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The current management of patients with patellofemoral pain from the physical therapist’s perspective

Capin, J.J. and Snyder-Mackler, L., 2018. The current management of patients with patellofemoral pain from the physical therapist’s perspective. Annals of joint, 3.

In today’s letter

• Key points of the Assessment & Treatment of patellofemoral pain

• Rapid Results = Theres 6 key objective examinations to look into:

  (1) Hip, ankle & knee ROM

  (2) Knee Swelling

  (3) Muscle strength (quads, hamstrings & calf’s)

  (4) Balance

  (5) Movement assessment

  (6) Step test

• 3 Reads to check out to further you knowledge about PFP

• Dank meme: Having back pain after treating back pain? 😥 

Aim of study

• The purpose of this review is to provide an overview of the physical therapist’s management, including the evaluation and treatment, of the patient with patellofemaral pain (PFP)

Did you know?

• About 23% of the general population experiences PFP annually, with adolescents facing a higher prevalence at around 29%, especially among female athletes.

• Engaging in recreational running or military training, which can increase patellofemoral joint contact forces, is linked to a heightened risk of developing PFP.

• Long-term implications of PFP are significant, with 57% of affected individuals reporting un-favourable outcomes five to eight years post-diagnosis.

Symptom Onset

• PFP, also known as anterior knee pain, encompasses various non-traumatic conditions resulting in knee discomfort around the patella or behind it.

• Several structures within and around the patellofemoral and tibiofemoral joints, such as the synovium or infrapatellar fat pad, may contribute to PFP either individually or collectively.

• Symptom onset may be influenced by various factors, with tissue homeostasis disruption through acute injury or repetitive overloading being primary contributors.

• Conservative management strategies initially focus on relative rest and avoidance of aggravating activities while aiming to prevent loss of muscle strength, range of motion, or function.

• Despite conservative efforts, PFP often persists over extended periods, requiring a more in depth approach.

Subjective Examination

• While anterior knee pain is commonly associated with young, active women without traumatic causes, it can affect individuals of all genders, activity levels, and ages.

• During assessment, talk about about various aspects including the onset of symptoms, any triggering events, pain characteristics, aggravating and relieving factors, medical history, diagnostic imaging, occupational demands, recreational activities, footwear, and patient goals.

• Referred knee pain might originate from hip issues such as osteoarthritis or paediatric conditions like slipped capital femoral epiphysis. Always think about the hip during subjective questioning and physical examination.

• Gradual or insidious onset of anterior knee pain is typical in PFP, while acute onset following trauma needs further testing for ligament, tendon, meniscus, or bone injuries.

• Clinicians should refer patients to specialists if serious pathology (e.g., fracture or osteomyelitis) or non-musculoskeletal causes (e.g., cancer or infection) are suspected, especially in the presence of red flags such as: 🚩🚩🚩

1. Fever

2. Unremitting night pain

3. Increased temperature and swelling around the knee

4. Leg length discrepancy

5. Limp, or limited hip range of motion, which may suggest conditions like Perthes disease or slipped capital femoral epiphysis

Range of motion

• It's crucial to test the range of motion (ROM) not only of the knee but also of the ankle and hip joints.

• Assessing muscle length is important, as individuals with PFP often have soft tissue tightness, which can increase symptoms.

• During evaluation, specific attention should be given to muscles like the rectus femoris, hip flexors, tensor fascia lata, iliotibial band, hamstrings, gastrocnemius, and soleus.

Swelling/Effusion

• The presence of knee joint effusion can be assessed using the stroke test, providing a simple evaluation method.

• Although knee effusion is not common in individuals with PFP, mild cases may occur.

• Significant effusion may suggest more severe underlying issues like ligament tears or fractures, which needs further investigation.

• Monitoring effusion levels can guide appropriate clinical progression during rehabilitation.

• Increased effusion may indicate that rehabilitation has surpassed the patient's current functional capacity, which requires a reduction or change rehabilitation exercises.

• It's crucial to track or talk about about activities outside the rehab plan to determine if the prescribed exercises or home programs contribute to effusion.

Step Test

• A modified step test, as illustrated in Figure 2, is recommended for assessment purposes. This involves standing on a 15-centimeter block with hands on hips and using the affected limb to slowly and smoothly lower the body until the opposite heel touches the floor.

• A Reproduction of the patient's symptoms is observed in 74% of people with PFP and has a modest positive likelihood ratio of 2.34.

• If the test shows positive results, clinicians often do a re-evaluation using the modified step test after applying patellar taping. This helps determine whether immediate symptom relief occurs and whether taping can be helpful as a treatment option.

Exercise therapy: Strengthening, stretching, and aerobic exercise

• High-quality evidence strongly supports the effectiveness of exercise therapy in decreasing pain and improving function over short-, medium-, and long-term periods, making it the most recommended intervention.

• Exercise plans should have hip and knee strengthening exercises, which include both open (non-weight-bearing) and closed (weight-bearing) kinetic chain movements.

• Studies by Steinkamp et al. showed varying patellofemoral joint contact forces between closed (e.g., body weight squat) and open (e.g., 9 kg weighted boot) kinetic chain exercises, suggesting that patients may benefit from open chain exercises in deeper knee flexion ranges and closed chain exercises in shallower ranges, particularly in the early rehabilitation stages.

• Throughout rehabilitation, exercises should be tailored to maximise muscle strength while minimising symptom increase.

• While the goal during the acute phase of rehabilitation is typically to perform pain-free exercises, in chronic conditions, the complete elimination of movement-related pain may be unrealistic and counterproductive.

• Including stretching into rehabilitation is essential, given that individuals with PFP commonly experience restricted range of motion, particularly in the hip, knee, and possibly the ankle.

Patello-femoral Taping

• There is contradictory evidence regarding the effectiveness of patellofemoral taping in managing PFP, as reported by various studies.

• This study suggest using taping as part of a varied treatment approach if it leads to pain relief during rehabilitation or functional tasks.

• Clinicians should evaluate its immediate impact on pain by comparing functional tasks pre- and post-taping

Top 3 reads

That will further your knowledge about patellar-femoral pain

1. A short overview of crepitus (Grinding, popping) & PFP in women

   https://www.sciencedirect.com/science/article/abs/pii/S1466853X18301056

2. An in depth article talking about PFP

   https://sportsmedu.com/2023/11/27/patellofemoral-pain-a-complex-challenging-condition/

3. An in depth article about treating & managing PFP

   https://sportsmedu.com/2023/11/27/treating-patellofemoral-pain-with-confidence/

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