Pattelo -femoral joint dysfunction - PowerPoint Presentation

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Pattelo-femoral joint dysfunction

A biomechanical approach to assessment, diagnosis treatment and prevention

Sports 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

What 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

Boney Anatomy

Saddel joint

Patella and Femur

Controlled by quads -extensor mechanism

Tracking aided by concave patellofemoral grooveConvex patella

Soft tissues influencing PFJ

Quadriceps

Quads tendon

Patella tendon

Patella retinaculum

Not this simple.......

Soft tissues influencing PFJ

Gluteals

Illiacus

and Psoas

Hamstrings

Gastrocnemius

Tensor fascia lataIlliotibial bandAdductors

Common 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

Athletes.....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!

Common 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

Common 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

Common 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........

Thomas Test

Provides lots of biomechanical information

Hip flexor length

Quads length

Adductor length

Anteriolateral chain

Thomas test

Increase hip extension by 1 degree = 2% increase in stride length

Performance enhancement

Injury prevention

Obers 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

Single leg squat test

Hip and pelvis control

knee control/position

Forefoot pronation/supination

Balance

Signs of fatigue

Pain Observe running if possible

PFJ stress tests

Lateral glide

Medial glide

Cephalad glide

Caudad glide

Compression

PainRestriction

Critical Test

Preferable in supine

Resisted knee extension throughout full range

Posiitve with reproduction of pain +/- weakness

Common 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

Typical 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

Typical 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

Key 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!!!