Week 4: Management of Knee Disorders (Masteclass) Flashcards
Patellofemoral pain general info
* Slightly more common in women or men?
* High recurrence rates (…..% - ….%)
* Not a …..-…… condition!
- ..% adolescents have persistent pain 2 years after being diagnosed
- > 50% of people with PFP who were enrolled in a RCT had unfavourable outcomes …..-…… years
Women
70-90%
Self-limiting
50%
5-8 years
Describe the clinical presentation of patellofemoral pain
- Insidious onset of poorly defined pain
- anterior retropatellar pain/peripatellar pain
- Slow build-up or rapid development
- Worsening of pain in loading positions
- Squatting (93%)
- Going up/downstairs (91%)
- Running (90%)
- Prolonged sitting (54%)
- Jumping
NOTE: NO SINGLE DIAGNOSTIC TEST (often a diagnosis by exclusion of all other conditions)
Potentially beneficial treatments for patellafemoral pain
- Exercise
- Patellar Taping
- Braces
- Orthoses
- Gait retraining –> more forefoot strike to help reduce load?
EP BOG
Ineffective treatment for patellofemoral pain
- Manual therapy (standalone treatment)
- Biofeedback
- Dry needling
- Electrotherapies/biophysical agents
Demographic risk factors for PFP
Demographic risk factors
* Height, weight, BMI are not risk factors
* Sex (females more likely to develop PFP)
Local risk factors for PFP
Knee extension strength or hypermobility of the patella
Note: Local factors (in and around the knee):
Proximal factors for PFP
Hip strength is not a risk factor
Distal factors for PFP
Inconclusive evidence on the role of foot mechanics
What should education focus on?
- Too much load through the knee cap then it is able to handle
What is knee crepitus? Is it a concern?
Cracking, popping, etc in the knee
Doesn’t matter much but is common in PFP patients
Not related with function, physical activity or pain
Psychological features of PFP?
Increased levels of anxiety, depression, pain catastrophising and pain-related fear in people with PFP
Biomechanical considerations when prescribing exercise for patients with PFP (OKC Vs CKC?)
- Non-weight bearing (open chain, OKC eg knee ext – feet off ground) vs weight bearing (closed chain, CKC –> feet on ground)
- Similar clinical effects
- Biomechanical differences, each one with advantages and disadvantages
**review study to get further detail on patellofemoral pain during weight bearing and non-weight bearing exercise
How can trunk position and shank position decrease load on PFP joint load
When PFP knee is the trail leg - lean forward shift some load across their hip and away from their knee
Exercise for PFP – combined hip and knee strengthening
Hip + knee strengthening slightly superior to knee strengthening alone
For PFP Hip-targeted exercise therapy should target the ….
Posterolateral hip musculature.
True or False: Preference to hip-targeted exercise over knee-targeted exercise may be given in the early stages of treatment of PFP.
TRUE
Adjunct treatments for PFP - Is tailored taping effective?
Short-term benefits when combined with exercise
Adjunct treatments for PFP - are braces effective?
- No evidence for pain/function/physical activity levels
- May be helpful for people with fear of movement
Adjunct treatments for PFP - are foot orthoses effective?
- Rationale: useful for people with excessive pronation
- Clinical outcomes are quite variable and only in the short term
Recommendations for foot orthoses in PFP patients
Recommendations
* Clinicians should prescribe …… foot orthoses for those with ….. than normal pronation to reduce pain in individuals with PFP, but only in the short term (up to ….. weeks).
* If prescribed, foot orthoses should be combined with an ….. therapy program.
* There is insufficient evidence to recommend …… foot orthoses over prefabricated foot orthoses
Prefabricated
Greater
6 weeks
Exercise
Custom
Patella tendinopathy - general info
* PT usually affects ….. athletes (15s-30s)
* ….. of athletes unable to RTS within 6mo
* …..% forced to retire
- Increased risk in …… & those with …… tendon maturation
- Training volume
Younger
1/3rd
53%
Men
Late
NOTE: **More localised than patella femoral pain. Looking for something in their history that indicates they are using their tendon as a spring ie jumps (eg in basketball) – less common in runners, but doesn’t mean it doesn’t occur. Pain occurs when they land - want a good amount of knee flexion so load is distributed during the jump (ie will require high ankle dorsiflexion – address this in treatment!)
What is the chief diagnostic criteria for patella tendinopathy?
- Pain localized in the tendon (inferior pole of the patella or distal patellar tendon)
AND
* Load-related pain with a dose-response component
Also consider:
* Pain free at rest;
* Pain in a few cases can decrease with loading (“warm-up phenomenon”), but it’s often increased the day after
Patella tendinopathy - common impairments
- Strength
- Flexibility
- Mobility
- Strength
- Hip ABD/ER/EXT
- Calf muscles (impact absorption)
- Flexibility
- Lower limb
- Mobility
- Excessive foot pronation
Patella tendinopathy overall treatment
- Education
- Activity modification
- Realistic rehabilitation time frames
- Address wrong beliefs about pain
- Passive treatments are low-value care
- Exercise
