Rehab of PFPS Thurs AM Conf 10/2010

Michael A. Shaffer

PT, ATC, OCS

Midterm/ ITBS Time

T/ F Questions

“Patellofemoral pain” is one of the most common musculoskeletal diagnoses.

Patellofemoral pain is a complex, multifactorial problem.

T/ F Questions

Patellofemoral pain responds reliably well to rehabilitation.

Certified Athletic Trainers and Physical Therapists provide rehabilitation.

T/ F Questions

The ideal rehabilitation program for a complex, multifactorial problem like patellofemoral pain is hard to define.

“Genius” is hard to define.

Therefore…..

Athletic Trainers

and

Physical Therapists

are geniuses!!

Thank you.

The evolution of a clinician….. “So what is our

patellofemoral pain protocol?”

“We don’t have ONE. We’ll never have one. No two PFPS rehabilitations are the same.”

Uh oh, first sign of trouble …..

Midterm time…..M/C Which of these people has PF pain?

Midterm Time…...Short Answer When rehabilitating/ requesting rehabilitation

for someone with PF pain, I most often utilize/ request…….? (List your top 3)

Top 3 ?

Quad strengthening VMO facilitation

Stretching (based upon need) Quadriceps Lateral structures Hamstrings Posterior calf (Soleus)

Hip abductor strengthening Taping/ Bracing Arch supports

When the PT’s “cover” clinic…. Referral hangs outside door

Evaluate and Treat Evaluate and Return to IOSMR Evaluate and Coordinate with PT close to home

When the PT’s “cover” clinic…. Referral hangs outside door

Evaluate and Treat Evaluate and Return to IOSMR Evaluate and Coordinate with PT close to home

The evolution of a clinician……. Evaluation AND Treatment

Pt expectation My view of the profession

Tools in the toolbox Timing and rationale → and dosing → and “buy in”

The evolution of a clinician…… Evaluation

Observation Foot position, Tibial varum, leg length, atrophy

Palpation Patellar position, patellar tracking, quadriceps “tone”

ROM (Flexibility) Quad, Hamstrings, “lateral structures” , calf

Strength SLR x 3, Quads- No

Functional Squat, Lunges (Stacy V)

The evolution of a clinician……. Now, for PFPS, just treatment

“Pattern recognition” More on this later

Assumptions Focused treatment

Treatment guides eval

Treatment Approach for PFPS Phase 1

Everyone gets QS/ SLR x 4 And some stretching

“It may not be exactly right, but it’s never wrong” “Get on base, don’t swing for the fence”

Phase 2 “Groucho Marx” Therapy

“Hey doc it hurts when I do this.” Ok let’s do that or something similar

Phase 3 Return to activity

Phase 4 Long term plan

Best Case Scenario Visit 1

QS, SLR, Stretching, Wall Sits Visit 2 (1 week later)

30-50% better Step ups Isotonics (ham curls, light leg press, hip)

Visit 3 (1 week- 2 weeks later) ~ 70% better CV Exercises Talk about progression to running (prn)

Visit 4 (3-4 weeks after I/E) “How’s running going?”……OK great, here’s how to

progress your HEP, have a nice life

Rule of 70’s

“at least 70% of

patients will feel at least

70% better within 2-3

weeks of starting

rehabilitation”

The remaining 30% …….

The tale of Roy McAvoy “I can make that shot” “I know you can, but not right now” You’re in good shape after 2…..

but you’re staring at a 12

PFPS History Lesson Part 1My summary of 20 years of PFPS PT Rx. Lit. Because most patients improve with PT, it is

unethical (maybe “unthinkable”) to include a control group

2 treatment groups Both improve Equally!!.....arrrgh

VMO Facil., OKC vs. CKC, Conc. Vs. Ecc. , Taping vs. Bracing, Bracing vs. Orthotics

2009:339:b4074

n = 131 14- 40 y.o. (X=24 y.o.) ~ 2/3 female BMI ~ 23

~ 70% Sx. < 6 mos ~ 60% bilateral Sx. Pain

4/10 rest 6/10 with activity

Supervised Rehab vs.

Info + HEP (“standard care”) 9 visits over 6 weeks Progressive resistance every 2 weeks Quadriceps, Adductors, Gluteal strengthening Stretching Balance

“Improved” but not “recovered”

Are they “needy” or “kneedy”Sensory Mapping of the Knee

Dye et al AJSM 1998

PFPS- A selective history/ update (Part 2) VMO Weakness

Quad strengthening VMO Facilitation

Differences in timing of VMO / VL – PFPS vs. non. Just one more risk factor

McConnell’s Critical Test / Taping Just tape it

When the foot hits the ground …..must control the midfoot Try some OTC inserts

But the results are stable……the understanding is not “So what is our

patellofemoral pain protocol?”

“We’re not sure, but patients keep getting better anyway”.

October is National PT Month

October is National PT MonthHappy PT Month!!

Just in case you were interested….The green lining perhaps

Supervised Rehab (9 visits/ 6 weeks vs. Info + HEP

Where do we go from here? “PFPS School ” at CRWC

Women aged 18-50 Information

Anatomy, Epidemiology, Natural History (young woman’s disease) Exercise

Stretching (Q, H, C, Lateral) Strengthening (Quads, Hip adductors/ abductors) Instruction for taping (kinesiotaping)

Encouragement Keep exercising

Call us if Sx. not at least 50% better after 4 weeks

“Other” groups Level 6 Evidence – One guy’s opinion Men with CMP- Stretching! Patellar Tendonitis – Eccentrics, Aggressive

quadriceps and hip abductor strengthening UI athletes with CMP-

Muscle Imbalances - Full, Static and Dynamic Eval Address specific imbalances – specific exercises Remember where you are “in season”- set expectations

accordingly Don’t assume strong quadriceps (if you only have 1 bullet)

Thank You.

Institute of Orthopedics Sports Medicine, and Rehabilitation

Exam findings most often associated with Patellofemoral Pain ….. Quadriceps weakness VMO dysfunction Tight lateral structures Pes Planus Hip Abductor weakness Increased Q angle

Occam

The evolution of a practice???? Does it even need to be focused treatment?

Treatment Algorithm

Options Treat the worst first Shotgun Top- down Ground- up

Check your baggage at the door “What is our PFPS protocol?”- Ned Amendola, MD

No two PFPS rehabs alike

Quadriceps weakness Weak hip abductors, tight posterolateral hip,

and pronation

Balance the forces (M/L) 1 + 1 = 4

Relief of Sx. Examination Treatment (S.V.)

What is PFPS?

Chondromalacia Patella Patellar Tendonitis Patellar Instability

Fat pad Syndrome Pre-patellar bursitis Plica syndrome

Patellofemoral Anatomy

Retinaculi Note interdigitations

Patellofemoral Anatomy

Retropatellar Anatomy Articular cartilage

7 mm thick

Facets

Patellofemoral Articulation

Reinold et al JOSPT 2006

Patellofemoral Anatomy

VMO Insertion Only dynamic

medial stabilizer

Patellofemoral Anatomy Q angle

Or……. “it’s not me, it’s you”

http://www.youtube.com/watch?v=U8TnhNxKNlU

Q angle is symmetrici.e. it doesn’t change

Rauh et al JOSPT 2007

Predisposing Factors

Hip Femoral Torsion Hip abductor weakness ITB tightness

Knee Q Angle Lateral retinaculum tightness

Lateral tilt Lateral positioning

VMO dysfunction Foot/ Ankle

Midfoot pronation Soleus Tightness

Predisposing Factors Hip

Femoral Torsion (Anteversion) Hip abductor weakness ITB tightness

Knee Q Angle Lateral retinaculum tightness

Lateral tilt Lateral positioning

VMO dysfunction Foot/ Ankle

Midfoot pronation Soleus Tightness

Predisposing Factors

Hip Femoral Torsion Hip abductor weakness ITB tightness

Knee Q Angle Lateral retinaculum tightness

Lateral tilt Lateral positioning

VMO dysfunction Foot/ Ankle

Midfoot pronation Soleus Tightness

Predisposing Factors

Hip Femoral Torsion Hip abductor weakness ITB tightness

Knee Q Angle Lateral retinaculum tightness

Lateral tilt Lateral positioning

VMO dysfunction Foot/ Ankle

Midfoot pronation Soleus Tightness

Examination Hip

Femoral Torsion Craig’s Test Frontal plane technique

Hip abductor weakness

- 26% - 36%

Lloyd Ireland JOSPT 2003

Examination Hip

Femoral Torsion Craig’s Test Frontal plane technique

Hip abductor weakness

- 26% - 36%

Lloyd Ireland JOSPT 2003

Hip Abduction Strength B’ween Groups

Piva JOSPT 2005

Robinson JOSPT 2007

Examination

Knee Q Angle Lateral retinaculum

tightness Patellar tilt/ lateral

positioning Patellar Glide

VMO dysfunction Quad set OKC Knee extension

Patellar Position Palpation of patellar position

Fitzgerald and McClure PT 1995

Tomishch JOSPT 1996

Watson JOSPT 1999

Examination

Ankle/ Foot Midfoot pronation

Navicular drop test Look/ see test

Soleus/ Posterior Ankle Tightness Bilateral squat vs. Wall squat or tilt board squat

“I have never been able to squat right”

Examination

Soleus/ Posterior Ankle Tightness Bilateral squat vs. Wall squat or tilt board squat

“I have never been able to squat right”

Examination Reliability

Piva BMC Musculoskeletal Disorders 2006

30 patients with PFPS 2 paired PT’s

ICC’s

Examination Findings

Piva BMC Musculoskeletal Disorders 2006

“Normative” values for PFPS SEM’s

Progressions - Phase 2

The myth of contact area Greater contact area with > Flexion

Progressions - Phase 2

The myth of contact area Greater contact area with > Flexion

The Myth of Contact Area

Besier et al JOR 2005

So then why do my knees hurt when I do this?

Progressions - Phase 2

The myth of contact area Peeing in the ocean

The Myth of Contact AreaLocation of the Lesion

Patellofemoral Joint Trochlea, patellar undersurface Extension = superior patella Flexion = more patellar contact

BUT…. Site of lesion Quadriceps loading Shin angle

Treatment Algorithm

“It hurts when I go down stairs” Translation

Eccentrics hurt Quadriceps Loading

Phase 1 QS, SLR x 4, Stretching (Quads)

Phase 2 Shuttle! → Leg press Front step ups → Front Step Up and BACK downs →

Dynamic lateral step downs → Front step downs

Treatment Algorithm

“It hurts when I squat” Translation

Quadriceps loading Soleus Tightness

Phase 1 QS, SLR x 4, Soleus stretching

Phase 2 Shuttle → Leg press (fast transition) Wall sits OKC Knee extension Multi- angle isometrics

Phase 2 Supplements

Patellar mobilizations Lateral retinacular stretching Medial glides – but medial counterpressure

PROM Thomas test stretching

2 versions

VMO facilitation

Selective Atrophy of the VMO? NO!

Selective Training? Hip adduction

Origin off Adductors

But…… Reports of exercises with

adduction …….conflicting

Bands vs. balls Anecdotal reports

Can you selectively train the VMO? SAQ (OKC terminal ext)?

No Lieb and Perry JBJS 1968, JBJS 1971 Basmajian Anat Rec 1971 Hallen et al Acta Orthop Scand 1967 Jackson/ Merrifeld Med Sci Sport Exe 1972 Reynolds et al Am J Phys Med 1983 Salzman et al. Clin Orthop 1993

Can you selectively train the VMO? Quad exercises

No Cerny Phys Therapy 1995 LaPrade JOSPT 1998 Vaatainen et al Int J Sports Med 1995 Mirzabeigi et al AJSM 1999

Can you selectively train the VMO? Biofeedback

Yes Cowan et al Med Sci Sport Ex 2002

No Dursun et al Arch Phys Med Rehabil 2001

Can you selectively train the VMO? Hip Adduction

Yes Hanten and Schulthies Phys Ther 1990 Hodges and Richardson Scand J Rehab

Med 1993 No

Karst and Jewett Phys Ther 1993 Grabiner Eur J Exp

Musculoskel Res 1993

Cerny Phys Ther 1995

Laprade JOSPT 1998

Can you selectively train the VMO? Internal Tibial Rotation

Yes Laprade et al. Phys Ther 1998

No Hanten and Schulthies Phys Ther 1990 Cerny Phys Ther 1995

Can you selectively train the VMO? “….it would appear that isolated recruitment

or strengthening of the VMO through selected exercises may not be a realistic goal and any emphasis on selective strengthening of the VMO would most likely translate into a general quadriceps strengthening program.”

Powers JOSPT 1998

Don’t speed through this section! Hip adduction

Force pulling laterally placed at the knee

Vs. Isometric hip adduction

Anecodotal reports??

When to use taping/ bracing

Is taping/ bracing effective?

To decrease pain? Yes

McConnel Aust J Physiotherap 1986 Gerrard Clin Orthop 1989 Finestone (RCT) Clin Orthop 1993 Moller and Krebs Arch Orthop Trauma Surg 1986 Palumbo AJSM 1981 Bockrath et al Med Sci Sports Exerc 1993 Grace JOSPT 1997 Powers JOSPT 1997 Crossley et al Clin J Sport Med 2001 Greenwald et al Clin Orthop 1996 Ng and Cheng Clinical Rehabilitation 2002 Cochrane 2003 (Taping) Wilson et al. (!!) JOSPT 2003

No Miller (RCT) Am J Knee Surg 1997 Kowall (RCT) AJSM 1996

Is taping/ bracing effective?

For changing patellar position? Yes

Shellock et al J Mag Res Imag 1994

Yes, but not maintained after ex Larsen AJSM 1995

Yes, but only at rest (vs. AROM) Muhle et al AJSM 2000

NO Bockrath Med Sci Sports Ex 1993

Is taping/ bracing effective?

On VM/ VL activation? Yes

Gilleard Phys Ther 1998

No Cerny Phys Ther 1995

When to use taping/ bracing

Critical test Manual medialization of patella

My preferred method Correct tilt Correct glide (bunch skin) Watch compression

Split tape prn

Patellar Taping

Wilson et al JOSPT 2003

Unilateral Step Down

Taping….temporaryBracing……long term

When to use orthotics

Pronation, Femoral IR, Increased Q angle Gross and Foxworth JOSPT 2003

Caucasians in Iowa

Phase 4 – Continued Exercise

Phase 4 – Continued Exercise

Incorporate your treatment into their routine Gym

Isotonics + coronal plane!

Home exercise Wall sits, Planks

Swiss Balls Ball squats, Bridges

Thank you. No, really, thank you.