Patellofemoral Pain Syndrome

Question 1

What is Patellofemoral Pain Syndrome (PFPS)?

Answer 1

Patellofemoral pain syndrome (PFPS), also known as “runner’s knee,” is a musculoskeletal condition characterised by pain in the anterior knee, around or behind the patella, often caused by dysfunction in patellar movement during activities like walking, running, squatting, or climbing stairs.

Question 2

What are the biomechanical factors that contribute to PFPS?

Answer 2

• Affected alignment of the patella in the trochlear groove due to muscle imbalances or structural issues.
• Weakness or poor control of the quadriceps, according to most of the physio - especially the vastus medialis oblique (VMO),although recent researches suggest that focusing solely on the VMO is less effective because the entire quadriceps group must work together to ensure proper knee extension, stability, and patellar tracking, and addressing only the VMO overlooks other important factors that influence knee function and pain.
• Overpronation of the foot, affecting knee tracking.
  Increased femoral internal rotation or valgus (inward) knee positioning.

Question 3

What is a common muscle imbalance in the quadriceps that contributes to PFPS?

Answer 3

A common imbalance is when the vastus medialis obliquus (VMO) is weaker than the vastus lateralis, causing the patella to track laterally (outward).

Question 4

What role does the vastus medialis obliquus (VMO) play in knee stability?

Answer 4

The VMO helps stabilise the patella and pull it medially (inward) during knee extension, ensuring proper alignment and movement.

Question 5

What effect does tightness in the IT band have on PFPS?

Answer 5

Tight IT band creates excessive lateral pull on the patella, which can cause patellar maltracking, leading to increased friction and pain in the patellofemoral joint.

Question 6

How can tight hamstrings contribute to PFPS?

Answer 6

Tight hamstrings can affect knee mechanics, leading to improper movement patterns that increase stress on the knee joint, contributing to PFPS.

Question 7

How does reduced flexibility in the calves affect the knee?

Answer 7

How does reduced flexibility in the calves affect the knee?

Question 8

How hip and glute weakness contributes to PFPS

Answer 8

Weakness in the hip abductors, external rotators, or glutes can lead to an inward collapse of the knee (knee valgus), which alters the alignment of the patella, further contributing to abnormal tracking and PFPS.

Question 9

What is muscle imbalance?

Answer 9

Muscle imbalance occurs when one group of muscles becomes stronger or more dominant than the opposing muscle group, leading to altered movement patterns and potential injury.

Question 10

What causes muscle imbalance?

Answer 10

Muscle imbalance is caused by overuse, poor posture, incorrect movement patterns, or a sedentary lifestyle.

Question 11

What is muscle weakness?

Answer 11

Muscle weakness is a reduction in the strength or ability of a muscle to produce force, leading to diminished performance and difficulty with movements.

Question 12

What causes muscle weakness?

Answer 12

Muscle weakness can be caused by lack of use, nerve damage, injury, or conditions affecting muscle function, such as arthritis or muscle atrophy.

Question 13

How does muscle weakness affect movement?

Answer 13

Weak muscles fail to stabilise joints properly, leading to poor posture and abnormal movement patterns, making it harder to perform tasks like lifting or squatting.

Question 14

What are the key points to consider in a subjective assessment for PFPS?

Answer 14

The subjective assessment includes:

• Gradual onset of anterior knee pain with no specific injury.
• Pain worsens with activities like squatting, stairs, or prolonged sitting (“theatre sign”).
• Possible sensations of instability or crepitus in the knee.

Question 15

Which demographics are most commonly affected by PFPS?

Answer 15

PFPS is most common in:

• Adolescents and young adults.
• Females, due to anatomical factors like a wider Q-angle (angle between the quadriceps and patellar tendon).

Question 16

What should be observed during the objective assessment of PFPS?

Answer 16

Look for:

• Alignment issues such as valgus knees or foot pronation.
• Muscle wasting, particularly in the quadriceps.

Question 17

What tests are commonly used to diagnose PFPS?

Answer 17

• Clarke’s test: Applying pressure to the patella while the patient contracts the quadriceps (pain indicates potential PFPS).
• Lateral patellar tilt test: Evaluates tight lateral structures(inability to lift the lateral border of the patella is positive sign)

Question 18

What functional tests can help assess PFPS?

Answer 18

Functional tests include:

Squatting, single-leg step-downs, or running to reproduce pain.
Observing patellar tracking during movement.

Question 19

What are some aggravating factors for PFPS?

Answer 19

Aggravating factors include:

Prolonged sitting with knees flexed.
Squatting, lunging, or kneeling.
Walking up or down stairs.
Running, especially on hills.
Activities requiring quick directional changes.

Question 20

What is the goal of pain reduction in managing PFPS?

Answer 20

The goal is to alleviate discomfort in the short term to allow the patient to engage in rehabilitation exercises.
Examples:

• Ice therapy: Apply ice packs for 15–20 minutes every 2–3 hours to reduce inflammation.
• Anti-inflammatory medications: Use NSAIDs like ibuprofen under medical supervision.
• Rest and Activity Modification: Reduce activities that worsen pain, such as running or squatting.

Question 21

Once the pain is under control, what exercises to give?

Answer 21

Strengthening exercises:
- Quadriceps strengthening: Exercises like leg extensions, squats, or step-ups target the vastus medialis oblique (VMO).
- Gluteal strengthening: Glute bridges and hip abduction exercises focus on the gluteus medius and minimus muscles.
- Hip and Knee Control: Incorporate lunges and step-down exercises to enhance knee stability and prevent knee valgus.

Question 22

How to address structural and mechanical issues that contribute to PFPS.

Answer 22

Stretching tight structures:
Iliotibial Band (ITB): Stretching the ITB with standing stretches or foam rolling can reduce lateral pull on the patella.
Lateral retinaculum stretching: Stretching the lateral retinaculum helps restore proper patellar tracking.
Orthotics: Use custom or over-the-counter orthotics to address overpronation and improve foot alignment, reducing knee stress.

Question 23

How to enhance proprioception and stability for better knee function during activities.

Answer 23

Proprioception training: Exercises like standing on one leg or using a wobble board improve joint awareness.
Stability exercises: Dynamic exercises such as controlled squats or lunges improve knee stability and alignment.
Neuromuscular re-education: Exercises on unstable surfaces (e.g., balance boards) retrain coordination and muscle activation.

Question 24

What should we teach people with Patellofemoral Pain Syndrome (PFPS) about its management?

Answer 24

• Load management: Gradually increase activity intensity to avoid knee overload (e.g., transitioning from walking to running).
• Activity modification: Advise avoiding high-impact activities like running uphill or deep squats until recovery.

-Gradual return to sport: Encourage strength and mobility exercises before resuming sport and ensure pain-free functional activities (e.g., walking, cycling).

Question 25

Give examples of modifying activities to prevent aggravating symptoms and promote healing.

Answer 25

Encourage low-impact activities like swimming or cycling instead of running or jumping until pain subsides.

Question 26

Explain what is PFPS to a patient

Answer 26

**“Imagine this is your knee, and this part here is the patella, or your kneecap. Now, think of the trochlear groove—the part of your thigh bone where the kneecap sits—as train tracks. The kneecap is like a train that should be moving smoothly along these tracks as you bend and straighten your knee.

In a healthy knee, the kneecap moves perfectly along these tracks without any issues. However, in Patellofemoral Pain Syndrome (PFPS), it’s like the train isn’t following the tracks properly. It might be too far left or right, or it might be rubbing against the sides of the groove, causing pain and discomfort. This can happen because the muscles that help guide the kneecap, like the quadriceps (the muscles at the front of your thigh), aren’t strong enough or aren’t working well together. When these muscles aren’t doing their job, the train (the kneecap) can get pulled out of line and rub against the rails.

Other things, like the way your foot hits the ground when you walk (we call this overpronation) or if your knees collapse inward, can make this problem worse. It’s like if the tracks themselves are a bit misaligned, the train will have even more trouble staying on course.

The good news is that we can help fix this. By strengthening the muscles around your knee and improving how you move, we can help the kneecap stay on track, just like keeping the train running smoothly along its rails. This will reduce the pain and make things feel much better.”**

Question 27

Explain to patient what is vastus medialis oblique (VMO)?

Answer 27

The quadriceps are the large muscles at the front of your thigh. The vastus medialis oblique (VMO) is the inner part of the quadriceps, and it plays a crucial role in stabilising the patella (kneecap) during movement.

What happens in PFPS: If the VMO is weak, the kneecap can shift out of alignment, causing pain.

Question 28

Explain to patient what are the glute muscles?

Answer 28

The glutes (especially the gluteus medius) are important stabilisers for your hips and knees.

What happens in PFPS: Weak glutes can cause poor control of the knee, leading to valgus knee positioning (when the knees collapse inward). This extra pressure on the knee joint can irritate the patella.
How strengthening helps: Strengthening the glutes helps keep the hips and knees aligned during movement. This reduces the inward collapse of the knees (valgus), which in turn reduces strain on the patella and prevents misalignment.