Patella Femoral Pain Syndrome

What is meant by Patellafemoral pain syndrome

PFPS is a general term for pain and discomfort from the patellofemoral joint. It is a chronic condition, typically caused by overuse and overload of the patellofemoral joint, muscle weakness, imbalance or dysfunction. 

What would a patient with patellofemoral pain syndrome typically complain about

Patients typically complain of symptom aggravation during activities which increase patellofemoral compression such as ascending/descending stairs, sitting with knees bent, or kneeling.

Outline all the structures affecting patella alignment

• The patella sits within, and glides on, the patellofemoral groove of the femur.

• The quadriceps tendon attaches to the patella superiorly on its ‘Base’ (confusing name)

• The patellar tendon attaches to the patella inferiorly on its ‘Apex’.

• The proximally, the quadriceps tendon is formed by fibres which extend from the vastus intermedius, vastus lateralis, vastus medialis and rectus femoris. Balance between the vastus medialis and lateralis is particularly important for patella alignment.

• Four ligaments stabilise the patella: lateral and medial patellofemoral ligaments, and the lateral and medial patellotibial ligaments.

• Finally, the iliopatellar band, an extension of the iliotibial band, attaches to the lateral side of the patella

How would a weakness in vastus medialis create PFPS

Patella may track laterally on the patellofemoral groove

How would a Weakness in vastus lateralis create PFPS

Patella may track medially on the patellofemoral groove

How would a Tight Iliotibial band and therefore iliopatellar band create PFPS

Patella may track laterally on the patellofemoral groove

or

The tibia may be externally rotated due to this, which would also create a lateral bias tracking of the patella through a lateral pull on the patellar tendon.

How would tight hamstrings create PFPS

Biceps femoris (strongest hamstring component) attaches laterally, which can externally rotate the tibia and increase lateral pressure on the patellofemoral joint.

How would Weakness in abductors or external rotators of the hip create PFPS

This may result in a hip with slight internal rotation which increases valgus and Q angle, and pressure on the lateral half of the patellofemoral fossa. Internal rotation bias may also be compensated with tibial external rotation which again increases lateral pressure on the patellofemoral joint via a lateral pull on the patellar tendon. 

Why are women more susceptible to PFPS

Women typically have a greater Q angle due to having wider hips. This may increase lateral patellofemoral pressure.

What should be included in a subjective assessment of a patient with PFPS

History of primary complaint

Have there been any changes the activities you take part in (volume or type) that correspond with the onset of the problem?

Past injuries or treatment, particularly at knee, hip and ankle.

Occupation

Hobbies / Sports / Gym Activity?

Aggravating factors, e.g seated for long periods

Current management techniques / treatment.

Are you using any medication to treat the issue?

Current limitations & goals - what would you like to be able to do.

What outcome measure could be used for PFPS

Kujala Score / Anterior Knee Pain Scale (AKPS)

What should be included in a objective assessment of a patient with PFPS

Standing posture

• Observe if the patient is biasing their weight to one side

• Observe any differences in size of the quadricep heads, per leg and between legs

Gait Observation

• Observe movements at the ankle, knee and hip

Knee ROM

• Passive and active, supine with hip into flexion

• Compare against unaffected side

Hamstring Flexibility

• Straight leg hip flexion in supine

• Compare against unaffected side

IT Band

• Modified Ober’s Test

Hip ER & IR

• For hip in flexion, side lying tests

• For hip in extension, prone tests

Quad / Knee Extension Strength

• Seated, shin off bed

• Compare between sides

What general points can be included in a PFPS treatment plan

General Points

• Try to avoid exercises that are known to aggravate the condition and symptoms

• Avoid use of pain relief/anti-inflammatory drugs if possible - the pain/inflammation is there for a reason.

Exercise Program

• Aim to complete the prescribed exercises each day

• Only work within your pain-free range of motion 

• If any of the exercises are creating pain - immediately or afterwards, let me know and we can modify.

• If you are finding any of the exercises to be too challenging, or too easy, let me know and we can modify.

• Do the exercises with intent and focus on the muscles they are intending to strengthen, don’t just ‘get them done’.

What quad strengthening exercises could be included in a PFPS treatment plan

See image

If the IT band is found to be an issue in PFPS, what treatment can be done

If the IT band is suspected of creating lateral tension on the patella, exercises to strengthen the abductors on the affected side may assist with this issue. At the hip, the IT band fibres originate from the tensor fascia latae, gluteus medius and gluteus maximus. 

The function of the TFL is to pull down on the illium of the pelvis during walking, maintaining a level pelvis so that the non-weight bearing leg doesn’t catch on the floor. 

A weak TFL may result in a person slumping on the affected side which will increase tension on the ITB (slight adduction of hip on that side)

The same could be said for gluteus minimus and medius

So strengthening the TFL may help with ITB tightness.

• Standing hip dips - the patient can stand on a step on the weight bearing leg, slumping into them pushing the floor away

• Side lying leg raises - for glute medius, minimus and TFL

• Clam shells

• Side plank

If the hamstrings are found to be tight, what could be done in the treatment of PFPS

If a tightness in the hamstrings is suspected to be contributing to a lateral shift of the patella, working the hamstrings through their length through stretching and hinging exercises may assist with this. An anterior pelvic tilt may also be present, in which case the anterior core and hip flexors should be considered.

• Single or double leg hamstring stretches, combined with isometric contractions

• Double and single leg RDLs

• Seated hamstring curls, gym machine (at more length at end of eccentric)

• Jefferson curls

If the affected leg is biased towards internal rotation in a patient with PFPS, what treatment could be done

If the lower limb is biased to internal rotation, potentially due to a weakness of the deep rotators of the hip, strengthening of these muscles may assist with any related knee problems.

• Clam shells

• Side lying external rotation 

• Prone external rotations (with knee bent)