A short video reminding us about terminology, and why it is important to the patient. Click here: Love_to_learn
13 year old county netballer with Patellofemoral Pain
PC. Vague distributed anteriorly located left knee pain. Ache with occasional sharp pain. No giving-way but feels a sense of ‘slipping’. No locking, no swelling.
Thoughts: This sounds like PFP but must also remember it could be patella tendon, fat pad, Sinding-Larsen-Johansson(SLJ) and/or Osgood-Schlatters.
Aggravated. Landing from a jump in netball. Stair descent after netball for the rest of the day but not into the next day. Kneeling fine.
24 hour. No pain/stiffness on waking. Fine until pays netball. Pain on stairs for 1-2 hours post netball.
Thoughts. The fact that the pain does not extend into the next day suggests very little inflammation. No stiffness on waking makes it less likely to be tendon, and also that kneeling is fine makes it less likely to be fat pad, (SLJ) or Osgood-Schlatters.
Eased. Doesn’t hurt when on holiday ad not playing netball.
Thoughts. This indicates there is something around the netball. Need To explore volume of load more.
HPC. Insidious onset 9 months ago, and steadily getting worse in terms of intensity of pain. On questioning, she has grown 10 cm in the last 18 months, and also got into the county netball squad 9 months ago which added in x2 more training sessions a week. She has not had any treatment so far but has had an MRI.
Thoughts. Growth of this volume will alter the relative length of soft tissues, alter proprioception, and the trochlea shape can alter in this final growth spurt.
Need to ask about total training across a week.
MRI. Normal chondral surfaces but shallow inclination of lateral side of trochlea. Normal patella tendon length and tibial tuberosity position, (TTTG). Tendon, fat pad, and growth plates all normal.
Thoughts. Great news re growth plates/ joint surfaces, tendon and fat pad. The shallow slope subtly compromises the lateral stability of the PFJ However, the TTTG and tendon length being normal suggest that it should be possible to have a stable PFJ.
SH On a sports scholarship to her school. Anxious re ability to keep playing as feels her scholarship is at risk. Plays Centre for school team and WA for county. X2 training and x1 match per week for school, x2 training and x1 match per week for county. Also enjoys running so runs for a cross-country club at weekend.
Thoughts. Accumulatively this is a lot! X6 netball plus her cross country means no days off. Her position for the school involves more movement than her position for the county. Cross country aerobic so not particularly giving her very useful fitness for her netball. The scholarship is heightening her anxiety about the situation which may be altering pain processing.
On Examination-Main Findings.
Observation. No effusion, no fat pad oedema. Good muscle definition. Very prominent ITB’s bilaterally. Medialising femurs.
Thoughts. Is this an anteverted femoral neck, lengthened hip external rotators, lazy posture, or the foot driving the limb into medial collapse?
Craig’s Test. Neutral hip, i.e. not anteverted.
Gluts Assessment. Good static resisted hip abduction and external rotation at 20 and 90 degrees of hip flexion.
Hop test. Poor landing technique. Dropping into adduction and medial rotation, with inadequate hip and knee flexion. Able to correct with instruction.
Thoughts. Proximally her femoral neck appears in a good position and her strength appears good. However, she is not using this strength and is dropping into a large valgus moment, which overloads the lateral PFJ. This combined with her poor lateral trcochlea means two risk factors are coming together.
Muscle Length. All normal except 1.TFL/ Gmax, which are very tight. No passive adduction available on modified Thomas test. N2. Soleus tight so in knee flexion there is little dorsiflexion.
Thoughts. This may be due to the growth spurt. The TFL/GMax tightness is pulling on the ITB which given the poor lateral trochlea will lateralize the patella. The tight soleus encourages excessive pronation on landing and encourages whole limb medial collapse.
PFP due to:
Growth revealing poor lateral trcochlea shape.
Growth and? habit leading to poor landing technique.
Sluggish control of femoral adduction and medial rotation.
Proximal tightness leading to lateralizing of patella via ITB.
Tight calf encouraging excessive pronation.
TRAINING LOAD EXCESSIVE.
Temporarily stop cross country to have a day off per week.
Liaise with school about her changing to WA temporarily.
Soleus, TFL and GMax stretches to be performed x3 a week, x3 sets of 30 secs.
Proprioceptive training with bias on landing technique.
GUEST BLOG by Dr Lee Herrington-Patellofemoral joint pain post ACL reconstruction, a change of thinking in early rehab required?
Patellofemoral joint pain (PFP) and its sequelae Patellofemoral joint osteoarthritis have been reported to occur in significant numbers of patients following ACL reconstruction (ACLR) and have a substantial impact on function and quality of life1. Researchers have for a long time now theorized that a diminished capacity of the quadriceps to control loads and provide joint stability may place abnormal stresses on articular structures of the knee, predisposing the knee to degeneration2,3. The first part of this blog will present some of the growing body of evidence showing that ACLR patients have deficits in performance which can be linked to deficiencies in their quadriceps function, both of which can then be associated with abnormal patellofemoral joint loading. The second part of the blog will discuss how ACLR rehab might have to be modified to reduce the ACLR patient’s susceptibility to developing PFP.
ACLR patients have abnormal movement patterns such as decreased knee flexion angles (and excursion), knee extensor moments and higher initial peak loading rates compared to controls, when descending stairs, landing, walking and running, which are present from three months post op and can persist beyond two years post op4,5,6,7. These behaviours are indicative of “quads avoidance” a phenomena described by Powers et al8 as occurring in PFP patients. Alongside the abnormal movement patterns ACLR patients also present with significant deficits in quadriceps strength, force development and activation levels (degree of inhibition)6,9,10,11. These strength changes and movement patterns would appear to pre date the onset of osteoarthritis certainly and possibly PFP reported by Culvenor1. So the question might be why could these changes predispose the individual to PFP?
Why ACLR patients develop PFP could be due to a number of factors, but principle amongst them is likely to be the development and maintenance of bony oedema and the alteration in the loading environment within the patellofemoral joint. The presence and extent of subchondral bone marrow lesion (bony oedema) is significantly related to subchondral bone attrition and damage12, with up to 80% of ACLR patients having significant bony oedema on MRI scanning, so provides an overt link to osteoarthritis. Elevated levels of water content in the patella have been shown to be related to increased pain levels in PFP patients13, linking this to PFP. The presence of pain and bony oedema is likely to have a significant impact on levels of quadriceps inhibition and so strength3, this in turn limits the ability to absorb impact, through eccentric contraction and is borne out by the reduced knee flexion angles and increased early peak loading found during functional tasks, which is associated with increased patellofemoral joint loading14. So the local tissue homeostasis is significantly disrupted by both the presence of oedema and the altered loading environment.
The question then becomes how to reverse this downward spiral of quadriceps dysfunction, aberrant movement and perpetuation of the bony oedema. The most obvious place to break into this circle would appear to be at the beginning! Patients with greater quadriceps strength pre-op have superior function and at a variety of stages post op15, this also fits with what is known in PFP were those patients even with PFP who have stronger quadriceps have less pain and greater function(17). So first thing would be have the patients engage in a pre-operative strengthening programme (we’ll get onto defining what that means shortly) and very early post op starting strengthening and improving quadriceps function. Wang et al16 reported greater than 80% recovery of quads strength after ACLR is associated with less severe patellar cartilage damage, so it all appears to make sense. So why isn’t it happening already? The improvement in quadriceps function and reduction patellofemoral joint vulnerability are almost certainly impacted upon by two factors, first is a poor understanding of what strengthening exercises are and the second is the open kinetic chain exercise issue.
Though it might appear obvious, in order to strengthen muscles a suitable amount of external load needs to be lifted. The majority of patients undertake (body) weight bearing exercises (closed chain exercises such as squatting and step ups) which involve just moving their own body weight or small (relative to their body weight) additional external loads; they then do multiple repetitions of this. Plainly lifting a load for a large number of repetitions will not develop strength, this requires high loads which only can be lifted for a small number of repetitions. The best way to do this for quadriceps would be to do loaded open chain knee extension exercises; this takes us to the second problem the open chain exercise issue.
The open kinetic chain quadriceps exercise issue comes from the belief that quadriceps contraction creates anterior tibial translation and so could stress the ACL graft, there is no doubt that quadriceps contraction can create translation, but is it sufficient to actually create damage? If a maximal isometric quadriceps contraction is carried out at 20 degrees knee flexion (point of greatest potential translation), the level of translation load recorded is significantly less than that found undertaking a maximal lachmans test at the same angle(18). The amount of potential for anterior translation is angle specific with no translation occurring on quadriceps contraction at angles greater than 60 degrees knee flexion(19). In studies were open chain quadriceps exercises have been added to a rehabilitation programme, there was no significant differences in laxity across groups(20).
So to conclude, there is a strong likelihood that quadriceps dysfunction is related to PFP in the ACLR patient. In order to mitigate the risk, the patient needs to engage in a: preoperative training programme; early in the post op phase start to activate (overcome inhibition) and then strengthen the quadriceps. As part of this restricted range open chain knee extension exercises are likely to be a good option, alongside more traditional neuromuscular control exercises aimed at improving limb alignment and general whole limb work capacity.
- Culvenor et al 2016 Arthritis Care and Research. 68,6,784-792
- Hurley 1999 Rheumatological Disorder Clinics of North America 25,2,283-298
- Palmieri-Smith et al 2009 Exercise and Sport Science Reviews 37,3,147-153
- Thomas et al 2015 Journal of Orthopaedic and Sports Physical Therapy 45,12,1042-1050
- Di Stasi et al 2015 Journal of Orthopaedic and Sports Physical Therapy 45,3,207-214
- Lepley & Palmieri-Smith 2015 Journal of Orthopaedic and Sports Physical Therapy 45,12,1017-1025
- Noehren et al 2013 Medicine and Science in Sport and Exercise 45,7,1340-1347
- Powers et al 2004 Clinical Journal of Sports Medicine 14,4,277-284
- Laudner et al 2015 International Journal of Sports Physical Therapy 10,3,272-280
- Kline et al 2015 American Journal of Sports Medicine 43,10,2553-2558
- Harput et al 2015 Journal of Sports Rehabilitation 24,4,398-404
- Roemer et al 2010 Osteoarthritis & Cartilage 18,1,47-53
- Ho et al 2014 European Journal of Sport Science 14,6,628-634
- Silva et al 2015 Clinical Biomechanics 30,971-975
- Logerstedt et al 2013 The Knee 20,3,208-212
- Wang et al 2015 American Journal of Sports Medicine 43,9,2286-2292
- Culvenor et al 2016 Arthritis Care & Research DOI 10.1002/acr.23005
- Yack et al 1994 Journal of Sports Physical Therapy 20,5,247-253
- Beynnon et al 1997 American Journal of Sports Medicine 25,823-829
- Glass et al 2010 North American Journal of Sports Physical Therapy 5,2,74-84
Dr Lee Herrington is the programme lead for the MSc in Sports Injury Rehabilitation at Salford Click here
Dolor Patelofemoral: Evaluacion subjetiva. Seminario web gratuito!
Best knee ROM to train quads to Minimise PFJ load.
Patients with patellofemoral pain often need quads training. Being careful about the ROM can maximise load on the muscle and minimise load on the joint.
Click here to view: https://youtu.be/rf6LOHxelFY
Calf and Patella pain-Top Tips
Here is my 3 min top tips for why you should consider the calf when assessing a patient with patellofemoral pain. Click here:
A behind the Scenes Look at Reflective Practice In My Patellofemoral Pain Practice: An Open and Honest Account.
Reflective practice is often banded around with many reminded of student journals they were made to write. In this blog I explain how I use it in my practice and how the literature on this topic helps to inform us.
‘I pay attention to my ‘experience’ because I constantly strive to become a more effective practitioner and realise my vision of practice.’ (Johns, 2004). Is paying attention to the ‘experience’ enough? As a researcher and clinician I would hate to stop either component. For me there is a richness that comes from my clinical practice but this vast experience I now have of PFP, is devalued without reflection.
Throughout the last decade I have had a note pad which has now evolved into the notes section on my phone to jot down things to look up, give further thought to or even research myself. My crepitus work came out of my reflections on many patients talking about their crepitus.
It is good to question and challenge yourself, and ask why did that patient not respond to treatment, why did a patient report an unusual symptom, why, why why…On those occasions where someone is looking to me as an expert in the field and they aren’t responding to treatment it’s imperative I ask why. This is not to beat myself up but learn from each and every patient through my questioning reflection.
Stages of Reflection
Kolb’s experiential learning cycle, (1984) reminds us of the stages of reflection. However, this doesn’t have to be a laboured process involving writing. This for me often occurs during practice so it is reflection in action as described by Schon (1983). So, for example, if I am about to ask a patient to do a single leg squat but I note their fear at the pain from getting out of a chair then I might reflect and in a second decide not to use a single leg squat.
Peer Support-Critical Friendships
‘All professionals are concerned with knowing and realizing desirable and effective practice, yet work in conditions where for one reason or another such realization is often difficult.’ (Johns, 2009). Peer support really can help with this. I am really fortunate that I work in a team that is passionate and friendly. When I’m stuck with a patient I will look to colleagues to reflect on the patient with them. Sometimes just verbalising in itself helps, and two brains knocked together is always better than one. As I have become more experienced I’ve been more comfortable to do this, accepting that we all have head scratchers! Critical friends to reflect with are valuable.
Gibbs, (1998) work reminds us that we have feelings and this can impact on our interactions. These may be brought in to the consultation from home, eg anger, frustration about something, or induced by something in the consultation. For example, a spate of patients not progressing well will take the edge off my confidence that may subtly alter my communication style. To reflect on this and be self-aware is important to for me to add to the rich understanding of my practice.
Patients’ give both formal, (e.g. questionnaires), and informal feedback. I have learnt so much off patients over the years especially ways in which they have innovatively found to do exercises at home. Apart from the patient who put his pedometer on his sausage dogs collar these will often be top tips that I ‘bank’ and pass on to future patients, leading to a richer experience for everyone. To listen well and reflect on patient’s experiences greatly aids this process.
We’ve all had them. Those consultations we’d rather forget about. But actually these are such useful sources of learning from reflection. Osterman and Kottkamp, (2004) refer to this as problem identification. As opposed to Kolb’s reflection they talk about analysis, so really breaking down the components of a negative experience. It is useful not to simply think of what didn’t go well and what you do differently next time, but reflect on the underlying assumptions that led you to act in a certain way. Just dealing with patients with PFP I need to be really careful with this. My inevitable strong pattern recognition with this patient group can lead to the wrong assumptions and reflecting on this helps guard against it!
Re-visiting a Reflection.
Ultimately we reflect and conceptualise with the information we have at any one moment in time. However when I reflect on a patient after a 6-month gap I am looking to see how my reflections have evolved due to six months of extra experience and reading. I often ask my course delegates to reflect on a patient in the light of my course and hope that their reflections will have evolved.
It is very easy to look for evidence to support a pre-existing belief. This can make us feel sure of our stance and avoid the discomfort of change. Argyris’s ladder of inference, (1982) neatly shows us how we easily select data to reinforce an assumption. This is something to be aware of when reading literature. The plethora of literature means that even the articles we select to read and their take-home messages may in itself be reinforcing assumptions. I try and make myself reflect on what literature I am choosing and why to ensure I keep evolving in my PFP practice and teaching.
‘People with a high level of personal mastery are acutely aware of their ignorance, their incompetence and their growth areas.’ (Senge, 2006). This really is very annoying at times as the more you know the more you realize you don’t know! However, it is also hugely exciting to be in a profession where I can learn, learn, learn, even if the ‘to read’ list gets a bit overwhelming at times.
I feel hugely privileged to be in a career that is so rewarding and stimulating. When I reflect on my days as a student with faradism, slings and de Lorme boots I can see what a journey I’ve been on. Reflection has, and continues to be a vital part of that journey.
‘Reflective practice is the antidote to complacency, habit and blindness.’ (Johns, 2004)
Top Tips for ensuring you have a Reflective Practice:
- Keep a log or pop things on your phone to look up, give further thought to.
- Regularly make time to talk to a ‘critical friend’ and reflect on tricky cases or problematical scenarios.
- Ask yourself why you have chosen to read the papers you have.
- Try and be self-aware of your own beliefs and feelings.
Argyris C (1982) Reasoning learning and action: Individual Organizational, San Francisco: Jossy-Bass
Gibbs G. (1998) Learning by Doing: a Guide to teaching and learning methods, Oxford: Further Education Unit, Oxford Polytechnic.
Johns C. (2004) Becoming a Reflective Practitioner, 2nd Ed, Oxford: Blackwell Publishing.
Johns C. (2009) Becoming a REflective Practitioner, 3rd Edition, Chichester: Wiley-Blackwell
Kolb D. (1984) Experiential Learning: experience as the source of learning and development, New Jersey: Prentice Hall
Ostermann KF, Kottkamp RB (2004) Reflective Practice for Educators,2nd edition, London: Kogan Page
Schon D. (1983) `the reflective practitioner, New York: Basic Books.
Senge P (2006) The fifth discipine, 2nd edition, London: Random House Business
42 year old female, right inferopatellar pain
Female, 42, describing intense pain sometimes burning, inferopatellar, worse laterally. Area swells up locally. Complains of intermittent giving-way associated with sharp pain. No locking.
Thoughts: Typical of inferopatellar fat pad but can’t discount patella tendinopathy or referral from PFJ. Giving way probably pain induced quads inhibition but can’t yet disqualify possibility of intra-articular pathology. Swelling sounds local to fat pad and not an effusion.
Agg. prolonged standing, kneeling.
Thoughts: Prolonged standing typical of fat pad-need to ascertain if type of shoe alters this. Kneeling could be fat pad/ PFJ or tendon.
Shoes. Worst in bare foot or very flat. Better in a slight heel.
Thoughts: Best clue so far that this is probably a fat pad problem. Unlikely to like a heel if PFJ or tendon.
Ease. Standing with knee flexed. Avoidance of kneeling.
Thoughts: Very unlikely to be PFJ if likes standing in flexion. Offloading her fat pad with this stance.
HPC. 4 months ago her 2 year old ran into her knee at speed and hit inferopatellar area. Very sore and swollen initially. Settled 70% over first 2 weeks but no further improvement. Anxious about her knee as she wants to try and get pregnant again but doesn’t know if that is a bad idea with her knee as it is. She comments she is very aware of her age and her declining fertility. Moving house out of area and very stressed about house hunting/ not knowing people/ moving away from family.
Thoughts: This lady has a lot on! She doesn’t know the meaning of her pain and how this should impact on her decision re getting pregnant. She sees this as a potential threat to something very important to her. Stress of moving and all associated with it has the potential to decrease her ability to cope with this current pain.
The blow to the front must also be considered for a potential PCL rupture as this can present as PFP as the PFJ gets overloaded by the posterior sag of the tibia.
PMH. Nil of note. Obese.
Thoughts: Obesity will increase the likelihood for catastrophic handling of her pain. The high BMI also increases her systemic inflammatory state as well as her inflammatory sate of her fat pad.
SH. Full time stay at home mum with one two year old. Spends a lot of the time on the floor playing with daughter and does not wear shoes at home.
Thoughts: A lot of kneeling going on here plus time bare foot, both of which are likely to stop an inflamed fat pad from settling.
Obs: Stands with knees in hyperextension. Fat pad oedematous compared to the other side.
Thoughts. Constant position of hyperextension creating impingement of patella on fat pad. Need to feel passive hyperextension to check posterior capsule not been overstretched by blow from the front.
ROM. R=L. 30 degrees hyperextension. Right painful on passive hyperextension.
Thoughts. Capsule normal but fat pad painful when compressed.
Ligament testing: ACL & PCL normal.
Palpation: Patella tendon soft and non tendon. Fat pad just lateral to the tendon very tender.
Quads: Some subtle atrophy. In single stance unable to control 30 to zero degrees and snaps back into hyperextension.
Thoughts. Poor terminal extension control means that she is likely to accelerate into hyperextension which creates a microtrauma to the fat pad.
Other: Excessive pronation of foot visible by abduction of forefoot and rearfoot valgus. Correction in weight bearing visibly makes the lateral fat pad appear less impinged by the patella.
Thoughts: This foot posture closes down the space for the lateral fat pad.
Inferopatellar fat pad inflammation initially started by a direct blow form toddler. A number of factors have meant that the fat pad is struggling to settle. These are:
- Tendency to hyperextend.
- Volume of kneeling.
- Foot posture exacerbated by volume of time bare foot.
There is also a concern here that there is a real risk of catastrophising as the knee problem is perceived as a threat to her future pregnancy, happily moving house and coping with her daughter with reduced family support.
- Reassure re the pain. Nothing serious and should be viewed as a nuisance but not a worry. She should not be considering delaying a second pregnancy because of this. Absolutely no need for surgery whatsoever.
- Calm the fat pad itself. Ice massage to oiled skin at end of day,(the ice-it-away is fantastic for this), fat pad tape offload and tape in the popliteal fossa to help educate re hyperextension.
- Indoor trainer with chunky rear foot sole to provide better foot position and help avoid hyperextension.
- One exercise only, (more may become a stressor in itself) to practice 30 to zero degrees in front of a mirror slowly, initially little and often. This must be done pain free,
- Avoidance of kneeling as a temporary measure. Sitting on her bottom not kneeling, and bathing daughter with a rolled up towel under knees on tiled floor.
- Gentle conversation re BMI stressing it should be viewed as a long-term plan and that she should turn her attention to it when the time is right for her, (ready for change).
J sign video before and after trochleoplasty, (surgeon, Mr Jonathan Bell)
Top tips. 3 min video on plyometrics and Patellofemoral pain
For 3 mins of top tips click here: simplify&clarify