The Movement Perfected team attended the London Sports Orthopaedics CPD event titled “Pop goes the kneecap!’’ on Tuesday the 4th of September. This is the take from a physiotherapy perspective.
Patellofemoral pain is the preferred term, and is a synonym for other terms including: (1) PFP syndrome; (2) chondromalacia patella; (3) anterior knee pain and/or syndrome; and (4) runner’s knee. (Ref 1)
Introduction
There are numerous reasons why a person may have patellofemoral pain. The kinematics of the knee can be altered, which tends to create pain generators. The change in kinematics can include patellar maltracking or patellar instability. These issues can then lead to further problems such as:
- patellar tendinopathy
- fat pad inflammation
- patellofemoral chondral damage
- patellofemoral arthritis.
Patellar morphology (normal vs dysplastic), abnormal patellar height (patella alta/baja), enlarged/inflamed plicae or Osgood Schlatters ossicles can all cause anterior knee pain. Diagnosis of the above can be confirmed with different types of imaging.
Types of imaging
The underlying causes of patellofemoral pain can be defined with the use of appropriate imaging. The consultants at London Sports Orthopaedic use X-ray, MRI, ultrasound and CT.
Skyline X-ray views of the patella show the position of the patella in the trochlear groove in early flexion, and can show potential maltracking. The sulcus angle and the congruence angle can be measured via X-ray to quantify the position of the patella in the femoral groove (although the congruence angle is not commonly used). Additionally, the shape of the patella can be viewed and classified via the Wiburg classification. Patellar height is also measured with the Blackburne-Peel index. This gives important information about the bone morphology and the position of the patella.
The soft tissues are best observed with an MRI scan, particularly with high-resolution imaging using the T3 MRI scanner on-site at LSO. This allows any inflammatory changes to be highlighted, as the T3 MRI is the highest quality MRI in London. The tibial tuberosity to the trochlear groove distance can also be measured via MRI, although this is more accurate from CT. Additionally, CT with 3D reconstruction can allow accurate and detailed visualization of the morphology of the knee, with special views available that clearly show the exact shape of the trochlear groove.
What does this all mean?
The diagnosis of anterior knee pain via clinical tests and biomechanical assessment can be enough in some cases. In scenarios where a patient’s symptoms are severe or persistent, the clinician should seek further input from a knee specialist who can arrange for appropriate imaging and who can help elucidate the exact underling potential pathologies.
This CPD event allowed the physiotherapists present to gain a better understanding of the consultants’ assessment, and it highlighted an in-depth analysis of the morphological variants that can exist and the clinical reasoning behind some of the surgical procedures that a surgeon might undertake.
How can physiotherapist and consultants work in partnership?
In many cases, obtaining detailed imaging and a full understanding of underlying pathologies does not necessarily mean that the patient will need to undergo actual surgical intervention; detailed investigation may simply provide a baseline measure of the morphological /pathological changes in a patient’s knee. This can then be reassessed at a later stage, to identify potential deterioration or improvement. This allows for a comprehensive view point of the client’s condition.
In terms of the physiotherapy assessment, we will provide a musculoskeletal assessment which will include the following;
- Biomechanical assessment.
- Dynamic kinetic assessment of the foot, knee and hip. This may require podiatry intervention.
- Assessment of static and dynamic strength.
- Plyometric strength through fatigue – a large majority of patellofemoral pain sufferers have pain in the late stage when performing their activity or exercise.
- Joint movement above and below the knee.
- Running gait analysis.
Once the assessment has identified any anomalies or influences to a patient’s pain, these will then be treated with a comprehensive treatment plan. Our team at Movement perfected may create a plan similar to the one you see below, informing the client of the treatment approach and strategy:
| Weeks | Treatment approach | Aim of treatment |
| 1 – 2 | Increase strength of proximal muscles in non-provocative position. Build static strength and position of the knee to prevent medial collapse including strengthening the calf muscles. Soft tissue release of the muscles plus or minus acupuncture. | 30 uniform and pain-free single-leg mini squats.
Increase technique and tolerance of bilateral hop x 10 reps pain-free. |
| 3 – 5 | Repetitive loading of upper biomechanical chain concentric and eccentric loading of hamstrings, glutes and abdominal muscles. Jump board plyometric exercises in anti-gravity positions bilateral and single leg. | Ensure equal strength capacity of glute med R+L in static positions, along with the quadriceps and calf muscles. Ensuring endurance capacity.
Single leg hop assessment to fatigue aim R=L pain-free. |
| 6 weeks onwards | High level strength program with Olympic weights and plyometrics in standing. Running gait analysis. | Return to running program with dynamic change of direction exercises. |
Conclusion
In conclusion, strong collaboration with the London Sports Orthopaedic team can help by giving an in-depth assessment and a potential treatment plan for individuals with patellofemoral pain. The more accurate the clinical assessment, the higher the likelihood of success in the treatment approach.
Reference
1) Patellofemoral Pain consensus statement from the 4th international patellofemoral pain research retreat, Manchester. Part 2: recommended physical interventions (exercise, taping, bracing, foot orthoses and combined intervention) consensus. Br J Sports Medicine 2016: 6(50): 8344-852
Emmanuel Ovola, Physiotherapist