Author: Claire

GUEST BLOG: How should we explain patellofemoral pain to patients?

Posted on by Claire

On a daily basis we face the challenge of explaining a patient’s pain to them. When this goes well it can reassure them, help them manage their condition and be a key starting point for treatment. Unfortunately, however, it doesn’t always go well and sometimes our words can have a negative impact if not chosen carefully. Patellofemoral pain can be particularly challenging issue to explain, so how should we approach it?

What are we trying to achieve?

First of all it’s worth considering what are our goals with this explanation? Broadly speaking our goals might be;

  • Reassure that pain doesn’t mean damage
  • Provide an explanation that the patient can understand and apply to their rehab
  • Be clear that movement is helpful not harmful
  • Help the patient find the right level of exercise to start with
  • Discuss a graded return to activity based on their goals
  • Change their attitude towards their joint and its response to exercise
  • Address any specific concerns and worries
  • Aim for physcological and physical resilience

So, not much then! Where do we start?..

…Before we talk, we listen! A good place to start is to ask the patient what they think is wrong with their knee. This can help highlight unhelpful beliefs that we might be able to change and identify specific concerns.

It’s also good to know what not to say! We know that our words can have a nocebo effect and certain words may be recieved more negatively than others by patients. Research in arthritis has suggested the terms, “wear and tear” and “degenerative changes” have an especially negative impact (see table below). How often have we said to patients, “it’s just a bit of wear and tear!”? Although I’m not aware of evidence on it I suspect the term, “mal-tracking” can be interpretted negatively too.

By contrast no negative impact was reported for the word, “inflammation”. The terms “irritated”, “sensitive” and “overworked” seem to be received quite well too. These might be good options to consider in our explanation. Pain specialist Mike Stewart also suggests talking about the distress that can accompany pain, thinking beyond the ‘ow factor’ and considering the broader impact pain has on people’s lives.

Source: Barker et al. (2014)

Changing perceptions

When you’re in pain it’s easy to see your body as damaged and fragile. We might hope to change this view and help people see that their bodies are amazing things that can adapt and strengthen in response to exercise. Combining this with the thoughts above we may try something like this,

“We know that when we exercise muscles they strengthen. Did you know that a joint can strengthen in response to exercise too? It just needs the right amount of exercise and enough time. If we work it too hard or don’t give it the time to strengthen it can become a bit overworked and irritated. When this happens, everyday activities can become painful because the knee becomes sensitive. In time this sensitivity reduces and we can build back up to where you want to be. This usually needs to be done gradually though to give the joint enough time to adapt and strengthen.”

It can help to use a positive anecdote here for some patients. I talk about one particular, wonderful patient who could only manage 1 minute on a bike before his pain become too severe. He started with just under a minute and gradually built up… 6 months later he cycled London to Brighton! While we, as scientists, don’t put much stock in anecdotes as evidence, patients can find them helpful to illustrate a point.

Some patients might want a more detailed explanation. Where I’m based, for example, we sit between two universities and treat a lot of lecturers and students who may be interested in research. For them I talk about this amazing study which suggests some joints are able to adapt even in the middle of a multi-day ultra-marathon event! This helps to challenge the view that a joint is simple hinge that get’s ‘wear and tear’ and instead shows it’s an amazing, living tissue that constantly tries to adapt to the stresses placed upon it.

Goldilocks theory

A barrier to our idea that exercise is helpful is that, for many with patellofemoral pain, exercise hurts! The challenge is trying to find the right type of exercise at the right volume, intensity and frequency. Like Goldilocks’ stolen porridge we want exercise that’s not too hot, or too cold, but just right. Ideally we can achieve this without having to burgle bears!

In more scientific terms we don’t want to underload the tissues and create deconditioning, or overload the tissues and cause lasting symptom aggravation. We want to find the right level to improve load tolerance and reduce pain. It’s important to use the patient’s own experience as examples with this to help make it relevant to them. For example, if a runner tells you they can run 3 miles but 4 causes lasting irritation we can suggest that 3 sits at the right level but more might be overloading the tissues a little at the moment. In time we can build up to 4 (and beyond potentially) but we would start at around 3 miles and progress from there. This links in nicely with recent recommendations from the excellent work of Barton et al. (2015) who highlight that activity modification is a key component of managing patellofemoral pain.

Normalise pain

It’s unlikely for many for patellofemoral pain that their rehab is going to be completely painfree. We usually need to load sensitive tissue in order to help it to strengthen and adapt so it’s likely, at times, that this may hurt. We need to be clear that this pain isn’t creating damage and it’s a normal part of the process. A pain monitoring system can be a useful way to ensure that we aren’t creating lasting tissue irritation;

We also want to try to keep exercise as comfortable as we can for the patient. Pain can be a significant barrier to adherence to rehab (Jack et al. 2010) and may cause a level of quads inhibition (Rice and McNair 2010).

Message received?

Image source

Providing the right explanation is, in a way, only half of the process. We also need to see if the patient understands the message and is happy to apply it. A good question to ask is, “how would you explain your knee to a friend?” Or, “can you explain back to me what you’ll take from today’s session?”

Psycosocial factors like stress, anxiety or depression may influence how someone interprets your explanation and whether it provides sufficient ressurance for them. Fear is a very powerful emotion and not one that can always be talked away,

“I must say a word about fear. It is life’s only true opponent. Only fear can defeat life. It is a clever, treacherous adversary, how well I know. It has no decency, respects no law or convention, shows no mercy. It goes for your weakest spot, which it finds with unerring ease. It begins in your mind, always.” Life of Pi, Yann Martel

On the flip side, low levels of fear and positive perception of return to sport are associated with a greater likelihood of returning to pre-injury level (Ardern et al. 2013). Hopefully our explanation fosters a positive perception of return to activity as something that strengthens our bodies rather than damages it!

We should consider the impact of mental health on rehab and seek appropriate help for those need it. It can also be very helpful to try to assess the patient’s outlook towards they pain. A Pain Catastrophizing Scale can be a good way of doing this and might help us prioritise our treatment more towards education in those with an especially negative view of their pain.

Building ‘resilience’

A careful consideration of the key messages delivered in the right way can be a very powerful part of our treatment process and empower the patients to make informed decisions about their rehab. Considering the impact of mental health and providing a comprehensive rehab programme can help a patient with patellofemoral pain build both physical and psychological resilience. There are no recipes though! This will always need to be taylored to the individual and their specific goals.

Tom Goom is a Running Specialist and Clinical Lead at the Physio Rooms in Brighton. His website, running-physio.com has become a popular source of evidence-based information for runners and clinicians and he teaches around the UK on his Running Repairs Course. You can follow Tom on Twitter via @TomGoom.

35 year old male with PFP

Posted on by Claire

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:

  1. Stretches x2 daily to TFL.
  2. Firing work for glut med in frontal plane to be progressed to alternate day endurance training.
  3. Rolling to lateral thigh, STM and practicing initially swaying weight without massive tensing of VL.
  4. Medialising tape to help in short term with discomfort.
  5. Swimming x3/ week crawl or back stroke for min 20 mins to help with weight, self esteem and sleep.
  6. Graduated increase in exercise as proximal strength improves, and ITB complex softer and lateralizing patella less.
  7. Long term restoration of dance with appropriate stretches and conditioning alongside.

 

 

 

Aquatic physiotherapy for patellofemoral pain – a case study from Aqua-Physio.

Posted on by Claire

Aquatic physiotherapy can be an excellent tool in the management of patellofemoral pain. Here is a recent case study where dry land treatment was incorporated with aquatic therapy.

Our case patient (PB) had a previous history of right sided patellofemoral pain and six years’ prior had undergone lateral release surgery to try and correct lateral tilt and maltracking of his patella. He is a keen amateur cyclist, a sport which he maintains to a good level and he had recently completed L’Etape Du Tour a gruelling amateur cycling event replicating one of the Tour De France stages. Not long after completing this event he described an innocuous flick with his foot to move a ball situated on the floor and the onset of his anterior knee pain.

On assessment his patella was excessively mobile laterally with poor vastus medialis obliquus muscle bulk and function, which is a muscle on the inside of the knee that helps to provide support to the patella from laterally tracking. He had weak lateral hip and trunk stabiliser muscles and showed internal rotation of his femur on loaded tasks such as a single leg dip, a classic movement pattern seen with this particular type of problem. An MRI scan had been completed which showed significant degeneration in his lateral patellofemoral joint and fat pad swelling. This was in addition to a shallow trochlea groove which would be reducing the structural stability for the patella and placing further emphasis on his biomechanical faults. Clinically he had a picture of lateral patellofemoral pain and a recent fat pad injection had already been trialled which was unsuccessful in changing his symptoms, indicating more of a patellofemoral joint dysfunction rather than fat pad pain. Expert clinical opinion was also sought through Claire Robertson who clarified the important clinical findings and gave practical solutions of how to proceed with PB’s dry land treatment.

Mechanical overload to the knee is often the key driver to the onset of patellofemoral pain. This may be due to a biomechanical issue which causes overload to the joint, or simply an increase in loading due to external factors such as recent increased sporting activity. As we often find clinically PB showed a combination of both biomechanical issues and a surge in activity levels with his recent cycling event. One benefit of exercising in water for this type of pathology is the ability to load the lower limbs without causing further mechanical overload and to begin working on the biomechanical faults in a relatively pain free environment.

PB used our aquatic therapy pool to exercise his trunk and lateral stabilising muscles using a host of different techniques utilising the properties of water to challenge him in ways he had not expected. It is interesting in this case how someone can cycle over mountains yet have some quite specific leg weaknesses. He was pleasantly surprised that with time in the water he could exercise through full functional knee movement without pain, thus giving an opportunity to correct his dysfunctional technique. Even light cycling had been painful up until this point and PB was becoming increasingly frustrated at his inability to exercise and felt he was losing his hard earned fitness levels. This highlights another great benefit of aquatic therapy for the treatment of anterior knee pain where fear avoidance or increased anxiety regarding exercise has been highlighted as one of the main causes of a poor long term prognosis and can potentially become a secondary pain driver.

Coupled with a progressive dry land exercise regime and some simple patellofemoral self-taping techniques PB has successfully returned to his long distance cycling. He is maintaining his exercises on dry land and is planning another attempt at L’Etape Du Tour this summer.

Here are a few words of his own regarding his treatment in the pool:

“Due to my limitations with respect to my knee injury I was not making much progress. So I decided to explore the avenue of Aqua Physio. I was as astounded on my first session how quickly we realised that my poor movement and poor core muscles was impacting my knee. Just trying to do some basic walking in the pool was challenging and I was constantly off balance. The first obvious advantage was that I could lose balance without injury. Also stability the water gave me, minimised impact to my knee. Over a period of several weeks I started to engage more of my core muscles which offered stability to my knee. I felt that I could I challenge my knee more. However, the greatest win for me was how incredibly quickly the flexibility in my knee improved.”

Written by Philip Morel, Physiotherapist

Aqua-Physio is a state of the art aquatic therapy pool based in Lower Morden, Surrey. Visit their website: http://www.aqua-physio.co.uk

Why Is my Knee swollen-what does this mean?

Posted on by Claire

What is swelling? What does it mean and what should be done in response to it? There are different causes of swelling and to understand how to respond to swelling it is really important to try and distinguish between the different causes. Trauma. This can be a sporting injury, direct blow or fall, but there is a very obvious moment of injury. Speed of swelling of the knee is really important in this instance. If the area swells within an hour it is suggestive of blood, (a haemarthrosis), which flags up the possibility of more serious injury such as a fracture or ligament injury. In the knee we would often consider fracture to the tibial plateau, or ACL rupture, depending on the nature of the injury. In these situations rapid action must be taken so that the injured person sees a clinician immediately. Direct blows to the knee area can also result in a bleed within the soft tissues, not the joint. Although these can often be managed with physiotherapy again it is important to ensure that a more serious injury such as quadriceps rupture is not overlooked. Swelling in a crescent shape below the kneecap. This is normally fluid in the fat pad that sits as a ‘u’ shape under and around the bottom half of the patella, (knee cap). This is very common in all age groups and can be suggestive of the kneecap knocking into the fat pad and disturbing it. For more on this read my blog on fat pads:

http://clairepatella.com/the-infrapatellar-hoffas-fat-pad-explained/

Fat pad swelling can occur alongside osteoarthritis of the knee, and recent literature suggests it may be part of the inflammatory cycle. When I see a large swollen fat pad I am always keen to see that come down in size. Ice massage to oiled skin can be very effective, (the  ice-it-away is brilliant for this) as can taping techniques to off load the fat pad or stabilize the patella. A physiotherapist should be able to help with this. Swelling over the front of the patella. This can be pre-patellar bursitis, an inflamed bursa, (a pouch of fluid). It is often seen in people after a direct blow to the front of the knee or after a lot of kneeling. Treatment is to avoid direct pressure, ice, elevate, and discuss the use of anti-inflammatory medications from a prescribing clinician. Non-traumatic knee joint swelling. If the knee joint is swollen without trauma the most common cause will be osteoarthritis, the wear and tear arthritis. Swelling can make the joint feel stiff when in one position for too long, and can make the communications between the knee and brain sluggish which in turn can inhibit the quadriceps muscles on the front of the thigh. This can lead to a feeling of lack of confidence in the knee and the sense that it might ‘give way’. For these reasons it is important to try and get this swelling down. First line attempts can be elevation and ice, but anti-inflammatory medications can also be used. A prescribing clinician should be consulted regarding this. Finally there are more unusual causes of knee swelling that are more systemic in nature. In other words the body’s immune system has got in a muddle and sets off an inflammatory response inappropriately. Clues to this can be multiple joints swelling, joints feeling stiff on waking, and often an accompanying sense of feeling unwell or fatigued. A GP or rheumatologist is the best person in this circumstance. Ultimately swelling is unhelpful. It restricts movement, makes the joint feel stiff, and can interfere with muscular firing patterns. However, as this blog has hopefully explained, there are many different potential causes and the best starting point is to ask, ‘why is this swelling present?’

Non-operative management of Patellofemoral Osteoarthritis

Posted on by Claire

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.

Latest VMO unpublished work!

Posted on by Claire

British Association of Clinical Anatomists, 2015.

I have had the privilege of being the only physio to present at this years BACA, primarily to an audience of anatomists and surgeons.

It was hard to follow on from an incredibly interesting and cutting edge presentation on hand transplantation (!!) but if we can bring things back to PFJ I’d like to share my key findings. This work is therefore in write-up with the goal of publication in 2016.

Key points:

Subjects:

  • 10 female, 6 male.
  • Aged 18-23 years.
  • Mean Tegner 3. (ie sedentary)

Outcome measures;

  • Ultrasound measurement of vmo fibre angle and insertion level.
  • Performed at baseline, 6 weeks and 12 weeks.

Groups:

All performed SQC and IRQ to light fatigue alternate weeks and then randomized into a group.

  • X1/week.
  • X2/week.
  • X3/week.

Results:

Fibre angle increased from 0-6 weeks. Those that stopped the angle reversed. The x1/week reversed a small amount. X2/week maintained the effect, x3 increased fibre angle further.

graph

 

 

 

 

 

Insertion level very difficult to draw conclusions as results in this small sample not significant.

Implication:

To maintain muscle architecture changes, 2 exercises x2 a week was the minimum.

Of course in patients, the presence of pain may alter results, and the potential for increased function may help to maintain muscle architecture change.

If you want a light infographic on my previous vmo research then click here:

https://www.youtube.com/watch?v=dpZH9-702ls

I will alert anyone on my mailing list when this work is published so don’t forget to pop your email in at the bottom of the page.

Tape in the management of Patellofemoral Pain

Posted on by Claire

Tape in the management of Patellofemoral Pain

There is a lot of hype around tape-what tape, what technique, what colour! The hype is not fully underpinned by robust academic rigour and yet do I use tape with my patients? Yes I do. Let’s explore this.
Overall the literature is poor quality with varied methodologies and as such there is no definitive answer to ‘should we use tape in patellofemoral pain, (PFP), to which patients and how?’ As always in these situations I go back to clinical reasoning: what am I trying to achieve, and how can I best do this? Will the patient be able to replicate this themselves? Here I present the most common scenarios I tape for, and what techniques I use.
1. Fat pad offloading. Fat pads often become oedematous and then impinge between the tibia and patella even more. Taking the pressure off the fat pad can really help break this cycle. First though I need to establish which part of the fat pad is impinged, and why.
If the central part of the fat pad is being impinged, (frequently due to tight quadriceps or uncontrolled hyperextension) then an elevating taping technique is useful to elevate the whole paella and tip the distal pole of the patella off the fat pad.
fatpad_tape
NB. I would not perform this technique on someone with patella alta, (ie long patella tendon) as it may increase their instability.
If the fat pad is impinged in its supra-lateral corner it is more likely to be patella tilt and/or poor control of femoral internal rotation. For the patella position I would be more likely to use a McConnell taping technique.
la glide_tape

If the femur is more the issue then a spiral from the medial knee across the anterior thigh diagonally to the glutei applied in slight knee flexion and femoral external rotation helps to give feedback if the femur starts dropping into internal rotation.
2.Patellofemoral Joint Pain.
Excess retropatellar pressure to the subchondral bone is often, (but not exclusively) from patella malalignment. If the patient has a good pain response from manual medial glide and/or tilt correction with a task such as squatting or step ascent then I will try a McConnell taping as shown above.
3. Dysplasia.
If a patient has a shallow trochlea or long patella tendon there is a multi-directional instability. In these cases they often present with puffy parapatellar soft tissues as the patella crashes around into the soft tissues. These patients along with hypermobile patients often benefit from:
www.pinterest.com

4. Unwanted hyperextension.
Some patients, (in my experience particularly those with hypermobility) flick their knees rapidly in to hyperextension and as such often traumatize the fat pad. They are often proprioceptively unaware of where neutral is. To help with this I will often place a small piece of vertical tape in the popliteal fossa with their knee in a few degrees of flexion. If the patient goes to move into hyperextension the tape should tug and remind them
5. Pain relief.
If pain relief is gained by tape I am all for it as long as a long-term dependence doesn’t ensue! Reduced pain helps to win the patients confidence in you, and will then often give you a window of opportunity to do exercises, re-educate movement that would previously have been pain limited.
To conclude:
There are many other taping techniques out there, some of which I occasionally use. However, the aforementioned are my ‘go to’ techniques. I’m sure this would be different for another clinician. Neither will be right or wrong.
What tape? I consider rigidity, skin tolerance and ability to stick, especially on hot, sweaty skin.
Finally and most importantly most clinicians in the UK do not have the luxury of seeing patients several times a week. If you are planning on using tape as a key part of your treatment then the patient has to be able to replicate it. I recommend; keep it as simple as you can and if the patient has a phone with a video facility then get them to film you talking through applying it.

Clinical Commentary on Latest research-stay right up-to-date

Posted on by Claire

Ford KR, Nguyen A-D, Discchiavi SL, Hegedus EJ, Zuk EF, Taylor JB. An evidence-based review of hip-focused neuromuscular exercise interventions to address dynamic lower extremity valgus. Open Access J of Sports Med. 2015;6: 291-303

Theoretical Framework for Hip-focused neuromuscular exercises to modify lower extremity valgus.

I love this model! It is very unusual in a review paper of strength exercises to see such consideration for all the many other factors that will impact on outcome. I congratulate the authors for this, and they have kindly given me permission to include the model here:

Figure 6

If you would like the full extensive commentary on this and 2 other papers, click here: http://clairepatella.com/product/annual-subscription-to-claire-patella-clinical-commentary/
1. £10 this issue
2. DISCOUNT £20 for the year, ie 4 issues! (Previously £25)

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