Patellofemoral pain syndrome Flashcards
(48 cards)
1
Q
Describe the patella and its role in the knee
A
- sesamoid bone
- increases the efficiency of the quad pull for the last 30º
- guide for quad tendon and decreases the friction
- boney shield for the tibiofemoral joint
- thickest cartilage in body
2
Q
Patella anatomy
A
- base is superior portion
- apex is the inferior portion
- medial side: medial facet and odd facet
- vertical ridge between medial and lateral facet
- superior and inferior facets
3
Q
Describe important lateral structures in the knee in regards to support for the patella
A
- vastus intermedius
- vastus lateralis
- lateral retinaculum
- Gerry’s tubercle (bursa underneath) insertion for IT band
4
Q
Describe important medial structure in the knee in regards to support for the patella
A
- vastus medialis
- quad tendon
- medial retainculum
- pes anserinus
- fat pat beneath patella ligament
- tibial tubersoity
5
Q
Patella contact area during
1) flexion
2) mid range
3) extension
A
1) superior patella
2) more contact
3) inferior patella
lateral tracking is normal as you go into extension
6
Q
Normal patella position
inreguards to patella ligment
A
- patella ligament length = patella body length
7
Q
Patella alta
also what this looks like and what happens anatomically
A
- patella higher than normal
- patella ligament longer than normal
- frog eyes in 90ºof flexion as patellae faces up and out
- causes the patella to not be firmly in the intracondylar groove
8
Q
Patella baja
A
- patella lower than normal
- patella ligament shorter than normal
- closer to the tibial tuberosity
9
Q
Compressive forces at the PFJ
A
- reflects the magnitude of force through the quads
- walking 0.5 x BW
- ascending stairs 2.5 xBW
- descending stairs 3.5 x BW
- squatting 7.8 x BW
- compression forces overtime can cause DJD
10
Q
Chondromalacia
A
- softening of cartilage on posterior surface of patella
- pitted tissues, fragmented
- may lead to DJD
11
Q
Chondromalacia signs and symptoms
A
- PFJ creptitis (can feel this)
- retropatella pain w/ ROM
- pressure
- common in patients with high compressive forces (kneeling, seat, stairs, sitting with excessive knee flexion)
- post trauma and surgery
- associated with Mal-tracking compression
12
Q
Patellar tracking
What allows tracking normally/what typically happens with mal-tracking
A
- opposing forces keep patella in groove
- Mal-tracking related to muscle imbalance, hyper/hypomobility
13
Q
What structures must balance to have normal patella tracking
A
- overall quad force
- VMO
- IT band
- lateral retinacular fibers
- medial retinacular fibers
14
Q
Causes of patella lateral mal-tracking
A
- muscle imbalance/weakness
- tight lateral structures
- laxity or tear fo medial patellar retinaculum
- bony dysplasia
- patella instability
- excessive pronation
- femoral IR torsion
- tibial bony lateral torsion
- knee alignment issues
15
Q
How can muscle imbalances cause patella maltracking
A
- VMO: doesn’t oppose pull of VL, VMO is not recruited properly
- Weak hip ERs and abductors causes excessive femoral IR and adduction = valgus collapse
- females > males
female with patella femoral syndrome> weakness than females without it
16
Q
How can tight lateral structures cause patella lateral mal tracking
A
- lateral retinaculum and ITB
- can pull the patella more laterally
17
Q
How can laxity or tears in medial structures cause lateral Mal-tracking
A
- medial patellar retinaculum
18
Q
How can bony dysplasia cause PFS
A
- shallow intercondylar groove of femur
- flat or smaller lateral femoral condyle
19
Q
Patella instability and how it cause lateral mal-tracking
A
- patella alta
- genu recurvatum (hyperextension)
- not seated in intracondylar groove
20
Q
Examples of alignment/posture that can cause lateral patella mal-tracking
A
- pronation (excessive)
- femoral IR torsion
- tibial bony lateral torsion - structure
a laterally seated tibial tubercle (similar to femoral IR) - knee alignment: genu valgum or Q-angle
21
Q
Q-angle
A
- measures the quads line of pull
- Measure ASIS to mid-patella to tibial tuberosity
- normal 12-18º
- larger Q-angle >18ºwith lateral subluxation results in PFPS
22
Q
Lateral retinacular release
A
- lateral patellofemoral/tibial ligament
- weak on medial side/sublux on lateral side = tight lateral structures
- done to reduce PFJ lateral mal-tracking
- arthroscopic or open procedure
23
Q
Post-op complications of lateral retinacular release
A
- swelling, hemarthrosis
- unsuccessful = chronic pain
- NOT done in isolation - not effective for lateral instability
- failure to realign patella more medially
- long term = high recurrence of dislocation
24
Q
Proximal extensor mechanism realignement surgery
what is it and when is it preformed
A
- medial patella femoral ligament repair/reconstruct to tighten it
Preformed if medial patelloefemoral ligament deficiency
- 1st time acute traumatic lateral patella dislocation
- chronic recurrent lateral instability with pain
- excessive lateral tracking w/ VMO insufficiency
- failed conservative management
25
Surgery to tighten medial patellofemoral ligament repair/reconstruction
- repair: suture tear, reattach MPFL to medial condyle and patella
- reconstruction: autograph, allograph- hams, TFL, quad tendon
26
Medial patellofemoral ligament repair/reconstruction done with any one of what procedures
- also post op complications
- Vastus médiales Oblique advancement: central or distal relocation of VMO to improve length tension
- lateral retinacular release (arthroscopic)
- tighten medial patellotibial, patellomensical ligament
- post op complications: infection, DVT, patella scaring, adhesions, arthrofibrosis and decrease ROM
27
MPFL repair/reconstruction rehab: protection phase
| Goals of rehab
Protection phase
- weeks 1-4
- control swelling/pain
- ROM 0-90 by 4th week
- strength of 3/5
- gait: FWB locked brace without AD
28
MPFL repair/reconstruction rehab: moderate protection phase
- weeks 4-8
- control swelling/pain
- ROM 0-120 by 6th week
- 0-135 by 8th week
- strength 4-5/5
- normalize gait
29
MPFL repair/reconstruction rehab: minimum protection phase
- weeks 8-12
- functional ROM
- 75% strength of uninvolved
- gradual return to ADLs
- educate on resuming normal activities
30
Distal realignment of extensor mechanism
- Tibial tubercle, patellar tendon medial transfer
Preformed if:
- painful lateral tracking, retro-patellar pain
- >15mm distance from tibial tubercle to femoral intercondylar groove
31
How does the distal realignment of extensor mechanism correct a laterally positioned tibial tubercle
- transfer tibial tubercle and patellar tendon medially
- decrease Q-angle
- decrease lateral directed patellar forces
32
distal realignment of extensor mechanism surgery complications and treatment
- complications: tibial tubercle fracture, nonunion, osteomyelitis
- Treatment: protocol to progress more gradually to allow bone healing; U/L WB 8 weeks, max quad contraction 12 weeks
33
Exercise precautions for proximal or distal extensor realignment
- initially in brace with ROM limits to avoid excessive flexion
- progress Flexion ROM gradually avoiding excessive valgus
- SLR exercise locked in brace
- begin WB shifts in BL stance brace locked
- progress to CC ex ROM limited unlocked brace (mini squats once 50% WB okay)
- keep brace locked in FWB activities and ambulation until quad control
- postpone U/L WB ex's on involved LE without brace as protocol and healing tissue allows: 4-6 weeks soft tissue, 8 weeks for bony
- do not preform max quad contraction for at least 12 weeks after VMO advancement or tibial tubercle osteotomy
34
Patella dislocation factors
- MOI external force = lateral patella dislocation
- bony abnormalities: flat lateral condyle, shallow groove
- weakness of VMO
- valgus deformity with tight lateral retinaculum and stretched medial retainaculum
- females > dislocation rates than men
- females have a higher Q-angle, ligament laxity, weak quad (VMO), weak ERs and abductors = valgus collapse
- recurrent dislocations: surgery to realign patella
35
Patella fx
| General rehab focus
- ROM, WB progression depends on the type
36
Types of patella fx and their treatment
- non-displaced fx: extension brace 3-6 weeks, early WBAT, ROM at 4-6 weeks
- displaced or commented fax: ORIF wire/screws, PWB initially ROM at 4-6 weeks
- patellectomy: rare = lose pulley system, extensor quad lag and los active terminal extension
37
Patellar tendonitis
| What typically causes this and what can be done to treat?
- jumper knee
- repetitive jumping
- rest , patellar tendon strap to dissipate forces for treatment
38
Quad tendon rupture
- usually >50 y.o
- repair: immobilize in full extension for 6-8 weeks
39
Patella tendon rupture
- <40 years old
- high energy trauma
- history of patellar tendonitis
- hx of steroid injections/ anabolic steroid use
- repair - ligament sutured to bone: immobilize full extension for 6-8 weeks PWB
40
Knee bursitis
- overuse
- trauma fall on knee/kneeling
- supra patellar burse
- pre patellar burse - housemaids
- fat pad
- superficial infrapatellar bursa
- deep infra patellar bursa
41
Pes anserine bursitis: ITB friction syndrome
- overuse/tightness
- ITB friction syndrome bursae
- pes anserine bursitis
42
Plica syndrome
- embryonic remnant fold of synodal tissue
- gets irritated with activity
- located medial, inferior and superior
- medial plica most prevalent (25-50%)
- plica irritation, inflammation fibrotic
- pain with palpation
43
Treatment for plica syndrome
- rest, refrain from aggravating activity NSADs
- arthroscopic resection
44
PFP classifications impairment/function-based
1. overuse/overloading; is 1º reason of pain, PFJ loading magnitude/rate that surpasses recovery
2. muscle deficits: hip/quad function/preformance; respond favorable to hip and knee resistance exercise
3. movement coordination deficits: when patient presents with poorly controlled knee valgus durning a dynamic task
4. mobility impairment: hyper/hypomobilities: excessive pronation and/or flexibility deficits in more than 1 of these: hamstrings, quads/rectus femoris, ITB, gastric/soleus, lateral retinaculum
45
PFJ outcome measures
- LEFS: LE functional scale
- anteiror knee pain scale AKPS
- PFP and osteoarthritis subscale of the knee
- Osteoarthritis outcome score (KOOS-PF)
- Visual analog scale
- Eng and pierrynowski Questionarie (EPQ) to measure pain and function in patietns with PFP
46
Tests that reproduce PF pain and assess LE movemtn and coordination
- squatting
- step-downs
- single leg squats
47
What to assess in potential PFPS patients in reference to body structure and function
- patellar provaocation
- patellar mobility
- foot position (pronation)
- hip and thigh muscule strength (valgus collapse)
- muscle length
48
How can retraining running gait help with PFPS
- cuing to adopt forefoot-striking pattern reduces the need for the quads to work
- increasing work of the quads can cause PFPS
