Download Patellafemoral Pain

Patellofemoral Pain
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Objectives
1.
2.
3.
4.
Understand the anatomy of the patellofemoral joint
Learn 3 causes of PFPS
Understand the muscular imbalances that lead to PFPS
Understand how the ankle, knee and hip effect patella
tracking
5.
Design/ Follow a rehabilitation program to safely
return the athlete to sport
What is Patellofemoral Pain??
• Anterior knee pain resulting from physical
and biomechanical changes in the
patellofemoral joint
• Pain occurs with activity, prolonged sitting
and increases with ascending/descending
stairs
• Classified as overuse or overload injury
The Knee
The bony anatomy consists of the distal
femur with its two condyles, the proximal
tibia with its two tibial plateaus and the
sesamoid bone in the quadriceps tendon,
the patella.
Knee Anatomy
Patellofemoral Joint
• The patella is a sesamoid bone in the quadriceps tendon
• It articulates with the intercondylar (trochlear) groove on the anterior
aspect of the distal portion of the femur
• The patella tendon inserts on the tibia at the tibial tuberosity
The Patella
• The patella moves superior, inferior, tilts and rotates as the knee
flexes and extends. This is referred to as tracking.
• As the knee flexes the patella slides down in the trochlear groove and
slides up as the knee extends
• The patella also tilts medially and laterally and internally and
externally rotates
• The posterior surface of the patella contacts the femur at various
points and is composed of facets designed to contact at specific
points during flexion and extension
• Tracking is controlled by muscle contraction to ensure appropriate
movement of the patella in the trochlear groove
Patella Tracking
• Improper patella tracking is thought to be one of the causes
of patella femoral pain syndrome
• Maltracking of the patella occurs when the patella no longer
remains centered in the trochlear groove,
• Abnormal biomechanics results in increased pressure on the
patellar joint surface.
• Repetitive maltracking causes abnormalities within the
articular cartilage, chronic inflammation and pain
Forces effecting patella tracking
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2.
3.
Q-angle
Pes Planus (pronation)
Muscular Imbalances
Q angle
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Angle between rectus femoris and
patella tendon. Formed by
measuring from ASIS to middle of
the patella and from mid-patella to
tibial tubercle
Normal angle is 10* in males, 15-20
in females
Increased angle results in lateral
patella tracking
Causes of increased Q-angle: genu
valgus, internal rotation of the femur
and a wide pelvis
Pes Planus
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“Flat foot” “over-pronation”
Causes a compensatory internal
rotaion of the tibia or femur
Results in increased Q-angle and
increased lateral patella tracking
Muscular Imbalances
• Vastus medialis obliqus(part of the
quadriceps) weakness
• Tight Iliotibial band
• Tight Hamstrings
• Weak Hip abductors
• Tight Hip flexors
• Tight Plantarflexors
Muscular Imbalances
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Weakness of the VMO allows the patella to track too far laterally
A tight iliotibial band places excessive lateral force on the patella and can
also externally rotate the tibia, resulting in excessive lateral tracking of the
patella
Tight hamstrings place more posterior force on the knee, causing pressure
between the patella and femur to increase
Abductor (gluteus medius) strengthening helps to stabilize the pelvis. of the
hip external Weak abductors results in compensatory foot pronation;
Tight calves can lead to compensatory foot pronation and, like tight
hamstrings, can increase the posterior force on the knee
Forces controlling patella
tracking
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Recognition
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Diffuse anterior knee pain
Edema
Crepitus
+ movie –goer’s sign ( pain with prolonged
sitting)
Recognition
• X-rays can be taken to rule out the
presence of a fracture or Osgood-Schlatters
• MRI should be taken to rule out a ligament
or meniscus injury.
Evaluation
It is important to keep in mind there is no
traumatic cause!
Evaluating for PFPS involves lower
extremity screening for the presence of
biomechanical deficiences in strength,
ROM and patella tracking.
The cause of the pain could be from the hip,
knee or ankle.
Evaluation
Ankle Assessment:
Does the athlete excessively pronate?
Does the athlete have tight gastrocs?
Evaluation
Knee Assessment:
Assess patella alignment for a “squinting” position. In standing, the patella will
look turned in.
“Special Tests”
1.
Clarke sign: The athlete is sitting with knee extended, press down
proximal to the top of the patella and ask the athlete to contract the
quadriceps as you press down. Positive test= pain in the patella and
unable to hold the contraction
2.
Patella Compression Test: The athlete sits with a towel rolled under the
knee to position in 20* flexion. Press down on the patella. Positive test =
pain in patella.
Evaluation
Hip Assessment:
1.
2.
Thomas test: Measures hip flexor flexibility
Ober Test: Measures ITB flexibility
Rehabilitation
1.
2.
Manage pain and inflammation: rest from painful activities, ice
Strengthen weak muscles:
1.
Strengthen to VMO to decrease patella lateral tracking
This is achieved through hip adduction exercises, quadriceps isometrics
2.
Strengthen hip musculature to decrease patella lateral tracking
This is achieved through glute strengthening exercises
3. Stretch hip flexors, ITB, hamstrings and gastrocs
Rehabilitation
Restore the biomechanical abnormalities:
Lower extremity strengthening exercises to strengthen the hip and
quads include:
Step-ups
Step-downs
Squats
Lunges
All exercises should be pain free and done with proper form. A sign of
weakness is allowing the femurs to internally rotate and knees to
come too far forward over the toes.
Rehabilitation
• Please see attached word document for
exercises
Return to play
The athlete should expect approximately 6 weeks of
physical therapy.
Once the athlete has no knee pain with normal activity, he or
she can return to sport.
Prevention
• Recognize signs of lower extremity
weakness and tightness
• Promote calf stretching, hamstring
stretching, hip stretching.
References
1.
2.
Tyler Timothy, Stephan Nicholas, Michael Mullaney, Malachy McHugh.
" The role of hip muscle function in the treatment of patellofemoral pain
syndrome” The American Journal of Sports Medicine. (2006) 34 (4)630635.
Mark S. Juhn. “Patellofemoral Pain Syndrom: A review and guidelines for
treatment” The American Family Physician. (1999)
3.
Carrie Halli, Lori Brody (2005).Therapeutic Exercise; moving
toward function. New York: Lippincott williams & Wilkins
4.
Web site:www.med.umich.edu/1libr/guides/knee/kneeart.htm