Patellofemoral Pain Syndrome in Female Athletes: a Review of Diagnoses, Etiology and Treatment Options

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Patellofemoral pain syndrome in female athletes: A review of diagnoses, etiology and treatment options

Article in Orthopedic Reviews · March 2018 DOI: 10.4081/or.2017.7281

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Orthopedic Reviews 2017; volume 9:7281

Patellofemoral pain syndrome females relative to males.2 The goal of this in female athletes: A review review is to guide physicians in making Correspondence: Xinning Li, Department of accurate clinical decisions when evaluating Orthopedic Surgery, Sports Medicine and of diagnoses, etiology PFPS in a female athlete. Shoulder Surgery, Boston University School and treatment options of Medicine - Boston Medical Center, 850 Harrison Avenue - Dowling 2 North, Boston, MA 02118, USA. Molly Vora,1 Emily Curry,2 Tel.: +1.508.816.3939. Amanda Chipman,3 Elizabeth Matzkin,4 Knee anatomy and E-mail: [email protected] Xinning Li1 patellofemoral pain syndrome 1 Boston University School of Medicine, The patellofemoral joint consists of the Key words: patellofemoral pain syndrome, MA; 2Boston University School of Public patella, the distal and anterior aspects of the PFPS, anterior knee pain, female athletes, Health, MA; 3Tufts University School of femur as well as the articular surfaces and treatment options 3-5 Medicine, Boston, MA; 4Harvard surrounding supporting structures. The patella is the largest sesamoid bone in the Contributions: MV, made substantial contribu- Medical School, Boston, MA, USA tions to the acquisition of data, formatting of body and is of a relatively constant length, 6,7 the manuscript and drafting the manuscript. width and thickness. Seventy-five percent EJC, made substantial contributions to the of the posterior aspect of the patella is cov- conception and design of the work and inter- Abstract ered by cartilage up to five millimeters pretation of the data for the work. AC, made thick. This cartilage has both elastic and substantial contributions to the conception of Patellofemoral pain syndrome (PFPS) viscous properties. The fluid component the work. She also was responsible for the is one of the most common causes of knee allows for force absorption and lubrication acquisition of the data for the work and draft- pain and is present in females dispropor- of the articular surface, while the elastic ing the work. EM, made substantial contributions to the conception of the work and inter- tionately more relative to males. PFPS caus- portion helps to distribute and absorb 8-10 pretation of the data for the work. She also es tend to be multifactorial in nature and are forces. The tendons of the four compo- was involved with the critical revision for described in this review. From a review of nents of the quadriceps muscle converge in importantonly intellectual content. XL, made sub- the current literature, it is clear that there the distal portion of the thigh and unite to stantial contributions to the conception of the needs to be further research on PFPS in form a single broad quadriceps tendon. The work and interpretation of the data for the order to better understand the complex eti- patellar tendon, which inserts on the tibial work. He also was involved with the critical ology of this disorder in both males and tuberosity is the continuation of this quadri-userevision for important intellectual content. females. It is known that females with ceps tendon in which the patella is embed- Conflict of interest: MV, EJC, AC, declares no patellofemoral pain syndrome demonstrate ded. The medial and lateral vasti muscles of conflicts of interest relevant to this submis- a decrease in abduction, external rotation the quadriceps also attach independently to sion. EM, declares no conflicts of interest rel- and extension strength of the affected side the patella and form aponeuroses, known as evant to this submission, but receives research compared with healthy patients. the medial and lateral patellar retinacula, support from Zimmer. XL declares no con- Conservative management, including opti- respectively.7,11 flicts of interest relevant to this submission, mizing muscle balance between the vastus PFPS is the name given to a variety of but is on the editorial board of JoMI and also medialis and lateralis around the patella pathologies that lead to anterior knee pain. holds equity in the company (<$5,000). along with formal therapy should be the PFPS is difficult to define because patients Received for publication: 25 June 2017. first line of treatment in patients presenting experience a variety of symptoms and may Revision received: 8 October 2017. with PFPS. Surgery should be reserved for have different levels of pain and physical Accepted for publication: 8 October 2017. patients in which all conservative manage- impairment.8,12 Further, most current litera- ment options have failed. This review aims ture focuses on studies performed with male This work is licensed under a Creative to guide physicians in accurate clinical- participants, limiting the knowledge of Commons Attribution NonCommercial 4.0 decision making regarding conservative and treatment options for females with PFPS. License (CC BY-NC 4.0). surgical treatment options when specifically ©Copyright M. Vora et al., 2017 faced with PFPS in a female Non-commercial athlete. Licensee PAGEPress, Italy Furthermore, we will discuss the anatomic Orthopedic Reviews 2017;9:7281 variants, incidence and prevalence, etiolo- Incidence and prevalence doi:10.4081/or.2017.7281 gy, diagnosis and treatment of PFPS. PFPS is the most prevalent orthopedic condition seen in sports medicine and is a common presenting complaint in adolescents associated with increased activity. Chronic 13,14 Introduction and young adults. PFPS is also the pri- overloading and overuse of the mary diagnosis in about 25% of all running 5,15 patellofemoral joint, rather than malalign- Patellofemoral pain syndrome (PFPS) injuries. Treatment for PFPS is especially ment, can also contribute to patellofemoral is the most common cause of knee pain in promising for the short term, but long-term pain.18 A study of freshmen at the United female athletes and is a result of imbalances results are much less successful.16 The total States Naval Academy conducted by Boling in the forces controlling patellar tracking incidence for PFPS ranges from 8.75% to 19 during knee flexion and extension (Table 17%; however, the incidence among females et al. found that females were 2.23 times 1).1 Symptoms include pain behind or is much greater at 12.7% compared to 1.1% more likely to develop PFPS compared with around the patella that is increased with of males.17 Young females who regularly par- males. Additionally, Boling et al found that running or other knee flexion activities, ticipate in running and jumping activities the prevalence of PFPS was not significantly such as squatting and walking up and down may be particularly at risk.2 In a clinical different between sexes at the time of admis- stairs. PFPS is disproportionately present in analysis of 40 women with PFPS, pain was sion to the US Naval Academy. This data

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along with other studies suggests that females patellofemoral instability, Shin et al.31 cle activity between the vastus medialis and are more affected than males by a rapid reported decreased trochlear volume and rectus femoris muscle. Another feature of increase in physical activity level, which in length compared to normal control groups. PFPS is decreased knee extensor torque. turn leads to a higher incidence of PFPS.19,20 Thus, normal patellofemoral tracking is Kaya et al.39 showed that women with PFPS dependent on many factors. have a decreased torque, total volume, and Although dynamic lateral patella mal- cross sectional area of the quadriceps mus- tracking is a risk factor for PFPS, static cle. Decreased torque also leads to muscular Etiology patellar malalignment can also be a con- imbalances that increases the risk of PFPS. tributing factor.32 Differential action of the Lephart et al.40 indicated that females The causes of PFPS in females are mul- quadriceps, in particular the vastus medialis have significantly more hip internal rotation tifactorial and include overuse injuries of obliquus, has been involved in the etiology to maximum angular displacement, and less the extensor apparatus (tendonitis or inser- of PFPS.33 Lin et al.32 observed that vastus lower leg internal rotation time to maximum tional tendinosis), patellar instability, chon- medialis obliqus activation in PFPS patients angular displacement compared to males. dral and osteochondral damage.21 caused greater medial patellar rotation than Females also have significantly less peak in healthy subjects. Additionally, they torque to body mass for the quadriceps and Malalignment of the lower extremity reported that the three-dimensional kine- hamstrings than males. Weaker thigh muscu- Malalignment of the lower extremity matic action of the vastus medialis obliquus lature could be associated with stiffening of has been cited as a potential contributory is actively modulated with knee flexion the knee and lower leg upon landing in factor in the development of PFPS. Femoral angle in healthy subjects, but that this mod- females.9 Additionally, Besier et al.41 reported neck anteversion, genu valgum, knee hyper- ulation was not present in PFPS patients. that PFPS patients had greater contraction of extension, Q angle, tibia varum and exces- These results could be attributed to differen- quadriceps as well as hamstrings and greater sive rearfoot pronation are some of the tial vastus medialis obliquus insertion on normalized muscle forces during walking, alignment factors that have been associated 8 the patella or medial quadriceps weakness. although the net knee moment was similar with PFPS. between PFPS patients and healthy pain-free Q angle is defined as the angle between controls. Females displayed 30-50% greater the line connecting the anterior superior Muscular imbalances only Decreased strength due to atrophy or normalized gastrocnemius and hamstring iliac spine to the center of the patella and muscle forces during both running and walk- the extension of a line from the center of the inhibition of the lower extremity muscula- 21 ture has been suggested as a possible cause ing when compared to males. patella to the tibial tubercle. A greater lat- 8 eralization angle is exerted on the patella for PFPS. There are a number of muscularuse Vastus medialis obliquus insufficiency with a greater Q angle, which increases the imbalances that are thought to contribute to load on the lateral facet of the patella and PFPS development and include decreased and atrophy the lateral femoral condyle. A 10% increase knee extensor strength, weakness in eccen- Vastus medialis obliquus imbalance rel- in the Q angle will result in increased stress tric muscle strength, imbalance between the ative to the vastus lateralis has been cited as to the patellofemoral joint by 45%.22 A Q- vastus medialis obliquus and vastus lateralis one of the main contributors to abnormal components of the quadriceps, and hip mus- patellar tracking.34 Under normal condi- angle greater than 20 degrees for women is 34 considered clinically abnormal.23 While cle weakness. Studies have shown that tions, the vastus medialis obliquus and vas- some data suggests that a greater Q angle is quadriceps atrophy is associated with PFPS tus lateralis counteract each other and are pain syndrome.35-37 However, Thijs et al.34 considered to be important patellofemoral not a risk factor for PFPS, others suggest 42 that a high Q angle may be a contributing observed that the strength of hip muscle joint stabilizers. When the balance of the factor in maintaining PFPS once it has been groups in female runners who developed vastus medialis obliquus and vastus lateralis acquired.24 Additionally, some authors have patellofemoral pain did not significantly is disrupted, it is often attributed to insuffi- attributed excessive dynamic knee valgus differ from those of the asymptomatic run- ciency of the vastus medialis obliquus due ners.34 Other more recent studies suggest to atrophy, hypoplasia, inhibition or malalignment in patients with PFPS com- 43 pared to normal patients.25 that female athletes with greater hip abduc- impaired motor control. Hence it has been Patterns of patellar malalignment tion strength might be at an increased risk of suggested that PFPS is linked to a decrease Non-commercialdeveloping PFPS.38 in vastus medialis obliquus muscle include subluxation with and without patel- 34,44 lar tilt as well as patellar tilt without sublux- mass. The insertion of the vastus medi- ation.8 In a computerized tomography study Decreased knee extensor strength: alis obliquus is along the medial border of of the patellofemoral joint during active quadriceps volume and strength the patella and it extends from one third to one half of the way down from the proximal flexion and extension, lateral patellar trans- deficiency 45 lation and tilt was present in 8 out of 20 Decreased knee extensor strength is a pole. Jan et al. found that insertion level of knees with anterior knee pain.26 Abnormal common finding in patients with PFPS.8 the vastus medialis obliquus was signifi- surface tracking at the patellofemoral joint Thomee et al.8 found that patients with cantly higher in patients with PFPS than has often been cited as a potential cause of PFPS have more symptoms and pain during healthy controls. Further the vastus medialis PFPS.27 Patellar tracking, which targets the last thirty degrees of maximal sitting obliquus fiber angle was significantly dynamic patellofemoral alignment through- extension. A study on young women with smaller than in healthy control knees. out knee range of motion, is essential for PFPS showed significantly lower knee healthy joint function and affects contact extensor strength in the symptomatic knee. Differential activation of vastus and load transmission.28 Cartilage thickness Further, the patients had less vertical jump- medialis obliquus versus vastus also has been suggested to influence joint ing ability and were weaker, with the largest lateralis contact and as a result may be another con- differences in eccentric knee extension. Another theory regarding the etiology tributing factor to PFPS.29,30 Furthermore, in Affected patients had lower strength, EMG of PFPS suggests that there is a differential patients with trochlear dysplasia and activity and significant differences in mus- activation time between vastus medialis

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obliquus and vastus lateralis. Poor coordi- PFPS. Females with PFPS have demon- cian must first evaluate the lower extremity nation of activation onset times of vastus strated increased hip internal rotation dur- alignment and the extensor mechanism.20 lateralis and vastus medialis obliquus can ing single step downs, running and jump- The clinician should aim to distinguish lead to abnormal patella tracking.46 Akkurt ing.53 Increased hip adduction and knee between an alignment problem within the et al.47 reported a significant delay in the abduction during walking have also been patellofemoral joint, an alignment issue out- activation onset time of vastus medialis observed in female patients with PFPS. side of the patellofemoral joint or absence obliquus in the affected knee of female These transverse and frontal plane rotations of malalignment.20 Within the so called mis- patients at fifteen, thirty and forty-five are thought to reduce patellofemoral contact erable malalignment syndrome, a CT Scan degree knee extension angles as measured area and increase patellofemoral joint is necessary to diagnose torsion, rotation by electromyographic recording. They also stress, which leads to pain. It has been pro- and femoral neck anteversion correctly.60,61 reported that the delay in female patients posed that altered neuromuscular control of The first step is visual inspection of the was more pronounced at knee angles closer the musculature that resists hip adduction lower extremity with the feet together. Full- to full extension. Conversely, Karst et al.48 and internal rotation may contribute to the length alignment radiographs is essential found no difference in the initial activation kinematic differences observed between for the accurate diagnosis and measurement of vastus medialis obliquus and vastus later- females with PFPS and healthy controls.53 of malalignment to guide management. alis activities in patients with PFPS and The source of pain in PFPS may not asymptomatic individuals during three test- Overuse always be malalignment or patella instabili- ing conditions: reflex knee extension, active Although many studies have attempted ty, but instead excessive loading of the knee extension in non-weight bearing and to explain the etiology of PFPS, most have patellofemoral joint. The excessive loading weight bearing situations. In a systematic focused on muscular imbalances and bio- may be a consequence of a single event or review and meta-analysis of the literature, may be chronic in nature.62 In the majority 49 mechanical abnormalities. However, physi- Chester et al. evaluated 14 studies com- cal activity level and overuse is also an of PFPS patients, no abnormal anatomical paring the timing of EMG onset of VMO important factor in the development of or biomechanical reasons for the symptoms 20 and VL in patients with PFPS versus PFPS.8 Fairbank et al.54 reported that female exist. Both a static and dynamic evalua- asymptomatic individuals and found con- patients with PFPS were more involved in tion onlyof the entire leg should be performed. siderable heterogeneity between each study competitive sports than age-matched con- The patient should stand and walk barefoot design. Although the data indicate a trend trols and that pain was related to increases while the alignment and functionality of the towards a delay in the VMO activation rel- in physical activity level. In fact, Thomee et lower extremity is evaluated. If there is a ative to VL in the PFPS patient population al.18 found that all female patients use who functional abnormality, the clinician should during both the voluntary task and reflex reported symptoms of an insidious onset of determine the reason for this compensatory activities, the authors could not draw a clin- PFPS had been involved in temporary over- mechanism, such as muscle weakness, mus- ical or therapeutic significance due to the use or a period of increased physical activi- cle tightness or patellar hypermobility. The variability in physiological function among ty. Interestingly, females with a high physi- clinician should also evaluate for discrepan- normal individuals. cal activity level did not report more pain cies in leg length and intrinsic foot imbal- than those with a lower activity level.18 This ances. If an intrinsic foot imbalance exists, Hip muscle weakness orthotics may be included as part of an suggests that a drastic increase or change in 63 While hip muscle weakness is not activity is the stimulus leading to PFPS effective treatment program. If malalign- directly associated with the patellofemoral development rather than a consistently high ment of the lower extremity is observed, joint, it is often associated with PFPS. The level of activity. mobilizing techniques and a formal exercise kinetic chain theory states that dysfunction and stretching program can be used to cor- of a joint can manifest injuries in other rect postural and movement dysfunction.20 joints, most usually those distal to the Additionally, the clinician can incorporate 5 34 affected joint. It has been demonstrated Clinical evaluation functional performance tests which include that during running, females exhibit signifi- anteromedial lunge, step-down, single-leg cantly greater external knee valgus move- Females (62% of cases) are at a signifi- press, bilateral squat, balance and reach to ment and hip internal rotation than Non-commercialmales.40 cantly greater risk of experiencing further assess patient progress.64 The ability to control and prevent these patellofemoral pain syndrome than males The patella should be evaluated for motions relies on the strength of the proxi- (38% of cases).55 Anatomic, hormonal fac- glide, medial and lateral tilt, anterior and mal muscle groups that are antagonistic to tors and knee laxity, and neuromuscular fac- posterior tilt, and rotation. Exam findings these movements. If there is not sufficient tors contribute to the higher risk, with should be compared to the contralateral nor- proximal strength, the femur may adduct or anatomic factors being the most commonly mal side as some patients have excessive internally rotate, which in turn increases lat- discussed.56,57 One of the neuromuscular laxity but without any pain. Examination eral patellar contact pressure which may factors lacking in females is hip muscle using radiographs, in particular the sunrise lead to pain.50 Ireland et al.50 reported that strength.58 Further, females have less hip view to evaluate patella tilt and CT should female PFPS patients had 26% less hip external rotation and abduction strength be used for further evaluation of patellar abduction strength and 36% less hip exter- than men. Female athletes who suffered a tracking. MRI should be utilized to rule out nal rotation strength. Other similar studies lower extremity injury during the season meniscal, ligamentous or cartilage patholo- conducted in a sample of females reported had a significant deficit in hip abduction gy. The condition of the non-muscular tis- results that were in agreement with this and external rotation strength compared to sue around the patellofemoral joint must study.51,52 injured controls.59 Excessive femoral also be examined. The medio-lateral dis- adduction and internal rotation may placement test allows the clinician to reli- Gluteal muscle activation increase the dynamic quadriceps angle and ably test the mobility of the patella and to It has been shown that altered hip joint lead to greater lateral patellar contact pres- determine whether it is normal, hypermo- kinematics is demonstrated in patients with sure.28 In order to evaluate PFPS, the clini- bile or hypomobile. Previous studies show a

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possible link between the role of the men- Sinding Larsen’s disease, Osgood developing rehabilitation programs for strual phase and hormonal factors in the Schlatter’s disease, and neuromas. females with PFPS.68 Adding a core muscle- development of PFPS. An increase in knee Patellar subluxation, dislocation, or strengthening program to the conventional laxity and other ligament mechanical prop- prior surgery may lead to articular cartilage physical therapy management can help erties caused by fluctuations in female sex injury which also results in anterior knee improve pain and dynamic balance hormones may increase the risk of ACL pain. Risk factors for PFPS in females in female patients with patellofemoral pain injuries and PFPS.65 Tenan et al.57 showed include overuse, trauma, muscle dysfunc- syndrome.69 DeHaven et al.10 reported that that the vastus medialis and vastus medialis tion, tight lateral restraints, patellar hyper- 89% of athletes were able to return to athlet- oblique initial firing rates vary throughout mobility, and poor quadriceps flexibility ic activity after a treatment program that the menstrual cycle. (Table 2). consisted of symptomatic control, a pro- gressive resistance program of isotonic hamstrings and isometric quadriceps exercises, a graduated running program and a Diagnosis Treatment approaches maintenance program. Reduction of loading to the patellofemoral joint and surrounding PFPS is a common cause for anterior Most treatment approaches for PFPS soft tissues by limiting exercise is primary knee pain and mainly affects young women are conservative and surgical interventions to reducing pain. Substitute activities such without any structural changes or signifi- are much less common (Table 3). There are as bicycling, swimming, or elliptical should cant pathological changes in the articular a wide variety of treatment programs for be encouraged. Icing can be beneficial but cartilage. Therefore, PFPS is often known PFPS but key components involve increas- heat is generally not recommended. 66 as a diagnosis of exclusion. Patients with ing strength, flexibility, proprioception, Weakness of the hip musculature may PFPS often describe pain behind, under- endurance, function training and gradual be a risk factor for PFPS; therefore, a prox- 1 8 neath, or around the patella. The symptoms progression. A multimodal nonoperative imal strengthening program is recommend- are usually gradual and pain in the anterior therapy with short-term use of NSAIDs, ed. In a study by Earl et al.,70 nineteen knee is the primary symptom of PFPS, medially directed tape, and complex exer- femalesonly with PFPS participated in an eight- although some patients also report instabili- cise programs with the inclusion of the core, week program aimed at strengthening the ty and crepitation of the patellofemoral lower extremity, and hip and trunk muscles hip and core musculature and improving joint, specifically during loading of the joint has been shown to be the best course of dynamic malalignment. They reported sig- 8 and palpation of the patella. The pain treatment. nificant improvements in pain, functional increases after prolonged sitting, squatting, use ability, lateral core endurance, hip abduc- kneeling and stair climbing. PFPS is Non-surgical interventions tion and hip external rotation strength. They defined as anterior knee pain or retropatel- Females with PFPS had lower eccentric also observed a significant decrease in knee lar pain after at least two of these activities: hip abduction and adduction peak torque abduction moment during running. These ascending and descending stairs, hopping, and higher eccentric adduction to abduction results suggest that an exercise plan that jogging, prolonged sitting, kneeling and torque ratios when compared with controls. focuses on strengthening and improving squatting.67 PFPS also excludes peripatellar Thus, clinicians should consider eccentric neuromuscular control of the hip and core tendonitis or bursitis, plica syndromes, hip abduction strengthening exercises when muscles produces positive results in female

Table 1. Patellofemoral pain syndrome (PFPS): summary. Definition of PFPS 1) Retropatellar pain during stairs, hopping/jogging, prolonged sitting, kneeling, squatting. 2) Negative findings on examination of knee ligament, menisci, bursa, synovial plica. 3) Pain on palpation of patellar facets, femoral condyles. Incidence/Prevalence 1) Females are twice as likely to develop PFPS compared to males. 2) 70% of cases are between the ages of 16 and 25

Table 2. Reasons for increased Non-commercialsusceptibility of patellofemoral pain syndrome in females. Increase static q-angle Increase dynamic Knee valgus angle; hip internal rotation angle; hip abduction moment; knee valgus moment Decrease dynamic Knee flexion angle Weaker strength of Quadriceps; hip external rotation; hip extension; hip abducto

Table 3. Patellofemoral pain syndrome treatment options. Surgical Non-surgical Lateral Retinacular Release Relative Rest Proximal Realignment Procedures Physical Therapy Distal Realignment Procedures Proximal Strengthening Elevation of Tibial Tubercle Gait Retraining Anteromedial Tibial Tubercle Transfer & Elevation Analgesics Articular Cartilage Procedures Bracing Patellectomy Patellar Taping

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patients, improves the strength of the hip found that the lateral release effectively and core muscles, and reduces knee abduc- reduces abnormal patella tilt.77 Fabbriciani Conclusions tion moment, all of which are associated et al.78 found 71% of all patients with 70 PFPS is one of the most common knee with the development of PFPS. patellofemoral pain and presence of patella complaints in young healthy female ath- There is a large amount of evidence that tilt had satisfactory outcomes after the later- letes. However, both researchers and clini- PFPS is at least partially due to faulty al release procedure. There is a fine balance 71 cians struggle to understand the factors that mechanics of the lower extremity. Over between too little of a release that will cause underlie PFPS because PFPS is often multi- time, repetitive exposure to motions such as persistent pain or too much release that may factorial in nature and may vary from increased hip adduction and femoral inter- result in medial patella instability.79 patient to patient. From a review of the cur- nal rotation may damage or overload the Additionally, this procedure is not recom- rent literature, it is clear that there needs to cartilage in the knee joint, which leads to mended for very young patients, those with 71 have further research on PFPS in order to the chronic pain of PFPS. The goal of gait advanced patellofemoral osteoarthrosis or better understand the complex etiology of retraining involves adopting new gait pat- patients with normal patellar tracking or this disorder in both males and females. terns and it can be a successful therapy for patellar tilt. Females with patellofemoral pain syndrome reducing pain and improving function in Proximal realignment procedures are demonstrate a decrease in abduction, exter- PFPS patients as well as long-term rarely used but are indicated for skeletally nal rotation and extension strength of the improvements. immature patients with a history of recur- affected side compared with healthy con- Although nonsteroidal anti-inflammato- rent dislocations, patients with an increased trols.48 Due to the complex nature of PFPS, ry drugs (NSAIDs) are commonly pre- congruence angle and patients with dysplas- a multitude of treatment approaches have scribed for patients with PFPS, there is little tic femoral trochlea and poor medial patel- 72 been suggested. However, there is not yet a evidence supporting their effectiveness. lar support of the vastus medialis obliquus clear consensus among clinicians regarding NSAIDs or acetaminophen may be consid- muscle which leads to recurrent patellar the optimal treatment of PFPS. Factors con- ered for patients whose symptoms cannot subluxations or dislocations.80 tributing to PFPS include lower extremity be reduced by icing. Furthermore, a variety Distal realignment or tibial tubercle malalignment, patellofemoral tilt or bal- of braces, sleeves, and straps have been osteotomy procedures are generally per- ance,only muscle imbalance, and soft tissue or used in the treatment of PFPS. Although formed on patients with recurrent patellar cartilage abnormalities. Optimizing the bracing alone may provide some sympto- dislocation or subluxation. Indications for muscle balance between the vastus medialis matic relief, studies have not found a bene- distal realignment procedures include per- and lateralis around the patella with formal fit when bracing is used in addition to phys- sistent patellofemoral pain coupled with 73 and home directed therapy should be the ical therapy. excessive patellar tilt, subluxationuse or first line of treatment in patients presenting The recommended approach for patellar increased congruence angle, as well as lat- 74 with PFPS. Surgery should be reserved for taping described by McConnell is widely eral facet osteoarthrosis in the setting of 75 patients with persistent knee pain with cited in treatments for PFPS. Werner et al. increased distance between the Tibial defined lesions within the knee, abnormal found that patients who had patellar hyper- Tubercle and the Trochlea Groove (TT-TG). tilt, and malalignment despite trying all mobility were able to increase their knee Less than 10% of all patients with PFPS avenues of conservative treatment options. extensor torque by taping. In contrast, will need a distal realignment procedure. Cerny et al.76 reported that the ratio of vas- There are several methods for distal realign- tus medialis obliquus to vastus lateralis as ment, with the most common one being the measured by elecrtromyographic activity Fulkerson osteotomy. A 5 to 7 cm bone References was not improved with patellar taping. pedicle is osteotomized at the distal tibial Hence further research is needed to deter- tubercle and the pedicle is moved both ante- 1. Rixe JA, Glick JE, Brady J, Olympia mine whether patellar taping is beneficial in riorly and medially. The amount of anterior- RP. A review of the management of the treatment of PFPS. ization versus medialization is dependent patellofemoral pain syndrome. Phys on the steepness of the osteotomy cut. The Sportsmed 2013;41:19-28. Operative intervention other classic distal realignment also 2. Taunton JE, Ryan MB, Clement DB, et Although surgical interventions Non-commercialare typ- includes the Elmslie-Trillat procedure and al. A retrospective case-control analysis ically not performed due to a wide range of Hauser procedure which involves medial of 2002 running injuries. Br J Sports effective conservative treatments available translation of the distal tibial tubercle with- Med 2002;36:95-101. for PFPS, there are a number of surgical out anterior translation. The Maquet proce- 3. Tecklenburg K, Dejour D, Hoser C, procedures that can be performed. Most of dure involves anterior translation of the tib- Fink C. Bony and cartilaginous anato- these surgical interventions aim at treating ial tubercle without medialization to my of the patellofemoral joint. Knee malalignment or injured cartilage. Surgical decrease patellofemoral contact forces. Surg Sports Traumatol Arthrosc consultation for PFPS may be considered Concomitant articular cartilage procedures 2006;14:235-40. for those patients whose symptoms persist may also be indicated and include open or 4. Horton MG, Hall TL. Quadriceps despite completing 6-12 months of conser- arthroscopic shaving of the patella, local femoris muscle angle: normal values vative management with both formal and excision of defects with drilling of the sub- and relationships with gender and home exercises and rehabilitation. chondral bone, and transplantation of autol- selected skeletal measures. Phys Ther Lateral retinacular release is performed ogous chondrocytes or osteochondral allo- 1989;69:897-901. when there is lateral compression syndrome graft procedures.81 Indications for these pro- 5.Devereaux MD, Lachmann SM. with tenderness and tightness of the lateral cedures are dependent on the status of the Patello-femoral arthralgia in athletes retinaculum which is combined with lateral cartilage at the time of surgery and is attending a Sports Injury Clinic. Br J patellar tilt.67 Fulkerson et al used CT beyond the scope of this review article. Sports Med 1984;18:18-21. images to compare patella tilt in patients 6.Collado H, Fredericson M. before and after the lateral release and Patellofemoral pain syndrome. Clin

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