What have we listened to lately? Patello Femoral Pain!
The David pope Physioedge PODcast with Dr Micheal Rathleff talking about adolescent patellofemoral knee pain, which has a prevalence of 6 to 7%.
Here is our summary:
Two thirds of the population do sports five times per week and often do the sports with pain. This group (adolescents) has usually been doing one sport their entire life and has had pain on and off. The other third of the population are adolescents who do not play sports at all. This group often are going from primary secondary school and encounter a lot of stairs or increased amounts of activity which is believed to contribute to the condition. So the majority are increased intensity or frequency of load whereas the other one is increased load only.
For the first group, playing in identifying with the sport is part of their social network and they would rather play with pain than be excluded.
One of the questions was “is there a different treatment protocol for each group”?
The short answer is no. Many times and adolescent in the “overuse” group is given additional exercises. Often this just contributes to increasing load. Education appears to be key in the rehab process. Males with the shortest duration of pain and lowest intensity seem to be the best responders to this program. Females with longest duration and highest intensity of pain seem to respond the least.
Not surprisingly, compliance with treatment protocol can be difficult with a teenager. In a recent RCT that they performed, 55% of folks that did their exercises three times per week were recovered in one year whereas those that did less were at 20%. These statistics are often put on the chart, laminatedand shown to the patients. This seems to improve compliance.
Another chart is made with these bullet points:
- Low hip strength
- low quadricep strength
- different movement pattern.
The anatomy is then shown and explained to the patient and an attempt is made to tie it all together.
Differentiation is made between: patellofemoral pain, Osgood-Schlatter’s disease, and patellar tendinopathy. The differentiating factors are with patellofemoral pain, the pain is diffuse; with Osgood-Schlatter’s it’s located over the tibial tuberosity and with patellar tendinopathy it is more at the inferior patellar pole.
Differentiation is always made between Sinding-Larsen-Johannsen disease and the others by the fact that this is mostly pain at the inferior patellar pole and relatively rare and adolescent population.
Differentiation between patellofemoral pain and Osgood-Schlatter’s disease usually involves the latter having locking in addition to pain. These conditions are usually confirmed with ultrasound or MRI.
There don’t appear to be specific reliable tests to rule in patellofemoral pain so the process becomes one of ruling out.
Palpation in the diagnostic process of course please large role. Also specific localization by the patient can be helpful. Dimension and “app” that the patient can draw on to show the examiner where the knee pain is. We really like this idea.
Exclusionary tests include the patellar fat pad compression test, but it is emphasize that this is more generalized rather than specific to the Tele femoral pain and a brief discussion as to its anatomy ensues.
Treatment includes 3 main steps
- patient education as to activity limitations.
- Patient refrains from activities a check of the pain for approximately four weeks and then his gradually reintroduce as long as they can keep their VAS scores below three.
- Exercise can begin at the four-week timeframe, again depending upon the patient’s symptoms. A gentle progression with pain as a guide is advised with a return to activity previous activity as early as 5 to 6 weeks. Frequency of training is increased first and then duration of training.
Exercise initially is confined to the more proximal joints such as the core and hips. They begin with open chain, theraband exercises (which we do not necessarily agree with). They also do RM testing 10 to 12 reps.some standardization is done with regards to therapy and length and amount of travel.
Compliance is discussed as adolescence often have an extensive social network. Exercise in 15 minute intervals is encouraged. Prognostically it shows that patients that can control their loads earlier tend to do better longitudinally.
Foot orthoses are discussed but it is pointed out that there is not a lot of data and research on their efficacy in an adolescent population for the telephone real pain. He goes on to talk about how a foot orthoses “takes your brain out of the equation” and can provide some degree of increased compliance albeit, passive. The orthotics are left in until they are “worn out” (they use a great expression:”until the natural mortality of the orthotic runs its course” which we loved ! and then see how the patient does.
Hip strengthening is discussed. It appears that adolescents develop weaknesses after patellofemoral joint pain, not as a result of it.
Other treatment modalities included “fat pad unloading tape”. A “v” pattern is done with crossing at the tibial tuberosity. The Chris Barstann method is given in a YouTube link is provided. Plane “white tape” can be utilized for adolescents who hyper extend their knees, with the tape running behind the knee a few hours at a time.David talks about an anchor above and below the knee with an X pattern crossing at the middle of the popliteal fossa and having the knee in slight flexion.
So after the progression of one activity modification, two taping three therapy and exercises they then move onto hip strengthening with close chain exercises such as squatting and lunches.backpacks with different amount of weight totaling there 10 or 12 RM are then employed. Care is exercised to keep them in a pain-free range. When they can accomplish this then they move onto one legged work
Stretching was deemphasized because of the increased compression at the patellofemoral joint.
Guidance as to speed, frequency and ranges of motion of exercise are carefully given to each patient. Eight seconds of time under tension for each repetition using a thorough band (three second concentric, two second isometric hold, three second eccentric) adding up to 80 seconds for each 10 repetitions. This allows good proprioceptive control because of the long contraction and increased exercise dose. They often use a “smart phone” to video the exercise for the patient (with the doing this for years and it’s a great way to assist in compliance; a person may lose a sheet of paper or their keys but they will not lose their phone).
All in all, an informative PODcast for those who have a deeper interest in treating PFP in the adolescent population.
The Gait Guys