Is walking bad for PFPS?
Do knee braces help with PFPS?
Signs and symptoms
The onset of the condition is usually gradual, although some cases may appear suddenly following trauma. The most common symptom is diffuse vague pain around the kneecap (peripatellar) and localized pain focused behind the kneecap (retro patellar). Affected individuals typically have difficulty describing the location of the pain. They may place their hands over the anterior patella or describe a circle around the patella. This is often called the “circle sign”. Pain is usually initiated when weight is put on the knee extensor mechanism, such as when ascending or descending stairs or slopes, squatting, kneeling, cycling, or running. Pain during prolonged sitting is sometimes termed the “movie sign” or “theatre sign” because individuals might experience pain while sitting to watch a film or similar activity. The pain is typically aching and occasionally sharp. Pain may be exacerbated by activities. The knee joint may exhibit noises such as clicking. However, this has no relation to pain and function. Giving-way of the knee may be reported. Reduced knee flexion may be experienced during activities.
In most patients with PFPS, an examination of their history will highlight a precipitating event that caused the injury. Changes in activity patterns such as excessive increases in running mileage, repetitions such as running up steps, and the addition of strength exercises that affect the patellofemoral joint are commonly associated with symptom onset. Excessively worn or poorly fitted footwear may be a contributing factor. To prevent recurrence the causal behavior should be identified and managed correctly. The medical cause of PFPS is thought to be increased pressure on the patellofemoral joint. There are several theorized mechanisms relating to how this increased pressure occurs:
- Increased levels of physical activity
- Malalignment of the patella as it moves through the femoral groove
- Quadriceps muscle imbalance
- Tight anatomical structures, e.g. retinaculum or iliotibial band.
Causes can also be a result of excessive genu valgum and the above-mentioned repetitive motions leading to abnormal lateral patellar tracking. Individuals with genu valgum have larger than normal Q-angles causing the weight-bearing line to fall lateral to the center of the knee causing overstretching of the MCL and stressing the lateral meniscus and cartilages. The cause of pain and dysfunction often results from either abnormal forces (e.g. increased pull of the lateral quadriceps retinaculum with acute or chronic lateral PF subluxation/dislocation) or prolonged repetitive compressive or shearing forces (running or jumping) on the PF joint. The result is synovial irritation and inflammation and subchondral bony changes in the distal femur or patella known as “bone bruises”. Secondary causes of PF Syndrome are fractures, internal knee derangement, osteoarthritis of the knee, and bony tumors in or around the knee.[self-published source?]
People can be observed standing and walking to determine patellar alignment. The Q-angle, lateral hypermobility, and J-sign are commonly used determined to determine patellar maltracking. The patellofemoral glide, tilt, and grind tests (Clarke’s sign), when performed, can provide strong evidence for PFPS. Lastly, lateral instability can be assessed via the patellar apprehension test, which is deemed positive when there is pain or discomfort associated with the lateral translation of the patella. Various clinical tests have been investigated for diagnostic accuracy. The Active Instability Test, knee pain during stair climbing, Clarke’s test, pain with prolonged sitting, patellar inferior pole tilt, and pain during squatting have demonstrated the best accuracy. However, careful consideration is still needed when using these tests to make a differential diagnosis of PFPS. Individuals with PFP may exhibit higher pain levels and lower function. Magnetic resonance imaging rarely can give useful information for managing patellofemoral pain syndrome and treatment should focus on an appropriate rehabilitation program including correcting strength and flexibility concerns. In the uncommon cases where a patient has mechanical symptoms like a locked knee, knee effusion, or failure to improve following physical therapy, then an MRI may give more insight into diagnosis and treatment.
PFPS is one of a handful of conditions sometimes referred to as runner’s knee; the other conditions are chondromalacia patellae, iliotibial band syndrome, and plica syndrome. Chondromalacia patellae is a term sometimes used synonymously with PFPS. However, there is general consensus that PFPS applies only to individuals without cartilage damage, thereby distinguishing it from chondromalacia patellae, a condition with softening of the patellar articular cartilage. Despite this distinction, the diagnosis of PFPS is typically made based only on the history and physical examination rather than on the results of any medical imaging. Therefore, it is unknown whether most persons with a diagnosis of PFPS have cartilage damage or not, making the difference between PFPS and chondromalacia theoretical rather than practical. It is thought that only some individuals with anterior knee pain will have true chondromalacia patellae.
The diagnosis of patellofemoral pain syndrome is made by ruling out patellar tendinitis, prepatellar bursitis, plica syndrome, Sinding-Larsen and Johansson syndrome, and Osgood–Schlatter disease. Currently, there is no gold standard assessment to diagnose PFPS.
Patellofemoral pain syndrome may also result from overuse or overload of the PF joint. For this reason, knee activity should be reduced until the pain is resolved. There is consistent but low-quality evidence that exercise therapy for PFPS reduces pain, improves function, and aids long-term recovery. However, there is insufficient evidence to compare the effectiveness of different types of exercises with each other, and exercises with other forms of treatment. Exercise therapy is the recommended first-line treatment of PFPS. Various exercises have been studied and recommended. Exercises are described according to 3 parameters:
- Type of muscle activity (concentric, eccentric, or isometric)
- Type of joint movement (dynamic, isometric, or static)
- Reaction forces (closed or open kinetic chain)
The majority of exercise programs intended to treat PFPS are designed to strengthen the quadriceps muscles. Quadriceps strengthening is considered to be the “gold” standard treatment for PFPS. Quadriceps strengthening is commonly suggested because the quadriceps muscles help to stabilize the patella. Quadriceps weakness and muscle imbalance may contribute to abnormal patellar tracking. If the strength of the vastus medialis muscle is inadequate, the usually larger and stronger vastus lateralis muscle will pull sideways (laterally) on the kneecap. Strengthening the vastus medialis to prevent or counter the lateral force of the vastus lateralis is one way of relieving PFPS. However, there is growing evidence that shows proximal factors play a much larger role than vastus medialis (VMO) strength deficits or quadriceps imbalance. Hip abductor, extensor, and external rotator strengthening may help. The emphasis during exercise may be placed on the coordinated contraction of the medial and lateral parts of the quadriceps as well as of the hip adductor, hip abductor, and gluteal muscles. Many exercise programs include stretches designed to improve lower limb flexibility. Electromyographic biofeedback allows visualization of specific muscle contractions and may help individuals performing the exercises to target the intended muscles during the exercise. Neuromuscular electrical stimulation to strengthen quadriceps muscles is sometimes suggested, however, the effectiveness of this treatment is not certain. Inflexibility has often been cited as a source of patellofemoral pain syndrome. Stretching of the lateral knee has been suggested to help. Knee and lumbar joint mobilization are not recommended as primary interventions for PFPS. It can be used as a combination intervention, but as we continue to promote the use of active and physical interventions for PFPS, passive interventions such as joint mobilizations are not recommended.
Manual therapy in addition to exercises helps in reducing pain and improving function, and knee range of motion in patients with PFPS. Manual therapy such as patellar joint mobilization, manipulation, and soft tissue mobilization along with Physical therapy exercises is found to be effective in treating PFPS. However, there is not enough evidence that supports lumbopelvic spine manipulation has any effect on quadriceps muscle activation to improve function & reduce pain.
Non-steroidal anti-inflammatory drugs (NSAIDs) are widely used to treat PFPS; however, there is only very limited evidence that they are effective. NSAIDs may reduce pain in the short term; overall, however, after three months pain is not improved. There is no evidence that one type of NSAID is superior to another in PFPS, and therefore some authors have recommended that the NSAID with the fewest side effects and which is cheapest should be used. Glycosaminoglycan polysulfate (GAGPS) inhibits proteolytic enzymes and increases the synthesis and degree of polymerization of hyaluronic acid in synovial fluid. There is contradictory evidence that it is effective in PFPS.
Braces and taping
There is no difference in pain symptoms between taping and non-taping in individuals with PFPS. Although taping alone is not shown to reduce pain, studies show that taping in conjunction with therapeutic exercise can have a significant effect on pain reduction. Knee braces are ineffective in treating PFPS. The technique of McConnell taping involves pulling the patella medially with tape (medial glide). Findings from some studies suggest that there is a limited benefit with patella taping or bracing when compared to quadriceps exercises alone. There is a lack of evidence to show that knee braces, sleeves, or straps are effective.
Low arches can cause overpronation or the feet to roll inward too much increasing the load on the patellofemoral joint. Poor lower extremity biomechanics may cause stress on the knees and can be related to the development of patellofemoral pain syndrome, although the exact mechanism linking joint loading to the development of the condition is not clear. Foot orthoses can help to improve lower extremity biomechanics and may be used as a component of the overall treatment. Foot orthoses may be useful for reducing knee pain in the short term, and may be combined with exercise programs or physical therapy. However, there is no evidence supporting the use of combined exercise with foot orthoses as an intervention beyond 12 months for adults. Evidence for long-term use of foot orthoses for adolescents is uncertain. No evidence supports the use of custom-made foot orthoses.
The scientific consensus is that surgery should be avoided except in very severe cases in which conservative treatments fail. The majority of individuals with PFPS receive nonsurgical treatment.
The use of electrophysical agents and therapeutic modalities is not recommended as passive treatments should not be the focus of the plan of care. There is no evidence to support the use of acupuncture or low-level laser therapy. Most studies claiming the benefits of alternative therapies for PFPS were conducted with flawed experimental designs and therefore did not produce reliable results.
Patellarfemoral pain syndrome can become a chronic injury, with an estimated 50% of people reporting persistent patellar-femoral pain after a year. Risk factors for a prolonged recovery (or persistent condition) include age (older athletes), females, increased body weight, a reduction in muscle strength, time to seek care, and in those who experience symptoms for more than two months.
Patellofemoral pain syndrome is the most common cause of anterior knee pain in the outpatient. Specific populations at high risk of primary PFPS include runners, bicyclists, basketball players, young athletes, and females. BMI did not significantly increase the risk of developing PFPS in adolescents. However, adults with PFPS have higher BMI than those without. It is suggested that higher BMI is associated with limited physical activity in people with PFPS as physical activity levels decrease as a result of pain associated with the condition. However, no longitudinal studies are able to show that BMI can be a predictor of the development or progression of the condition.
Biomechanics of PFPS
Taking a closer look at PFPS reveals the internal structures involved in this condition and their impact on the pain felt in the anterior knee. Of particular interest to massage therapists are these major contributing factors of PFPS:
- Lower limb muscle imbalances
- Overuse and repetitive weight-bearing activities
- Arch variations (flat, high)
- Wider hips and knock-knees (Q-angle)
Many sports massage therapists support the theory that muscle imbalances may be responsible for poor patella alignment. Normally, the patella moves up and down as well as tilts and rotates through the trochlear groove in the distal femur as the knee flexes and extends. As pressure between the patella and the groove increases, it can become potentially damaging to the cartilage if the patella misaligns to either side of this groove. Over time, this misalignment causes the cartilage to wear down as the patella and the head of the femur rub against one another. Much of the pain associated with this condition is due to the accumulation of inflammatory waste products from the friction, which leads to swelling and further damage to the joint’s synovial lining.
Looking at this condition from a soft tissue point of view, an evaluation of the muscles/fascia from the hip area to the foot should be conducted, with an eye on any associated gait problems. Strong torsional forces travel through the knee during gait. For example, a pronated foot internally rotates the tibia, externally rotates the femur, misaligns the pelvis, and can eventually pull the patella laterally. As a result, soft tissue on the medial side of the knee builds up as the stretch-weakened vastus medialis relies more on the adductor magnus muscle. When running, this type of gait problem would cause the person to land on the lateral portion of the flat foot and roll inward, causing the lower leg to internally rotate. Simultaneously, the vastus lateralis and ITB resist this motion by externally pulling on the lateral side of the patella causing increased friction between the patella and femur.
Of further interest to bodyworkers working with clients with PFPS are shortened quadriceps and hamstring muscles. When working properly, the patella acts as an efficient pulley system between the medial and lateral quads in leg extension and deceleration of leg flexion. However, when massive lateral thigh muscles shorten and fascia thickens due to stress and strain, the medial knee musculature loses the ability to properly track the patella.
Massage for Treatment of PFPS
Massage therapy should be included in a comprehensive rehabilitation program that addresses the management of PFPS either before or after surgery for debridement of patellofemoral cartilage intended to reduce crepitus and clicking. The treatment goal of the therapist is to eliminate excessive compressive and/or torsional forces at the patellofemoral articulation. Soft tissue methods such as fascial release and friction massage have helped clients with anterior knee pain, with much of the treatment directed to the medial and lateral retinaculum. The retinaculum stabilizes the patella along with the patellofemoral ligaments.
A comprehensive massage protocol for PFPS begins with evaluating the gluteus maximus (superficial) and tensor fasciae lata (TFL), which together become the iliotibial band (ITB), which branches at the knee to the lateral retinaculum, inserting below the lateral epicondyle. Fibrous tissue caused by myofascial adhesions may be palpated assessing for active trigger points in the tensor fascia latae, vastus lateralis, and biceps femoris as well as in the superior lateral aspect of the patella and lateral aspects of the IBT-vastus lateralis border. Palpation of these muscle areas is likely to reveal tender, nodular, restricted areas, tender points, or active trigger points.
Research has found a strong relationship between iliotibial tightness and decreased medial glide of the patella. The ITB can be tested with Ober’s test. Tight quadriceps muscles, particularly the rectus femoris, can lead to PFPS. Test the rectus femoris by the Thomas test or a prone knee bend. Decreased hamstring length has also been found to be an influencing factor in PFPS. Test the hamstrings via a straight leg raise and look for 80-100 degrees of hip flexion. Other researchers have found a correlation between quadriceps weakness and PFPS. The vast medialis oblique (VMO), in particular, plays a major role in patellar tracking and should be evaluated for active trigger points.
Should there be any inflammation in the knee area, begin with lymphatic drainage prior to proceeding with other massage techniques. Once the inflammation has been reduced, proceed with Swedish techniques, including effleurage and petrissage to warm up the gluteus muscles, hamstrings, quadriceps, adductors, TFL, ITB, and gastrocnemius and to promote general relaxation. Fibrotic tissue around the patella can be reduced using myofascial release and cross-fiber friction followed by ice massage to mitigate any potential inflammatory response to this therapy. Passive range of motion and passive stretches should be performed several times during therapy.
Muscle energy techniques successfully decrease hypertonic musculature and increase the length of the TFL, ITB, vastus medialis oblique, adductors, and the hamstring muscle group. Post-isometric relaxation and reciprocal inhibition techniques work best for the hamstring muscle group to reduce flexion contractures and increase the range of motion in the knee. Myofascial release is performed to lengthen tissue and normalize hypertonic muscles and fibrous tissue, particularly in the TFL, ITB, and vastus lateralis. Neuromuscular techniques can be used to deactivate trigger points in the TFL, ITB, vastus lateralis, and biceps femoris. Tender points identified in the biceps femoris, semitendinosus, and/or semimembranosus can be addressed with the passive positional release.
The massage was found to be an effective complementary therapy in the rehabilitation of post-ACL reconstruction PFPS (Zalta, 2008). Subjects reported reduced pain levels after massage therapy as well as a significant reduction in flexion contracture. The massage was effective in decreasing the degree of hamstring flexion contracture. Further, self-care exercises and self-massage were given to patients and, when performed regularly during therapy, strengthen the quadriceps.
One last word about contraindications. As with any massage therapy to the legs above the knee, blood clots (Deep Vein Thrombosis) can break off and travel up the bloodstream, resulting in a blocked blood vessel in the lung (pulmonary embolism). During massage therapy, be aware of swelling, pain, discoloration, and abnormally hot skin in the affected area.
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