A little infographic to help with some of the key clues to help differentiate between a fat and and PFJ problem.simplify&clarify
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:
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?’
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.
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.
- 10 female, 6 male.
- Aged 18-23 years.
- Mean Tegner 3. (ie sedentary)
- Ultrasound measurement of vmo fibre angle and insertion level.
- Performed at baseline, 6 weeks and 12 weeks.
All performed SQC and IRQ to light fatigue alternate weeks and then randomized into a group.
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.
Insertion level very difficult to draw conclusions as results in this small sample not significant.
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:
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
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.
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.
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.
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:
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.
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.
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:
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)
Having recently met for my regular research meeting with an anatomy colleague of mine, it reminded me of the importance of anatomy and why we should understand it.
There has been controversy recently about the need for cadaveric teaching, the need for detailed anatomy, and from some quarters a push for moving right away from this ‘dry’ anatomy. I would like to take this opportunity to argue for its role, certainly with respect to understanding and treating patients with patellofemoral pain.
One of the counter arguments is that we need to consider behavioural response to pain, and not especially the source of the pain, particularly in patients who have central sensitization. However, I would ask how easy it is to understand and spot non-mechanical pain if you do not understand mechanical pain in the first place?
At the recent Patellofemoral Research Retreat that I attended there was a lot of focus on patellofemoral pain as a continuum with patellofemoral osteoarthritis. In line with this question there was interest around dysplasia. I personally am very interested by patellofemoral dysplasia and think that it is seen on a huge spectrum with many patients showing subtle anatomical variation. Dysplasia is such a good example of where understanding the anatomy really helps to alter treatment. So, for example if a patient has a lateralized tibial tuberosity I understand they will find it hard to absorb medial femoral rotation, so I think of particularly addressing horizontal plane control. In contrast someone with a long patella tendon, (patella alta) will take longer into flexion for their patella to engage, and hence receive stability from the trochlea. Understanding this anatomy leads me to focus their dynamic control work in the early ranges of knee flexion.
Understanding anatomy also helps me to understand potential tissue damage after dislocation, and helps me give out realistic prognosis and know when to refer on for a surgical opinion. So, for example take the medial patellofemoral ligament. This poor old ligament doesn’t even get a mention on the physiotherapy degree, and yet it plays a major part in stabilizing the patella. If I suspect a rupture after dislocation, I need to get this looked at.
Anatomy is also at the centre of my current research on the VMO. Our group our looking at the changes in fibre angle and insertion onto the patella, and forming a new paradigm as to what might be happening when we do quadriceps exercises. Understanding the anatomy helps to potentially identify who are good candidates for hypertrophy work.
Understanding anatomy further helps us work out what is the likely dysfunction when structures get tight. So, for example by understanding that the ITB itself cannot be stretched, but its contractile proximal attachments of gluteus maximus and tensor fascia lata can be, and by understanding that the distal ITB attaches to both the tibia and patella, I can understand the potential alteration that can occur if these structures get tight.
I do not for one-minute want to send the message out that understanding pain science and/or the psychosocial part of biopsychosocial is not important. It is very important, as evidenced by blog my on activity modification (http://www.clairepatella.com/activity-modification-in-the-treatment-of-patellofemoral-pain/ ). However, it is my belief that a deep understanding of applied anatomy has a definite place for anyone treating patients with patellofemoral pain.
Ideas para Médicos Clínicos desde el Retiro Femoropatelar, Manchester, 2015
Hay un problema inherente con el retiro: solamente puedes participar si estás presente. Por esta razón, he intentado extraer los puntos sobre los cuales los médicos deben desear reflexionar y que puedan auxiliar a evolucionar su práctica.
En mi opinión, el campo está todavía muy limitado en la biomecánica. Por supuesto que esto es relevante, pero todavía hay una división entre los practicantes de esta área y aquellos preocupados con la ciencia del dolor y de la adaptación comportamental. Un ejemplo de esto fue una discusión sobre si el ‘dolor’ debe ser eliminado de la etiqueta diagnóstica. ¡No! Es sobretodo por el dolor y, en última instancia, ¡es por esta razón que los pacientes vienen a batir en nuestras portas!
Andrew Amis hizo una charla inaugural realmente fantástica. Si estás interesado en biomecánica y alguna vez tenga la oportunidad de oír a Amis hablar – ¡ve! Sin ego aquí, realmente él no necesita tener tanta calidad o ser tan prolífico como su trabajo. Amis dijo que nosotros debemos estar conceptualizando el área de contacto, y no el mal encarrilamiento. Mucho antes del mal encarrilamiento, nosotros obtenemos presiones alteradas capaces de generar dolor, y frecuentemente estos resultados serán 30% elevados en PFP. Amis puso mucha atención en morfología anormal, como tendón rotuliano largo, forma tróclea y la distancia TTTG, y afirmó que esto tiene el potencial de alterar presiones de manera más rápida. Yo estoy completamente de acuerdo con esto, y como en muchas ocasiones, observo en clínica que esto ocurre en gran medida en un espectro. Finalmente un desafío para aquellos de ustedes que les gustan: Amis describe que el MPFL se une a la cabeza medial del gastrocnemio. Sin discusiones adicionales, considerando la importancia de esto…
Vincenzino presentó alteraciones en la sensibilidad termal y de dolor en PFP. Busque por pacientes que informen rodilla fría, sin importar el clima. James Selfe descubrió esto hace una década. ¡Es frustrante que nadie más haya realizado pesquisas sobre lo que hacer con estos pacientes! De manera intuitiva, ejercicios CV aparecerían en el topo de mi listado.
Michael Rathleff se presentó de manera muy buena en el retiro. ¡Qué pesquisador! Trabajo de alta calidad, en grandes números, céntrase en la población adolescente con PFP en Dinamarca. El trabajo que él presentó fue n=2200 (!!) A pesar del dolor, los adolescentes todavía tienen una frecuencia media de 5 episodios de deportes por semana. ¿Entonces sería un problema de carga excesiva? 55% de los adolescentes con dolor seguían así 2 años después. Más pesquisa es necesaria en este momento sobre los efectos del crecimiento.
Lee Herrington presentó una pieza muy breve sobre la velocidad de la corrida y el momento de aducción de la cadera. En pocas palabras, lo más rápido que corras, más grande es la aducción observada de la cadera. Esto es normal. ¿Podemos entonces utilizar velocidad como una manera de alterar la carga PFJ en rehabilitaciones? – Sí.
Lee también hizo una presentación sobre la utilización de ultrasonido para evaluar la carga de peso de la posición PFJ. Como parte de esto, él nos recuerda el trabajo de 2014 de Peng que muestra que aquellos que pueden reducir la inclinación con una SQC tienen más probabilidad de responder al fortalecimiento cuadrangular.
Matthews mostró una correlación muy útil: Si un paciente con PFP tiene más de 11mm de diferencia en su anchura media del pie en carga de peso de inexistente a completa, entonces un soporte ortopédico artificial es recomendado. Una pinza digital de una tienda de herramientas puede ser utilizada para esto. Bueno.
Otro de mucho peso, Felson (¡más de 500 publicaciones!), presentó un discurso sobre OA. Las mejores correlaciones con dolor en OA son la presencia de edema en medula ósea y sinovitis. Podemos detectarlos en una imagen de resonancia magnética. Esto está de acuerdo con el trabajo de Callaghan mostrando que el uso diario de un aparato ortopédico Q puede reducir el edema en la medula ósea en la tróclea lateral. Van der Hejiden presentó resultados de MRI para toda la populación normal de 14 hacia 40 años, y nos recordó que mismo en esta joven edad, 60% tenían osteofitos.
Hubieron muchas discusiones sobre la cuestión: ¿la PFP está en un continuo con la PFJ OA? Todavía sin conclusiones. Personalmente yo pienso que esto está relacionado con la morfología, y que con el tiempo nosotros seremos capaces de predecir aquellos que estén con un riesgo más grande de desarrollar PFJ OA por medio de su morfología PFJ.
Kay Crossley demostró la pérdida observada en la extensión de la cadera en PFJ OA. Esto encaja para mí y es por cierto algo que yo maximizaría en cualquier persona con PFP. La pérdida de la extensión de la cadera significa una flexión de rodilla más grande en la postura terminal.
Toby Smith presentó la Puntuación de Inestabilidad Femoropatelar Norwich para utilización después de la primera dislocación. En sus palabras, si buscas ‘Puntuación de Inestabilidad Femoropatelar Norwich’ en Google, podrás encontrar este recurso gratuito validado.
Hubo muchas presentaciones sin conclusiones sobre corrida y PFP. Esculier está demostrando hasta hora con su doctorado que la educación solamente ¡es tan eficaz como el fortalecimiento o la reeducación de la marcha en el tratamiento de PFP en corredores! Wow, esto realmente evidencía mi ya fuerte creencia en el poder de la educación.
Al final, ¡mi trabajo propio! Yo presenté un poco de mi trabajo vmo, mostrando simplemente que un programa cuadrangular en casa por 6 semanas en adultos sedentarios va a cambiar el ángulo de la fibra y la cantidad de músculo ligado a la borda mediana de la rótula, de acuerdo a las medidas realizadas con ultrasonido.
Se te gustaría aprender más sobre la integración de cualesquiera de los puntos arriba en su práctica clínica, entonces ¿por qué no unirte a mí para un curso de PFJ de 1 día? Si te gustaría un poco más de conocimiento de nicho, entonces busque mis clases magistrales. Y para aquellos que no pueden encontrar un curso próximo de ustedes, tienen dos opciones: Primeramente yo estoy siempre en búsqueda de nuevos lugares, entonces por favor contáctenme para hablar sobre recibir mi curso. En segundo, yo estoy para empezar a grabar toda una serie de webinars. Para todas las informaciones sobre ellos y más, por favor verificar en www.clairepatella.com
Si les gustaría mas blogs en español, por favor me envíen un correo y me lo dejen saber. Si hay demanda suficiente yo haré blogs futuros también en español.
There are various fat pads, but the one at the knee that causes a lot of problems is the infrapatellar fat pad, also known as Hoffa’s fat pad after the man who first described it.
The fat pad has been shown to be very pain sensitive. It is rich with nerve endings that can fire off messages of pain to the brain, and it is therefore of no surprise that people with fat pad problems are often in a lot of pain.
The fat pad is often overlooked, with clinicians concentrating on joint surfaces, cartilage, ligaments and tendons, and dismissing the patient if these structures appear normal on imaging.
So what can go wrong in this funny pad of fat? There are two very different scenarios. The first is mechanical. The fat pad gets a trauma to it. Now this may be an obvious one off blow to the knee, or where the patient straightens their knee at speed and feels an immediate very sharp pain in the fat pad. Or, as is seen more commonly the fat pad may get nipped between the patella and the tibia, and microtrauma leads to a macro problem. In either of these situations it is common to see an inflammatory response. This is a problem as inflammation leads to swelling, and leads to the scenario where the fat pad gets pinched and caught even more. This feeds into a vicious cycle that many patients get completely stuck in. Furthermore, once the fat pad becomes big it alters the way the kneecap moves, and this in turn can lead to high pressure under the patella, which is also often painful.
Can anything be done? Yes! The first is to try and break the vicious cycle of inflammation and swelling. I often recommend ice massage to oiled skin, right on to the fat pad, (the ice-it-away is really effective for this), and will often tape the kneecap off the fat pad. Wearing a slight heel can help stop the patella knocking onto the fat pad, and most definitely avoiding standing with the knee locked back.
A treating clinician should also be assessing if there are other factors contributing to squashing the fat pad. These may, for example be quadriceps tightness, or poor movement patterns, particularly in people who are hypermobile.
There are also non-mechanical sources of problem in the fat pad, and these should be referred to as metabolic. This is seen with obesity and osteoarthritis of the knee.
Let’s take obesity. When someone is carrying excess fat they will have systemic inflammation. This is one of the reasons for raised cardiovascular risk, but the fat pad becomes inflamed and can hurt. The good news is that weight loss not only reduces load to the knee but also with immediate effect has been shown to reduce the inflammatory state of the knee.
In osteoarthritis it appears that the fat pad changes its state to produce unhelpful pro-inflammatory cells. As the fat pad is housed within the capsule of the knee the fat pad drives further joint breakdown that clearly is undesirable. The good news here is that any efforts to reduce the inflammatory state of the fat pad will have a positive effect on the inflammatory state of the whole knee.
To conclude, as weird as it is, this little pad of fat under the kneecap can be a very painful and persistent source of problem. Make sure you seek the right help to treat the problem, and help you get back to the things you love doing.
If you want to understand this in more depth why not look at my webinar on the fat pad https://t.co/juxILqftIm