Patellofemoral pain syndrome (pfps)

Assessment and Management
of Patellofemoral pain
syndrome
Dr. Venus Pagare (PT)
MPT, KMC Mangalore
SEHA EMIRATES HOSPITAL
Abu Dhabi, UAE
1ASSESSMENT AND MANAGEMENT OF PFPS

 Introduction
 Anatomy of Patellofemoral Complex
 Epidemiology
 Aetiological Risk factors
 Pathogenesis
 Clinical Features
 Assessment
 Differential Diagnosis
 Management
 The Patellofemoral Foundation
ASSESSMENT AND MANAGEMENT OF PFPS 2
CONTENTS

Anterior knee pain (AKP)- most common
musculoskeletal complaint
Common overuse injury in sports
medicine
More prevalent in the athletic population
specially runners
The Black Hole of Orthopaedics
INTRODUCTION

IT Band Syndrome
Articular
cartilage injury
Hoffa’s
disease
Patellar instability
subluxation
Patellofemoral
arthritis
Pre –patellar
bursitis
Sinding-Larsen-
Johannson- Syndrome
Quadriceps
Tendinopathy
Referred pain
from hip
Neuromas
Osgood-schlatter
Plica
synovialis
Patellar
Tendinopathy
Symptomatic
bipartite patella
Pes anserine
bursitis
Osteochondritis
Dissecans
Chondromalacia
patellae
Bone Tumors
Loose-
Bodies

An overuse injury, a syndrome
Idiopathic AKP, runner’s knee, retropatellar pain
syndrome, lateral facet compression syndrome.
Accounts for 20%-40% of patients presenting
with AKP
25% of knee injuries in athletes in a sports medicine
clinic

Frequently becomes chronic
Pain may limit physical activities
May lead to patellofemoral osteoarthritis
Diagnosis by Clinical and by Exclusion

Anatomy and Biomechanics of
Patellofemoral Complex
Interface between articular surface
of the patella and trochlear groove
Modified plane joint
3 degrees of freedom

Passive structures / Static
stabilizers
Anteriorly: patellar
tendon limits the
excursion of patella from
the tibia.
The superficial and deep
lateral retinaculum on the
lateral side
Medially: medial
patellofemoral ligament,
aided by menisco-patellar
ligament.
Active structures /
Dynamic stabilizers
Quadriceps Muscle
Resultant pull of the
4 muscles that
constitute the
Quadriceps &
patellar tendon
Clinicaly: Q
angle

PFJ reaction
force
Influenced by quadriceps angle
and angle of the knee joint
Knee in full extension: minimum
compressive force on patella
As knee flexion ↑, compressive
forces ↑
Beyond 90 ̊, only odd and lateral
facet

Patellofemoral joint reaction forces depend upon the knee
flexion angle and as the knee is flexed, the patellofemoral
compressive load is increased.

Activity Patellofemoral compressive
force
Stance phase of walking
(peak knee flexion is about
20°)
25 - 50% body weight
Ascending stairs 2 – 3 times body weight
Running 5 – 6 times body weight
Flexion greater than 90° 8 times the body weight
Squatting 20 times the body weight

Factors affecting Patellar Tracking
Local Factors
Tight ITB, Lateral
retinaculum
Lax medial patellar
retinaculum
Trochlear dysplasia
Weakness of
quadriceps Flat Trochlea
Lax medial structures

Excessive Subtalar
Pronation
Global
Factors
Excess genu
valgum
Ext. rotation of
tibia
Excess femoral
anteversion
Asso. with foot
pronation

INCIDENCE
Common in young adults; high socioeconomic
importance
More common in Militiary recruits and athletes
Female : Male :: 2 : 1

ETIOLOGY
1. Intrinsic factors
Alterd Biomechanics of leg
Altered biomechanics of foot
Anatomic Anomalies
Med-Lat. patellar Mobility
Soft-tissue tightness
Muscle Imbalance
2. Extrinsic
Factors
3. Others

Increase in Q angle = ↑ lateral
patellofemoral contact pressure
Excessive laterally tilted patella
Other malalignments: femoral
anteversion, genu valgum and
varum, genu recurvatum, external
tibial torsion
1. Altered Biomechanics of leg

2. Altered Biomechanics
of the foot
Subtalar joint pronation  alters
tibial rotation
During terminal knee extension 
tibia remains internally rotated
To compensate: femur rotates
externally  ↑ Q angle
Flat foot → internal rotation of tibia
→ ↑ Q angle

3. Anatomic Anomalies
Dysplasia or hypoplasia
of patella or trochlea
Patella Alta / Baja →
Maltracking

4. Medial- Lateral
Mobility
Increased medial-
lateral movement
Rapid translation of the
patella
Repeated blows by the
medial facet on trochlea

Gastro-
soleus
↓dorsiflexio
n ↑ subtalar
pronation
↑ valgus
force= ↑ Q
angle
Hamstrings
Knee flexion at
heel strike →
increased
quadriceps
activity
↑ PFJ
compression
Iliotibial Band
Increased
lateral tracking
and lateral tilt
of the patella
↑ PFJ
compression
5. Soft Tissue Tightness

Quadriceps
Restrictes full
excursion of
patella in
trochlear groove
Causes lateral
tracking along
with TFL
Lateral Retinaculum
Predisposes to
ELPS
Laterally tilted
patella

6. Muscle Imbalance
Hip muscles
weakness
Abductors &
External
Rotators
Excessive
adduction &
Internal Rotation
↑ Q angle
Quadriceps
weakness
↓ activity of
VMO
VL activates
before VMO
Maltracking
of the patella

Extrinsic Factors
Excessive duration or frequency of physical
Errors in training such as sudden increase in
mileage
Activities change of training surface
Inappropriate foot wear such as high heels

Others
Female
Gender
Greater knee
valgus moment
Greater internal
rotation
↑ Q angle
Generalised
ligamentous
laxity
↑ Total
patellar
mobility
Alters
patellar
tracking

A study has identified 4 factors that have predictive
values for the development of patellofemoral pain,
which included:
 Tightness of the gastrocnemius and quadriceps
 Delayed reflex of vastus medialis obliquus
 Hypermobility of patella
 Decreased power of the quadriceps muscle.

PATHOGENESIS
Varied theories for cause and
source of pain
3 types : Hypoxic, mechanical,
inflammatory

Factors inducing patellofemoral nociceptive output

Single loading event
of sufficient
magnitude or
Series of repetitive
loading events of a
lesser magnitude
Differential loading of
PFJ
Beyond a certain
level, loss of tissue
homeostasis
Theory of
Homeostatis
1. Theory of Homeostasis

Certain activities highly load the PFJ
Climbing up or down stairs, hills or inclines,
kneeling, squatting
Stress = load applied + surface area
High loading beyond the safe acceptance
capacity of the joint
Length testing in neck and trunk and upper
extremity
Mosaic of pathophysiologic process
Patellofemoral pain

The “Envelope of
Function”
Torque that can be safely
withstood and transmitted
Zone of subphysiologic underload
Zone of homeostatic loading
Zone of supraphysiologic overload
Zone of macrostructural failure

2. Ischaemia
Low levels of
pulsatile blood
flow
When knees
are flexed
Hypoxia-
release of
neural growth
factors and SP
3. Raised Intra-
osseous pressure
Limited
venous
outflow

Pain
Giving
way
Swelling
StiffnessCrepitus
Pseudo-
locking
Popping or
catching
sensation
CLINICAL
FEATURES

Source of pain: Unclear
Any structure with sensory
nerve endings
Except Articular cartilage
Subchondral bone,
synovium, retinaculum,
fat pad

ASSESSMENT
DEMOGRAPHIC
DATA
Age: 10- 40 yrs
Gender : F : M
:: 2 : 1
Athletes &
Militiary
recruits
CHIEF
COMPLAINT
Pain
Crepitus
Giving way /
Locking
Swelling &
stiffness

Onset : Insidious or Gradual, can be precipitated by
Trauma
Area: peri-patellar, retro-patellar, ‘circle sign’
Behind,underneath, around the patella
Diffuse dull ache, sometimes sharp
Pain History

Aggravating Factors
Descending stairs >
Ascending
Going uphill or walking
on incline
Standing up from
squatting
Movie goer’s / theatre’s
sign
Relieving Factors
Extension of
the knee
Rest

Functional status, Activity Level, Sports
Specific Questions
Recent changes in activity
Any changes in the frequency,
duration, and intensity of training
A history of injuries, including patellar subluxation
or dislocation, trauma

Objective Examination
Observation: Posture- Standing
Malalignment: genu-varum (bowleg) or genu-
valgum (knock-knee)
Tibial Torsion: Medial →Genu varum
Lateral→Genu valgum
Size, shape, position of the patella:
grasshopper/ squinting/ patellar alta
Subtalar joint Pronation: antero-superior view
Anterior View

Lateral View
Patellar alta, camel
sign
The longitudinal
arches
Genu recurvatum

Posterior View
↑ Genu-varum :
Intercondylar space
↑ Genu valgum :
Distance between the
malleoli
Subtalar joint Pronation
Level of popliteal crease
Sitting: Anterior
and Lateral View
Patella faces
forward
Patella alta:
more aligned
with anterior
surface of femur
“Grasshopper eye”
appearance

GAIT ASSESSMENT
Tight ITB or hip
abductor
weakness
↑ Internal
rotation of hip
Opposite side
pelvis drops
↑ Q angle
PF tightness
Prevents full
knee
extension
Tight Hamstrings
Need for↑
Dorsiflexion
If DF range is not
available
Subtalar pronation
↑ Q angle

Local
Observation
Wasting of
quadriceps
Echymosis
Swelling
Surgical
Scars
Palpation
In PFPS: Lateral
retinacular
tenderness
IT band
tightness
Palpate scars or
arthroscopy
portals
Note: Warmth/ Cold,
Edema, Tenderness

EXAMINATION
Active & Passive ROM of Hip,
knee and Ankle
Pain with rotations of Hip
→Hip Pathology
Full ROM of knee
Crepitus: asymptomatic
Movement testing

Patellar tracking while knee
Flexion-Extension
Abrupt lateral deviation of
patella during terminal knee
extension (J-sign)
Can be due to VMO
defeciency, patellar alta,
trochlear dysplasia
During knee Extension,
palpate VL & VMO: delay in
onset of VMO contraction

Observe Movement
Patterns
Hip Abduction & Hip
Extension
Alteration reveals hip
abductor and gluteus
maximus weakness

Muscle Strength
Testing
Quadriceps
Hip
abductors
Hip Internal
Rotators
Flexibility
Testing
ITB
Rectus Femoris
Hamstrings
Hip Flexors
Gastrocnemius

Limb Length
Measurement
Externally rotated
hip: Lengthened
Subtalar joint
pronation: Shortened
Limb Girth
Measurement
Quadriceps atrophy
Athletes have near
same bilateral
symmetry

Functional Performance
Testing
PFPS patients:
lower strength
capacity
Decreased
performance in:
Vertical Jump Performance
Antero-medial Lunge

Single Leg Press
Step Down

Balance and Reach Test
Bilateral Squatting

Special Tests
1. Patellar Tilt Test
Compare height of
medial and lateral
patellar border
Laterally tilted: medial
border is more anterior
Compress medial
border→lateral border
cannot be raised = tight
lateral retinaculum

2. Patellar Glide
Test
Passive translation of
the patella,
measured as % of
patellar width
25%: Normal, >50 :
laxity of medial
constraints

3. Vastus Medialis Co-ordination
Test
Terminal Knee
extension
Lack of co-ordinated
full extension:
Positive Test

4. Patellar Apprehension Test
Knee flexed to 30°
Push the patella as lateral
as possible
Positive Test: Pain /
Apprehension
Less sensitive for PFPS

5. Waldron’s Test
Phase I- Press the patella against
femus while flexing the knee
passively
Phase II- slow, full squat while
pressing the patlla against femur
Presence of Pain and Crepitus

6. Patellar Grind /
Clark’s Test
Knee is in slight
flexion
Press the patella distally (with
the hand on the superior
border of the patella)
Contraction of Quadriceps
muscle
Pain, However specificity is
low

7. Eccentric Step Test
Stands on 15 cm (6
inches) stool
Steps down. First
with uninvolved and
then involved leg
Pain at the
knee
Highly specific
and sensitive
Test
9. Sustained Flexion
Test
Sustained
passive flexion
Pain in the knee
Ischaemia of patella
on prolonged
flexion

In patients presenting with knee pain, a
positive outcome on either the vastus
medialis coordination test, the patellar
apprehension test, or the eccentric step test
increases the probability of PFPS.

Q Angle
Patient is supine
with knees
extended
Line from ASIS to
centre of patella
Center of patella
to tibial tuberosity
Sitting or Standing
(more reliable)
Tubercle
sulcus angle
Line Perpendicular to:
The line from the center of
patella and tibial tubercle
Line through femoral
condyles
Normal: 0°
> 10° : lateralization of
tibial tubercle

External Tibial Torsion
Angle between: bimalleolar
plane and longitudinal axis of
femur
Femoral Anteversion
Prone, knee
flexed to 90°
IR > ER = ↑
Femoral
anteversion

VAS & NPRS for pain
Functional Independence Questionnaire (FIQ)
Anterior knee pain- specific questionnaire
Patellofemoral Function Scale (PFS)
PFPS severity scale
The Activity of Daily Living Scale (ADLS) of the Knee
Outcome Survey

Axial view with knee flexed
to 30°-40°
AP View: varus, valgus
angulation, patella height
and tibial tubercle location.
Lateral view: rotational &
vertical malalignment,
morphological
characteristics
Skyline view at 30-45° knee
flexion: morphology of the
PFJ
Radiographs
Investigations

• Q angle
• incongruenc
ies
• Activity of
bone
remodelling
in patella/
trochlea
• Articular
cartilage
• Lateral
retinaculum
• 0°, 15°, 30°,
45° Knee
flexion
• Precise mid-
patellar
transverse
images
CT MRI
CT Hip,
patella
and
tibial
tubercle
Radio-
nuclide
scans

Scintigraphy
Increased osseous
metabolic activity
Abnormal joint
homeostasis
Pinhole
collimator and
SPECT
Pathological
scintigraphic uptake
pattern,
localization and
intensity in
patellofemoral joint
can be detected

DIFFERENTIAL DIAGNOSIS
Chondromalacia
Patallae
Pes anserine bursitis Ilio- tibial Tenonitis
Patellar subluxation/
dislocation
Plica syndrome Osteochondritis
dissecans
Patellar tendinitis Sinding-larsen-
Johannson syndrome
Patellofemoral
osteoarthritis
Osgood- schlatter
lesion
Symptomatic bipartite
patella
Prepatellar bursiis
Hoffa’s Disease Quadriceps
tendinopathy
Patellar stress fracture
Referred pain from hip
and lumbar pathology
Loose bodies Saphenous neuritis

MANAGEMENT OF PFPS
No Two Rehabilitation programs are same
Underlying mosaic of patho-physiology and
tissue healing responses are unique
Depends on the findings of the assessment
The aim of non-operative management is to
alleviate pain and correct the mal-alignment

Clinical Classification of

1. Relative Rest
PFPS is an overuse/ overload syndrome
Runners: reduce mileage
Cyclists: lower gear, high pedal revolutions per
minute
Breast stroke to be avoided
For those engaged in high impact activities: swimming,
elliptical trainer

2. ICE, NSAID’S, Electrotherapy
Ice particularly after exercise
Ice-massage at tender areas
NSAID’s if pain is during ADL’s or not
controlled by ice application
Ultrasound, Electrical stimulation
Gentle mobilization of patella
Dry needling

3. Strengthening : Quadriceps/ VMO
Current evidence suggests that the VMO cannot be
exercised in isolation
The first step for the patient to learn to contract the
muscle.
Determine which position gives the best contraction
The patient should palpate the VMO while contracting
their quadriceps in various degrees of knee flexion and
/ or in different activities

Starting in sitting with knees bent to 90
Emphasis on weight bearing and functional
activities
Bio-feedback or Neuro-muscular electrical
stimulation to enhance the contraction.
Minimal pain before these exercises, else muscle
action may be inhibited.
Taping can be applied before exercise

Open kinetic chain (OKC) exercises have been
reported to exacerbate symptoms in PFPS patients
Closed kinetic chain exercises are a more
functional way of rehabilitation
CKC place less stress on PFJ
CKC: last 30° of knee extension
OPC: 90° - 40° Of knee flexion
Open v/s Closed Kinetic Chain Exercises

ISOKINETIC TRAINING
Provides optimal loading of the muscles
Allows muscular performance at different
angular velocities
Less compressive forces on the joint surfaces
during high angular velocity.
Isokinetic training at high angular velocity
(120°/s) is preferred
Eccentric contraction is more difficult

Isokinetic eccentric training should initially at 90°/s or
lower angular velocities
Patients with maltracking of the patella should
avoid isokinetic training at high angular velocities
during eccentric actions
Risk for possible patellar subluxation or
dislocation..
Isokinetic training at high angular velocity
(120°/s) is preferred
Isokinetic training improves proprioception as well as
muscular strength.

Strengthening exercise : Hip Muscles
Particularly hip abductors and external rotators
Stabilizes pelvis and controls hip internal rotation
Start from non-weight bearing → weight
bearing
Activation with VMO
Pelvic and hip-stabilizing muscles: Transverse
abdominus, Gluteus medius, and Gluteus minimus.

4. Flexibility Exercises
Hamstrings
Rectus Femoris
Gastro-soleus
IT Band
Hip Flexors

5. Taping
To maintain the patella correctly within the femoral
trochlea during full knee range of motion.
McConnell Technique is most commonly used
McConnell’s Rehabilitation Program: Patellar taping +
stretching of lateral tight structures + VMO strengthening
Aim of taping: to medialize the patella, to improve
patellar tracking
Correction is made on individual mal-alignment

Correcting
Lateral Glide
Knee in
extension
Tape started at
mid-lateral
border
It is brought across
the face of the
patella

Centering Effect

Correcting
Lateral Tilt
Tape started in the
middle of patella
Secured to the medial
border of medial hamstring
tendons, lifting the lateral
border of the patella.
Correcting
External Rotation
Tape started at
middle of the
inferior border of
patella
The inferior pole of the
patella is manually rotated
internally.
Secured to medial soft
tissues in superior and
medial direction while
the manual correction
is maintained.

The effect of taping should be assessed
immediately using a pain provoking activity
Acute cases may initially need tape applied
24hrs a day until the pain reduces
The tape time is then gradually reduced.
Kinesiotaping method

Clinical Prediction Rule to identify those patients who
would immediately receive a 50% reduction in
patellofemoral pain with a medial patellar taping, four
variables were identified:
Degree of tibial angulation
Soleus muscle length
Patellar tilt test
Relaxed calcaneal stance
 Positive patellar tilt test and tibial angulation greater
than 5° of varus: best predicted success with taping.

6. Knee braces and sleeves
Coumans bandage technique:
influences tracking of the
patella + massaging effects to
the peripatellar structures
during motion.
Protonics orthosis: patella’s
tracking pattern by improving the
pelvic position via an active
resistance mechanism

The Palumbo dynamic patellar brace consists of a
lateral pad that ’floats’ over the patella, maintaining
effective position during knee motion.
Cho-Pat knee strap functions dynamically , improves
patellar tracking and spreads pressure uniformly over
the surface area.
Over prolonged periods, bracing can lead to atrophy
in the quadriceps, and should be avoided.

7. Orthotics
Control excessive foot
pronation
Reducing excessive pronation in individuals with PFPS will
result in reduced internal rotation of the lower limb
Reduced Q angle
Navicular drop test is a convenient clinical method for estimating
the amount of foot pronation. 10 mm is considered to be a
normal amount of navicular drop, whereas values greater than 15
mm indicate excessive motion and reason to consider the use of
foot orthoses in runners.

The Clinical Prediction Rule for use of off-the –shelf
orthotic insert for patients with PFPS:
Forefoot valgus alignment (2° of valgus)
Limited passive extension of the first MTP joint (78°)
Minimal motion on the navicular drop test (3 mm)
Evidence indicates that combining physiotherapy with
prefabricated foot orthoses may be superior to
prefabricated foot orthoses used alone.

8. Biofeedback
Significant improvement in
the vastus medialis oblique
: vastus lateralis EMG ratio
Pain Relief

9. Lumbo-pelvic Manipulation
Sacro-iliac joint (SIJ) or lumbopelvic
region manipulation → ↓ in
quadriceps inhibition in the
involved knees of patients with PFPS.
Clinical Prediction Rule for determining
which patients will exhibit a rapid
response to lumbopelvic manipulation.
The most robust was a side-to-side
difference in hip internal rotation range
of motion of greater than 14°.

10. Activity Modification & Patient Education
Activities requiring flexion-extension
of knee against body weight to be
avoided
Squatting and steps to be avoided
when acute pain is present
Increased body mass index (BMI) correlates with
increased rates of PFPS. Thus, reduction in weight
will significantly diminish the stresses

MEDICAL MANAGEMENT
If no adequate relief from NSAID’s and physical
therapy
Intra-articular hyaluronic acid (HA) injections-
glycosaminoglycan .
It forms viscous synovial fluid that lubricates
joints, absorbs mechanical shock and protects
the articular cartilage.
It is administered as a series of 3-5 intra-articular
injections given 1 week apart.

SURGICAL INTERVENTION
 If symptoms persist despite completing 6 – 12
months of thorough rehabilitation
Lateral Retinacular
Release
Proximal
Realignment of
extensor
mechanism
Distal Realignment
of extensor
mechanism
Repair or
reconstruction of
patellofemoral
ligament
Arthroscopic
debridement
Abrasion
arthroplasty /
chondroplasty
Interposition
trochleoplasty
Replacement
arthroplasty of
patella or
patellectomy
Repair of patello-
femoral articular
cartilage lesion eg.
Mosaic plasty

PRE & POST OPERATIVE REHABILITATION
Control Pain and inflammation: Protection, Rest, Ice,
compression, Elevate (If acute)
Maintain or improve strength and flexibility of the
quadriceps and the hamstrings
Improve general lower extremity alignment
Patellar bracing and taping to prevent more
damage
Post- op Reahabilitation depends on the type of
surgery

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