Structural Deviations Causing Patello Femoral Pain

1
Structural Deviations Causing Patello Femoral Pain
2
Patello Femoral Pain

• Patellofemoral pain syndrome can be defined as
  retropatellar or peripatellar pain resulting from
  physical and biochemical changes in the
  patellofemoral joint. It should be distinguished
  from chondromalacia, which is actual fraying and
  damage to the underlying patellar cartilage.
  Patients with patellofemoral pain syndrome have
  anterior knee pain that typically occurs with
  activity and often worsens when they are
  descending steps or hills. 18
• Patellofemoral syndrome probably arises from
  repetitive stress of the patella on the femur,
  but the exact etiology is unknown. 17

3
Redundant Causes

• Working with athletes in athletic training and
  patients at rehab and chiropractic clinics, I
  have found the majority of injuries to stem from
  3 main causes.
• Traumatic Injuries
• Malalignments
• Muscular Imbalances

4
Dr. Jennifer Earl, MS, PhD, LAT

• Tissue can adapt to increased loading when in
  proper alignment.
• Malalignment equals injury. 7

5
Preliminary Problems of Pronation

• In the pronated position, the cuboid loses much
  of its mechanical advantage as a pulley
  therefore the peroneus longus tendon no longer
  stabilizes the first ray effectively. This
  condition creates hypermobility of the first ray
  and increased pressure on the other metatarsals.
  There is also an increase in tibial rotation,
  which forces the knee joint to absorb more
  transverse rotation motion.
• Prolonged pronation of the subtalar joint will
  not allow the foot to resupinate in time to
  provided a rigid lever for push-off, resulting in
  a less powerful and efficient force. Thus,
  various foot and leg problems will occur with
  excessive or prolonged pronation during the
  support phase these problems include stress
  fractures of the second metatarsal, plantar
  fasciitis, posterior tibial tendinitis, achilles
  tendinitis, medial tibial stress syndrome, and
  medial knee pain. 15
• Keep in mind that this has also been reported by
  numerous practitioners to cause hip and back
  problems as well, which we will touch base on
  later.

6
Pronation Climbs High

• A study designed to identify the risk of MTSS
  (medial tibial stress syndrome) including 30
  collegiate athletes, 15 with recurrent MTSS and
  15 healthy matched controls were assessed for
  walking gait pattern, static foot posture,
  navicular drop, rearfoot and forefoot alignment,
  ankle range of motion and ankle strength.
• Discriminate analysis revealed that a
  hyperpronation gait pattern (19.4), excessive
  forefoot varus (6.9), and diminished DF strength
  (5.9) were collectively the most predictive
  factors.
• A hyperpronation gait pattern was found to be the
  most predictive risk factor of recurrent MTSS. 5

7
Internal Changes 19

• The internal rotation of the bones of the leg can
  also cause problems in the knees, hips, and lower
  back.
• Rotation of the tibia/fibula causes the head
  (front) of the talus to move forward and down,
  and causes the calcaneus to evert.
• The anterior and inferior motion of the talus,
  combined with the external rotation of the
  calcaneus, causes the foot to lengthen,
  stretching the plantar fascia and putting
  particularly high stress at the medial attachment
  of the plantar fascia to the calcaneus. This
  stress is a primary cause of heel pain syndrome
  and can cause plantar fasciitis as well.
• Pronation places increased strain on the medial
  aspect of the Achilles tendon, the tendons
  posterior to the medial malleolus, and other
  muscles and tendons. 6
• Tendinitis of the tibialis posterior and MTSS
  often occur secondary to such a malalignment.

8
Pronation Affecting the Knee

• In weight bearing, if the arch drops, this causes
  tibial internal rotation and results in genu
  valgum at the knee.
• This leads to an increased Q-angle and typically
  causes the patella to ride against the lateral
  boarder of the patellar grove. It also stretches
  the medial tissues and compresses the lateral
  tissues.
• Obesity can be of further detriment by placing
  extra stress on the joints.
• One study found that athletes with increased BMI
  exhibited significantly decreased hip flexion
  angle (P0.01) and knee flexion angular velocity
  (P0.01) at initial ground contact, and increased
  peak knee extension moment during landing. The
  increased BMI and decreased relative strength may
  increase the risk of ACL injuries. 2
• A related study concluded that the combination of
  reduced qudriceps force associated with greater
  trunk flexion, and reduced patllar tendon angle
  of insertion associated with greater knee flexion
  likely reduced the anterior tibiofemoral shear
  force. These results suggest that active trunk
  flexion may effectively attenuate force imparted
  on the ACL. 1

9
Proximal Factors

• Much of the current research is focusing
  deviations in the hip and femur being the
  culprits for distal problems, particularly in the
  knee.

10
Robert Manske, Med, MPT, SCS, ATC, CSCS of the
Department of Physical Therapy at Wichita State
University.

• In an extensive critical review of non-operative
  treatment of the patellofemoral joint (PFJ), he
  displays several studies concerning the VMO-VL
  relationship.
• In conclusion, several studies found that lateral
  tracking of the patella leading to patellar
  femoral pain was a result from a slightly slower
  firing time of the VMO when compared to the VL.
• Conversely, he found several other studies
  showing equal firing times of the VMO versus the
  VL in both PFP subjects and asymptomatic
  controls.
• The variance in opposing significant differences
  can be attributed to different causes of PFP. 11

11

• Manskes two primary points in rehabilitating PFP
  is to first enhance pelvic and trunk stability
  followed by correcting hip musculature
  imbalances.
• Genu Valgum
• Manske suggests that increased genu valgum can be
  a result of internal femoral rotation.
• Runners Knee
• ITB friction syndrome can occur from genu varum,
  excessive pronation, leg length discrepency,
  inflexible muscles, weak musculature and of
  course overuse. 11

12
The IT Band is Easy

• Foot pronation increases internal rotation 9, but
  a tight IT band will increase tibial external
  rotation and can cause the patella to ride
  against the lateral femoral condyle. 6,7
• Internal tibial rotation from pronation causes
  the IT band to be stretched, sometimes resulting
  in IT band syndrome. 6
• The majority of runners have weak Abductors and
  hip flexors and stronger and tighter adductors.
• ITB syndrome study found a deficit in strength
  compared to the uninjured leg and control
  patients.
• Restrengthening the hip Abductors healed 22 of
  the 24 runners! 16

13
Dr. Jennifer Earl, MS, PhD, LAT, Director of
Neuromechanics at the University of Wisconsin
Milwaukee

• Suggests that rehabilitation for knee pathology
  should focus on femoral position more than
  patellar position.
• Dr. Earl presented a study of subjects with
  patellar femoral pain (PFP) having weaker hip
  Abductors and external rotation of the hip than
  the placebos. The PFP subjects performed more
  ADDuction and internal rotation of the hip than
  the painless subjects.
• Gait retraining should be focused on increasing
  hip Abduction and external rotation, decreasing
  genu valgum (of the knee) in both running and
  resistance training. 7

14
PFP Factor

• Twenty-four female subjects with a diagnosis of
  PFP and 17 female subjects without PFP
  participated in study.
• The PFP group demonstrated significantly less
  femur internal rotation compared the comparison
  group.
• The finding of decreased femur internal rotation
  in the PFP group suggests that this motion may be
  a compensatory strategy to reduce the quadriceps
  angle. 14

15
Osteoarthritis Genu Valgum and Weak Quads

• Patients with increased OA knee pain have a
  significant inversely related decrease in the
  peak external adduction (varus) and flexion
  (quadriceps) moments, whereas patients who have
  less or no knee pain have relatively normal peak
  external adduction, flexion, and extension
  moments. 4

16
Final Intriguing Findings

• A study of 14 subjects with chronic ankle
  instability (CAI) and 16 controls compared the
  sagittal plane movers of the ankle (PF/DF), knee
  (FLEX/EXT), hip (FLEX/EXT).
• There were significant strength deficits in the
  hip and knee extensors of the involved side of
  the CAI group.

17
Runners Clinic

• Achilles tendinosis treatments
• steroid injection does not appear to help.
• Heavy load eccentric calf training have shown
  excellent results! (3 sets of 15)
• Eccentric training is the emerging key for LE
  injuries!
• Runners typically have stronger (and tighter) HS
  strength than quadriceps.
• Runners do not show a higher incidence of
  osteoarthritis than of non-runners.
• Shoe experts recommend buying shoes that feel the
  most comfortable.
• Switching shoes or models can decrease adaption
  and increase injury.
• Reported a study that found subjects wearing
  uncomfortable shoes caused more oxygen
  consumption than wearing comfortable shoes.
• Reports that at least 70 of runners will show
  some pain relief with orthoses.
• Proposed orthoses function decrease muscle work.
  16

18
Simple Eval

• To visually test malalignments, have the subject
  perform unilateral step down tests, single leg
  squats and make sure the PSISs are equal in
  height. 12
• One way to test malalignment in the LE is to
  measure the linear distance between the knees
  before landing and at landing. The distance
  should NOT decrease.

19
References

• Blackburn, J. T. (2005). Effects of trunk
  kinematics on knee joint kinetics, kinematics,
  and extensor EMG. Journal of Athletic Training,
  40, p. 33.
• Brown, C. N., Yu, B., Krikendall, D. T., Garrett,
  W. E. (2005). Effects of Increased body mass
  index on lower extremity motion patterns in a
  stop-jump task. Journal of Athletic Training, 40,
  p. 32-33.
• Cosgarea, A. J., Browne, J. A., Kim, T. K.,
  McFarland, E. G. (2002). Evaluation and
  Management of the Unstable Patella. The Physician
  and Sports Medicine, 30 No. 10, p. 33.
• Divine, J. G., Timothy, E., Hewett. (2005).
  Valgus Bracing for Degenerative Knee
  Osteoarthritis Relieving Pain, Improving Gait,
  and Increasing Activity. The Physician and Sports
  Medicine, 33 No. 2, p. 40.
• Domorski, S. N., Evans, T. A., Hertel, J.,
  Denegar, C. R. (2002). Risk factors associated
  with recurrent medial tibial stress syndrome.
  Journal of Athletic Training, 37, p. 99.
• Dunn, P. F. (2004). Information for Runners
  Regarding Shoe Fit and Selection, Biomechanics,
  Running Injuries, and Orthotics. Retrieved
  October 1, 2005, from http//home.earthlink.net/p
  andmdunn/runners-shoes,biomechanics,running_injuri
  es,and_orthotics_files/frame.htmslide0018.htm
• Earl, J. (2005). Seminar in Indianapolis for the
  annual national athletic trainers association.
• Gribble, P. A., Hertel, J., Denegar, C. R.
  (2005). Chronic ankle instability is associated
  with strength deficits in proximal lower
  extremity muscle groups. Journal of Athletic
  Training, 40, p. 28.
• Gross, M. T. (2005). Seminar in Indianapolis for
  the annual national athletic trainers
  association.
• Knopp, W. D., Matthew E. B., McCoy, J. C.,
  (1997). Hypothyroidism Presenting as Tendinitis.
  The Physician and Sports Medicine, 25 No. 1.
• Manske, R. C., Davies G. J. (2003). A
  Nonsurgical Approach to Examination and Treatment
  of the Patellofemoral Joint, Part 2 Pathology
  and Nonsurgical Management of the Patellofemoral
  Joint. Critical Reviews in Physical and
  Rehabilitation Medicine, 15 (34)253-293.
  Retrieved October 1, 2005, from
  http//www.edata-center.com/download/article/57a2f
  d97757fa0ed/06-CRP-161.pdf
• Manske, R. (2005). Seminar in Indianapolis for
  the annual national athletic trainers
  association.
• Padua, D. A., Marshall, S. W., Beutler, A. I.,
  DeMaio, M., Boden, B. P., Yu, B., Garrett, W. E.
  (2005). Predictors of peak proximal anterior
  tibial shear force during a jump-landing task.
  Journal of Athletic Training, 40, p. 32.
• Powers, C. M., Chen, P. Y., Reischl, S. F.,
  Perry, J. (2004). Comparison of Foot Pronation
  and Lower Extremity Rotation in Persons With and
  Without Patellofemoral Pain. Retrieved Oct. 1,
  2005, from http//www.datatrace.com/medical/faiint
  lweb/2307_08.htm
• Prentice, W. E., Arnheim, D. D. (2000).
  Principles of Athletic Training (10th ed).
  McGraw-Hill Humanities/Social Sciences/Languages.
• Simons, S. (2005). Seminar in Indianapolis for
  the annual national athletic trainers
  association.
• Wall, E. J., (1998). Osgood-Schlatter Disease.
  The Physician and Sports Medicine, 26 No. 3, p.
  29.
• Cutbill JW, Ladly KO, Bray RC, Thorne P, Verhoef
  M. Anterior knee pain a review. Clin J Sport Med
  1997740-5.
• Index of image. (n.d.). Retrieved October 1,
  2005, from http//www.aafp.org/afp/991101ap/2012.h
  tml