Management of Patellofemoral Pain

Question 1

What is PFP commonly associated with?

Answer 1

women more than men and associated post ACL or meniscal injury

common in runners

Question 2

What is likely etiology for PFP?

Answer 2

repetitive micro traumas caused by:

1. posture/alignment- Q angle, pronation
2. LE Biomechanics- Hip IR, knee valgus
3. neuromuscular factors- weak glutes, quad timing

Question 3

What is a Wiberg classification?

Answer 3

shape of patella
1- normal
2- lateral facet larger
3- lateral facet largest

Question 4

When is the patella is greater contact with the femur?

Answer 4

90 degrees flexion

least contact at 0 degrees extension

Question 5

What happens if superficial oblique soft tissues are tight?

Answer 5

there will be a lateral translation of the patella

Question 6

What happens if the deep transverse soft tissues are tight?

Answer 6

there will be a lateral tilt of the patella

Question 7

Which soft tissue in the medial compartment is the biggest passive stabilizer of the patella?

Answer 7

medial patella femoral ligament

Question 8

What are active soft tissue stabilizers of the patella?

Answer 8

quadriceps

Question 9

What happens if there is swelling in the knee and its effect on the VMO?

Answer 9

only needs 20-30 ml of fluid to inhibit VMO as a result other quad muscles will pull patella laterally

Question 10

What is the primary role of the patella?

Answer 10

facilitate knee extension , w/o patella quad would have to work twice as hard

Question 11

What is typical path of the patella during movement?

Answer 11

lateral “C” shape

Question 12

What are predisposing factors of PFP?

Answer 12

gender, body weight, activity level, type of activity, biomechanical alignment (hips,feet)

Question 13

What are risk factors of PFP?

Answer 13

1. excessive pronation- increases lateral contact surface on patella
2. muscle imbalances- quad and hip muscles
3. decreased flexion angles-decreases contact area of patella

Question 14

Why are muscle imbalances a major risk factor of PFP?

Answer 14

” think of the tracks moving under the train”

train is the patella

Question 15

What is important to remember about most risk factors of PFP?

Answer 15

most of them are modifiable and should be addressed with prevention program

Question 16

What is typical PP of PFP?

Answer 16

females, insidious onset, anterior, vague, diffuse pain, limited function, quad weakness, joint crepitus, mild swelling, pain with stairs or standing up, “feels like its giving way”

Question 17

What anatomical features should PT examine during eval?

Answer 17

Q angle, genu valgum, femoral anteversion, lateral tibial tubercle

consider Q angle changes during dynamic activity

Question 18

How can you determine VMO weakness?

Answer 18

palplate and observe during quad set firing, will most likely be delayed

Question 19

What is most likely to cause PFP hips or feet?

Answer 19

most likely hips but feet can as well

Question 20

What is patella alta?

Answer 20

high unstable patella usually found in females, less then 0.8

Question 21

What is patella baja?

Answer 21

low patella likely in males causing more compression

Question 22

What is protocol for patella tendinitis?

Answer 22

NSAIDS, ice, restore ROM, restore flexibility and improve strength

Question 23

What is protocol for patella tendinosis?

Answer 23

active warm up, friction massage, stretch quad, eccentric strengthening (12 weeks)

Question 24

What is a common diagnosis with similar to PFP?

Answer 24

ITB syndrome - treated in similar ways

Question 25

What is primary function of ITB?

Answer 25

stabilize lateral hip and knee, resist hip ADD and IR, pure sagittal plane activities

Question 26

What are keys to success for PFP rehab?

Answer 26

must treat the cause and not the SX, accurate diagnosis, controlled activity and Pt education

Question 27

What should a comprehensive tx approach include?

Answer 27

strengthening , stretching, taping, foot orthotics

Question 28

Can you isolate the VMO for strength?

Answer 28

probably not but don’t really need to just improve timing of VMO and must reduce swelling

Question 29

What muscles are important to stretch for PFP?

Answer 29

rectus femoris, ITB, hamstrings, Gastroc-soleus (compensatory pronation if these are tight)

Question 30

Why is it important to treat cause and not symptoms?

Answer 30

because if you don’t correct faulty biomechanics all the strength won’t matter as problem will come back over time, strength also must be functional not just on a table

Question 31

What are indications for a lateral release surgery?

Answer 31

a soft tissue procedure, anterior knee pain, failed long conservative treatment, evidence of lateral tilt

Question 32

What are contraindications for a lateral release?

Answer 32

hypermobile pts, not for just lateral dislocations

Question 33

What are indications for a distal realignment surgery?

Answer 33

tibial tube realignment, pateller instability due to Q angle and tibial tubercle malaignment, patellar tilt and subluxations

Question 34

What are advantages and disadvantages of a distal realignment?

Answer 34

corrects subluxation and tilt and allows for more aggressive rehab

dis: does not address MPFL

Question 35

What are indications for a MPFL reconstruction?

Answer 35

lateral patella instability due to laxity of proximal medial restraints,

Question 36

What are contraindications for a MPFL reconstruction?

Answer 36

not performed for malalignment,arthrosis or pain