Patellofemoral pain syndrome (PFPS) is one of the most prevalent musculoskeletal conditions. It accounts for 25-40% of all knee problems seen in sports medicine, and may have a prevalence of around 25% in the general adult population. It also remains one of the most challenging to manage. There is growing evidence that many young PFPS patients (up to 91%) experience persistent pain (21), and some may have a greater likelihood of developing early PFJ degenerative changes (14).
You may be familiar with the ‘McConnell programme’, which was developed around 30 years ago, and is still popular today. Jenny felt VMO weakness contributed to patellar mal-tracking. She treated this with VMO strength programmes along with patellar taping techniques and other interventions (5). Below is a brief summary of the most up-to-date research on interventions for PFPS.
Taping
There is good research evidence that patellar taping helps symptoms in the short-term. However biomechanical studies have shown it does not do this by altering patellar tracking or improving VMO function. One theory is that taping works by compressing the patella into the groove, thus improving its area of contact, and reducing joint stress (11,20).
VMO retraining
While there is some evidence of VMO wasting in PFPS (8), and delayed onset of VMO contraction (15), research shows that quadriceps weakness is a generalized occurrence, affecting all four groups. It is still debated if this is cause or effect, as PFPS and knee swelling are potent inhibitors to quadriceps function. There is no evidence that specific VMO training is of any additional benefit to general quads training. While quadriceps strength programmes have proven beneficial in improving symptoms (6), there is increasing evidence that hip / gluteal strength may be of equal or greater importance than quads strength for longer-term PFPS management (22).
Hip strengthening
There is evidence that females with PFPS have significantly increased femoral adduction compared to controls, when running or performing a single leg squat (18,22). Both males and females with PFPS had increased contralateral pelvic drop (18). There is also evidence of delayed gluteus medius onset and a shorter duration of contraction in PFPS subjects (1).
Dynamic MRI studies have shown that in certain subjects with patellofemoral disorders, the patella does not track laterally. Rather, the femur internally rotates beneath the patella (10,12). There is also evidence that a group of subjects with PFPS have relative weakness of their hip external rotators and abductors (7). Rehab programmes specifically targeting hip rather than quads strengthening have demonstrated benefits in the short to medium term (7,21).
Biomechanical interventions
It is well recognized that individuals with faulty lower limb biomechanics are at greater risk of ACL rupture. And strategies such as the PEP programme have proven successful in part by targeting these
Patellofemoral Pain Syndrome
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deficiencies. More recently there has been interest in the role of biomechanical interventions & neuromuscular retraining to reduce PFPS. Video biofeedback, mirror imaging & verbal cueing has been used successfully to assist runners with PFPS to reduce over-striding, pelvic drop and functional valgus, thus improving control and getting the knees wider during running (3,17,18,19).
Pain control and central mechanisms
As with any chronic pain state, there is mounting evidence of potential ‘central sensitisation’ mechanisms for maintaining pain states and dysfunction. Quads inhibition and inability to adequately load the knee are common long-term consequences of PFPS. There has been recent interest in disinhibitory interventions to help overcome this neural inhibition (4).
Orthotics
Studies have shown inconsistent results for the effectiveness of foot orthoses for treating PFPS. Some studies have shown good short-term results (16). There is most likely a sub-group of individuals who will benefit from this intervention (2,16).
For more information on physiotherapy treatment of this condition, see:
http://www.cssphysio.com.au/pdfs/0-Rehabilitation.pdf
References:
1. Barton, C et al (2012). Gluteal muscle activity and PFPS: a systematic review. BJSM, 47, 4. 207-214.
2. Barton, C et al (2011). Greater peak rearfoot eversion predicts foot orthosis efficacy in individuals with PFPS. BJSM, 45, 697-701.
3. Cheung, R & Davis, I (2011). Landing pattern modification to improve patellofemoral pain in runners. JOSPT, 41, 12, 914-919.
4. Harkey, M et al (2014). Disinhibitory interventions and voluntary quadriceos activation: a systematic review. Journal of Athletic Training, 49, 1, Epub.
5. McConnell, J (1996). Management of patellofemoral problems. Manual Therapy, 1, 60-66.
6. Natri, A et al (1998). Which factors predict long-term outcome in chronic patellofemoral pain syndrome. A 7-year prospective follow-up study. Medicine and Science in Sports and Exercise, 30, 11, 1572-1577.
7. Noehren, B (2012). Proximal and distal kinematics in female runners with patellofemoral pain. Clinical Biomechanics, 27, 4, 366-371.
8. Pattyn, E et al (2011). VMO atrophy: does it exist in PFPS? AJSM, 39, 7, 1450-145.
9. Peters J & Tyson, N (2013). Proximal exercises are
effective in treating patellofemoral pain syndrome: a systematic review. International Journal of Sports Physical Therapy, 8, 5, 689-700
10. Powers, C (2003). The influence of altered lower-extremity kinematics on patellofemoral joint dysfunction. JOSPT, 33, 11, 639-646.
11. Powers, C et al (1997). The effects of patellar taping on stride characteristics and joint motion in subjects with patellofemoral pain. JOSPT, 26, 6, 286-291.
12. Souza R et al (2010). Femur rotation and patellofemoral joint kinematics: a weight-bearing magnetic resonance imaging analysis. JOSPT, 40, 5, 277-285.
13. Stathopulu E & Baildam, E (2003). Anterior knee pain: a long-term follow-up. Rheumatology, 42, 2, 380-382.
14. Thomas, M et al (2010). Anterior knee pain in young adults as a precursor to subsequent patellofemoral arthritis. BMC Musculoskeletal Disorders, 11, 9, 201
15. Van Tiggelen, D et al (2009) Delayed VMO to VL onset timing contributes to the development of patellofemoral pain in previously healthy men. AJSM, 37, 6, 1099-1105.
16. Vincenzino, B et al (2010). A clinical prediction rule for identifying patients with PFPwho are likely to benefit from foot orthoses. BJSM, 44, 12, 862-866.
17. Willey, R et al (2012). Mirror gait retraining for the treatment of patellofemoral pain in female runners. Clinical Biomechanics, 27, 10, 1045-1051.
18. Willey R et al (2012). Are mechanics different between male and female runners with patellofemoral pain. Medicine and Science in Sports and Exercise, 44, 11, 2165-2171.
19. Willson, J et al (2013) Effect of step length on patellofemoral joint stress in female runners with and without patellofemoral pain. Clinical Biomechanics, 29, 3, 243-247.
20. Wilson, T et al (2003). A multi-centre single-masked study of medial, neutral and lateral patellar taping in individuals with PFPS. JOSPT, 33, 8, 437-443.
21. Witvrouw, E et al (2013). Patellofemoral pain: consensus statement from the 3rd International Research Retreat. BJSM, 48, 3, 411-414.
22. Noehren, B et al (2013). Prospective evidence for a hip etiology in patellofemoral pain. Medicine and Science in Sport and Exercise, 45, 1120-1124.
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