Thoughts for Clinicians from the International Patellofemoral Pain Research Retreat, Sep 2015.
2nd – 5th September 2015
Thoughts for Clinicians from the Patellofemoral Retreat, Manchester, 2015.
There is an inherent problem with the retreat: you can only attend if you present. For this reason I have tried to draw out the points that clinicians may want to ponder over and may help evolve their practice.
In my opinion the field is still far too housed in biomechanics. Of course this is still relevant, but there is still a divide between the biomechanists, and those concerned with pain science and behavioural adaptation. An example of this was a discussion around whether ‘pain’ should be dropped from the diagnostic label. No! It is all about pain and ultimately this is why patients come knocking at our doors!
Andrew Amis gave a truly fantastic keynote talk. If you are interested in biomechanics and ever get the chance to hear Amis talk-go! No ego here, in fact he doesn’t need to be as his work is of such high quality and so prolific. Amis discussed that we should be conceptualizing contact area, and not maltracking. Well before maltracking do we get altered pressures capable of creating pain, and often these will be 30% elevated in PFP. Amis put a lot of focus on abnormal morphology, eg long patellar tendon, trochlea shape, and TTTG distance and stated that this has the potential to alter pressures more readily. I fully concur with this, and like most things observe in clinic that this occurs very much on a spectrum. Finally one for those of you that like the challenge: Amis reports that the MPFL attaches onto the medial head of gastrocnemius. No further discussion given re the relevance of this….
Vincenzino presented alteration in thermal and pain sensitivity in PFP. Look out for patients who report a cold knee, whatever the weather. James Selfe found this over a decade ago. Frustratingly no one has researched what to do with these patients! Intuitively CV exercise would feature high on my list.
Michael Rathleff featured highly at the retreat. What a researcher! High quality work, on big numbers, focuses on the adolescent population with PFP, in Denmark. The work he presented was n=2200 (!!) Despite pain adolescents still have a mean frequency of 5 episodes of sport per week. Is this all about excess load then? 55% of adolescents with pain still had it 2 years later. More work now needed on the effects of growth.
Lee Herrington presented a very succinct piece on running speed and hip adduction moment. In a nutshell, the faster you run, the more hip adduction seen. This is normal. Can we therefore use speed as a way of altering the PFJ load in rehab-yes.
Lee also presented on using ultrasound to assess weight bearing PFJ position. As part of this he reminds us of Peng 2014 work that shows that those who can reduce tilt with a SQC are more likely to respond to quads strengthening.
Matthews showed a very useful correlation: If a patient with PFP has more than 11mm difference in their midfoot width from non to full weight bearing then an orthotic is indicated. A digital caliper from a hardware shop can be used for this. Nice.
Another heavyweight, Felson, (over 500 publications!) presented a keynote on OA. The best correlates with pain in OA are the presence of bone marrow oedema and synovitis. We can see these on MRI scan. This fits nicely with Callaghan’s work showing that daily use of a Q brace can reduce bone marrow oedema in the lateral trochlea. Van der Hejiden presented MRI findings across the 14-40 year normal population and reminds us that even at this young age, 60% have osteophytes.
There was a lot of chat around the question: is PFP on a continuum with PFJ OA? No conclusions yet. Personally I think it is linked with morphology, and that with time we will be able to predict those who are at higher risk of developing PFJ OA by their PFJ morphology.
Kay Crossley demonstrated observed loss of hip extension in PFJ OA. This fits for me and is certainly something I would look to maximize in anyone with PFP. Loss of hip extension means greater knee flexion in terminal stance.
Toby Smith presented the Norwich Patellofemoral Instability Score for use after first time dislocation. In his words if you Google ,’ Norwich Patellofemoral Instability Score’ then you should find this free validated resource.
There were lots of inconclusive presentations around running and PFP. Esculier is demonstrating so far with his PhD that education alone is as effective as strengthening or gait re-education in the treatment of PFP in runners! Wow that really emphasizes my already held belief of the power of education.
Finally my own work! I presented some of my vmo work quite simply showing that an easy home quads programme for 6 weeks in sedentary adults will change both the fibre angle, and the amount of muscle attached to the medial border of the patella, as measured on ultrasound.
If you would like to learn more on integrating any of the above into your clinical practice then why not join me for my 1 day PFJ course? If you would like a bit more niche knowledge then look out for my master classes. And for those of you that can ‘t see a course near you there are two options: Firstly I’m always looking out for new venues so please do approach me about hosting my course. Secondly I’m about to start recording a whole array of webinars. For all info on these and more then please look at www.clairepatella.com
Thanks! Any thoughts/comments very welcome!! Claire