Patellofemoral pain syndrome
|Patellofemoral pain syndrome|
|Classification and external resources|
Patellofemoral pain syndrome (PFPS) is a syndrome characterized by pain or discomfort seemingly originating from the contact of the posterior surface of the patella (back of the kneecap) with the femur (thigh bone). It is a frequently encountered diagnosis in sports medicine clinics.
The cause of pain and dysfunction often results from either abnormal forces (e.g. increased pull of the lateral quadriceps retinaculum with acute or chronic lateral PF subluxation/dislocation) or prolonged repetitive compressive or shearing forces (running or jumping) on the PF joint. The result is thinning and softening (chondromalacia) of the articular cartilage under the patella and/or on the medial or lateral femoral condyles, synovial irritation and inflammation and subchondral bony changes in the distal femur or patella known as "bone bruises". Secondary causes of PF Syndrome are fractures, internal knee derangement, Osteoarthritis of the knee and bony tumors in or around the knee.
As patellofemoral pain syndrome is the most common cause of anterior knee pain in the outpatient, a variety of treatments for patellofemoral pain syndrome are implemented. However, there is little supporting evidence. Most patients with patellofemoral pain syndrome respond well to conservative therapy.
A 2011 systematic review stated that evidence supports the use of quadriceps exercise for managing patellofemoral pain syndrome and that quadriceps strengthening is considered to be the "gold" standard treatment for patellofemoral pain syndrome. Various exercises have been studied and recommended.
Quadriceps strengthening is commonly suggested because the quadriceps muscles help to stabilize the patella. Quadriceps weakness and quadriceps muscle imbalance may contribute to abnormal patellar tracking. If the strength of the vastus medialis muscle is inadequate, the usually larger and stronger vastus lateralis muscle will pull sideways (laterally) on the kneecap. Strengthening the vastus medialis to prevent or counter the lateral force of the vastus lateralis is one way of relieving PFPS. Moderate evidence supports the addition of hip abductor and external rotator strengthening, as well as exercises targeting hip flexion and hip extension. When executing these exercises, proper form is very important in order to ensure that the musculature is activated in such a way that will not lead to further injury. Inflexibility has often been cited as a source of patellofemoral pain syndrome. Stretching of the hip, hamstring, calf, and iliotibial band may help restore proper biomechanics.[improper synthesis?] Furthermore, the use of a foam roller may help to add flexibility and relieve pain from sore or stiff muscles in the leg.
A 2013 study showed that high-dose, high-repetition medical exercise therapy was associated with a decrease in pain and an increase in functional outcome measures (P<0.05).
Magnetic resonance imaging rarely can give useful information for managing patellofemoral pain syndrome and treatment should focus on exercise. In the uncommon cases where a patient has mechanical symptoms like a locked knee, knee effusion, or failure to improve following physical therapy, then an MRI may give more insight into planning treatment.
Patellofemoral pain syndrome may also result from overuse or overload of the PF joint. For this reason, knee activity should be reduced until the pain is resolved. Those with pain originating from sitting too long should straighten the leg or walk periodically. Those who engage in high impact activity such as running should consider a nonimpact activity such as swimming or aerobics on an elliptical machine.
Ice and medication
To reduce inflammation, ice can be applied to the PF joint after an activity. The ice should be kept in place for 10 to 15 minutes. Additionally anti-inflammatory drugs such as NSAIDs can also be taken immediately after an activity or judicious use during daily activities and for those people whose symptoms aren't controlled with ice.
Orthosis and taping
In addition to physical therapy, external devices such as patellofemoral knee orthosis and tape could be used to stabilize the knee. Current medical evidence is not sufficient to describe the extent to which athletic taping has effects in treating patellofemoral pain.
These orthoses will not correct the underlying source but may prevent further injury. For this reason, they should be used in conjunction with and not in lieu of physical therapy. The technique of McConnell taping involves pulling the patella medially with tape (medial glide). The underlying goal of taping is multifaceted and intended to correct the position of the patella, increase vastus medialis oblique activation, and stretch the tight lateral structures of the patella leading to pain reduction and facilitating strengthening exercises of the quadriceps. Studies have shown that patella taping may reduce pain and potentially increase the activity of the VMO, however the underlying mechanisms of taping are not clearly understood. Findings from some studies suggest that there is limited benefit with patella taping or bracing when compared to quadriceps exercises alone.
Low arches can cause overpronation or the feet to roll inward too much increasing the Q angle and genu valgum. Poor lower extremity biomechanics may cause stress on the knees and ultimately patellofemoral pain syndrome. Stability or motion control shoes are designed for people with pronation issues. Arch supports and custom orthotics may also help to improve lower extremity biomechanics.
Specific populations at high risk of primary Patellofemoral Syndrome include runners, bicyclists, basketball players, young athletes and females. Typically patients will complain of anterior knee pain or giving away of the knee which is exacerbated by sports, walking, stair climbing, or sitting for a long time, often called the "Theater Sign" or "Movie-Goers Sign." The pain from prolonged sitting is thought to occur because of the constant pull of the quadriceps muscle on the knee cap while sitting, which causes its impaction against the hard and unyielding surfaces of the bones of knee joint. Descending stairs may be worse than ascending. Unless there is an underlying pathology in the knee, swelling is usually mild to nil. Palpation, as well, is usually unremarkable.
- Plamondon, Tom (12 Aug 2009). "Special tests in the clinical examination of patellofemoral syndrome". Doctors Lounge. Retrieved 2012-08-20.[self-published source?]
- Prins, Maarten R.; Van Der Wurff, Peter (2009). "Females with patellofemoral pain syndrome have weak hip muscles: A systematic review". Australian Journal of Physiotherapy 55 (1): 9–15. doi:10.1016/S0004-9514(09)70055-8. PMID 19226237.
- Dixit, S., Difiori, J. P., Burton, M., & Mines, B. (2007). Management of patellofemoral pain syndrome. American family physician, 75(2).
- Bolgla, LA; Boling, MC (2011). "An update for the conservative management of patellofemoral pain syndrome: A systematic review of the literature from 2000 to 2010". International journal of sports physical therapy 6 (2): 112–25. PMC 3109895. PMID 21713229.
- Earl, JE; Vetter, CS (Aug 2007). "Patellofemoral pain". Physical medicine and rehabilitation clinics of North America 18 (3): 439–58, viii. doi:10.1016/j.pmr.2007.05.004. PMID 17678761.
- van der Heijden, Rianne A; Lankhorst, Nienke E; van Linschoten, Robbart; Bierma-Zeinstra, Sita MA; van Middelkoop, Marienke; van Middelkoop, Marienke (2013). Exercise for treating patellofemoral pain syndrome. doi:10.1002/14651858.CD010387.
- Putra, BE; Sutarina, N (2014). "Combination of hip‑quadriceps strengthening exercise: Is it more potential than single conventional strengthening exercise to reduce pain in patellofemoral pain syndrome patients?". Saudi Journal of Sports Medicine 14 (1): 9–13. doi:10.4103/1319-6308.131579.
- Thomeé, R.; Renström, P.; Karlsson, J.; Grimby, G. (2007). "Patellofemoral pain syndrome in young women". Scandinavian Journal of Medicine & Science in Sports 5 (4): 237–44. doi:10.1111/j.1600-0838.1995.tb00040. PMID 7552769.
- Tria Jr, AJ; Palumbo, RC; Alicea, JA (1992). "Conservative care for patellofemoral pain". The Orthopedic clinics of North America 23 (4): 545–54. PMID 1408039.
- Kannus, Pekka; Niittymäki, Seppo (1994). "Which factors predict outcome in the nonoperative treatment of patellofemoral pain syndrome? A prospective follow-up study". Medicine & Science in Sports & Exercise 26 (3): 289–96. doi:10.1249/00005768-199403000-00004. PMID 8183092.
- Natri, Antero; Kannus, Pekka; Järvinen, Markku (1998). "Which factors predict the long-term outcome in chronic patellofemoral pain syndrome? A 7-yr prospective follow-up study". Medicine & Science in Sports & Exercise 30 (11): 1572–7. doi:10.1097/00005768-199811000-00003. PMID 9813868.
- Zappala, FG; Taffel, CB; Scuderi, GR (1992). "Rehabilitation of patellofemoral joint disorders". The Orthopedic clinics of North America 23 (4): 555–66. PMID 1408040.
- Callaghan, Michael J.; Oldham, Jacqueline A. (1996). "The Role of Quadriceps Exercise in the Treatment of Patellofemoral Pain Syndrome". Sports Medicine 21 (5): 384–91. doi:10.2165/00007256-199621050-00005. PMID 8724204.
- Douciette, S. A.; Goble, E. M. (1992). "The effect of exercise on patellar tracking in lateral patellar compression syndrome". The American Journal of Sports Medicine 20 (4): 434–40. doi:10.1177/036354659202000412. PMID 1415887.
- Labrier, Karen; Oʼneill, Daniel B. (1993). "Patellofemoral Stress Syndrome". Sports Medicine 16 (6): 449–59. doi:10.2165/00007256-199316060-00007. PMID 8303143.
- O'Neill, D. B.; Micheli, L. J.; Warner, J. P. (1992). "Patellofemoral stress: A prospective analysis of exercise treatment in adolescents and adults". The American Journal of Sports Medicine 20 (2): 151–6. doi:10.1177/036354659202000210. PMID 1558242.
- Cerny, K (1995). "Vastus medialis oblique/vastus lateralis muscle activity ratios for selected exercises in persons with and without patellofemoral pain syndrome". Physical therapy 75 (8): 672–83. PMID 7644571.
- Powers, CM; Landel, R; Perry, J (1996). "Timing and intensity of vastus muscle activity during functional activities in subjects with and without patellofemoral pain". Physical therapy 76 (9): 946–55; discussion 956–67. PMID 8790273.
- Laprade, J; Culham, E; Brouwer, B (1998). "Comparison of five isometric exercises in the recruitment of the vastus medialis oblique in persons with and without patellofemoral pain syndrome". The Journal of orthopaedic and sports physical therapy 27 (3): 197–204. doi:10.2519/jospt.19184.108.40.206. PMID 9513865.
- Mirzabeigi, E; Jordan, C; Gronley, JK; Rockowitz, NL; Perry, J (1999). "Isolation of the vastus medialis oblique muscle during exercise". The American journal of sports medicine 27 (1): 50–3. PMID 9934418.
- Puniello, MS (1993). "Iliotibial band tightness and medial patellar glide in patients with patellofemoral dysfunction". The Journal of orthopaedic and sports physical therapy 17 (3): 144–8. doi:10.2519/jospt.19220.127.116.11. PMID 8472078.
- Winslow, J; Yoder, E (1995). "Patellofemoral pain in female ballet dancers: Correlation with iliotibial band tightness and tibial external rotation". The Journal of orthopaedic and sports physical therapy 22 (1): 18–21. doi:10.2519/jospt.1918.104.22.168. PMID 7550298.
- Osterås B, et al. Physiotherapy. 10 Jun 2013. [Epub ahead of print]
- American Medical Society for Sports Medicine (24 April 2014), "Five Things Physicians and Patients Should Question", Choosing Wisely: an initiative of the ABIM Foundation (American Association of Blood Banks), retrieved 29 July 2014, which cites
- Yeung, Simon S; Yeung, Ella W; Gillespie, Lesley D; Yeung, Simon S (2011). Interventions for preventing lower limb soft-tissue running injuries. doi:10.1002/14651858.CD001256.pub2.
- Bockrath, Kelly; Wooden, Cindi; Worrell, Teddy; Ingersoll, Christopher D.; Farr, Jack (1993). "Effects of patella taping on patella position and perceived pain". Medicine & Science in Sports & Exercise 25 (9): 989–92. doi:10.1249/00005768-199309000-00003. PMID 8231783.
- Powers, CM; Landel, R; Sosnick, T; Kirby, J; Mengel, K; Cheney, A; Perry, J (1997). "The effects of patellar taping on stride characteristics and joint motion in subjects with patellofemoral pain". The Journal of orthopaedic and sports physical therapy 26 (6): 286–91. doi:10.2519/jospt.1922.214.171.1246. PMID 9402564.
- Gross, M. L.; Davlin, L. B.; Evanski, P. M. (1991). "Effectiveness of orthotic shoe inserts in the long-distance runner". The American Journal of Sports Medicine 19 (4): 409–12. doi:10.1177/036354659101900416. PMID 1897659.
- Eng, JJ; Pierrynowski, MR (1993). "Evaluation of soft foot orthotics in the treatment of patellofemoral pain syndrome". Physical therapy 73 (2): 62–8; discussion 68–70. PMID 8421719.
- http://www.healthhype.com/knee-cap-pain-causes-and-treatment.html[full citation needed]
- Patient handout for patellofemoral pain syndrome by the American Academy of Family Physicians
- Runner's Knee Prescribe Treatments for patellofemoral syndrome on PrescribeExercise.com
- Patellofemoral Pain Syndrome by the Institute for Physical and Sports Therapy
- Patellofemoral Pain on patient.co.uk
- Patellofemoral Syndrome at eMedicine
- Patellofemoral Joint Syndromes Treatment & Management at eMedicine