Patellofemoral Dysfunction Treatment PDF

Considerations for the Management of Patellofemoral Dysfunction Mohammad Yabroudi, PT, PhD Jordan University of Science and Technology Patellofemoral Alignment: Frontal Plane Rotation (Patellar Tilt) Excessive lateral tilt may occur from shortening of lat...

Considerations for the Management of Patellofemoral Dysfunction Mohammad Yabroudi, PT, PhD Jordan University of Science and Technology Patellofemoral Alignment: Frontal Plane Rotation (Patellar Tilt) Excessive lateral tilt may occur from shortening of lateral retinacular tissue, ITB, etc. Oatis CA. Kinesiology: The Mechanics & Pathomechanics of Human Movement. Lippincott, Philadelpia, PA 2004. Patellofemoral Tracking Inferior with flexion Superior with extension Also some medial and lateral gliding occuring with inferior and superior gliding Effect of the Quadriceps on Patellofemoral Tracking Compressive load from quad contraction creates stability VMO functions to counter lateral vector from remainder of quads (Lieb and Perry 79) Where Does Patellofemoral Pain Come From? Cartilage? Chondromalacia vs Patellofemoral Chondrosis aneural, no pain fibers Some patients with cartilage degeneration do not have pain, others with no cartilage degeneration do have pain Perhaps pain related to cartilage degeneration may actually be from subchondral plate, which is innervated Where Does Patellofemoral Pain Come From? ▪ Retinacular Tissues? ▪ Excessive tension on lateral retinaculum may cause irritation or inflammation ▪ Fulkerson (1985) reported neuromatous degeneration of small nerve fibers in tight lateral retinacular tissue Where Does Patellofemoral Pain Come From? Other Possibilities Patellar tendon, fat pad Medial Plica Osteochondral Lesions Synovial impingement (Odd facet syndrome) Patellofemoral Dysfunction Blunt Trauma Malalignment or Mal Tracking Excessive Compression  Patellofemoral Dysfunction Anterior knee pain Usually gradual onset Painful Activities ascending and descending stairs prolonged positioning with knee flexed jumping, quick stop and starts More common in adolescent females Also common in young and 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 P-F Dysfunction: Contributing Factors ▪ Bony Structural Abnormalities ▪ Soft Tissue Restrictions ▪ Quadriceps Femoris Dysfunction ▪ Hip Abductor/External Rotator Weakness Flattened Lateral Condyle Patella Alta Patella Inferna (Baja) Lower Extremity Malalignments Restricted Lateral Restraints 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 Exercise ▪ PFJR & contact stress greater with OKC from 0 to 450 ▪ PFJR & contact stress greater with CKC from 45 to 900 General LE Stengthening Ex Early Rehab Later Rehab (PRE) quad sets Leg extensions 90-45 SLR Leg Press 0-45 1/2 squats Leg Curls 0-90 Lateral step ups leg extensions with cuff weights 90-45 Hip Abduction/Lateral Rotation Weakness ▪ May result in excessive medial rotation of femur during stance ▪ May result in excessive valgus at knee ▪ May increase Q angle ▪ May result in tracking and alignment problems Powers CM, JOSPT, 2003 Non-Wt bearing, patella displaces on femur Wt- bearing, femur rotates under patella Need to control hip in patients who collapse into valgus  S.E.R.F. StrapTM Patellofemoral Brace S – Stability thru E – External R – Rotation of the F - Femur General Treatment Guidelines for PF Dysfunction Foot orthotics if associated with sx Stretching of restricted soft tissues Strengthening of quads in limited arc Strengthening of hip abd/later rot Functional activity modifications Patellar taping or bracing IT Band Syndrome (Runner’s Knee): Traditional Mechanism ▪ Pain and irritation of IT band from increased friction over lateral femoral epicondyle. ▪ Common in distance runners. ▪ Posterior fibers of ITB impinge on lateral femoral condyle at about 30 degrees of knee flexion, due to tightness Fredericson and Wolf, 2005 IT Band Syndrome (Runner’s Knee): Potential Contributing Factors Running in one direction around track Excessive downhill running Reduced eccentric strength for breaking forces of LE Weak hip abductors (less control of hip adduction moment during wt bearing, places more tension through ITB) Shortened ITB complex Fredericson and Wolf, 2005 IT Band Syndrome (Runner’s Knee) Anterior, lateral knee pain, gradual onset, associated with running or walking, descending stairs Tenderness over anterior tibial tubercle (Gerdy’s) and/or lateral retinaculum, lateral femoral epicondylar region Increased skin temp and swelling + Ober’s test, modified thomas test + Symptoms reproduced with knee flexion/ext, resisted contraction of tensor facia latae General Treatment Approach for ITB Syndrome Stretching of ITB Modified Thomas Position Ober’s position Medial patellar glide Combination Soft tissue mobilization techniques Strengthening of hip abductors Anti-inflammatory treatment if signs of inflammation are present (ice, NSAIDS) Patellar Tendinitis/Tendinosis (Jumper’s Knee) ▪ Pain and irritation of patellar tendon ▪ Gradual onset of pain, associated with jumping, quick stops, sprinting ▪ Tenderness,  skin temp and swelling ▪ Pain reproduced with resisted quad contraction or passive stretching of quads.  Tendonitis vs Tendinosis Tendonitis Implies presence of inflammation with pain and sometimes weakness May respond to anti-inflammatory treatment Tendinosis Implies degenerative change in tendon May have pain and weakness, but no clinical or histological signs of inflammation Will not respond well to anti-inflammatory treatment General Rehab Approach for Patellar Tendinosis. Flexibility of Quadriceps and Hamstrings Relative Rest During Symptomatic Periods to Allow for Tissue Healing Strengthening of the Quadriceps (eccentrics) Patellar Mobility/Taping/Bracing?