Posted in Case Studies, Featured
35 year old male with PFP
Male 35, Pain vague distribution around patella. No swelling, no giving way.
Thoughts: typical of PFP. Nothing to make me suspicious of meniscal pathology.
Agg. Stair descent, prolonged sitting, turning with foot fixed.
Thoughts: stair descent and cinema sign typical, turning on foot fixed makes me suspicious of joint pathology, (tibiofemoral), or shallow trochlea.
Ease. No pain after cessation of aggravating movements.
Thoughts. No Inflammatory component here.
HPC. Insiduous onset 2 years ago after increasing volume of salsa dancing to 5 x2 hour sessions per week. No other exercise. Pain increased and forced him to stop. Sought physio who gave him squats and lunges. Pain worsened. Sleep disturbance but not through pain. Sought orthopaedic opinion and had an MRI. Mild superficial changes on retropatellar surfaces but shallow trochlea with small angle to slope of lateral edge of trochlea. Referred to me.
Thoughts. This is a lot of exercise with no s&c alongside. Unlikely to be weak in quads as no swelling and came on at a time of lots of exercise. Repeated loading of PFJ through squats and lunges have worsened pain. Sleep disturbance may be from stopping exercise. This is likely to feed the possibility of central sensitization.
PMH.x2 ankle arthroscopies on ipsilateral side 5 years ago. Great recovery from ankle and not aware of any ongoing issues.
Thoughts. Need to look at ankle ROM/stability and gluteal function as ankle problems can inhibit gluteus medius
SH. Office worker who drives to work. No issue with work/commute. No exercise for last 18 months. Has put on 8 kg.
Thoughts. This man has gone from being an intense exerciser to very sedentary. He has lowered self esteem, has lost a major part of his social life and is low in mood. He now cannot imagine getting back to dancing. We need to explore other avenues of exercise as a preliminary stage.
O/E.
Obs. Overweight, no effusion. Small patella.
Thoughts: small patella can indicate hypermobility.
ROM full, 20 degrees hyperextension. Little pain.
Beighton score: 9
Palpation. No tender areas. Patella highly mobile. Negative apprehension sign.
Thoughts. Patella easily becomes malaligned due to shallow trochlea and global hypermobility.
Quads: bulk reasonable, no obvious deficits.
Thoughts. Not going to be great as very sedentary but not convinced they are primary problem but will need improving as part of later stages of rehab before return to dance, especially with a shallow trochlea as dynamic stability more important.
Gluteal assessment. Poor firing and force generation of gluteus medius in frontal plane. Compensating massively through TFL.
Thoughts. Probably a legacy from the ankle problems as vey one-sided. Rotational strength fine.
Length. Modified Thomas test reveals pain provoked by hip adduction and a subluxing patella. Very tight. Tightness perceived by pt down lateral thigh and he comments that he often gets a sense of tightness in lateral thigh with walking.
Thoughts. Tightness through ITB complex, ie TFL shortening and immobility of ITB itself lateralizing the patella that will move easily due to trochlea shape and hypermobile patella. Comment re walking tightness suggests gross overuse in simple tasks.
Standing double stance swaying side to side. Huge bracing of lateral thigh and VL making ITB bow out.
Thoughts. Excess inappropriate tone on low level activities. Need more strength proximally and retrain VL to decrease in tone.
Ankle assessment normal.
Thoughts. Ankle itself may be fine but it’s left a legacy of gluteal inhibition.
Impression.
PFP from lateralizing patella creating excess contact pressures between trochlea and lateral patella. Cause is insufficient strength proximally, driven initially by ankle injury and compensation by TFL that has got tight, and overactive bracing from VL.
Plan:
- Stretches x2 daily to TFL.
- Firing work for glut med in frontal plane to be progressed to alternate day endurance training.
- Rolling to lateral thigh, STM and practicing initially swaying weight without massive tensing of VL.
- Medialising tape to help in short term with discomfort.
- Swimming x3/ week crawl or back stroke for min 20 mins to help with weight, self esteem and sleep.
- Graduated increase in exercise as proximal strength improves, and ITB complex softer and lateralizing patella less.
- Long term restoration of dance with appropriate stretches and conditioning alongside.
Dave 19-05-2016
Nice post Claire, very informative; thanks! How are you testing Glute med? In side lying? Also what would be your choice of exercise to get the Glute firing? Thanks!!
Claire 20-05-2016
Yes I'm looking at recruitment, force generation and endurance with long static resisted testing in side ly. With respect to getting the Gmed firing I find it varies person to person as to what hits the spot. I will sometimes use open chain side-ly abduction with a quarter turn of the whole body forwards, or sometimes abduction in standing works better. Sometimes isometric abduction by pushing the contralateral leg into the wall side on in standing is handy. This is where the 'artistry' comes in slightly. With someone who is very poor at recruitment time of day can also be really important! Late in the day when tired is often a bad time to do recruitment exercises but is often the time when people do exercises after returning from work!
Genevieve Simpson 22-05-2016
Thank you Claire, very interesting, how will you reduce firing of VL, is this possible I thought quads had one innervation therefore you cannot consciously change the firing? Many thanks
Claire 23-05-2016
Great question! You are correct in that you cannot selectively recruit say the VL or the vmo, However there are situations where tone is excessive. For example slow swaying side to side with both feet on the ground. This is a low level task and shouldn't bring about maximal VL activity. The patient can practice that sway without maximally tensing. This can then be evolve into stride standing. Hoe that helps? Thanks Claire
Amjad Mahmood 04-01-2017
How are you stretching TFL, plus will rolling of lateral thigh make a difference
Claire 05-01-2017
Hi My first 'go to' stretch is stood over crossing one leg in front of the other and pushing the hips to one side to get a curve as the hip goes into adduction. Foam rolling alters tone in the VL so I would use it when I felt the VL was hypertrophied and overactive.