(3) Pathologies of the patellofemoral complex Flashcards

1
Q

What is the function of the patella?

A
  • increases the mvmt of the quadriceps muscle
  • bony protection
  • reduces compressive forces on the quads tendon with resisted knee extension
  • allows the transfer of forces evenly on underlying bone
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2
Q

What is Patellar Tendinopathy?

A
  • Repetitive stress/loading of extensor mechanism (“Jumpers Knee”)
  • Degenerative > Inflammatory
  • Loss of arrangements of collagen bundles
  • Clefts between bundles filled with mucoid ground substance
  • Increased fibroblasts
  • Neovascularization
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3
Q

What are the risk factors for developing PT?

A
  • Genetics & bone structure
  • Age
  • Sudden increase in activity/intensity
  • Training volume
  • Increased BMI
  • Decreased quads/hams flexibility
  • Decreased quad strength
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4
Q

How does overuse tendinopathy develop (Pathogenesis)?

A
  • Shear stress applied to tendon (rupture if excessive)
  • Micro tears leading to inflammatory process
  • Acute Inflammation = Tendinitis
  • Neovascularization & nerve growth
  • Collagen reorganization
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5
Q

What are the signs of tendinosis?

A
  • Swelling
  • Localized pain on palpation
  • Pain on tendon loading
  • Stiffness
  • Crepitus
  • Decreased strength
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6
Q

What are the clinical signs of PT on examination?

A

c/o Pain:
- sudden/gradual onset - localized
- intermittent
- activity related
o/e Pain on:
- resisted extension
- single leg squat
- palpation inf. pole/proximal tendon (in full extension)
- +ve Royal London Hospital test

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7
Q

What is the Royal London Hospital Test?

A
  • with knee fully extended, local tenderness with palpation of tendon
  • tender portion re-palpated with knee flexed 90 degrees
  • +ve pain reduced or absent with knee flexion
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8
Q

What is the treatment for PT?

A
  • Activity modification (load management)
  • Maintain CV and pulmonary fitness
  • Ice/heat/massage
  • Corticosteroid/surgery (advise against)
  • Isometric contractions in mid range as tolerated
  • Voluntary contractions 70% max held 45 to 60 seconds (4 times twice/day)
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9
Q

What are the exercise rehab options for PT?

A
  • Eccentric training programme
  • Heavy slow resistance (HSR) training
  • 4-stage rehab programme
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10
Q

What is the eccentric training programme for PT?

A
  • 25 degree decline squat
  • Single leg eccentric squats
  • Concentric phase of squat
  • 3 sets of 15 reps twice/day
  • 7 days/week for ~12weeks
    However….
  • may be pain provocative if high irritability
  • ignores other kinetic chain issues
  • limited evidence
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11
Q

What is HSR training for PT?

A

Consists of:
- concentric/eccentric
- leg press
- squats and hack squats
- uses both lower extremities
- Progress 15RM to 6RM for 3/4 sets
- 3 times/week for 12/52
- involves high loads (70-85% of 1RM)
*1RM testing difficult due to pain

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12
Q

What is the 4 stage rehab programme for PT?

A

Stage 1 Isometric loading:
- initiate if more than min pain during isotonic exercises
- 5 reps 45 secs 2 to 3times/day

Stage 2 Isotonic loading:
- initiate if minimal pain during isotonic exercise
- 3 to 4 sets 15RM (progress to 6RM)
- Every second day
- fatiguing load

Stage 3 Energy-storage loading
- initiate if adequate strength and load tolerance
- progressively develop volume and then intensity to replicate sport

Stage 4 RTP
- initiate if load tolerance to energy storage exercises progression replicates sport
- progressively add training drills

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13
Q

What is Patellofemoral Pain Syndrome (PFPS)?

A
  • pain from patellofemoral junction
  • previously “Anterior knee pain”
  • female > male
  • recurrent/longstanding
  • decreased QOL and functioning
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14
Q

What are the risk factors of PFPS?

A
  • femoral anteversion
  • external tibial torsion
  • muscle imbalances (short/tight vs long/weak)
  • Abd/quads weakness
  • tight hamstring
  • tight iliopsoas and quads
  • tight iliotibial band
  • tight gastrosoleus complex
  • volume of activity
  • environment
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15
Q

How do you test for hamstring tightness?

A

Passive knee extension test
- +ve knee extension >20

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16
Q

How would you test for iliopsoas and quadriceps tightness?

A

Modified Thomas test
- +ve iliopsoas inability of opposite thigh drop to neutral/below
- +ve quads knee flexion >80

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17
Q

How would you test for tightness of the iliotibial band?

A

Ober test
- +ve if leg remains abducted position

18
Q

What are the clinical signs of PFPS on examination?

A

c/o
- pain anteriorly
- Agg. compressive forces (stairs, prolonged sitting, squatting)
- Crepitus
- giving way
o/e
- little to find
- +ve Clarkes’s test
- pain single leg squat
- pain on resisted quads

19
Q

What is the treatment for PFPS?

A
  • stretching/strengthening programs
  • taping and bracing strategies
  • activity modification
  • orthotics
  • education/rehab
  • avoid “wait and see” approach
20
Q

What is chondromalacia patella?

A
  • Different to PFPS
  • Softening of articular cartilage on articular groove surface of patella
  • +/- trochlear groove
  • fissuring and erosion
  • Diminished load capability
21
Q

What are the clinical signs of chondromalacia patella on examination?

A

c/o
- pain (anterior)
- crepitus
- swelling
o/e
- Same as PFPS
- pain on single leg squat
- +/- pain on resisted quads

22
Q

What are the patella’s different planes of motion?

A
  • flexion-extension
  • medial-lateral patellar tilt
  • medial-lateral rotation
  • medial-lateral patellar shift
23
Q

What is patellofemoral stability dependent on?

A

Osseous anatomy
- trochlea femur, patella position etc

Transverse stabilizers
- VM/VL muscles, ITB, MPFL, retinaculum

Longitudinal stabilizers
- extensor mechanism

24
Q

What are the causes for Patellofemoral Instability?

A
  • lateral instability
  • subluxation
  • dislocation
  • traumatic (+/- recurrent)
  • MoI: non contact twisting with knee extended and external rotation of foot
  • non-traumatic: ligamentous laxity +/- PFPS presentation
25
What are the risk factors for recurrent instability?
- female> - FHx patellar instability - Anatomical (anteversion, rotation etc)
26
What are the clinical signs of patellofemoral instability on examination?
c/o - pain (anterior) - instability - agg. stairs, running, jumping o/e - squinting patellae - +ve J sign - +ve Clarkes (patella grind test) - +ve patellar apprehension sign - decreased bulk/activity - +ve patellar glide test
27
What is the treatment for patellofemoral instability?
- Rx what you find (little evidence) - advice & education - gluts/quads/VMO exercises - muscle imbalance & gait correction - functional & sports specific rehab - taping and braces - Not improved: ortho
28
What is the calf composed of?
- Gastrocnemius - Soleus - Achilles tendon - Myotendinous Junction (MTJ)
29
What are common causes of calf injuries?
- Sudden ballistic foot mvmt from dorsiflexion to plantar flex in knee ext (Gastroc) - Contraction of tensioned muscle can abruptly tear/rupture medial head of gastroc - medial > lateral head - Overuse - Soleus -
30
What are the clinical signs of calf injuries on examination?
c/o - sudden pain - swelling - pop? o/e - pain/weak resisted PF/calf raise - palpation - local pain (belly, MTJ)
31
What is the treatment for calf injuries?
Acute (1-2 weeks) - POLICE (crutches, heel raise) Subacute - stretches, strengthen, proprioception - progression (RTP)
32
Describe a rehab protocol for a calf strain
Week 1 - PRICE Week 2-3 - ice, ROM 10-20 reps 2 times/day, NO stretching Week 4-6 - Theraband, stationary cycle, slow treadmill walking, gentle pain free stretching twice a day Week 7-12 - 'Toe raising progression', stationary cycle, gentle stretching, start return to full speed Week 12+ - Start RTP
33
What is deep vein thrombosis (DVT)?
A condition where blood clots form in veins located deep inside the body, causing pain and swelling
34
What are risks for developing DVT?
- injury to vein - major surgery (abdomen, pelvis, LL) - bed rest - limb immobilization - contraceptive pill - past hx DVT
35
What are the signs and symptoms of DVT?
- Midline calf tenderness - Homan's sign (pain on passive DF) - Pain - Redness - Swelling & Warmth
36
What is Medial Tibial Stress Syndrome?
It is a pain along the posteromedial border of the tibia, also referred to as "shin-splints"
37
What are the causes of medial tibial stress syndrome?
- Tibial bone overload - Repetitive loading stress or muscle traction during running and jumping - inflammatory traction - periostitis - changes in training - hard/uneven surfaces - over-pronation & leg length discrepancy
38
What can be expected on clinical examination of medial tibial stress syndrome?
c/o - dull pain middle/distal third posteromedial tibial border - agg: exercise - ease: rest o/e - pain on palpation - provoke pre appointment? - very focal tenderness
39
What is the rehab protocol for medial tibial stress syndrome?
- 2-6/52 rest (acute) - advice and education - activity modification - address modifiable 'risk factors' - graded return to running protocol
40
What is Chronic Exertional Compartment Syndrome?
It is an increased pressure within a closed anatomical space which compromises the circulation and function of tissues within that space
41
What is expected to be found on clinical examination of chronic exertional compartment syndrome?
c/o - usually bilateral lower leg - posterior compartment = calf - anterior compartment = antero-lateral lower leg - pain exercise - ease: rest o/e - little to find initially - exacerbate pre appointment - swollen, enlarged, bulge appearance - palpation = pain/tight
42
What is the treatment for chronic exertional compartment syndrome?
- live with it - advice on activity modification - stretch/massage - surgery (decompression)