852: patellar pain and extra articular conditions

Medial diagnosis for patella femoral pain syndrome (PFPS)

• pain joint involving lower leg

• Runner’s knee

• Chondromalacia patella

• Retropatellar pain syndrome

• Anterior knee pain syndrome

Pathobiological mechanisms of PFPS

Due to a combo of factors: repeated stress, abnormal mechanics of PFJ, overuse activity

Results in pain and inflammation along retropatellar surface

Potential pertinent history of PFPS

• recent change/increase in activity

• Previous ACL reconstruction

• History of knee pain

• History of or recent patellar subluxation

Potential predisposing factors

• female (increased if general LE strength deficits present)

• Age < 60

• Altered foot posturing

Grade A recommendations for PFPS

Reproduction of peripatellar or retropatellar pain with squatting or ascending and descending stairs

Grade B recommendations for PFPS

• presence of peripatellar or retropatellar pain AND

• Reproduction of familiar pain with squatting, stairs, prolonged sitting AND

• Exclusion of any other condition causing anterior knee pain

Typical clinical picture PFPS

• female

• < 48 years old

• Localized anterior knee pain

• Often a runner

Exclude PFPS if:

If the patient is > 58 years old and pain is more diffuse throughout the knee, and knee ROM is limited

Symptoms of PFPS

Localized anterior knee pain

• behind patella, or peripatellar pain

Swelling

Crepitus

Symptom descriptors of PFPS

Dull or sharp ache

Aggravating factors for PFPS

• prolonged sitting

• Running

• Walking

• Stairs

• Squatting

• Bicycling

Easing factors for PFPS

Limiting or avoiding knee flexion postures or knee flexion activities

24 hr pattern for PFPS

Increased pain with increased activity

PFPS objective exam: observation

• increased knee valgus with squatting

• Pain with eccentric step down

• Reproduction of familiar pain with functional activities that load PFJ (squats, stairs, prolonged sitting)

PFPS objective exam: palpation

Painful palpation to medial or lateral retropatellar surface

PFPS objective exam: strength

Decreased knee extensor and hip musculature strength

PFPS objective exam: ROM

Pain with EROM knee flexion and/or extension

PFPS objective exam: Special tests

+ Clark’s grind test, patellar compression

PFPS objective exam: Accessory motion

Likely hypomobile and/or painful PFJ accessory motion, specifically medial glides

Scoring criteria for lateral step down test

• removal of hand from waist

• Leaning in any direction

• Loss of horizontal plane

• Tibial tuberosity medial to second toe

• Tibial tuberosity medial to medial border of foot

• Stepping down on nontested limb

• included exercises focused on both hip and knee strength

• Interventions performed in combo vs isolation yield superior outcomes

• Prefabricated foot orthoses for patients with significant foot pronation for up to 6 weeks in conjunction with a therapeutic exercises program

Grade A recommendations for PFPS

Grade B recommendations for PFPS

• patellar taping along with exercise therapy for immediate pain reduction

• Interventions performed in combo vs isolation yield superior outcomes

Medical management of PFPS

• pharm: oral NSAIDs

• Surgery: rarely recommended

• Conservative: taping, PT

• Imaging: performed to rule out other diagnoses if no improvement

Medical diagnosis for patellar tendinopathy

• patellar tendonitis

• Patellar tendinopathy

• Enthesopathy of LE

PT diagnosis for patellar tendinopathy

Knee flexion, knee valgus, femoral adduction, and IR

Acute inflammatory phase of patellar tendinopathy

Overload of tendon resulting in micro lesions to collagen fibers that exceed tendons capacity to repair

Tendon micro trauma occurs resulting in swelling and matrix degradation

Histopathological changes to tendon leading to failed healing response

Collagen fibers regenerate in disorganized manner, with marked fibrosis and neovascularization

• impacts ability to take load

Incidence and risk factors for patellar tendinopathy

• impacts predominately males in sports

• 15-30 years old

• Abnormal knee alignment

• Repetitive loading

Symptoms of patellar tendinopathy

• localized pain and or swelling over inferior patellar aspect (even when aggravated)

• Stiffness after prolonged rest

• Pain common during and after activities

• Increased symptom intensity with increased loading to tendon

Symptoms descriptors for patellar tendinopathy

Aching, occasionally sharp pain along anterior knee

Aggravating factors for patellar tendinopathy

Running, jumping, squatting, stairs, cutting, decelerating, prolonged sitting

Easing factors for patellar tendinopathy

Rest, patellar tendon bracing, activity may initially ease symptoms

24 hr pattern for patellar tendinopathy

Activity dependent

Objective examination for patellar tendinopathy: palpation

Palpable tenderness (familiar pain) and thickness over patellae tendon (not diagnostic)

Objective examination for patellar tendinopathy: Strength

Quads weakness

Pain with restricted knee extension

Objective examination for patellar tendinopathy: ROM

Normal knee ROM, pain at EROM flexion

Decreased ankle DF ROM

Objective examination for patellar tendinopathy: Mobility

Flexibility deficits in rectus femoris and hamstrings

Pain with decline squats, stairs, jumping/hopping

Objective examination for patellar tendinopathy: Accessory motion

May have pain with PFJ accessory motion, apprehension with lateral glides

PT management for patellar tendinopathy: therapeutic exercises

• strengthening exercises for quads and hip musculature

• Motor control activities for LE

• Quads and HS flexibility

• Eccentric loading exercises for chronic cases supported in literature

PT management for patellar tendinopathy: manual therapy

• STM or instrument assisted soft tissue mobs

• Joint mobs as appropriate

• Cryotherapy for acute cases

Patellar tendinopathy exercise progression order

1. Isometric exercises

2. Isotonic exercises

3. Energy storage exercises

4. Progressive return to sport

Indication to initiate and dosage for stage 1: isometric loading

More than minimal pain during isotonic exercise

5 reps of 45 seconds, 2-3 times per day, progress to 70% max voluntary contraction as pain allows

Indication to initiate and dosage for stage 2: isotonic loading

Minimal pain during isotonic exercise

3-4 sets at a load of 15RM, progressing to a load of 6RM, every second day; fatiguing load

Indications to initiate and dosage for stage 3: energy storage loading

Adequate strength and consistent with other side

Load tolerance with initial-level energy storage exercise

Progressively develop volume and then intensity of relevant energy storage exercise to replicate demands of sport

indication to initiate and dosage for stage 4: return to sport

Load tolerance to energy storage exercise progression that replicates demands of training

Progressively add training drills, then competition, when tolerant to full training

Pharmacologic management for patellar tendinopathy

Acute: short course of NSAIDs

Injection options: corticosteroids, platelet rich plasma

Surgical options for patellar tendinopathy

• open tenotomy with excision of necrotic tissue

• Arthroscopic patellar tenotomy

• Drilling/resection of inferior pole of patella

• Resection of tibial attachment with quads BTB graft

Conservative management for patellar tendinopathy

Bracing, taping, activity modification

Imaging for patellar tendinopathy

US and MRI helpful to rule out/in other diagnoses

Patellar dislocation/subluxation medical diagnosis

Closed dislocation of patella

Patellar instability

Patellar dislocation/subluxation pathobiological mechanism

• dislocation: occurs when no contact between patella and trochlear groove

• Subluxation: temporary partial dislocation of the patella from trochlear groove

• Most occur laterally

• Atraumatic more common due to laxity

Patellar dislocation/subluxation incidence and risk factors

• females > males

• Risk decreases with age

• Young, active, female

• General lax ligaments

• Excessive foot pronation

• Patella alta

• Femoral anteversion

Patellar dislocation/subluxation diagnosis

• requires a combo of subjective history, mechanism of injury, and clinical signs

• Diffuse anterior knee pain

• Swelling

• Positive patellar apprehension test

Patellar dislocation/subluxation PT management

• initial treatment to focus on pain, swelling resolution

• Address joint mobility and flexibility deficits

• Quads strengthening in ROM that is lowest stress for PF joint

• Hip strengthening exercises

• Motor control activities

• Patellar taping

• Supportive footwear

• Balance/proprioception/sport specific activities

Patellar dislocation/subluxation medical management

• pharm: NSAIDs or acetaminophen

• Surgery: not common

• Conservative: bracing to immobilize for 2-3 weeks post acute injury, patellar taping

• Imaging: radiographs, CT, MRI

ITB syndrome PT diagnosis

Might be femoral adduction, IR, or knee flexion

ITB syndrome pathobioligical mechanisms

• pathology thought to occur at distal ITB due to friction with lateral femoral epicondyle

• Imaging supports thickening of ITB over LFE with fluid, but no bursae present anatomically

• Distal portion of ITB and LFE claimed to be separated by highly vascularized, innervated layer of fatty connective tissue: pain source

ITB syndrome incidence

Second most common cause of knee pain due to repetitive activities or overuse

ITB syndrome diagnosis

• recent increase in activity/training

• Highly active adult patient

• + ober test

• + Noble compression test

ITB syndrome symptoms

• aching or sharp pain in lateral hip, thigh, or knee

• Swelling or thickening of tissue over lateral distal femur

• Snapping, popping, clicking over lateral knee

ITB syndrome aggravating factors

Long distance running, stairs, cycling, jumping

ITB syndrome easing factors

Anti inflammatory meds, walking, ice, rest

ITB syndrome objective exam

Palpation: familiar pain with palpation over lateral femoral condyle or 1-2 cm proximal lateral joint line

ROM: limited knee flexion to and from extension due to pain

Strength: deficits in hip abductors and glutes

Special tests:

• + Ober test

• + noble compression test

ITB syndrome PT management

• address soft tissue mobility and flexibility deficit in musculature surrounding or attaching to ITB

• Myofascial trigger point release as appropriate

• Strengthening exercises focused to hip, knee, ankle

• Motor control exercises to improve dynamic stability of LE in squatting

• Hip or knee joint accessory mobs if appropriate

ITB syndrome medical management

• pharm: NSAIDs, muscle relaxants

• Surgery: rare

• Conservative: PT, heat/ice, activity modifications

• Imaging: MRI

Pes anserine bursitis pathobiological mechanisms

• overuse can lead to inflammation of the bursa

• Tendons can become compressed or irritated

Pes anserine bursitis risk factors

Potential Pertinent History

• avid runner

• Athletic overuse

• Known history of knee OA in same knee

• May have had recent trauma

Potential predisposing factors

• female > 40

• Higher BMI

• Previous medical meniscus or MCL injury

• Valgus deformity

Pes anserine bursitis symptoms

Local swelling and tenderness about 3 finger widths distal to medial tibiofemoral joint line

Pes anserine bursitis symptoms behavior

• aggravating factors: stairs, STS, prolonged sitting, squatting, swimming, cycling, running

• Easing factors: rest, ice, meds

• 24 hr: increases with increased activity

Pes anserine bursitis objective examination

• may have familiar pain with Valgus stress test

• Familiar pain over insertion of three muscles

• Bursa tenderness only notable when swelling or thickening present

• Painful active contraction of the three muscles

Pes anserine bursitis PT management

• activity modification and symptom relief!

• Stretching if flexibility deficits, noted in aggravated musculature

• Strengthening of antagonist and supporting muscles in hip, knee, ankle

• Cryotherapy

• Ultrasound

• Return to activity

Pes anserine bursitis medical management

• pharm: NSAIDs

• Surgery: rare

• Conservative: corticosteroid injection, cryotherapy

• Imaging: follow Ottawa knee rules if trauma related and MRI