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Patellofemoral Rehabilitation: An

Evidence Based Approach

Stephen LaPlante PT, ATC

Objectives

• Review research regarding patellofemoral pain

and rehabilitation.

• Discuss evaluation techniques to determine

the cause of patellar dysfunction.

• Discuss general rehabilitation principles

regarding patellar rehab.

• What we won’t be discussing

What are the “best” exercises

• Mulifactorial

• Can’t just assume that strengthening will fix the problem

• Pain can either increase or decrease muscle activation.

It is related to the task being performed

-Cholewicki, Van Vliet 2002

• Patellofemoral pain is a common source of anterior knee pain among young physically active populations.

• Affects 1 in 4 athletes, with more than 70% being between 16 and 25 years of age.

-Pappas et al. 2012

• No general consensus to the causes of patellofemoral pain– No agreement on how PFP should be treated

- Powers 2003

• The source of the pain (the knee) is not always the cause– Source of sx’s may be intrinsic to the knee

– Cause of sx’s may be extrinsic to the knee

– These extrinsic factors may magnify a minor intrinsic problem of the knee

“The victim screams but the

culprit remains silent”

• For this reason, a proper evaluation needs to be performed to determine the cause

• This includes looking at the body as a whole

• Need to determine if it’s a mobility or stability or combination of the two.

• Is it a “top down” or “bottom up” problem or a combination of the two

• Multiple evaluation tools available. Need to be consistent and thorough.

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Patellar Anatomy

• Largest Sesamoid bone

• Multiple Facets

– Medial facet

• separate “odd” facet

• “odd” facet oriented

vertically

– Lateral facet

• Larger

• Concave longitudinally

and transversely

• Patellar instability may be

– Lateral or Medial

– Subluxation or dislocation

– traumatic or atraumatic

– congenital

Patellofemoral Biomechanics

• Patella provides

mechanical advantage

during knee extension.

– Distributes compressive

stress on the femur by

increasing contact

between patellar tendon

– Protects patellar tendon

against flexion

Patellofemoral Biomechanics

�In full extension, there is little to no contact between patella and femur

�Inf. Margin of patella and trochlea articulation begins at 10-20º of knee flex

�As knee flexes the patellofemoral joint contact moves proximally along patella

-@ 60º of flexion middle facets of patella articulate with trochlea

-@ 90º of flexion superior facets of patella articulate with trochlea

Patellofemoral Pain

• Mutifactorial– Quadriceps flexibility

– Hamstring flexibility

– Gastroc/Soleus flexibility

– IT band flexibility

– Q Angle

– Patellar Position

– Hip Strength

– Core Stability

– Foot pronation

– Limited Ankle DF mobility

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Flexibility

• Witvrouw et al. concluded that decreased quadriceps and gastrocnemius flexibility was significantly associated with PFPS, HS flexibility was not.

Am J Sports med 2000

• Patients with PFPS demonstrated significantly less flexibility of the HS, quadriceps, gastrocnemius and soleus muscles compared to healthy control subjects.

Piva et al. 2005

• Decreased Quadriceps Flexibility

– Leads to � patellofemoral stress

– Anterior pelvic tilt

– Limits HS activation

– Limits Gluteal Activation

• Hamstring tightness

– Leads to � patellofemoral stress 2° � knee

flexion

– Limits knee extension and quadriceps activity

• Increased patellofemoral joint reaction forces

– Leads to posterior pelvic tilt

– Is it really an issue with HS being tight?

• Can your athlete touch their toes?

• If not, find out why

• Gastroc/Soleus Tightness

– Limited ankle DF mobility will transfer up the

kinetic chain

– Often see a toe out or “pronated” foot

– Increased tibial IR to gain additional ROM for

terminal stance phase of gait

– Increased knee valgus to compensate

IT band tightness

• Theorized that this may pull the patella laterally and increase the stress over the patellofemoraljoint

• No conclusive evidence to support thisPiva et al. 2005

• What we do know– Resists femoral adduction

– Associated with• Genu varum

• Weak hip abductors

Strength

• Knee extension isometric strength as a

predictor for PFPS when normalized to body

weight.

• Decreased muscle strength for knee flexion

and hip abduction were also associated with

PFPS

-Boling, Am J sports med 2009

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Strength

• Patients with PFPS had significantly weaker

hip external rotators and abductors compared

to control subjects.Ireland et al. 2003

• No differences between hip ER and abduction

strength between controlsPiva et al. 2005

Compared to controls, males and females with

PFPS showed increased ipsilateral trunk lean,

contralateral pelvic drop, hip adduction, and

knee abduction during a single-leg squat.

Is the VMO to blame?

• Lieb et al. -1968

– VMO fibers oriented at 55° from the longitudinal axis of the femur.

– Primary restraint to lateral subluxation of the patella

– Insufficient balance of VL and VMO has long been considered a contribution to developing PFPS.

– Suggested that the VMO was able to counterbalance the pull of the much larger VL due to the discrepancy in mechanical advantages

VMO/VL timing

• Cowan et al. found that subjects with PFPS

have an imbalance of timing between the

VMO/VL.

• McConnell and colleagues have shown that

patella taping and VMO strengthening

through combined knee adduction/extension

is beneficial

– Evidence is inconsistent to support this

9 different ex. Found that vastus medialis oblique muscle cannot be significantly isolated during these exercises.

• No significant difference in VMO/VL EMG between control and PFPS.– LaPrade 1998, Souza 1991, Cerny 1995, Boucher 1992

• EMG biofeedback to retrain the VMO is not supported in the literature

-Collins 2012

VMO Atrophy

• Theory is that the VMO atrophies more

compared to the rest of the quadriceps

muscles following surgery.

• Giles et al. found atrophy of all portions of the

quadriceps with no selective atrophy of the

VMO in subjects with PFPS

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VMO

• Can the VMO be isolated?– During 22 exercises for the

quadriceps, VMO activity was not higher compared to VL Cerny 1995

– In a RCT, Song et al. found no evidence that the VMO can be isolated

– Andersen et al. found that no selective activation of VM over VL.

– Grabiner et al. found that it would take approx 60% of MVC to stimulate VMO hypertrophy

• When we are performing “VMO strengthening” we are really working on the entire quad.

• We should stop “hammering” the concept of a weak VMO into our athlete’s head

Q- Angle

• The relationship between PFPS and Q-angle has not been consistent.

• Typically taken statically. The contribution of abnormal segmental motions and muscle activation may not be appreciated during dynamic tasks.

• An increase in Q-angle can result in increased lateral facet pressure as the patella is being forced against the lateral femoral condyle.

-Powers

The Influence of Altered Lower-Extremity Kinematics on Patellofemoral Joint

Dysfunction: A Theoretical Perspective

Christopher M. Powers, PT, PhD1

• FIGURE 1. (A) The Q angle is measured as the angle formed by the intersection of the line drawn from the anterior superior iliac spine to the midpoint of the patella and a proximal extension of the line drawn from the tibial tubercle to the midpoint of the patella. Normal alignment of the tibia and femur results in an offset in the resultant quadriceps force vector (proximal) and the patellar tendon force vector (distal), creating a lateral vector acting on the patella; (B) tibia internal rotation decreases the Q angle and the magnitude of the lateral vector acting on the patella; (C) femoral internal rotation increases the Q angle and the lateral force acting on the patella; (D) knee valgus increases the Q angle and the lateral force acting on the patella.

Q-angle

Powers et al. 2003

• Can be affected distally by the rotation of the tibia

• Can be affected proximally by the rotation of the femur

• Knee valgus angle can also increase knee valgus

• Powers et al. found that the primary contributor to lateral patellar tilt and displacement was femoral IR and not patellar motion.

Biomechanics during landing

• Decreased peak knee flexion during landing as

a predictor for PFPS.Boling et al. 2009

• Knee valgus moment at initial contact during

landing was predictive of PFPS.Myer et al. 2010

Boling et al. concluded that strengthening of the quadriceps and hamstrings

along with teaching proper technique for performing dynamic tasks are all

components of an effective injury prevention program.

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Rehabilitation of PF disorders

•Weight bearing exercises have shown to be effective in short and long term outcomes in decreasing patellofemoral pain and enhancing cruciate ligament rehab and return to sport •(Boling, et al., 2006; Heintjes, et al., 2003; Natri, et al., 1998; Witvrouw, et al., 2004; Witvrouw, et al., 2000; Shelbourne & Nitz, 1990)

•However, patellofemoral and tibiofemoral joint loading has been shown to vary according to exercise and technique variations.•(Escamilla et al. 1998; Escamilla et al, 2001; Escamilla et al, 2008; Wilk et al., 1996

• Patellofemoral force and stress increased with knee flexion, and was great in the wall squat exercises compared to the one leg squat between 50-90° knee flexion during the squat ascent

• There were no significant differences in patellofemoral force and stress between the two wall squat exercises

• A more functional knee flexion range between 0-50° may be appropriate during early phases of patellofemoral rehabilitation due to lower force and stress magnitudes compared to higher knee angles

• During lunging and squatting, excessive anterior knee translation (> 2-3 inches) beyond the toes should be discouraged due to higher patellofemoralloading

Treating PFPS

• Have to do a thorough evaluation

• One in which we can determine if it’s an issue with mobility/flexibility, strength/stability, neuromuscular control, or a combination of all of these.

• We can’t just assume.

• Have to asses not guess.

• Examples

SFMA, FMS, DMA, Y-balance test

Conclusion

1) Assess ankle, hip, thoracic mobility

2) Assess foot, knee, hip and core strength

3) Assess functional movement patterns

4) Assess for asymmetries

5) Treat mobility issues first

6) Don’t load a dysfunctional movement pattern

7) Must be cleared to return to sport through a functional testing program

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