Patellofemoral Pain L1-2: PFP Flashcards
What is patellofemoral pain?
pain arising from the front of the knee (insidious onset)
What are 3 characteristics of patellofemoral pain?
- peripatellar or retropatellar pain
- can be medial, lateral or infrapatellar
- can be localised, or non-specific / vague
What are PFJ aggravating factors?
aggravated by activities that load the PFJ … knee flexion in WB - running, stairs, hills, squatting, sitting
PFJ sometimes has crepitus, or episodes of ___ (subluxation, quads pain inhibition)
giving way
How should PFP be diagnosed?
pain around or behind the patella, which is aggravated by at least one activity that loads the patellofemoral joint during weight bearing on a flexed knee (eg, squatting, stair ambulation, jogging/ running, hopping/jumping).
Additional criteria (not essential):
A. Crepitus or grinding sensation emanating from the patellofemoral joint during knee flexion movements
B. Tenderness on patellar facet palpation
C. Small effusion
D. Pain on sitting, rising on sitting, or straightening the knee following sitting
What are 8 possible local structures can could be potential sources of pain?
- ligament
- meniscus
- tendons
- articular cartilage (not as much- not innervated = less likely source of pain)
- medial/ lateral retinaculum
- subchondral bone
- synovium
- fat pad (highly innervated and good blood supply= source of pain)
Where are possible referred pain areas for PFP?
Differential diagnosis is essential to identify knee pain arising from sources distant to the knee
Most common referral sources are hip joint and lumbar spine
The _____, _______, and _____ caused the most pain. The _____ isn’t innervated, thus cannot be a source of pain. The underlying ______ bone can cause pain.
fat pad; anterior synovium; joint capsule; cartilage; subchondral
Adolescents with PFP may reduce physical activity. What is the effect of that?
may have implications for general & mental health, as well as cartilage health (Also for maintaining muscle strength and tendon quality. Important for maintaining cardiovascular and respiratory health.)
PFP indicates a need for___________ treatments, and treatments that will reduce ______ effectively.
early; pain
Patients with PFP who had early signs of raiographic were the strongest predictor of _______.
future definite OA
What is Grade OA?
No OP
What is Grade 1A?
Doubtful (early preliminary signs of OA): possible osteophytic lipping, doubtful JSN
What is Grade 2A?
Mild: definite osteophytes, possible JSN
What is Grade 3A?
Moderate: moderate multiple osteophytes, definite JSN, some sclerosis, possible bone contour deformity
What is Grade 4A?
Severe: large osteophytes, marked JSN, severe sclerosis, definite bony contour deformity
Based on the OA continuum, what is a pattern that is found with age and prevalence of OA?
Increasing age –> increase prevalence
Since PFP is a strong predictor of PFJ OA, what must be done?
need to intervene early in the disease process
(How do you stop PFP from worsening and becoming OA?- to prevent or delay OA –> total knee replacements)
What are signs of degenerative joint disease?
e.g. radiographic joint space narrowing, osteophytes
why is PF OA a problem? What is the prevalence compared to TF OA? How does OA affect people?
more potent source of symptoms than TFJ
OA tends to occur earlier in life than TFJ
OA structural changes are permanent impact on daily function, quality of life & economic productivity
What happens to patients who have PFJ stress and are unable to adapt to this?
Pain
How does PFJ stress increase? List 2
- Increased magnitude of PFJ force- higher loading activities (eg. jumping, squating)
- Decreased PFJ contact area
Even _______decreases in body weight can substantially reduce PFJ ______during functional activities. Give an example.
small; load
A reduction of weight of just 1 kg, is a reduction of approximately 7-8 kg on the knee.
Quadriceps torque during functional activities:
- Level walking = 0.5 x BW
- Stair climbing = 3-4 x BW
- Squat = 7-8 x BW
_______ atrophy may decrease VMO pennation angle and medial stabilising force.
Quadriceps
_______ strength deficits may be present before PFP onset, and persist, How does that relate to prevalence (and age).
Quadriceps Lower quadriceps strength in older adolescents & adults
There is altered _____ neuromuscular control and how does this affect the patella?
quadriceps; will have a lateral directed force- PFP have a laterally positioned knee Quadriceps dysfunction may be present before PFP onset, and persist
________ onset of ___ vs ____ was a risk factor for PFP development
Delayed; VMO; VL
Why is an altered quadriceps neuromuscular control important? What does that lead to? How can it be fixed?
significant increase in lateral PFJ load with 5ms
VMO delay lateral patellar stress is associated with lateral patellar lesions, and can be reduced by increased VMO activity
A delay in VMO onset timing _____ (is/is not) present in all people with PFP
is not
People with PFP have shorter ______ compared to controls. How does that affect the PFP?
hamstrings
people with reduced hamstring length have greater total and lateral PFJ stress during squat descent and ascent and this may increase pressure on the lateral patellar facet
What should be done about shorter hamstrings?
Rehabilitation should be potentially be targeting the medial hamstring muscle
hip _____ and ____ are predictors of pain and function
adduction; IR
Why is hip adduction and IR predictors of pain and function?
increased femoral IR (5-10°) during walking increases PFJ cartilage stress by ~30%
In NON-WB: Lateral patella tilt results from ______ moving in femur
In WB: Femur moving ______ the patella (this is coming from hip joint)
patella; underneath
Deficits in ________ may be a result of PFP, rather than a cause. Thus, ____ (is/is not) a precursor for developing PFP
isometric hip muscle strength; is not
There is decreased lower ______ isometric strength in PFP vs. controls. Be specific with the 2 muscles.
trunk
- Transversus abdominus
- Internal oblique
Greater foot _____ may be present before PFP onset, and persist
pronation
List 6 things that people with PFP (vs. controls) have significantly greater?
- ankle dorsiflexion
- calcaneal angle
- navicular drop, navicular drift
- Foot Posture Index arch height
- mobility foot
- mobility magnitude (midfoot width- more pronated (mobile foot))
Greater ________ drop (foot related) is a risk factor for PFP development.
navicular drop
PFP intervention should primarily aim to address ______.
pain
Exercise is recommended to reduce ______ in the short, medium and long term, and improve _____ in the medium and long term (for PFP).
pain; function
Combining ____ and ______ exercises is recommended to reduce pain and improve function in the short, medium and long term – preferable to knee exercises alone
hip; knee
What are the hip muscles that need to be improved (function) in PFP?
- hip extensors
- external rotators
- abductors
What are the hip muscles that need to be improved (function) in PFP?
quadriceps
As the quadriceps atrophy, the ______ of VMO changes. Thus quads strengthening may correct this without ______ retraining.
pennation angle; specific
Does the type of training have an impact on effectiveness with PFP patients?
The type of exercise (strengthening or timing) does not seem to matter - exercise alone is beneficial.
If there is a lesion in the cartilage loaded at 20 degrees knee flexion, then you want to target the exercises that avoid loading at ___degrees. This would include _____ (exercise) that are in a _____ (open/closed) kinetic chain working between ____ and ____ degrees.
20; squats; closed; 30; 90
If there is a lesion in the cartilage loaded at 90 degrees knee flexion, then you want to target the exercises that avoid loading at ___degrees. This would include _____ and ______(exercise) that are in a _____ (open/closed) kinetic chain working between ____ and ____ degrees.
90; leg extension (variable resistance: leg extension (constant resistance); open; 0; 60
Thus, it is shown that _____ of training does actually matter. Why?
specificity
If there is a vasti dysfunction, strengthening alone may not correct the dysfunction … vasti retraining may be required
______ interventions are recommended to reduce pain in the short and medium term
Combined
It is important to maintain ____ over a prolonged period.
treatment
Which 3 patella taping techniques are helpful? Which 2 must be done?
- Medial glide (MUST)
- Medal tilt (less)
- Fat pad deload (MUST- even without irritation)
What patella taping technique does not work?
Rotation- hard to do
Patellar taping reduces knee pain… but not in the ______ term
long
Taping is effective in the first 6 weeks, but by 7-12 weeks, the taping loses its effect compared to a sham tape.
Patellar taping reduced ______ during single leg squat in people with AKP. Tape_______ contact area by gliding the patella.
PFJ reaction force; increases
Patellar taping changes ______activation
vasti
Foot orthoses are recommended to reduce _____in the _____ term. Is there a difference in effectiveness between custom made and prefabricated orthotics?
pain; short No
Prescribe orthotics to _____ - an uncomfortable orthotic can affect the foot. How?
comfort Less likely to wear Can increase hip abduction and VL activity
amount of peak adduction is _____ (higher/lower) with the orthoses
higher
The people with _____ (a lot of/ not a lot of) foot mobility walked with less dynamic knee valgus when using the orthotic. It had a _____ effect.
a lot of; normalising
How did orthoses affect the dynamic knee valgus of people with less mobile feet?
The orthotic didn’t change the dynamic knee valgus in people with less mobile feet.
How did orthoses affect the dynamic knee valgus of people with more mobile feet?
The people with a lot of foot mobility walked with less dynamic knee valgus when using the orthotic.
In PFP, prefabricated foot orthoses impart ____ (beneficial /negative) changes in frontal plane knee load during walking in those with ___ (more/less) mobile feet. The direction of change is favourable in a population that typically demonstrates increased dynamic knee _____ (valgus/varus)
beneficial; more; valgus
Biomechanical factors may play a role in therapeutic outcomes of foot orthoses for PFP … but only in those with ____(more/less) mobile feet
more
Thus, PFP is a _____ condition
mechanical
PFP might have _____ & other joint damage in some people
cartilage
PFJ ___ is a key contributor to PFP
stress
_____, _______, and _____ increase PFJ stress
Local; proximal; distal impairments
