A biomechanical approach to assessment diagnosis treatment and prevention Sports Physiotherapist specialising in swimming Founder and practice principal physiotherapist Newcastle Physiotherapy ID: 910691
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Pattelo-femoral joint dysfunction
A biomechanical approach to assessment, diagnosis treatment and prevention
Slide2Sports Physiotherapist specialising in swimming
Founder and practice principal physiotherapist, Newcastle Physiotherapy
Former Senior GB International swimmer and British record holder for 200 and 400 I.M
Member of the GB Swimming Physiotherapy team, London 2012 Olympic Games
Darren
Wigg, Bsc (Hons) MCSPSM, HCPC Reg.
Introduction
Slide3What is patellofemoral joint dysfunction
?As the name infers, patellofemoral dysfunction is an injury that occurs at the articulation between the patella (kneecap) and the underlying femur. Anatomically, the patella is a diamond-shaped bone which lies in a correspondingly shaped groove in the front of the femur. It is designed to function as a pulley, assisting the quadriceps by providing a mechanical advantage for added strength. Generally speaking, patellofemoral dysfunction occurs under one of two broad circumstances -- either when the patella is forced with excessive pressure against the underlying femur or when it tracks excessively on one side or other of the groove. In either case, this would cause irritation and abrasion of the cartilage of the patella, resulting in inflammation and pain.
Umbrella term used for pain arising
patello
-femoral joint
Also known as anterior knee painOften insidious onset but can be traumatic
Extremely common in runners and sports involving running, jumping and kicking
Slide4Boney Anatomy
Saddel joint
Patella and Femur
Controlled by quads -extensor mechanism
Tracking aided by concave patellofemoral grooveConvex patella
Slide5Soft tissues influencing PFJ
Quadriceps
Quads tendon
Patella tendon
Patella retinaculum
Not this simple.......
Slide6Soft tissues influencing PFJ
Gluteals
Illiacus
and Psoas
Hamstrings
Gastrocnemius
Tensor fascia lataIlliotibial bandAdductors
Slide7Common subjective findings
Usually intermittent pain located around/under pattella
Insideous
onset more common
Aggravating activities: running, prolonged walking, ascending and decsending stairs, squatting, prolonged sitting, wearing unsupportive footwear (flip flops!)Easing activities: avoidence of aggs,
ice, NSAIDSActivity dependent diurnal patternSpecial Q’s:
No true lockingNo true giving wayNo 'cluncking' but may report clicking
Slide8Athletes.....all about the detail
Training errors and what has changed?
- increase in volume
- increase in intensity
- change of terrain- change of footwear- change of technique- change of coach- injury prevention strategiesPast injury history -compensation for other injuries?
You should be 95% sure of diagnosis following a good subjective!
Slide9Common objective tests/findings
Confirmation of provisional diagnosis!
No
joint effusion
Pain on single leg squatPain on full squatCritial test positivePatello
-femoral joint compression positiveHypomobile PFJ
Postural imbalances.............Note: always clear meniscal and ligamentous stress tests first!Not uncommon for PFJ dysfunction to be a secondary problem
Slide10Common objective findings
Hip/pelvic postural variation
Deficiencies
in length and / or strength in any of the muscle groups that can act upon the PFJ
Foot biomechanics
Slide11Common postural findings
Click to add text
Asymmetries
Boney land marks
AcromionSpine- Illiac
crests- PSIS- ASIS- Greater trochanter- Base/pole patella/post knee creases
- Tibial tuberosity- Malleoli- Medial archValgus or varus presentation........
Slide12Thomas Test
Provides lots of biomechanical information
Hip flexor length
Quads length
Adductor length
Anteriolateral chain
Slide13Thomas test
Increase hip extension by 1 degree = 2% increase in stride length
Performance enhancement
Injury prevention
Slide14Obers test
Length test of:
- Tensor fascia
lata
- ITB- General anterolateral chainPositive test- reproduction of pain- reduced range in comparison to asymptomatic side/knee unable to rest on bed
Slide15Single leg squat test
Hip and pelvis control
knee control/position
Forefoot pronation/supination
Balance
Signs of fatigue
Pain Observe running if possible
Slide16PFJ stress tests
Lateral glide
Medial glide
Cephalad glide
Caudad glide
Compression
PainRestriction
Slide17Critical Test
Preferable in supine
Resisted knee extension throughout full range
Posiitve with reproduction of pain +/- weakness
Slide18Common diagnosis
PFJ maltracking causing retropatella pain/infrapatella fat
pad inflammation (biomechanical +/- training error)
ITB
friction syndrome (biomechanical +/- training error)*Patella tendon tendinopathies or calcification (biomechanical +/- training error)
*Chondromalacia patellae (genetic)
*PFJ OA (genetic or post trauma)*Referred pain from lumbar spineDiagnosis is relatively easy – underlying cause is fundamental for successful treatment outcomes
Slide19Typical problem list
Training load errors
Poor injury prevention program/strategies
Biomechanical deficiencies such as:
Valgus knee postureWeak medial quads/underactive
glutesTight hip flexors/quads/ITB
Forefoot pronator with inappropriate footwear
Slide20Typical treatment plan
Advice and education surrounding acute pain management and adaptation of trainingPFJ taping (Kinesio
tape or
McConell
)Manual therapy:PFJ/SIJ/Lumbar spine mobilisationSpecific soft tissue mobilisation ( commonly QL, glutes, TFL, ITB, biceps femoris, gastrocnemius
)PNFExercise
therapy: - Progressive strength, stability, proprioceptive program for weak/underactive muscle groups focussing on lumbopelvic, hip and knee region - Stretching and foam roller program for hypertonic/overactive/short muscle groupsAnti-pronation taping followed by orthotic fitting
Slide21Key points to take away
Common sports injury
Diagnosis should be easy
Thorough subjective assessment important
Knowledge and understanding of athletic training/overload principles, biomechanics and muscle imbalance is fundamental for successful outcomes
Expert manual and exercise therapy skills fundamental for successful outcome
Don’t forget your injury prevention program!!!