well, and how PFPS can develop and progress.

References

  1. Robinson R., Nee R. Analysis of Hip Strength in Females Seeking Physical Therapy Treatment for Unilateral Patellofemoral Pain Syndrome. Journal of Orthopaedic & Sports Physical Therapy. (2007) 37(5): 232-238
  2. Devereaux MD, Lachmann SM. Patello-femoral arthralgia in athletes attending a Sports Injury Clinic. Br J Sports Med. 1984;18:18-21.
  3. Dye S., Vaupel G., Dye C. Conscious neurosensory mapping of the internal structures of the human knee without intraarticular anesthesia. (1998) The American Journal of Sports Medicine. 26(6): 773-777
  4. Piva S., Goodnite E., Childs J. Strength around the hip and flexibility of soft tissues in individuals with and without patellofemoral pain syndrome. (2005) J Orthop Sports Phys Ther. 35: 793-801
  5. Tyler T., Nicholas S., Mullaney M., et al. The Role of Hip Muscle Function in the treatment of Patellofemoral Pain Syndrome. (2006) The American Journal of Sports Medicine. 34(4): 630- 636
  6. Dolak K., Silkman C., McKeon J., et al. Hip strengthening prior to functional exercises reduces pain sooner than quadriceps strengthening in females with Patellofemoral Pain Syndrome: A randomized clinical trial. (2011) Journal of Orthopaedic & Sports Physical Therapy. 41(8): 560-570
  7. Bolgla L., Malone T., Umberger B., Uhl T. Hip strength and hip and knee kinematics during stair descent in females with and without patellofemoral pain syndrome. Journal of Orthopaedic & Sports Physical Therapy. (2008) 38(1): 12-18
  8. Ireland M., Willson J., Ballantyne B., Davis I. Hip strength in females with and without patellofemoral pain. Journal of Orthopaedic & Sports Physical Therapy. (2003) 33(11): 671-676
  9. Mascal C., Landel R., Powers C. Management of patellofemoral pain targeting hip, pelvis, and trunk muscle function: 2 case reports. (2003) J Orthop Sports Phys Ther. 33(11): 647-659
  10. Crossley K., Dip G., Bennell K., et al. Physical Therapy for Patellofemoral Pain: A randomized, double-blinded, placebo-controlled trial. (2002) The American Journal of Sports Medicine. 30(6): 857-865
  11. Vicenzino B., Collins N., Cleland J., et al. A clinical prediction rule for identifying patients with patellofemoral pain who are likely to benefit from foot orthotics: a preliminary determination. (2010) Br J Sports Med. 44: 862-866
  12. Iverson C., Sutlive T., Crowell M., et al. Lumbopelvic manipulation for the treatment of patients with patellofemoral pain syndrome: development of a clinical prediction rule. (2008) J Orthop Sports Ther. 38(6): 297-312
  13. Lesher J., Sutlive T., Miller G., et al. Development of a clinical prediction rule for classifying patients with patellofemoral pain syndrome who respond to patellar taping. (2006) J Orthop Sports Phys Ther. 36(11): 854-864

4 Responses to “Patellofemoral Pain Syndrome”

  1. Patrick McNamara

    Mike G., to clarify a few points initially for point 1 – from a literature viewpoint the vast majority of studies are retrospective OR utilizing patients that already have PFPS. Since these studies were retrospective, we are unable to draw true conclusions of whether weakness is a symptom or a cause of PFPS. A few studies that looked prospectively found that hip abductor eccentric weakness was a consistent risk factor for PFPS. We can also look at studies that strengthen weak muscle groups, and see if the individuals have reduced pain after documented strengthening. One study was done by Boling et al., that targeted quadriceps and hip musculature strengthening. Significant reductions in pain were noted around 5 weeks. However, VMO:VL timing also normalized so again it is hard to say whether strengthening or normalized VMO:VL timing led to reduced pain. Lankhorst et al. found that females with longer symptom durations (over 6 months) had better outcomes with strengthening exercises.

    Regarding point #2, I did not find any studies mentioning retinacular structures, though in my limited experience I have found these to be tight. I will continue to search for articles that measure this and the response noted if stretching was applied.

    Regarding #4, I know you didn’t get to listen to my presentation — my opening slide I show a picture of my family. We are all McNamaras, but all unique. I compare that to PFPS patients, the complains may be the same (my knee hurts with squatting etc.) but there are underlying differences. Regarding point #5, my strategy is to examine strength, soft tissue extensibility, what the individual looks like doing functional movements (squats, step-ups, etc.), and what their foot structure/gait mechanics look like. Since it is a complex disorder with a litany of potentially causative factors, it is critical to examine a large number of items.

    For #6, it seems that studies like what Crossley et al., conducted with a multitude of interventions (taping, stretching, strengthening) as well as biofeedback for the VMO:VL and hip musculature strengthening had good results. Likewise Whittingham et al. found taping and exercise to be more beneficial than either singly. Powers had a case series where he provided multiple interventions as well with excellent success.

    Reply

  2. Michael Gross

    Pat- Good work on your capstone. The Power Point and the CAT were nice end-products. I did not have the advantage of hearing you deliver the Power Point, but based on what I could see, I have the following points of feedback for you as well as questions:
    1. Is the weakness that is seen with PFPS patients a cause or effect of the condition?
    2. I did not see you talking at all about patellofemoral hypomobility from tightness in the retinacular tissues and the contribution of this to their pain secondary to increased contact pressures at the joint.
    3. Why would one want to do a lumbar manipulation for a PFPS patient? What would indicate that this was necessary, and how would it have influence on patellofemoral biomechanics?
    4. If you have ever read any of the literature by Chris Powers and others who have written sensibly on this topic, I would hope that you would come away with the conclusion that every patient who has this condition has a unique set of causative agents that are driving the pathology. This means that a comprehensive evaluation is necessary to uncover this unique set of “drivers” so that an effective intervention plan can be instituted. I did not get this impression, at all, from your power point.
    5. Building on the last point, I hope you have come away with an evaluation plan for patients who you will see who have PFPS.
    6. Finally, relative to point #4, since each patient with PFPS has a rather unique set of drivers for the pathology, most researchers have a very difficult time demonstrating the efficacy of a single intervention where the only inclusion criterion for the study is the presence of PFPS. If, for example, the study design is to test the efficacy of foot orthoses for patients who have pronounced foot pronation and PFPS, then the likelihood of demonstrating efficacy may be improved. This is how we should operate in the clinic, right?

    All in all, this was a good project for you, and I think you came away with lots of good information. Best regards, Mike

    Reply

  3. Pat McNamara

    Hey Mike it will take a few posts for me to answer everything, but I think the important parts of a physical exam are easier to address.

    Take your MMTs first, they’re non-painful and give you a sense of isolated movements. If you have core “strength” assessments you like, early on is a good time to check. After that would be your special tests for tightness (Ober’s, 90-90, Ely’s) and general hip and L-spine mobility in prone. I’d next check balance and gait. If running is painful, you may eventually want to examine their gait in running… but remember it is likely going to be painful.

    Since kinematics are an essential part of the condition, watch them squat (double and single leg… with and without heel lift). I would also look at their trunk angle and knee relative to the ankle joint while going up/down stairs. Anything you can do to decrease the compressive stress of the patella on the fat pad/synovium/etc. will make them sing your praises (and likely result in them bringing you cookies). See if changing their movement pattern, changes their pain levels. It’s critical to show that you can change their pain levels.

    If they meet the CPR for the lumbopelvic manipulation and you can perform one, you absolutely do it so long as there are no contraindications. I’d honestly just put tape on everyone, it’s cheap and can be immediately effective for quite a few people.

    Otherwise in my experience, I would try exercises like bridges, hip thrusts, and abductions/clamshells to see if they can even activate their glutes. I concluded my presentation with an excellent case study by Chris Powers (the PFPS guru) which I would highly recommend.

    Reply

  4. Michael Irr

    Hi Pat,

    Awesome job on your Capstone! I liked the depth of evidence in your presentation. It certainly doesn’t seem like you missed anything! Your videos were good as well – I can see you’ve been working on your form since our days of lifting during 1st year! But in all seriousness, they were helpful in giving me ideas for my patients down the road.

    Questions I have related to assessment for PFPS: If you were going to perform a physical exam for an athlete with PFPS, what would be items I should ask during the subjective history to fully understand what’s going on with the patient? Also, is there a specific order for the objective physical examination you recommend? Along with that, are there specific impairment-level outcome measures you think are particularly important that may provide the best information?

    Also, I can see how the hip is very important to consider for PFPS and you did a great job of linking it to the condition. Is there any evidence about the foot and ankle being the cause for PFPS in athletic populations? If so, how would you approach or treat that patient?

    Again, great work on your capstone and congrats on putting together a solid project. I can tell you put a lot of time into searching for evidence and synthesizing the information.

    Take care,
    Mike

    Reply

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