Volger Patellofemoral Physical THerapy · 2019-02-14 · Knee and hip strength ROM. Special Test • Ober’s Test – decreased IT band extensibility ... improve knee proprioception

Physical Therapy and the Patellofemoral Joint

Casey Vogler, PT, DPT

1

Objectives

2

• Illustrate and understand Physical Therapy evaluation and treatment for non-surgical and post surgical patellofemoral dysfunction.

• Identify protocols and understand interventions including blood flow restriction therapy, taping, and bracing for patellofemoral patients.

• Present an overview of a general PT plan of care/protocol for non-surgical PFPS and following surgery for medial patellofemoral ligament repair.

Patellofemoral Pain (PFP)Loose term for pain on anterior aspect of the

knee.

3

Patellofemoral Pain Subtypes• Non specific or

functional patellofemoral

pain, includes overuse

injuries of the extensor

apparatus (tendonitis

and insertional

tendinosis)

• Structural damage

associated with PFP

includes chondral and

osteochondral damage,

osteoarthritis (OA) and

patellar instability.

4

Demographics

�Female > Male

�50-59 age group >10-19 age group

� Athletes ages 16-25

�Prevalence

� 21-45% in active adolescents

� 15-33% in adults

�Adolescents and Young Adults

� Higher in Athletes

� A quarter of all knee

problems in athletes

�Soccer, volleyball, running female

athletes

� Cyclists, young athletes of

both genders

5

Demographics

• Affects 11-17%

patients seen by

primary care

physicians.

• Incident rate was

approximately 7.3%

of all orthopedic

visits.

• Approximately 25% of

recreational athletes

affected by

patellofemoral pain

will stop

participation in

sports.

6

Common Activities that

cause Pain

PFP is typically

associated with

activities that load the

patella such as

ascending or

descending stairs,

jumping, running, and

squatting.

PT Evaluation

Functional Tests•Squat ability

•Stair climbing

•Single leg stance

•Single leg squat

8

Gait pattern – Trendelenburg pattern

or antalgic

VMO atrophy/control

Effusion

Patellar mobility – limited or painful

or hypermobile

Point tenderness

Flexibility –typically tight in IT Band,

hamstrings and quadriceps

Knee and hip strength

ROM

Special Test

• Ober’s Test – decreased IT band extensibility

• Patellar Grind Test

• Patellar Apprehension Test-positive if previous dislocation/subluxation

• Medial and Lateral Patellar Glide Tests - often limited medially due to tight lateral structures

• Patellar Tilt - sometimes present

TapingClassical Taping McConnell/Leukotape

• Correct lateral patellar

maltracking and patellar

tilt by applying adhesive

strips to the skin

• Biomechanical effects

plus neuromuscular

effects

• Taping can stimulate

earlier VMO activation

relative to vastus

lateralis

10

Taping

Kinesio Taping (KT)

• Elastic tape strips are

used to increase the

space between muscle

and fascia stimulating

cutaneous

mechanoreceptors to

improve knee

proprioception

• Depending on

application, KT can

either stimulate muscle

activity or prevent

muscle overuse

• Can increase muscle

flexibility and improve

motor function to

decrease pain

11

Taping Literature

Classic Taping

• Systemic review:

moderate evidence that

the addition of classical

taping provides better

pain relief than exercise

alone after 4 weeks.

• Long-term effects not

established recommend

to use in short term with

exercise.

Kinesio Taping

• Systematic review: both

taping techniques had a

positive effect on pain

and quality of life but

meta-analysis showed

that KT provided more

effective pain relief.

12

Taping vs. Bracing

Taping Advantages:

• Less bulky/restrictive

• Cost-effective in short

term

• Multiple applications

and intervention focus

Taping Disadvantages:

• Less protective

• Long-term costs

• Learning curve and

assistance needed for

patient application

• Applied force dissipates

over time, need for

reapplication

13

Braces

14Breg 20/50 Knee Brace

DonJoy Hinged Air

DonJoy Hinged Lateral J

Breg PTO Brace

DonJoy Reaction Web Brace

Breg Buttress Knee Brace

Over the Counter Braces

Bracing Literature

• Draper et al

demonstrated using real-

time MRI that a knee

brace could reduce

patellar lateralization

and tilt in women with

PFPS.

• Callaghan et al use of a

patellar brace alters

position and increases

contact area between

the patella and the

femoral trochlea in PFOA

patients.

• A 2015 meta-analysis

found insufficient

evidence to recommend

the use of knee braces in

the treatment of

patients with PFPS

16

Bracing vs. Taping

Bracing Advantages:

• Easier application

• No cost past purchase

price

• Consistent medial force

that does not dissipate

• External protection from

impacts

Bracing Disadvantages:

• Bulky/restrictive under

clothes/equipment

• Higher upfront purchase

price

• Singular intervention

focus

17

PT Interventions• Manual interventions, therapeutic

exercise and modalities aimed at

strengthening knee/hip musculature and

improving extensibility of lower

extremity musculature and soft tissues to

help improve PFP symptoms.

18

19

Effectiveness of Exercise Therapy in Treatment of Patients with Patellofemoral Pain Syndrome: A Systematic Review and Meta-AnalysisRon Clijsen, Janine Fuchs, Jan Taeymans in Physical Therapy July 2014

• Used PEDro and ended up with 15 studies out of 285 that were included in the Meta-

Analysis

– Exercise Therapy vs No-Exercise Therapy

– Exercise vs Exercise with Additive Therapy

– Knee Extension Exercises vs Other Forms of Exercise

• Exercise prescription varied widely across the trials

– 3 to 5 times a week vs 2 or less a week vs home-based exercise only

• Exercise showed improvements in surveys (PRMALP) but not in VAS pain scale in both the

short and long-term.

• Exercise vs Exercises with Additive Therapy (Electrical Stim or splinting) showed that

exercise was more favorable in the long-term than adding additional therapy

• Closed-Chain vs Open-Chain exercises showed no significant difference between the

groups

• Overall, determined that exercise was important in achieving pain relief with PFPS

– Closed-chain exercises do show a slight advantage over open-chain exercises, just

not a statistically significant one.

Important Exercises for

Patellofemoral PainHip/Knee Exercises

1. Side-lying hip abduction, Prone hip extension, Prone hip extension with

knee flexion

2. Side-lying clamshells with theraband. Quadruped fire hydrants

Closed Chain Exercises

1. Forward Step Downs, Lateral Step Downs

2. Squats (with theraband if needed for positioning)

Core Stability Exercises

1. Front Planks, Side Planks

2. Bridges and multiple variations of Bridges

Other Exercises to Consider

1. Monster Walks

2. Double/Single leg balance on varying surfaces

21

Other Modalities and

Interventions

22

Neuromuscular Electrical

Stimulation (NMES)

• Research shows improvement in knee and hip EMG

values, demonstrating improved force-generating

capacity

• Works best when PFPS is caused by muscle imbalance

or poor activation

• Great supplement to exercise in beginning phase of

rehabilitation

23

24

“Immediate effect of patterned electrical neuromuscular stimulation

on pain and muscle activation in individuals with patellofemoral pain”

• Objective with to determine if single patterned NMES would alter muscle

activity and pain during Single-leg squat and lateral step down

• Randomized into 2 groups: 15 minutes of NMES with strong motor response

on 2 alternating channels (VMO/gluteus medius for channel 1 and middle

adductor muscle group/middle hamstring group for channel 2)or 15

minutes subsensory treatment

• Looked at EMG pre-and post-intervention for VMO, vastus lateralis, gluteus

medius, adductor longus, biceps femoris and medial gastroc. Also used

VAS for pain.

• Found that NMES caused an immediate improvement in gluteus mediusactivation during lateral step down and a reduction in pain during

functional tasks.

Low Impact Therapeutic Exercise• Research demonstrated a

positive effect from

trunk stabilization

exercises, targeting core

muscles.

• These results suggest

patients could

incorporate more

proximal exercises early

in rehab because they

have added benefit and

may cause fewer adverse

effects.26

Is there anyway to target knee musculature for strengthening without increasing stress to the joint??

27

Blood Flow Restriction (BFR)• Blood flow restriction

(BFR) training: occluding

venous outflow while

maintaining arterial

inflow with the

application of an

extremity tourniquet.

• BFR ultimately reduces

oxygen delivery to

muscle cells, creating an

anaerobic environment,

allowing patients to

exercise with low

resistance while

stimulating muscle

hypertrophy and strength

that would normally

result from using heavy

weight/resistance.

28

BFR to treat PFP

29

BFR to Improve

Quadriceps Strength using

Low Loads

30

BFR to treat PFP

• Single BFR-exercise bout

immediately reduced

AKP with the effect

sustained for 45 minutes.

• Compared with standard

quad strengthening, low

load training with BFR

produced greater

reduction in pain with

ADLs at 8 weeks post

treatment initiation in

people with PFP.

31

BFR after Surgery

32

Rehab Protocol Following Medial

Patellofemoral Ligament Repair

33

Rehab Protocol Following

Lateral Release and Medial

Plication

34

Caution with Protocols

• Protocols are general guidelines. Patients

should not be progressed to next phase

until they demonstrate proper form with

all activities and all criteria are met in

current phase. Protocols do not replace

clinical judgement and collaboration with

the medical team.

35

Precautions

MPFL

• Brace/immobilizer at all

times x 8 weeks. Brace

locked in extension x 4

weeks.

• Bilateral crutches PWB x

2 week; week 2-4 WBAT.

• Edema management and

attaining full knee

extension first priority

36

Knee Flexion ROM Progression

MPFL

• Week 1= 45 degs

• Week 2= 60 degs

• Week 3= 75 degs

• Week 4= 90 degs

• Week 5= 105 degs




37

Immediate Post-Op Phase

Goals Weeks 1-2MPFL

38

• Promote healing and protect repair

• Decrease pain/swelling/

inflammation

• Restore voluntary muscle activation

• Decrease/minimize pain, muscle

spasm and fascial binding

• Educate in joint protection/proper

ambulation

Immediate Post-Op Phase

Treatments Weeks 1-2Day 1-7 Day 8-14

• Add double leg bridge w/

swiss ball

39

• Gastroc Towel stretch

• Quad sets using NMES

• SLR flexion with locked knee

brace

• 3-way SLR

(abduction/abduction/extension)

• Supine and/or seated heel slides

Early Rehab Phase

Goals/Criteria Weeks 3-4Criteria to Enter

• Full passive knee

extension

• Appropriate quadriceps

control (no lag with SLR)

• Knee flexion to 60 deg

• Minimal joint effusion

• Independent ambulation

with crutches and locked

brace

Goals

• Gradually improve knee

flexion ROM

• Diminish swelling and

pain

• Improve muscle control

and activation

• Normalize superior and

inferior patella mobility

40

Early Rehab Phase

Treatments Weeks 3-4

Day 15-21

• Seated Stepper (limited

ROM)

• Patellar Mobilizations

(superior and inferior)

• Double leg

proprioception

• Well leg exercises

• Consider BFR use

• Continue ice and NMES

Day 22-28

• Seated and standing calf

raises

• Pool walking program (if

incisions closed and

healed)

• Pain modalities PRN

41

Intermediate Rehab Phase


• Active ROM 90 degrees or

greater

• Minimal to no joint

effusion

• Minimal/no joint line or

patellofemoral pain

• Active quadriceps

contraction w/o SLR lag

• Heel to toe gait pattern

with knee brace

Goals

• Restore full Knee ROM

• Improve lower extremity

strength

• Enhance proprioception,

balance, and

neuromuscular control

• Improve muscular

endurance

• Restore limb confidence

and function

42

Precautions Weeks 5-10

Intermediate Phase

• Avoid pivoting or twisting

• Avoid multi-planes moves

• Avoid closed-chain

movements with deep

knee flexion angles over

90 degrees

• Wear post-op brace

during all functional

activities until week 8

43

Intermediate Rehab Phase

Treatments Weeks 5-10Weeks 5-7• Upright bicycle

• Prone planks

• Leg press (0-100 deg)

• 1/4-1/2 squats

• Forward and lateral cone steps

• Forward step-up (4-6”)

• Non-resisted to resisted side-

stepping

• Single leg proprioception drills

• Pool program (deep water jogging)

Weeks 8-10• Eccentric single leg calf

raises (for running)

• Shuttle plyometric jumps

• Stair stepper (week 10)

• Light plyometric drills

(week 10)

44

Advanced Activity Phase


• Flex ROM 125 degs

• No pain with ADLs

• Adequate quadriceps

strength

• Continue to avoid deep

knee flexion angles past

90 degrees

Goals

• Normalize joint ROM and

muscle performance

• Enhance muscular power

and endurance

• Improve proprioception

and neuromuscular

control

• Initiate sport specific

drills

45

Advanced Activity Phase

Treatments Weeks 11-16• Elliptical and incline

treadmill

• Multi-directional CKC

exercises

• Isokinetic hamstrings and

quadriceps with

machines

• Agility ladder drills

• Medicine ball toss

46

Return to Activity Phase


• Quadriceps torque/body wt

ratio (55% or greater)

• Hamstrings/Quadriceps

ratio (70% or greater)

• Able to perform quality

single leg squat to 45 deg

• 70% maximum contralateral

leg press

• Brisk walk for 20 minutes

• Reciprocal bounding for 50

ft with good form

Goals• Gradual return to full

unrestricted sports/Achieve

maximal strength and

endurance

• Normalize neuromuscular

control/Progress skill

training

47

• No abnormal gait

patterns while walking as

fast as they can on the

treadmill for 15 minutes

• ≥ 80% 1-repetition

maximum (1-RM) on the

leg press (90-0 °)

• 30 step and holds

without loss of balance

or excessive motion

outside of the sagittal

plane

• 10 consecutive single leg

squats to 45 ° of knee

flexion without loss of

balance, abnormal trunk

movement,

Trendelenburg sign,

femoral IR or the knee

deviating medially

causing the tibial

tuberosity to cross an

imaginary vertical line

over the medial border

of the foot

48

Return to Running Test

Y Balance Test

• ≥ 90% composite score on Y-balance test.

Composite score = (anterior

reach + posteromedial

reach + posterolateral reach)/(3 x limb

length)

49

Return to Activity Phase

Treatments Weeks 16-22• Interval running program

• Progressive multi-

directional agility drills

• Circuit training

• Sport specific training

programs

50

Discharge

Typical 6-8 months

• Demonstrate quality and

symmetrical movement

throughout body

evaluated with

comprehensive

movement screen or

assessment process

• Symmetrical and

acceptable compressive

scores on CKC LE testing

• At least 90% symmetry

when comparing right to

left side per isokinetic

test or hamstrings and

quadriceps.

51

Take Home Thoughts• Research shows that

combining exercise

interventions work better

than knee specific

interventions alone.

• Bracing/Taping maybe

beneficial for some

patients but exact type will

vary depending on the

individual.

• Patient compliance with

therapy and HEP goes a

long way towards

determining long term

outcomes.

• Blood Flow Restriction

therapy is a relatively new

treatment intervention

with great potential for

positive outcomes.

International Patellofemoral Group

• http://www.patellofemoral.org/pfoe/index.html

References

• Barton CJ, Lack S, Hemmings S, Tufail S, Morrissey D.

The ‘Best Practice Guide to Conservative Management

of Patellofemoral Pain’: incorporating level 1 evidence

with expert clinical reasoning. Br J Sports Med.

2015;49(14):923–923.

• Clijsen, Ron Janine Fuchs, Jan Taeymans Effectiveness

of Exercise Therapy in Treatment of Patients With

Patellofemoral Pain Syndrome: Systematic Review and

Meta-Analysis Physical Therapy December 2014 ; 94

(12) 1697-1708.

• Clement DB, Tauton JE, Smart GW, McNicol KL. A

survey of overuserunning injuries. Phys Sportsmed.

1981;9(1):47–58.

• Crossley KM, Stefanik JJ, Selfe J, et al. Patellofemoral

pain consensus statement from the 4th International

Patellofemoral Pain Research Retreat, Manchester.

Part 1: terminology, definitions, clinical examination,

natural history, patellofemoral osteoarthritis and

patient-reported outcome measures. Br J Sports Med.

2016;50(14):839–843.

• Crossley KM, van Middelkoop M, Callaghan MJ, et al.

Patellofemoral pain consensus statement from the 4th

International Patellofemoral Pain Research Retreat,

Manchester. Part 2: recommended physical

interventions (exercise, taping, bracing, foot orthoses

and combined interventions). Br J Sports Med.

2016;50(14):844–852.

• Glaviano, Neal R., and Susan A. Saliba. "Immediate

effect of patterned electrical neuromuscular

stimulation on pain and muscle activation in individuals

with patellofemoral pain." Journal of Athletic Training,

vol. 51, no. 2, 2016, p. 118 Glaviano NR, Kew M, Hart

JM, Saliba S. Demographic and Epidemiological Trends

in Patellofemoral Pain. Int J Sports Phys Ther. 2015

Jun; 10(3): 281–290

• Lachlan Giles, Kate E Webster, Jodie McClelland and

Jill L Cook blood flow restriction in the treatment of

Quadriceps strengthening with and without

patellofemoral pain: a double-blind randomized trial.

Br J Sports Med 2017 51: 1688-1694

• Michael J. Mullaney, Takumi Fukunaga CURRENT

CONCEPTS AND TREATMENT OF PATELLOFEMORAL

COMPRESSIVE ISSUES The International Journal of

Sports Physical Therapy December 2016 (11)891-902.

• Nicholas N. DePhillipo, Mitchell I. Kennedy, Zachary S.

Aman, Andrew S. Bernhardson,.,Luke O’Brien, and

Robert F. LaPrade, Blood Flow Restriction Therapy

After Knee Surgery: Indications, Safety Considerations,

and Postoperative Protocol Arthroscopy Techniques �

September 2018 e1-e7.

• Vasileios, Korakakis ,Rodney Whiteley , Konstantinos

Epameinontidis Blood Flow Restriction induces

hypoalgesia in recreationally active adult male anterior

knee pain patients allowing therapeutic exercise

loadingPhysical Therapy in Sport 32 (2018) 235-243.

54

Thank You!

55

Questions?

56

Documents

Volger Patellofemoral Physical THerapy · 2019-02-14 · Knee and hip strength ROM. Special Test • Ober’s Test – decreased IT band extensibility ... improve knee proprioception