Patellofemoral Dysfunction Management

Patellofemoral Dysfunction

• Considerations for Management: Presented by Mohammad Yabroudi, PT, PhD.
• Patellofemoral Alignment: Excessive lateral tilt from shortening of lateral retinacular tissue, iliotibial band (ITB), etc. A diagram demonstrating this is included.
• Patellofemoral Tracking: Tracking involves inferior movement with flexion, superior movement with extension, and medial and lateral gliding. Also, some medial and lateral gliding happens with both inferior and superior movement. A diagram is provided.
• Quadriceps Effect: Quadriceps contraction creates compressive load, promoting stability. Vastus medialis obliquus (VMO) counters the lateral vector from the rest of the quads. This is supported by the work of Lieb and Perry (1979). A diagram visualizes this.
• Patellofemoral Pain Origin: Pain can arise from cartilage issues (chondromalacia vs. patellofemoral chondrosis—aneural, no pain fibers), but some patients without degeneration report pain, while others with degeneration don't. Alternatively, the pain may stem from the subchondral plate, which is innervated.
• Retinacular Tissues: Excessive tension on the lateral retinaculum can cause irritation or inflammation. Fulkerson (1985) notes neuromatous degeneration in tight lateral retinacular tissue.
• Other Possible Causes: Potential sources for patellofemoral pain include: patellar tendon, fat pad, medial plica, osteochondral lesions, and synovial impingement (odd facet syndrome).

Causes of Patellofemoral Dysfunction

• Blunt Trauma
• Malalignment or Mal Tracking
• Excessive Compression

Symptoms of Patellofemoral Dysfunction

• Anterior Knee Pain: Usually gradual onset.
• Activity-Related Pain: Pain during activities like ascending & descending stairs, prolonged knee flexion, jumping and quick stops.
• Common Populations: Adolescent females and young/middle-aged active adults.

Differential Diagnoses

• Medial Plica Syndrome
• Meniscal Injury
• Patellar Tendon/Fat Pad Injury
• Quadriceps Tendon Injury
• IT Band Syndrome
• Osteochondritis Dissecans/Chondral Fracture
• PCL Injury

Contributing Factors to P-F Dysfunction

• Bony Structural Abnormalities: Including flattened lateral condyle and patella alta/baja.
• Soft Tissue Restrictions
• Quadriceps Femoris Dysfunction
• Hip Abductor/External Rotator Weakness
• Lower Extremity Malalignments: Internally rotated hips, genu valgum (knock-knees), and pronated feet (flat feet)
• Restricted Lateral Restraints
• These are visualised with images

Diagnostic Tests

• ITB Tightness: Ober test and modified Thomas test.
• Medial Patellar Glide
• Patellar Tilt Test
• Restricted Rectus Femoris
• Restricted Hamstrings
• Restricted Gastrocnemius
• Quadriceps Femoris Dysfunction

Open vs. Closed Chain Exercises

• Open Chain: PFJR & contact stress is increased from 0 to 45°.
• Closed Chain: PFJR & contact stress is increased from 45 to 90°. This is demonstrated by graphs.

Treatment Guidelines

• General LE strengthening: Early rehab like quad sets, SLR, ½ squats, lateral step-ups, and leg extensions with cuff weights (90-45°). Later rehab (PRE) might include leg extensions (90-45°), leg press (0-45°), and leg curls (0-90°).
• Hip Abductor/Lateral Rotation Weakness Issues: May cause excessive medial rotation of femur during stance, excessive knee valgus, and increase in Q angle. This is thought, in part, to affect tracking and alignment problems.
• Powers CM (2003) and non-weight bearing rotations: Non-weight-bearing, patella displaces on femur. Weight-bearing, femur rotates under patella. Important for controlling the hip.
• S.E.R.F. Strap™ Patellofemoral Brace: Provides stability, external rotation of femur.
• General Treatment Guidelines: Foot orthotics (if associated with symptoms), stretching of restricted tissues, strengthening quads (limited arc), strengthening hip abductors and rotators, functional activity modifications, as well as patellar taping/bracing.

IT Band Syndrome

• Mechanism: Pain and irritation of the IT band from increased friction over the lateral femoral epicondyle, commonly seen in distance runners. Posterior fibers impinge on the lateral femoral condyle at about 30 degrees of knee flexion, due to tightness. This is illustrated by diagrams.
• Potential Contributing Factors: Running in one direction, excessive downhill running, reduced eccentric strength, weak hip abductors affecting hip adduction moment during weight bearing, and a shortened ITB complex.
• Symptoms: Anterior/lateral knee pain, gradual onset, associated with running, walking, and descending stairs. Tenderness over anterior tibial tubercle (Gerdy's), lateral retinaculum, lateral femoral epicondylar region. Increased skin temperature and swelling. Positive Ober's test and modified Thomas test. Symptoms often reproduced with knee flexion/extension, resisted contraction of tensor fasciae latae.

Other Conditions

• Patellar Tendinitis/Tendinosis (Jumper's Knee): Pain and irritation of the patellar tendon. Gradual onset of pain associated with jumping, quick stops, and sprinting. Increased tenderness,skin temperature and swelling. Pain with resisted quad contraction or passive stretching.

• Tendonitis vs. Tendinosis: Tendonitis involves inflammation (potentially responding to antiinflammatory treatment), while tendinosis represents degenerative changes, typically not responding to anti-inflammatory treatment.

Rehabilitation

• General Rehab for Patellar Tendinosis: Flexibility exercises for quads and hamstrings, relative rest during painful periods to facilitate healing, eccentric strengthening of the quadriceps and patellar mobility/taping/bracing.
• General Rehab for ITB Syndrome: Stretching of ITB (modified Thomas position, Ober's position, medial patellar glide), soft tissue mobilization, strengthening of hip abductors and anti-inflammatory treatment (ice, NSAIDs) if needed.