Patellofemoral Treatment Guidelines

Now that we have spent some time discussing the differential diagnosis of patellofemoral pain and principles of patellofemoral rehabilitation, we can move on to discussing specific treatment strategies for each of the differential diagnoses we previously discussed.   If you have not read part 3 of this series on the classification of patellofemoral pain, you may want to go back as the following suggestions are based on that information. 

Remember, if you take one thing away from this series, treatment should be based on an accurate diagnosis!  Diagnosing someone with patellofemoral pain syndrome is like giving up and saying you don’t know what is wrong with the patient!

The following is part 5 of the series on solving the patellofemoral mystery:

 

Specific Treatment Based on an Accurate Diagnosis

Patellar Compression Syndromes

In general, the main goals of treating a patient with a compression syndrome is to loosen the restrictions and minimize the subsequent inflammation.  These are the patients that respond well to what I call a “loss of motion” protocol: 

  • Heat/whirlpool to warm up the tissue and prepare for treatment
  • Continuous ultrasound to tight area.  We can argue about the efficacy of US but I think this is a good time for it’s use.  I am aggressive – continuous, jack it up to 2.0 and keep the area small, of course use patient tolerance as a guideline!
  • Soft tissue massage progressing to aggressive massager or friction as inflammation subsides.  Specific trigger point and muscle energy techniques can be helpful as well, especially in the patient with tight hips that are contributing to ELPS.
  • Patellofemoral joint mobilization in whatever direction is needed
  • image For a patient with ELPS, I would consider trying patellar taping.  I don’t use this to really change the alignment or biomechanics of the patellofemoral joint, study after study shows this does not happen with tape.  I do however believe that the tape can be applied to potentially cause a low-load, long-duration stretch of the soft tissue/retinaculum around the knee.  Remember, that stress and tension of the surround tissue may be the cause of patellofemoral pain.
  • Generalized stretching of the lower extremity with specific emphasis on tight structures impacting the PF joint (i.e. the IT band).
  • As with anything else related to the patellofemoral joint, look at the hip and foot to see if any biomechanical factors are contributing to lateral tightness of the knee.

There are also some things that should be avoided in these patients:

  • Bike riding – it is just going to compress the PJ joint and cause more symptoms
  • Exercises with high PF joint reaction forces, such as knee extension.  Again, just going to cause more compression and more irritation.
  • In the patient with global compression syndrome, I would recommend you avoid taping.  Again, just going to cause undue compression.
  • In general, I would be conservative in strengthening exercises for the global compression patient.  Straight leg raises, pool work, and other basic exercises should be enough while you loosen up the soft tissue.

Patellar Instability

The treatment for patellar instability depends on the chronicity of symptoms.  For acute episodes, treatment will revolve around the “damage control,”  or settling down the acute effusion and trauma associated with the incident.

For the later phases of acute instability or those with chronic recurrent instability, we are basically dealing with a lack of “static” stability from the osseous and ligamentous structures of the knee.  Thus, treatment should focus on enhancing stability in two ways:

  • image Enhance static stability.  If this is an anatomical issue, this may be difficult if not impossible.  This is the perfect patient for a patellofemoral brace.  While a general donut knee sleeve or some of the older patellofemoral braces may be enough for some patients, there are a lot of newer and more advanced bracing.  I have used the DonJoy Tru-Pull brace with success.  What types of braces have you tried and preferred?
  • Enhance dynamic stability.  This is the general long term goal for these patients.  It starts with enhancing strength and progresses to neuromuscular control exercises.  This in itself is a lengthy topic, but I recommend you check out a DVD of the principles of neuromuscular control during knee treatment that Kevin Wilk and I have produced (more information here from AdvancedCEU).  This will include dynamic stability of the entire lower extremity as any weakness in the kinetic chain could cause an excessive lateral stress on the patellofemoral joint.  More to come on this in a future post in this series.

 

Biomechanical Dysfunction

image As previously stated in my post on the classification of patellofemoral pain, the knee appears to take a good amount of stress when biomechanical faults are present both proximally and distally within the kinetic chain.  Alterations in foot and ankle mechanics, hip strength, leg length discrepancy, flexibility deficiencies, and any combination of these factors can have a negative impact on the forces observed at the patellofemoral joint.  Not only can biomechanical dysfunction lead to increased stress, it can also lead to chronic adaptations over time.  Take for example someone with weak hip external rotation.  This could lead to a dynamic inability to control the hip adduction and IR moment at the knee and cause the femur to rotate into internal rotation during activities.  This will cause the patella shift laterally and can cause articular cartilage and soft tissue changes that will mimic a typical ELPS patient.  You can loosen up the lateral soft tissue but without treating the true cause, the hip weakness, symptoms will continue to occur.

This will be discussed in greater detail in a future post in this series as this is an important factor to consider.

 

Direct Patellar Trauma

Ouch, I hate even thinking about direct patellar trauma.  My knee hurts just thinking of it!  With this pathology, we are worried about either a patellar fracture or articular cartilage damage. 

Once the initial trauma subsides, treatment should attempt to enhance cartilage healing.  This means frequent ROM of the knee.  In addition to standard PROM, this can be in the form of a bike, if minimal resistance is applied.  You do not want to compress too much but a little bit of motion is better for cartilage healing.  I also like the pool for these patients if possible.  You’ll have to limit patellofemoral joint reaction forces with exercises but this should subside with time.

If symptoms do not resolve, the patient should be sent back to their doctor for further evaluation to rule out a fracture or a OCD type cartilage lesion.

 

Soft Tissue Lesions

Treatment of soft tissue lesions to the plica, IT band, fat pad, or medial patellofemoral ligament involves an understanding of the basic principles of patellofemoral pain rehabilitation, but there are a few things to consider as well.  In general, you should stop the activity that is causing the irritation and avoid direct pressure on that area, so no transverse friction massage initially.  This may be appropriate when chronic to stimulate healing, but in my experience this tends to make things worse for soft tissue lesions.  I have found that direct anti-inflammatory modalities, such as an iontopatch, is helpful for these superficial areas of inflammation.  Other treatment strategies for specific lesions include:

  • image Suprapatellar plica syndrome.  The plica will get stressed over the medial femoral condyle with knee flexion, so avoid activities with repetitive flexion, such as bike riding and running.
  • IT band friction.  Similarly to above but with the lateral femoral condyle.  Lengthening massage to the IT band has been helpful in my practice.
  • Fat pad syndrome.  The patient should avoid excessive quadriceps activities, especially if this causes irritation to the fat pad as the patellar tendon can compress the area when contracting the quad.
  • Medial patellofemoral ligament injury.  These patients should actually have treatment similar to the ELPS patient above.  A brace to control lateral patellar translation may be helpful too.

 

Overuse Syndromes

Overuse syndromes include tendonopathy to the patellar tendon, and less commonly quadriceps tendonitis superiorly, and apophysitis of the tibial tuberosity or inferior patellar pole.

  • imageFor tendonopathy, treatment begins with assessing the chronicity of symptoms.  If acute, reduce inflammation and restore strength and flexibility.  I hate to be vague, but I doubt you’ll see a lot of patients that are this acute.  Realistically, people put off treatment for months and end up with chronic tendonosis.  This is another lengthy topic, but the key here is that the patellar tendon is not actually inflamed, it is degenerative due to a lack of healing blood supply (that is why the surgery for this is debridement to stimulate healing).  Thus, traditional treatment to reduce inflammation is not going to work.  In a way, you need to induce a certain amount of trauma, such as with transverse friction massage.  I also recommend that general orthopedic patients need to feel about a 3-4/10 on a pain scale during exercises to actually stimulate healing.  Any less and you probably aren’t stressing the area enough and any more and you may overloading.
  • Apophysitis of the tibial tuberosity or inferior patellar pole can be a pretty limiting pathology.  The two best treatments are time and avoiding the activity that causes symptoms.  That means many youth injuries will need to take some time off from basketball, or whatever may be causing their symptoms, as their body grows and the symptoms resolve.  Treatment is basically to reduce symptoms, there isn’t much you can do to actually “heal” the injury.

 

Now that we have discussed the basic principles of patellofemoral rehabilitation and some specific treatment guidelines for various diagnoses, you should have a good basis to improve the care of your patients.  The principles discussed so far are extremely important to understand and apply to each patient to assure you are optimizing your treatments and enhancing your outcomes.  The next two posts in this series will take treatments one step further as we talk about the biomechanics of the patellofemoral joint during exercises and the influence of the kinetic chain on the patellofemoral joint.

 

Continue reading to part 6 – Biomechanics of Patellofemoral Rehabilitation

 

Please comment on your experiences as well, specifically your experience with taping and bracing of the patellofemoral joint.  I know many people swear that taping is extremely effective.  Maybe some of those people can share their perspective and some advice on indications and how to maximize the effectiveness of taping?

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  • Kory Zimney, PT

    I like your comment with the tendonopathy patients that it is okay to have a little pain with these patients. I think it is important to understand and respect pain with our treatment. There are times we do not want pain and times to have a little pain. Also since this is challenging to get patients to understand the right amount of pain is important. Some come with the no pain no gain attitude and push to hard, while others are so afraid of a little pain they have fear avoidance behaviors.

    I'm glad you brought this up because this is some of the art of what we do within the science of treatment, by getting patients to perform at the right level with exercise and understanding the pain level they are truely at.

  • Christie Downing, PT, DPT, cert MDT

    I've used the Bioskin Q-lock for instability…but I have to admit, the Donjoy true pull looks much more comfortable.

    I'm going to echo Kory's comments about tendonosis…it's time to get off the "rest and ice" notion for tendonosis…it's a dysfunctional tissue that needs to remodel. Remodeling soft tissue requires intermittent stress that is sufficient enough to cause the tissue to change, but not so much as to cause damage.

    Your point about the exercise being acceptable to hurt a little is not only acceptable, it's necessary. The stipulation, however, is that the symptoms must subside shortly upon ceasing the exercise.

  • Jess Barsotti, DPT, ATC

    Hi Mike,

    I'm new to this site; I like what you're doing here.

    I wanted to bring up a point about soft-tissue mobilization for PFP. Let me start off by saying I've found no evidence to support this other than assimilation of various trials' results and anecdotal experience.

    I think we should stop focusing massage at the IT band for several reasons. The structure of the IT band shouldn't be lengthened because this would make the TFL muscle unable to perform its job: it would soon become actively insufficient. I also don't think we're actually doing anything to the IT band length due to its molecular structure and elasticity.

    However, STM at the TFL does wonders for a lot of my patients (sometimes with very little else) in terms of decreasing pain and restoring function. In more provocative patients, I have to stabilize the patella from tracking laterally during the treatment (this is also a good indication that I've found the cause of pain). Foam-rolling also does a great job but I have to make sure to tell my patients to get the TFL.

    Keep up the good work.

  • Mike Reinold

    Makes sense Jess, thanks

  • Jennie

    I believe I have some sort of patellofemoral issue..my knee hurts excruciatingly after sitting for a little while, or exercising. I dance ballet 5-6 days a week, which doesn't seem to aggravate it (only when I do deep plies), but maybe that is – only I don't notice it? What do you think?

  • http://Website(optional) Michael Brynkus, MSc

    Hey Mike I was wondering what your take on leg length discrepencies are in regards to patellofemoral pain. Can leg length discrepencies of greater than 0.5 cm lead to PFPS? Do you recommend a heel wedge for leg length discrepencies of around 1 cm?

    • http://www.mikereinold.com Mike Reinold

      That is a pretty small difference and could mean a lot of things. I always check alignment first, I dont correct a leg length unless it is truly anatomical, which I dont see often. You should check out FST for the Lower Body at FunctionalStability.com

      • http://Website(optional) Michael Brynkus, MSc

        Wow! The product looks very comprehensive. Thanks for the resource. I think I am going to have to purchase at least 2 of the modules.

        My question was in regards to an anatomical leg length discrepancy of about 1 cm(confirmed via scannogram)and subsequent pelvic misalignment (pelvic torsion) due to the LLD. Would this need to be addressed with a heel wedge if the patient has chronic patellofemoral pain syndrome and tight IT band, and traditional physiotherapy seemed to only help mildly?

        Also, is their any evidence showing that pelvic mis-alignment can lead to knee pain(anterior knee pain,patellofemoral pain etc..)? I would be interested in some studies or even anecdotal evidence if thats all thats available.

        Really enjoyed reading this informative series on PFPS.

        • http://www.mikereinold.com Mike Reinold

          I do look at the pelvis first!