Musculoskeletal Case Study

Josh de Rooy Musculoskeletal Analysis, Prescription and Rehabilitation S00164793

Patello-Femoral Pain Syndrome – Clinical Review

Client

A 21 year old female who is a marathon runner has started experiencing knee pain around

the patella. She has recently changed her training location to an area with more hill climbs

and descents, and has increased her training from twice per week to 4-5 times per week to

prepare for a marathon.

Title/Condition:

Patello-Femoral Pain Syndrome

Differential Diagnosis:

With the main symptom of PFPS being pain around/posterior kneecap, this is also a

symptom similar to many other knee related injuries. These include:

Pes anserine bursitis

Articular cartilage injury

Iliotibial band syndrome

Osgood-Schlatter

Osteochondritis dissecans

Patellar instability/subluxation

Patellar stress fracture May have tenderness directly over patella

Patellar tendinopathy

Patellofemoral

Patellar tendinopathy

Plica synovialis

Prepatellar bursitis

Quadriceps tendinopathy

Sinding-Larsen-Johansson syndrome (Dixit, Difiori, Burton & mines, 2007)

1


Description:

Patello-femoral pain syndrome is a commonly suffered cause of knee pain, with high

prevalence in active adolescents, young adults and particularly woman (van Linschoten et

al., 2007). The patellofemoral joint consists of the patella and femoral trochlea, and relies on

medial and lateral forces to align the patella within the femur, called ‘patella tracking’.

Alterations in patella tracking causes rubbing of the articular cartilage that covers the

posterior patella against the femur, stimulating nociceptors within the joint, resulting in pain.

PFPS generally see’s pain reported as under and around the patella, and is exacerbated

upon loaded knee flexion and extension, alongside impaired lower limb functioning (Moyano

et al., 2013) Activities of daily life (ADL) which can be affected include: walking up and down

stairs (particularly down), jogging, sitting with knees flexed for prolonged periods of time,

squatting, and kneeling (Boling et al., 2010; Linschoten et al., 2012)

Forms of management differ between: resting until symptoms decrease, taping or bracing to

align the patella (for incorrect tracking), and exercise to correct gait biomechanics and

strengthen muscle weakness and imbalance, which are the suspected underlying issue

(Moyano et al., 2013)

Causes:

Although the pathology is not yet completely understood, there are many likely cause which

contribute to development of PFPS.

Slowed activation of Vastus Medialis Obliquus compared with vastus lateralis is

evident, an imbalance between medial and lateral stabilizers occurs and force

distribution at the joint is compromised (Boling et al., 2010). Frequent, high intensity

2


activity of malaligned extensor function causes increased irritation and debilitation, if

not treated, further degeneration and complications may occur (Fulkerson, 2002).

It is also evident that weak hip musculature, particularly gluteus medius, causes

increased internal rotation of the femur and valgus force at the knee, which combined

can cause an increased Q-angle, leading to further lateral maltracking of the patella

(Boling et al., 2010; Ireland, Wilson, Ballantine & Davis, 2003).

Risk factors:

Gender - difference in: q angle, internal rotation, hip adduction and knee valgus

(boling et al., 2010)

Lack of physical conditioning

Joint angles

Increased navicular drop

Increased patella mobility (Linschoten et al., 2012)

Slowed activation of VMO compared with VL

Decreased gastrocnemius flexibility

Compressive and shearing forces to under surface of patella

Excessive lateral pressure to patella (Lankhorst, Bierma-Zeinstra & Midelkoop,

2012)

Tight musculature and attachments

Weak hip abductors and external rotators

Overuse

Direct trauma (Dixit et al., 2007)

3


Examination

Subjective

Management: Has the client undertaken medical management in the past or

currently? Did this have any effect on knee pain?

Medication: Is the client taking any anti-inflammatories or similar pain management

medication?

Tests conducted: Has the client had any x-rays or imaging done?

Alternative treatment: Has the client experimented with alternative options such as

acupuncture or remedial massage? Or management such as bracing or icing, and

their benefit?

Previous treatment: Has the client undertaken physiotherapy or occupational

therapy for the current injury? Were these beneficial?

Aggravating/Alleviating factors: Does the client experience pain in certain

activities? E.g. running, stair climbing/descending, squatting or sitting with knee

flexion? How long until pain onset?

Chart: Ask client to circle/shade areas of pain on a body chart.

Nature of symptoms: Ask the patient to describe symptoms e.g. pain, stiffness,

feeling of giving way? Or uncommon: catching, swelling, and clicking.

VAS Pain Scale: On a scale of 0 – 10 (10 being severe) ask the client to rate their

pain best, worst, and currently, and occurences.

Patterns: Does the client experience symptoms at certain times of day? E.g. night,

morning, mid-day.

Sleep Problems: Does the client awake at night due to pain or discomfort? How

many times?

Other symptoms: Ensure it is noted any other symptoms that cause onset of pain or

unusual symptoms requiring medical attention.

4


Footwear: Does client wear old or un-supportive footwear?

Previous medical history – Notes previous knee conditions, comorbidities? List

previous conditions, and pain in places other than knee e.g. hip, ankle, and lower

back.

Functional problems: Note any ADLs which have been affected.

Objective

Gait abnormality: Observe clients lower limb alignment while walking, into to room

upon meeting and when asked .Identify excessive lateral tracking of patellar or

abnormal eversion of rear foot.

Joint mobility: Passively examine mobility and tracking of patella and tightness of

surrounding structures.

Palpate: Identify any atrophy, tone and activation at end point knee extension,

compared with vastus lateralis. Is there any tenderness of retinacula?

Posture: Examine trunk, pelvic, and lower limb alignment. Examine alignment of the

leg and knee and identify patella positioning and Q angle size, via goniometer.

Check for over pronation at the subtalar joint via navicular drop test.

Reflexes: Ensure standard reflex of calcaneal and patella tendons.

Strength: Assess knee, ankle, and hip musculature strength with comparison of

sides, via single-leg squat, step down test, which would have minimal medial rotation

at the hip or adduction.

Diagnostic Tests

5


“J-sign” test: Ask patient to actively extend knee while standing, starting in 90

degree flexion, watch for lateral patella movement at end-point extension.

Lateral pull test: Patient starting in supine, have them contract knee extensors,

observe patella movement (lateral = positive)

Patella glide test: Examine mobility of patella by manually moving in all 4 directions.

Patella tilt test: In supine, lift lateral patella border, if not horizontal, lateral

attachment are tight. Lift also the medial border to assess laxity (positive if tilt is

more than contralateral side).

Ober’s test – Assess tightness in ITB and TFL

Thomas test – Assess tightness in quadriceps and hip flexors.

Range of motion: Observe active and passive ROM of the knee, hip and ankle

joints, along with ITB, quadriceps, hamstring, and gastrocnemius flexibility.

(Tyler et al., 2006)

Functional Testing

Bilateral Squat – squat to 90o flexion – as many as possible in 30 seconds

Step Down – left and right, 8 inch box - as many as possible in 30 seconds (Louden

at al., 2002)

Desired Outcomes

• Decreased pain in ADL

• Increased strength of quadriceps

• Increased VMO strength, with improved activation patterns compared to vastus

lateralis

• Increased hip abductor and external rotation strength

6


• Increased flexibility of surrounding structures and joints

• Reduced excessive rearfoot eversion in gait

• Decreased pain with prolonged sitting

• Improved ability to participate in sports Improved ability to ascend and descend stairs

• Improved awareness/self-management of aggravating factors

Outcome measures:

• The self-administered patellofemoral pain severity scale

• Kujala self-administered questionnaire – improved score

• Manual muscles tests – Negative Ober’s and Thomas test

• Patient satisfaction

• VAS pain scale – reduced pain

• Goniometry – Increased ROM of the hip, knee and ankle joints, also muscles:

gastrocnemius, hamstrings, quadriceps and ITB.

Assessment / Plan

Overall Contraindications/Precautions

Avoid activities that cause excessive patellofemoral joint reaction forces.

Avoid excessive knee flexion for around 4-6 weeks of rehabilitation.

Reduced flexion ROM if pain occurs.

Prognosis

The prognosis of the client is determined based on history of injury and examination, which

will expose contributing factors to the condition. According to Kannus and Niittymaki et al.

(1994), atleast 70% can be rehabilitated with quadriceps strengthening, independent of age,

sex, biomechanical factors, and fitness level.

7


It depends on comorbidities, but a poor outlook will present if the aggravating factors are not

altered or reduced. Identification of these factors and correct treatment as early as possible

will have an improved prognosis, but a worse prognosis is seen with symptoms present for

over a year in duration, before treatment (Collins et al., 2010).

Other considerations:

- Activity modification

- Anti-inflammatory medication and modalities

- Patellar taping and bracing (Patellar taping/mobilization)

- Orthotic management for subtalar joint pronation

- Open kinetic chain exercises—avoid terminal extension

- Closed kinetic chain exercises—avoid excessive flexion

These factors apply especially in early treatment.

Treatment Summary

Each phase to be performed 3 times per week, pending pain.

Goals week 1-4: increase strength, flexibility, retrain quadriceps activation, introduce

balance.

Week 1-2:

- Swiss ball squat – 40 degree knee flexion (quadriceps, gluteal, hamstring strength)

- Isometric contractions of VMO - seated with knees at 90° flexion (quadriceps activation)

- Theraband front pull - standing on uninjured leg, extend thigh with flexed knee – repetitions

(Hip flexors)

- Theraband isometric hold - standing on uninjured leg extend thigh with flexed knee – resist

adduction (using abductors/external rotators)

- Single leg calf raise

8


Week 3-4:

- Wall slides – 40 degree knee flexion, with theraband around knees

- Mini Squat – 30 degree flexion

- Lateral step down – from 4 inch step

- Forward Lunges – onto 8 inch step with gentle push off.

- Single leg calf raise – on bosu ball

Goals week 5-8: increase functional strength, flexibility, quadriceps eccentric strength,

proprioception and balance training.

Week 5-6:

- Single Leg Mini Squat – 30 degree flexion.

- Lateral step down – from 6 inch step

- Side stepping – with theraband just below knees – slight knee flexion

- Forward Lunges – onto 8 inch step with regular push off.

- Single leg stance – catch and pass ball to partner, maintain balance (week 6 add bosu ball)

Week 7-8:

- Single Leg Squat – as deep as possible pain free.

- Side stepping – with theraband just below knees – slight knee flexion

- Forward lunges – as deep as possible, pain free.

- Straight leg, single leg deadlift – focus on hip and ankle stability.

- Single leg hopping (forward/back/side) – while catching and passing ball to partner.

After all sessions the following stretches will be performed:

- Standing quadriceps

- Seated hamstring

- Standing calf

- Figure 4 gluteal

- Foam roller on ITB and TFL

9


Weeks 1-4 passive, 4-8 active (Boling, Bolgla, Mattacola, Uhl, & Hosey, 2006; Fredericson

and Powers,2002)

Maintenance and Prevention

Once rehabilitation is successfully completed, it’s vital to maintain strength and endurance

in: hip abductors and external rotators for pelvic stability, and quadriceps for patellar

stabilization. All stretches included in the above program are to be performed atleast 3 times

per week (specifically after exercise), to maintain active and passive ROM, particularly within

gastrocnemius, ITB/TFL, and hamstrings.

Exercises include:

- Isometric theraband hold

- Single leg squat

- Side stepping with theraband around knees

10


References

Boling, M. C., Bolgla, L. A., Mattacola, C. G., Uhl, T. L., & Hosey, R. G. (2006). Outcomes of

a weight-bearing rehabilitation program for patients diagnosed with patellofemoral

pain syndrome. Archives of physical medicine and rehabilitation, 87(11), 1428-

1435.

Boling, M., Padua, D., Marshall, S., Guskiewicz, K., Pyne, S., & Beutler, A. (2010). Gender

differences in the incidence and prevalence of patellofemoral pain syndrome.

Scandinavian journal of medicine & science in sports, 20(5), 725-730.

Collins, N. J., Crossley, K. M., Darnell, R., & Vicenzino, B. (2010). Predictors of short and

long term outcome in patellofemoral pain syndrome: a prospective longitudinal

study. BMC musculoskeletal disorders, 11(1), 11.

Cowan, S. M., Bennell, K. L., Crossley, K. M., Hodges, P. W., & McConnell, J. (2002).

Physical therapy alters recruitment of the vasti in patellofemoral pain syndrome.

Medicine and science in sports and exercise, 34(12), 1879-1885.

Dixit, S., Difiori, J. P., Burton, M., & Mines, B. (2007). Management of patellofemoral pain

syndrome. American family physician, 75(2).

Fulkerson, J. P. (2002). Diagnosis and treatment of patients with patellofemoral pain. The

American journal of sports medicine, 30(3), 447-456.

Fredericson, M., & Powers, C. M. (2002). Practical management of patellofemoral pain.

Clinical Journal of Sport Medicine, 12(1), 36-38.

Ireland, M. L., Willson, J. D., Ballantyne, B. T., & Davis, I. M. (2003). Hip strength in females

with and without patellofemoral pain. Journal of orthopaedic & sports physical

therapy, 33(11), 671-676.

11


Kannus, P., & Niittymäki, S. (1994). Which factors predict outcome in the nonoperative

treatment of patellofemoral pain syndrome? A prospective follow-up study.

Medicine & Science in Sports & Exercise.

Lankhorst, N. E., Bierma-Zeinstra, S. M., & van Middelkoop, M. (2012). Risk factors for

patellofemoral pain syndrome: a systematic review. journal of orthopaedic & sports

physical therapy, 42(2), 81-A12.

Loudon, J. K., Wiesner, D., Goist-Foley, H. L., Asjes, C., & Loudon, K. L. (2002). Intrarater

reliability of functional performance tests for subjects with patellofemoral pain

syndrome. Journal of athletic training, 37(3), 256.

Moyano, F. R., Valenza, M. C., Martin, L. M., Caballero, Y. C., Gonzalez-Jimenez, E., &

Demet, G. V. (2013). Effectiveness of different exercises and stretching

physiotherapy on pain and movement in patellofemoral pain syndrome: a

randomized controlled trial. Clinical rehabilitation, 27(5), 409-417.

Tyler, T. F., Nicholas, S. J., Mullaney, M. J., & McHugh, M. P. (2006). The role of hip muscle

function in the treatment of patellofemoral pain syndrome. The American journal of

sports medicine, 34(4), 630-636.

van Linschoten, R., van Middelkoop, M., Berger, M. Y., Heintjes, E. M., Verhaar, J. A.,

Willemsen, S. P., ... & Bierma-Zeinstra, S. M. (2009). Supervised exercise therapy

versus usual care for patellofemoral pain syndrome: an open label randomised

controlled trial. BMJ: British Medical Journal, 339.

12

Documents

Musculoskeletal Case Study