Week 4: Management of Knee Disorders (Masteclass)

Question 1

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

Answer 1

Women
70-90%
Self-limiting
50%
5-8 years

Question 2

Describe the clinical presentation of patellofemoral pain

Answer 2

• 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)

Question 3

Potentially beneficial treatments for patellafemoral pain

Answer 3

• Exercise
• Patellar Taping
• Braces
• Orthoses
• Gait retraining –> more forefoot strike to help reduce load?

EP BOG

Question 4

Ineffective treatment for patellofemoral pain

Answer 4

• Manual therapy (standalone treatment)
• Biofeedback
• Dry needling
• Electrotherapies/biophysical agents

Question 5

Demographic risk factors for PFP

Answer 5

Demographic risk factors
* Height, weight, BMI are not risk factors
* Sex (females more likely to develop PFP)

Question 6

Local risk factors for PFP

Answer 6

Knee extension strength or hypermobility of the patella

Note: Local factors (in and around the knee):

Question 7

Proximal factors for PFP

Answer 7

Hip strength is not a risk factor

Question 8

Distal factors for PFP

Answer 8

Inconclusive evidence on the role of foot mechanics

Question 9

What should education focus on?

Answer 9

• Too much load through the knee cap then it is able to handle

Question 10

What is knee crepitus? Is it a concern?

Answer 10

Cracking, popping, etc in the knee
Doesn’t matter much but is common in PFP patients
Not related with function, physical activity or pain

Question 11

Psychological features of PFP?

Answer 11

Increased levels of anxiety, depression, pain catastrophising and pain-related fear in people with PFP

Question 12

Biomechanical considerations when prescribing exercise for patients with PFP (OKC Vs CKC?)

Answer 12

• 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

Question 13

How can trunk position and shank position decrease load on PFP joint load

Answer 13

When PFP knee is the trail leg - lean forward shift some load across their hip and away from their knee

Question 14

Exercise for PFP – combined hip and knee strengthening

Answer 14

Hip + knee strengthening slightly superior to knee strengthening alone

Question 15

For PFP Hip-targeted exercise therapy should target the ….

Answer 15

Posterolateral hip musculature.

Question 16

True or False: Preference to hip-targeted exercise over knee-targeted exercise may be given in the early stages of treatment of PFP.

Answer 16

TRUE

Question 17

Adjunct treatments for PFP - Is tailored taping effective?

Answer 17

Short-term benefits when combined with exercise

Question 18

Adjunct treatments for PFP - are braces effective?

Answer 18

• No evidence for pain/function/physical activity levels
• May be helpful for people with fear of movement

Question 19

Adjunct treatments for PFP - are foot orthoses effective?

Answer 19

• Rationale: useful for people with excessive pronation
• Clinical outcomes are quite variable and only in the short term

Question 20

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

Answer 20

Prefabricated
Greater
6 weeks
Exercise
Custom

Question 21

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

Answer 21

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!)

Question 22

What is the chief diagnostic criteria for patella tendinopathy?

Answer 22

• 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

Question 23

Patella tendinopathy - common impairments
- Strength
- Flexibility
- Mobility

Answer 23

• Strength
• Hip ABD/ER/EXT
• Calf muscles (impact absorption)
• Flexibility
• Lower limb
• Mobility
• Excessive foot pronation

Question 24

Patella tendinopathy overall treatment

Answer 24

• Education
• Activity modification
• Realistic rehabilitation time frames
• Address wrong beliefs about pain
• Passive treatments are low-value care
• Exercise

Question 25

Patella tendiniopathy - exercise treatment (4 stages - break it down)

Answer 25

Stage 1: isometrics eg le ext, spanish squat hold - -Reduced quadriceps motor cortex inhibition
- No muscle fasciculation (load too high)
- Mid range may be more comfortable

Stage 2: isotonics eg lunge, leg press, leg ext
- Start this phase when phase1 is tolerable
- 5/10 pain acceptable if no residual pain

Stage 3: Energy storage
- Examples: jumping, accelerating, cutting, declerating, etc

Stage 4: return to sport

Question 26

In a fat pad impingement what movement causes pain?

Answer 26

Pain in activities involving passive/active knee ext eg standing

Question 27

How is EOR flexion impacted in fat pad impingement?

Answer 27

Pain with movements close to EOR flexion once fat pad is swollen (patella can’t glide down) - can cause pain in exercise eg split squats

Question 28

What treatment can be used to assist fat pad pain?

Answer 28

A heel insert – puts knee into slightly flexion
Tape (extension block)
Ice
Activity modification

Question 29

What is the compression zone in ITBS

Answer 29

Around 20-30 deg knee flex (ie walking down stairs)

Question 30

Who is ITBS common in?

Answer 30

Runners and cyclists

Question 31

ITBS is the most common cause of….

Answer 31

• Most common cause of lateral pain (lateral femoral condyle)

Question 32

What causes ITBS pain?

Answer 32

• Small highly innervated bit of fat is compressed by the ITB band causing pain

Question 33

True or false - ITBS onset is insidious

Answer 33

TRUE

Question 34

What aspect of gait should be assessed in ITBS?

Answer 34

• Crossing the midline during running (gait retraining) –> common in men
• Knee valgus –> common in women (improving lower limb biomechanics both proximally and distally)