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Aim of Session
Understand patellofemoral pain syndrome Quick tests that can be used in a general practice setting (full assessment 45mins) (How to examine the knee) How to differentiate it from patellar tendinopathy and tibiofemoral pathology and fat pad impingement How to treat PFPS
Patellofemoral Pain
Rewarding to treat Usually easy to diagnose Model required
is the term used to embrace all retropatellar and peripatellar pain in the absence of other pathologies Patellofemoral pain is caused by overload or injury to the joint secondary to
Bony
malalignment/morphology hip and knee Overuse Trauma Muscle imbalance hip or quadriceps Poor lower limb biomechanics Combination of these
Not to be Missed
Slipped Capital Femoral Epiphysis
Osteochondrits Dissecans
Perthes Disease
Tumor
History
(up and down) Sometimes walking and particularly hills Prolonged sitting
? Value of X-Rays
Imaging
Doesnt prove diagnosis Malalignment on films is a risk factor but not diagnostic proof Frequently misses OCD Doesnt change conservative management Usual views of AP, lateral and Skyline not sensitive to early changes or tracking Tracking is a dynamic thing and a single image is a poor representation CT with contracted quadriceps more useful
Practical Session
Quick tests
Squat
Tests
for effusion Passive movement of the knee Resisted leg extension at 0, 20,45,90,120 Differentiation
Practical Session
Hip assessment Leg Length assessment Knee examination Patella biomechanics Functional tests Observation/measurement of thigh girth/vmo bulk/vmo emg/vl emg testing of quadriceps throughout examination Palpation for tenderness/effusion Ligaments collaterals, cruciates, patellofemoral Range of motion Patellofemoral tests medial tilt and medial glide, lateral glide Response to tape
Treatment
Settle pain
Medication Taping, Bracing, activity modification, Correction of quadriceps imbalance (Neptune et al 2000
Clinical Biomechanics)
Correction of biomechanics
Lateral retinacular stretches (NHMRC guidelines) ?Hamstring and Gastrocnemius stretches Orthotics (Clinical Journal of Sports Medicine. 11(2) 103 -110 April 2001) footwear
Nisha J. et.al Twin Research and Genetic Epidemiology Unit, St. Thomas' Hospital, London, UK
Orthotics
Excessive foot pronation shown to increase internal rotation of the knee and is common with patellofemoral pain Biomecanical modelling supports the notion that they reduce patellofemoral pain in many subjects (Newton 2002) Correction of overpronation improve outcomes in the treatment of patellofemoral pain (Clinical Journal
VMO strengthening
VMO strengthening as a treatment for PFPS is supported by biomechanical studies which show lower PFJ force with stronger VMO and clinical studies which show that it is an effective treatment.
(Neptune et al 2000 Clinical Biomechanics)
Must be comfortable, closed chain where possible or open chain towards terminal extension
Tape
Shown to
Reduce
pain (Crossley etal 2002) Alter position of patella (Crossley et al 2002, Larssen et al 1995) in most people Alters vastii function Improve quadriceps strength
Patellofemoral Bracing
See handout