PFPS/patellar dislocation - exam 3 Flashcards
PF GRF:
- walking
- near 30 deg flx
- stair climbing
- squatting
- peak at:
- 50% BW
- BW
- 3x BW
- > 7x BW
- 90 deg
what % of PFPS is recurrent and persistent?
70-90 %
risk factors for PFPS
military recruits
dynamic (NOT static) excessive pronation
females
– larger Q angle
– differing hip strength and coordination
patellar and femoral bone shape
is PFPS normally caused by gradual unknown onset or trauma?
gradual and unknown onset
what is the theory for the cause of PF malalignment and/or maltracking?
patella glides and tilts more laterally relative to femur
Someone with PFPS has ________ surface area contact between the patella and femur
decreased
less contact puts more force in a smaller area —-» wear down and causes P!
PF malalignment and/or maltracking is due to:
- patellar and femoral bone shape
- femoral IR and add
- quad weakness, incoordination and atrophy
- unclear contribution from excessive pronation, and tibial IR
pathomechanics of PFPS:
overload of patellar subchondral bone, esp lateral facet
tissue ischemia
loss of tissue homeostasis
neural ingrowth and increase in substance nerve fibers that transmit more P!
how does the infrapatellar fat pad become inflamed? where can it refer to?
excessive tibial IR and patellar hypermobility
groin
what makes up the bursae?
superficial infrapatellar - between skin and patellar tendon
deep infrapatellar - between patellar tendon and tibia
what are other structures involved in PFPS?
subchondral bone of patella
quad and patellar tendons
synovium
med & lat retincaculum - help hold patella and tendon in position
what are symptoms of PFPS?
- onset
- location of P!
- P! increased with:
- gradual
- anteromedial knee p!
- stairs, squatting, kneeling, or prolonged sitting (holding pressure on a small area for a period of time)
Observation of PFPS:
increased Q angle
open chain maltracking of patella
quad atrophy
observation of PFPS: impaired LE control
proprioceptive deficits
dynamic excessive pronation
–> possible contributions from impaired DF because if DF limited then more EV may occur
abnormal planar motions, esp in females
consider possible contributions from L4-S1 regional interdependence
observation of PFPS: impaired LE control in frontal and sagittal plane:
increased
e.g. hip add
- glue med and/or max incoordination
- hip ext and abd weakness
observation of PFPS: impaired LE control in transverse plane
hip ER weakness and incoordination
mixed conclusions with contributions from rotational impairments
Observation: PFPS
Trunk weakness including ___________
Consider possible contributions from __________ regional interdependence
excessive trunk lean
L4-S1
signs of PFPS:
- rom:
limited and painful, particularly at end ranges if symptomatic
- flx: greater PF compression
- ext: more fat pad irritation
signs of PFPS:
- resisted:
possible P! with ext MMT and weakness
likely inhibited quad activity, part. VM
potential anti-gravity trunk and hip weakness
signs of PFPS:
- stress tests:
- neuro tests
- accessory motion
- possible pain with PF compression
- limited Dural mobility of femoral nerve in 1/3 patients
- typically excessive lateral motion and limited medial motion
- all glides could be hypermobile
Which of the following PFPS special test(s) is being described:
compression through inferior medial borders of patella towards underside then ext the leg
- (+) =
medial patella plica
(+) = p!, more in ext
Which of the following PFPS special test(s) is being described:
ext knee in 90 flx while PT creates resistance
resisted testing for knee ext
(+) = P! around patella, esp inf. med border and underneath
Which of the following PFPS special test(s) is being described:
hold pressure under patellar tendon. ask patient to ext their knee
(+) = ?
Hoffa’s sign (no support)
(+) = P!
Which of the following PFPS special test(s) is being described:
knee flexed ~30 deg.
laterally glide patella
(+)= ?
PF apprehension test
(+) = excessive motion, instability signs
what are possible muscle length tests for PFPS? what are they testing?
thomas test for rectus
obers for TFL/IT band
SLR for hamstrings
gastroc
in PFPS, where would you feel TTP?
peri-patellar (around the patella)
where does the patella sit normally?
inferior pole aligned with joint space at 90 deg
what is patella alta?
due to?
patella is sitting higher than normal
due to a short rectus (use thomas test and test inf. glide of PF)
what is patella baja?
due to?
patella is sitting lower than normal
due to trauma or a contracted patellar tendon
PT Rx: PFPS
for acuity:
- POLICED
PT Rx: PFPS
taping:
- direction:
- improves:
- effective for:
- less effective:
- benefits:
- not as effective as:
- arch limits:
- start lateral and superior and pull medial. to unload fat pad
- positioning for better surface contact
- P!, kinematics, function
- in patients with higher BMI and smaller Q angle
- proprioception
- exercise
- excessive pronation
PT Rx PFPS:
knee orthotic:
- neoprene sleeve with hole:
- J lat brace:
- doesn’t interfere with:
- increases surface contact between patella and femur without changing alignment or tracking. help with function when added to exercise.
- straps pull patella medial
- muscle activity
PT Rx PFPS:
foot orthotics:
- effective when?
- prefabricated orthotics vs custom:
immediately and short and mid-term
no difference at a year
just as effective as custom
PT Rx PFPS:
dry needling:
STM and JM:
not effective
P! short term, better with exercise
PT Rx MET:
Focus on _____:
- direct relationship:
- indirect relationship:
- avoid:
quads
- direct relationship as knee extends with Non-WBing
- indirect relationship as the knee extends with WBing
- 45-0 deg OC & 45-90 deg CC
PT Rx MET:
addition of _____
earlier benefits due to:
_____ term benefits
hip exercises. earlier dissipation of P!, esp addition of ERs, ABD, EXT
improved neuromuscular control
long
you get the best progress when combining quad ______ and ________
strengthening and stretching
how does verbal feedback improve someone with PFPS?
give two “cues” that help with running
they’re more conscious of the problem
1. cued to run softly - less heel strike
2. cued to not let knee fall in - helps mechanics
what is an example of verbal and visual feedback you can give a runner?
contract glutes and keep knee pointing straight ahead
- visual of hip angle w mirror
Prognosis: PFPS
80% of individuals who compiled a rehab program for PFPS still experienced __________
74% had _______their physical activity at a 5yr. follow up
How might this lead to OA:
P!
reduced
- may lead to OA due to disuse or changing of the bone
should your patient with PFPS get a lateral retinacular release? if not, what can it lead to?
should only be used in rare instances
will lead to medial instability if additional tissue cut or used in wrong patient
should your patient with PFPS get extensor mechanism realignment? what is it?
no
repositioning of tibial tuberosity
long term extensor lag problems
what is patellar dislocation? is it common?
worst case of PFPS
usually dislocates laterally
rare
RF for patellar dislocation:
pre-existing patellar hypermobility
more common with a shallow sulcus angle or trochlear groove and large positive congruence angle or laterally located patella
etiology of patellar dislocation:
trauma with lateral patellar displacement
more likely with pre existing patellar hypermobility
structures involved with patellar dislocation:
patella
med retinaculum and other medial tissues
S&S of patellar dislocation:
traumatic and worse case of PFPS
patellar apprehension likely to be (+)
PT Rx: patellar dislocation
- POLICED:
non-WB to PWB up to 3 weeks
immobilizer
taping for protection and muscular control
brace for patellar control
what would you focus on with MET for patellar dislocation?
- ____ before _____
- isometrics and isotonics
- extensibility and elasticity of:
CC prior to OC - more muscles involved which provides more stability
quads
postlat structures (hams, IT band, gastroc)
prognosis of patellar dislocation:
Redislocation
up to 44% redislocation rate
higher without sx
