Non-operative management of Patellofemoral Osteoarthritis

So the first and probably most important point to make is that this is a diagnostic label about structure, not experience of pain. Pain is an incredibly multi-dimensional phenomenon that people experience in very varying ways. It is therefore possible for two people to have the same diagnostic label of patellofemoral osteoarthritis and yet one is ‘suffering’ a lot more than the other.
This blog aims at empowering the patient to lose the ‘helpless’, ‘inevitability’ feeling of the situation and to improve their quality of life.
I very often get asked, ’Can I still play tennis?’ or ‘Can I ski?’ etc. I wouldn’t dream of answering this, ‘yes’ or, ‘no’ as there is a huge middle ground to be explored between full on skiing all day, for example and modification to include shorter days and dare I suggest it longer lunches on the slopes. There is a world of difference between singles tennis for 2 hours a time on consecutive days and doubles alternate days. Now this can be met with, ‘but I don’t want to change!’ especially in patients who have this diagnosis in their 40’s or 50’s as there seems to be an injustice about the situation. But perhaps in this situation exploring goals for 5-10 years and seeing activity modification as part of helping achieve this can help with this mindset. For more on activity modification see my blog; www.clairepatella.com/activity-modification-in-the-treatment-of-patellofemoral-pain/ and specifically for skiing with an osteoarthritic knee: http://www.wimbledonclinics.co.uk/blog/skiing-with-an-osteoarthritic-knee-december/
Although physiotherapy can’t restore worn cartilage, it can help to offload the worn joint, which can both ameliorate symptoms in the short term, and potentially decrease the rate of further deterioration. Off loading can be achieved through intrinsic or extrinsic factors.
Intrinsic factors are quite literally within the patient. So, for example tight calf leads to an early heel rise in gait, which in turn means the patient is spending longer with their knee flexed, and hence increasing patellofemoral load. Tight hip flexors will also have the same effect. Tight quads will compress the joint, which is highly undesirable especially when the knee is flexed. Muscle mass acts as a shock absorber, helping to absorb shock away from the joint, and yet this is often a time that muscle mass is lost. Quads strength will also help to spread the load across a larger surface of the patella. Finally if the knee joint itself won’t go straight then the patella never gets a ‘break’ as it is constantly loaded against the femur.
Extrinsic factors are elements such as footwear. In my experience people with this problem often are very aware of their outdoor footwear, ensuring good shock absorbency. However, with the trend for harder floor surfaces at home this also needs to be considered for patients spending significant periods of time on their feet at home, (I recommend an indoor trainer). Tight jeans can aggravate patellofemoral joints as can sitting for prolonged periods with a knee too flexed. Regarding sport I recommend walking poles to hill walkers, and anecdotally I have good response from skiers using the ski mojo.
Patellofemoral osteoarthritis is often characterized by flares where the joint suddenly becomes more painful. It is really important to get on top of these flares quickly to manage disruption to day to day life, and loss of muscle and confidence. There is often an inflammatory component to these and utilizing ice packs can help, with the leg elevated. In consultation with a prescriber, strategic use of non-steroidal anti-inflammatory medications can be very useful during flare-ups. Pacing and relative rest to try and avoid doing too much on consecutive days, and sitting with the leg elevated when possible. Some people find tape very useful, and this can help to break the cycle of pain/altered movement/muscle loss.
So what is the take home message here? We are aiming for a position where the patient is in charge of their knee, and not vice versa. Where through some strategic exercises, pacing and activity modification they are still active. No activity is not an option.

Peter Mulvey 14-01-2016

Nice accessible article as always! The 'modification' chat is always tricky....

Claire 14-01-2016

Sooo tricky! This is where clinicians for me can really stand out. It's not whether you can do the latest manip/fancy exercise, but realizing when these conversations need to be had, what language to use and how to get the patient on board. For me this has to be what challenges me the most but also what I enjoy most about my job.

Nigel Roff 15-02-2017

Hi Claire, nice practical blog. The opposite probably I find is the patients who use the imaging findings as justification to "not" to do anything for fear of further damage. Can be harder than slowing the proactive ones down. Thanks again.

Caroline Schofield 15-02-2017

Hi Claire, thanks for this blog! Has definitely made me rethink my approach to some of my clients with knee problems.

Claire 23-02-2017

Hi Caroline, That's great. It's a really exciting emerging area to watch.

Claire 23-02-2017

Absolutely. Of course this can be an issue with too much imaging. Thanks for your comment.

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