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Patellofemoral SMCA 2014 Handout

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Patellofemoral SMCA 2014 Handout Patellofemoral Pain Syndrome / How can a Sesamoid Bone Anterior Knee Pain / Runners’ Knee cause So Many Problems? _ n Most common cause of Patellofemoral Pain and knee pain Patella Instability n Most common symptom presenting to SM n Diagnostic challenge n Treatment controversies n Lack of evidence to support Sarah Kerslake BPHTY Ax and Rx PFPS Patellofemoral Anatomy n Multifactorial Etiology n Considering the PF joint is one of the most n Non-operative treatment is successful highly loaded joints in the human body, the prevalence of AKP is not surprising. n Strong evidence supports treatment with multimodal therapy n Anatomy: n Sesamoid bone in extensor apparatus n Routine clinical Ax of muscle strength in athletes may not detect deficits n Acts as pulley/cam in extensor mechanism n Protects the tibiofemoral joint n More challenging functional tests required n Anchored by Active and Passive elements PFPS Anatomy PFPS Anatomy n Active (Dynamic) restraints n Passive (Static) restraints n Quadriceps muscle n Bony anatomy (Facets <=> Trochlea) n Vastus Lateralis Obliquus/Longus n Quadriceps Fascia + Patellar Tendon n Rectus Femoris + Vastus Intermedius n Lateral Peripatellar Retinaculum n Vastus Medialis Obliquus/Longus n Medial Peripatellar Retinaculum, particularly n Patella Tendon the medial patellofemoral ligament n Iliotibial band n Balance between structures is v. important 1 PFPS Symptoms PFPS Pathology n Symptoms include pain, swelling, n Patellar Tracking weakness, instability, mechanical n Patellar Tendinopathy symptoms & functional impairment n Bursitis n Pain results from loading the PF n Osgood-Schlatter joint, i.e. climbing up/down stairs, n Sinding-Larsen-Johansson squatting, kneeling, and prolonged n Iliotibial Band Syndrome flexion of the knee joint n Plica Syndrome n Intrapatellar Fat Pad Syndrome PFPS Pathology Patient History n Chondral Cartilage Pathology n Pain vs Instability, or Both? n Osteochondritis Dessicans n Onset - trauma or insidious onset, +/- dislocation or instability, or overuse n Stress Fractures n Location n Trauma n Character - ache, burn, crepitus / click, sharp, n Bipartite Patella throb intermittent / prolonged n Patellar Instability n Aggravating factors - stairs, “movie theatre” n Neuromuscular Dysfunction n Swelling - none, local, or global Patellofemoral Evaluation Patellofemoral Evaluation n “A comprehensive knee, hip, n Functional testing of athletes with AKP has and lower extremity demonstrated decreased performance on evaluation including vertical jumping, anteromedial lunge, step- assessment of alignment, down, single-leg press, and balance and range of motion, lower limb reach tests. and core strength, and n Research has not definitively concluded if functional movement patterns this lower functional strength capacity is a should be completed” risk factor for, or result of, the condition. 2 Patellofemoral Screening Ax Patellofemoral Functional Ax n Knee Extensor Strength n Single Leg Squat n Hip Abductor/IR/ER Strength n Controlled n Quadriceps Muscle Length n Well- aligned n Assess depth of squat, dynamic valgus, side flexion of trunk, and pain Patellofemoral Functional Ax Patellofemoral Functional Ax n Hop Down / Single Leg Landing n Balance n Patient stands on one leg and then n On BOSU ball or foam hops off ≥20cm step and lands block, patient balances 15+cm in front of step for up to 30secs n Assess quality of movement, and n Compare movement evidence of dynamic valgus, hip quality, ROM outside drop, or rotation due to poor gluteal BOS, dynamic valgus, hip and/or core strength, lateral flexion drop or rotation, lateral of trunk, etc trunk flexion, etc. Patellofemoral Functional Ax Patellofemoral Treatment n Active Hip Extension n Relative Rest / Envelope of Function n Patient instructed to lift leg 5–10 cm off bed n Loss of homeostasis of tissues about the knee while lying prone. Palpate gluteal and n Control Inflammation hamstring muscle activation; ideally gluteals n Cryotherapy ✔ should fire first. n Anti-inflammatories / Analgesics (Topical NSAID✔, n Assess for excessive motion, lumbar lordosis or short-course of medication) to achieve lift, altered timing of hamstrings n Platelet rich plasma / Hyaluronic acid and gluteal firing, and hip or trunk flexion n Acupuncture ✔ / Dry Needling n US/TENS/Laser 3 Patellofemoral Treatment Patellofemoral Treatment n Improve Lower Extremity Biomechanics n The treatments for AKP are numerous but n Patellar Taping (✔ for pain management) lack evidence for their use, owing to n Patellofemoral Bracing insufficient research quality n Foot Orthotics n It must be borne in mind that a lack of n Stretching ✔ quality evidence for specific treatments is n Strengthening ✔ not proof that these treatments are n Daily exercise program: 2 - 4 sets of 10+ ineffective repetitions over ≤ 6 weeks Patellofemoral Treatment Patellofemoral Instability n Each patient will present with unique n 5.8/100,000 but 30/100,000 under 19 symptoms and predisposing factors years (Fithian 2004) n With improving evidence, it will become n Up to 77/100,000 in military recruits (Hsaio increasingly more straightforward to tailor 2010, Sillanpaa 2008) treatments unique to each athlete n >50% of first time dislocations è recurrent n Until such times, the use of best clinical n ≈75% of patients suffer ongoing knee pain judgment and application of available EBM n ≈90% of patients suffer chondral damage" Why does the Patella Dislocate? Anatomy of the MPFL n! Patella n! Superior half of the n! “There exists no evidence that any amount medial border of the of malalignment will cause dislocation patella unless the passive stabilizers are n! Femur damaged.” Davis and Fithian 2002 n! Inserts in the saddle between the adductor tubercle and the medial epicondyle 4 Biomechanics of the MPFL Factors Associated with PI n! Acts as a passive leash to lateral n! Anatomic translation of the patella n! Femur / tibia rotational abnormalities n! Valgus alignment n! Functions in the first 30 degrees of flexion n! High Q angle n! Anisometric n! Multiple ligamentous laxity n! Passively ‘longest’ or ‘tightest’ at 30 degrees n! Patella alta n! Trochlear dysplasia n! Loosens with flexion n! Torn/stretched MPFL n! Immature physes Factors Associated with PI What do we need to know?? n! Neuromuscular n! Injury mechanism n! Chronic VMO insufficiency/weakness n! Degree of instability n! Altered timing of quadriceps activation n! Anatomic predisposition n! Transient inadequate neuromuscular control n! Positive J-sign n! Tissue quality n! Neuromuscular control, core strength n! Alignment issues n! Bony anatomy n! Is arthrosis a big issue? Defining the Patient Population WARPS n!Strong n!Weak n!Weak n!Traumatic n!Atraumatic n!Atraumatic n!Anatomy Normal n!Risky Anatomy n!Risky Anatomy n!Instability n!Pain n!Pain n!Dislocation n!Subluxation n!Subluxation 5 STAID Neuromuscular Control n!Strong n! Alignment n! One – Legged n!Traumatic Squat n!Anatomy Normal n! Hip and Core Strength n!Instability n! Balance n!Dislocation Tissue Quality Q-Angle n! Multiple n! Q Angle ASIS to centre Ligamentous Laxity patella to tibial tubercle n! Beighton Score n! Range 8-17 degrees n! Number of n! Leg at 0, 30, 90°? Dislocations n! Quads relaxed or n! Degree of lateral contracted? Laxity n! Lateral moment acting on patella Q-Angle “J” Sign n! Intra-rater Reliability (7 studies) n! Knee fully extended n! ICC ranges from 0.22-1.0 n! Patient actively flexes knee n! Inter-rater Reliability n! Examiner observes for n! ICC ranges from 0.17-0.83 exaggerated lateral to medial n! Criterion Validity translation of the patella into n! Disagreement the trochlear groove n! Critical Appraisal n! ?Tight lateral / weak medial n! Poor quality studies (Smith 2008) structures or ?anatomy 6 Single Leg Squat Diagnostic Imaging n! Poor neuromuscular control n! AP n! Abnormal bony anatomy n! Weight bearing PA views (30 degrees) n! Dynamic J-sign n! Skyline views n! Multifactorial n! True lateral at 30 degrees n! Patellar height n! Trochlear Dysplasia n! Patellar tilt n! Arthritis Imaging – Trochlear Dysplasia Imaging n! Crossing Sign (DuJour) n! CT/MRI n! TT-TG >20mm n! Osirix n! MRI n! Newer sequences improving assessment of cartilage n! Osteochondral defects, bone bruises, torn MPFL Imaging Degree of Pain and/or Instability n! Good Intra-Observer Reliability (>0.70) n! Predominant presenting symptom instability n! tibial tubercle-trochlear groove (TT-TG) or pain (or both) n! the sulcus angle n! Chronic instability or degenerative disease n! patellotrochlear index; Insall and Salvati methods n! Subluxation or Dislocation n! the congruence angle n! Constant or Occasional n! lateral patellar displacement n! n! patellar morphology Controlled by Bracing n! Laxity testing – at 0 and 30 degrees 7 Physical Exam Physical Exam n! Rotational Alignment n! Translation n! Hip Internal/External Rotation n! 0 degrees - endpoint n! Apparent torsion n! 30 degrees - laxity n! Palpation for tenderness n! Apprehension n! Check Ligaments n! Jumpers n! Physiologic n! Patella Alta n! “Don’t touch me” n! Tilt Prehabilitation Prehabilitation n! Goal = ↑ strength ↓ symptoms n! Home Program n! EMS = adaptation of muscle fibers n! Electrical Muscle Stimulation n! PT treatment – often is either not specific or n! Phase 1 - knee-centric too challenging for the patient’s strength n! Phase 2 - hip-centric n! EMS Research: greater strength and muscle n! Daily mass recovery at 3/12 post-op; improved n! At least 6 weeks knee extension strength, improved function (Hasegawa et al 2011, Avramidis et al 2010) Rehabilitation Rehabilitation n! Same for MPFL-I and n! Protocol Phases MPFL-R n! 1. Early Post-Operative (1-4 wks) n! Therapist guided n! 2. Quads activation and Core stability n! EMS (4-12 wks) n! Phases based on n! 3. Strength and Control (6-26 wks) goals not time n! 4. Sport readiness (3–9 months) n! Patients are very variable 8 Resources n! www.banffsportmed.ca n! Prehabilitation and Rehabilitation Protocols available under “Your Injury” then Knee, Shoulder or Osteoarthritis headings n! Patient education videos available under Osteoarthritis section and Knee: anterior cruciate ligament.
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