Garrison - Patellofemoral Webinar[1]
11/18/13
The Patellofemoral Joint: Func%onal Assessment and Treatment Craig Garrison, PhD, PT, ATC, SCS Ben Hogan Sports Medicine Fort Worth, TX
Agenda • • • •
Epidemiology Mechanism of Injury Anatomy and Biomechanics PresentaEon • Anterior Knee Pain, Fat Pad Syndrome, Patellar Instability, Plica Syndrome
• FuncEonal Assessment • Treatment • Return to FuncEonal AcEviEes
Epidemiology • Incidence of PFPS in sports med clinics 25% • 9% in students (17-‐21 y/o) in PE • 43% in army recruits during 6 wks of training – Callaghan and Selfe, Phys Ther Sport, 2007 – Andersen and Herrington, Clin Biomech, 2003 – Witrouv E et al., Am J Sports Med., 2000 – Thijs Y, et al., Clin J Sport Med., 2007
1
11/18/13
Epidemiology • 60% of parEcipants w/ PFPS in ex program – symptoms a]er 1 yr • Clark DI, et al., Ann rheum Dis., 2000
• PFPS sx present 5 yrs a]er dx • Blond L, et al., Acta Orthop Belg., 1998 • Kannus P, et al., J Bone Joint Surg Am., 1999
Epidemiology • 1525 parEcipants from USNA – followed for PFPS -‐ 2.5 yrs – incidence rate 22/1000 person-‐years – females 2.23x more likely to develop PFPS than males • Boling M, et al. Scan J Med Sci Sports., 2010
Mechanism of Injury • Insidious onset – Anterior Knee Pain – sicng – stair climbing/descending – running – squacng
www.moveforwardPT.com
2
11/18/13
Mechanism of Injury • Repeated stresses across joint – valgus and IR – incr. ant. Ebial translaEon (knees over toes) • patellar instability and plica Syndrome
Anatomy • Patellofemoral Joint
Anatomy • Envelope of FuncEon – Fat pad – Joint capsule • peripatellar synovial lining
– Osseous metabolic acEvity – Plicae
3
11/18/13
Anatomy
Dye et al., Am J Sports Med, 1998
Anatomy • Patella – posterior surface covered by arEcular carElage – divided by verEcal ridge (30% also have a 2nd verEcal ridge medially) • medial, lateral, and odd facets
Biomechanics • Patella – funcEon – anatomic eccentric pulley – ability of patella to perform funcEon depends upon its mobility – movements?
4
11/18/13
Biomechanics • Patellofemoral Joint – 0° = no patellar contact with the trochlea – 15 ° to 20 ° = iniEal contact w/ trochlea – contact area (patellar surface and trochlear surface) ↑s from 0 ° to 60 ° – *contact area remains constant from 60° to 90° – contact area ↓s a]er 90°
Biomechanics
Biomechanics
5
11/18/13
Biomechanics • Patellofemoral Joint ReacEon Forces – Stress = F/A • snowshoe ex.
– very limle PF compression in full extension – closed chain – PFJ stress ↑s from 0° to 90° • ↓s from 90° to 120°
Stress
0°
120° Flexion Angle
Biomechanics • Patellofemoral Joint ReacEon Forces – open chain – PFJ stress ↑s from 90° to Stress 0° • ↑ in contact stress unEl ~ 25°
0°
120° Flexion Angle
Biomechanics • Females with PFPS demonstrate > medial femur rotaEon during SL squat b/n 45° and 0° than controls – altered PF kinemaEcs related to excessive femoral rotaEon rather than lateral patella rotaEon • Souza et al., JOSPT, 2010
6
11/18/13
Biomechanics • Anterior Interval – fat pad displaces posteriorly during flexion • pressure from patellar tendon
– fat pad displaces anteriorly during extension Steadman et al., AJSM, 2008
Biomechanics • Q-‐Angle – IntersecEon of the line of quadriceps pull and the line from the middle of the patella to the center of the Ebial tuberosity – Male and female differences
Biomechanics
7
11/18/13
Biomechanics • Femoral adducEon • Increased hip adductor moment • Knee valgus – hip abductor strength a predictor of frontal plane moEon (Claiborne et al., 2006)
Biomechanics • Frontal plane projecEon angle (knee valgus) during SL squat (45°) – knee angle closely associated with Hip ER strength (Willson et al., Med Sci Sports Exerc, 2006)
Biomechanics
8
11/18/13
Biomechanics “Top-Down Approach”
• Transverse Plane – Femoral IR → Ebial IR → rotaEon of the talus → calcaneal eversion – At the knee • squinEng patella or frog-‐eyed patella • femoral anteversion and retroversion *
Biomechanics • In weight-‐bearing condiEons, the femur rotates underneath the patella – moving toward terminal knee extension (18° to 0°)
Powers et. al., 2003
Biomechanics • Femoral rotaEon and movement toward the midline of the body can influence the knee – patellar alignment • patella tethered w/in the quadriceps tendon and therefore, does not have to follow the femur • PF dysfuncEon may be due to the femur rotaEng under the patella (Powers, 2003)
9
11/18/13
PresentaEon • Patellofemoral Pain (tradiEonal anterior knee pain) • Patellar instability • Fat pad syndrome • Plica syndrome
PresentaEon PFPS • SubjecEve Exam – – past history – MOI – Anterior Knee Pain Scale (AKPS) • correlated with PFP
– anterior/retropatellar knee pain • with prolonged sicng, stairs (down worse than up) • squacng, kneeling, hopping, running • symptoms not related to trauma
PresentaEon PFPS • ObjecEve Exam – – pain on palpaEon – decreased flexibility hamstrings, hip flexors – decreased strength • hip abducEon, extension, external rotaEon, knee extension – decreased peak eccentric hip abducEon torque – decreased avg. concentric and eccentric hip ER torque » Boling et al., J Athl Train, 2009
10
11/18/13
PresentaEon PFPS • ObjecEve Exam – Patellofemoral Pain • + Eccentric Step Test • Sn. 42, Sp. 82
PresentaEon PFPS • Decreased hip strength is related to increased frontal plane moEon at the knee and trunk in paEents with PFPS – 15 paEents w/ PFPS performed jump landing – eccentric hip strength of hip abd and ER
Boling and Padua, Int J Sports Phys Ther., 2013
PresentaEon PFPS • Runners with PFPS demonstrate weaker hip abd. strength than controls • Significant correlaEon b/n peak hip adducEon angle and hip abductor strength at end of run • No associaEon b/n arch height and peak knee adducEon angle – Dierks et al., J Orthop Sports Phys. Ther, 2008
11
11/18/13
PresentaEon
Patellar Instability Predisposing Factors for Patellar Instability (dislocation/subluxation)
• Other Factors
• Anatomical
– Hx. TraumaEc dislocaEon
– Patella dysplasia – Shallow trochlear groove (DysplasEc femoral trochlea) – Femoral anteversion – Genu Valgum – Patella alta – Large Q angle – Pes Planus – Generalized ligamentous laxity – Weak VMO – Tight lateral so] Essues (ITB/lateral reEnaculum)
PresentaEon
Patellar Instability • Diagnosing Patellar Instability – SubjecEve ExaminaEon • Thorough history is a must! • Does the paEent have predisposing anatomic factors? • DifferenEate giving way (instability or muscle inhibiEon) from subluxaEon of patella – “Feels like something jumps out of place or gets hung up”
• How many Emes have they dislocated or subluxed? – Frequent vs. one Eme acute traumaEc?
PresentaEon
Patellar Instability • Diagnosing Patellar Instability – ObjecEve ExaminaEon • Tenderness to palpaEon of medial patellar reEnaculum, proximal or distal patellar poles • Medial and Lateral patellar joint play
PATELLAR TILT LINES
– 50% or greater patellar width over LFC = patellar instability
+ Patellar Apprehension Test (Fairbank’s sign)
• Sn. 32, Sp. 86
12
11/18/13
PresentaEon
Patellar Instability • Diagnosing Patellar Instability – Surgical ConsideraEons • MPFL provides 50% -‐ 60% so] Essue resistance to patellar translaEon LeGrande, Sports Med Arthroc Rev, 2007
PresentaEon
Patellar Instability • Diagnosing Patellar Instability – Surgical ConsideraEons • reconstrucEon of the MPFL w/ semitendinosus, gracilis, quads tendon, syntheEc gra]s LeGrande, Sports Med Arthroc Rev, 2007
PresentaEon
Patellar Instability
• Diagnosing Patellar Instability – Surgical ConsideraEons
• competent gra] will withstand loads assoc. with normal joint moEon • moEon loss related to dissecEon and MPFL gra] locaEon Fithian, Clinics in Sports Medicine, 2010
13
11/18/13
PresentaEon
Patellar Instability • Acute and Post-‐op Patellar DislocaEon – Post-‐op – limitaEon of knee ROM up to 4 weeks – AssisEve devices as needed • Tru-‐Pull brace
– ModaliEes as indicated – PreventaEve bracing or taping – OrthoEcs (decrease foot over-‐pronaEon, reduce Q-‐angle, leg length discrepancy)
PresentaEon
Fat Pad Syndrome • SubjecEve – entrapment of fat pad 2° poor l/e kinemaEcs – anterior interval scarring • post-‐op or trauma-‐related
– significant pain generator • substance-‐P nerve fibers
www.bonesmart.org
PresentaEon
Fat Pad Syndrome
Steadman et al., Am J Sports Med., 2008
14
11/18/13
PresentaEon Plica Syndrome • Background – incidence of 18.5 to 80% – infrapatellar plica most common – incidence high in males and females (20s and 30s) • may be present in children or adolescents
– elicited w/ strenous physical acEvity or increase in acEvity
Schindler, Knee Sports Traumatol Arthrosc., 2013
PresentaEon Plica Syndrome • SubjecEve – non-‐specific anterior or anteromedial knee pain • popping or snapping w/ flexion
– intermiment, dull aching pain • aggravated by patellofemoral loading acEviEes
– pliability of synovial Essue is altered • inflammatory process -‐ synoviEs
Schindler, Knee Sports Traumatol Arthrosc., 2013
PresentaEon Plica Syndrome • ObjecEve – increased TTP medial jt line or proximal at anteromedial capsule – mild to moderate quads atrophy – altered l/e kinemaEcs • decreased hip and core strength
– pliability of synovial Essue is altered – medial patellar plica test • sensiEvity – 89.5% • specificity – 88.7% – Kim et al., Arthroscopy, 2007
Schindler, Knee Sports Traumatol Arthrosc., 2013
15
11/18/13
PresentaEon Plica Syndrome • Treatment – surgical resecEon or excision – correcEon of altered l/e kinemaEcs – hip and core strength
Schindler, Knee Sports Traumatol Arthrosc., 2013
FuncEonal Assessment
FuncEonal Assessment • Overhead Squat – breakout: • hands behind head • manually assisted
• Single Leg Squat • Y Balance Test™ • RDL
• SI joint assessment • Patellar Mobility – fat pad
• Fibular Head Mobility – anterior – posterior
– DL – SL
16
11/18/13
FuncEonal Assessment • Overhead Squat – breakout: • hands behind head • manually assisted
FuncEonal Assessment • Single Leg Squat – common faults/ deviaEons • • • • •
knee valgus knees forward of toes contralateral pelvic drop forward or lateral trunk heels raised/excessive ST pronaEon
FuncEonal Assessment • SL squat has the highest muscle acEvaEon for gluteus medius and maximus – compared to FSU, DLS – Gmed = 65.6 – Gmax = 47.4 • decreased acEvity with valgus load
• Lubahn et al., IJSPT, 2011
17
11/18/13
FuncEonal Assessment • Y Balance Test™ – components • anterior • posteromedial • posterolateral
– comparison b/n involved and un-‐involved
FuncEonal Assessment • Y-‐Balance Test™ – reliable test (.82 to .87) – anterior reach distance of > 4cm = 2.5x more likely to injure l/e
Plisky et al., JOSPT, 2006
FuncEonal Assessment • Y-‐Balance Test™ – normalized composite reach distance ≤ 94% associated with l/e injury Plisky et al., JOSPT, 2006
18
11/18/13
FuncEonal Assessment • RDL – DL S • assess eccentric hamstring funcEon and core NM control • *compensaEons at hip and spine
FuncEonal Assessment • SI joint assessment – pelvic asymmetry • muscle inhibiEon • increased PF compressive forces
– SI joint dysfuncEon increased tension across fat pad via ITB • Fairclough et al., Journal of Science and Medicine in Sport, 2007
FuncEonal Assessment • Patellar Mobility – patella – fat pad
19
11/18/13
FuncEonal Assessment • Fibular Head Mobility – anterior • decreased flexion
Anterior fibular glide
FuncEonal Assessment • Fibular Head Mobility – posterior • decreased knee extension
Posterior fibular glide
Treatment
20
11/18/13
Treatment • ObjecEves: – Restore ROM – Re-‐establish glute, core, and quad funcEon – Progress SL funcEon – Return to funcEonal acEviEes
Treatment • ObjecEves: – Restore ROM • • • •
patella fat pad Ebiofemoral quads/hip flexors muscle length
Inferior patellar glide
Treatment • ObjecEves: – Restore ROM • fat pad – limit flexion/extension – quadriceps inhibiEon
Inferior pole Epping
21
11/18/13
Treatment • Patellar and Fat Pad MobilizaEons – to avoid joint compression • Ahmad et al., Am J Sports Med., 2008
Treatment • Quads/hip flexors muscle length tension relaEonship
Treatment • ObjecEves: – Re-‐establish gluteal, core, and quad funcEon • top-‐down control
22
11/18/13
Treatment • Proximal exercises are effecEve for PFPs – decrease pain – improve funcEon – Peters JSJ, Tyson NL. Int J Sports Phys Ther. 2013
– exercises may improve and proximal and distal alignment – Meira EP, Brummit J. Sports Health, 2011; Lee SP, et al. Gait Posture, 2012
Treatment
Importance of Core Stability
• An unstable COM secondary to hip or core weakness – can place additional stress on the tissues to counteract the perturbations Powers, CSM, 2005 Garrison et al., J Sport Rehab, 2005
Treatment
RelaEonship between the Hip and Knee Hip ER strength a risk factor for l/e injury (Leetun et al., 2004 Females w/ PFP and excessive hip and knee movement (Mascal et al., 2004)
23
11/18/13
Treatment Establish hip/core control
Boren et al., Int J Sports Phys Ther. 2011
Ekstrom RA, et al., J Orthop Sports Phys Ther. 2007 DiStefano et al., J Orthop Sports Phys Ther., 2009
Treatment • Quadriceps acEvaEon – RestoraEon of knee extension: • > quadriceps recruitment – may have full PROM, but limited in terminal strength
• preparaEon for single leg tolerance
Treatment • Evidence-‐based recommendaEon for exercise in paEents w/ PFPS – daily exercise of 2-‐4 sets of 10 or more – 6 or more weeks – Harvie D, et al. J MulFdiscip Healthc, 2011.
24
11/18/13
Treatment • ObjecEves: – Progress SL funcEon • NM control of SL – demonstrate good l/e kinemaEcs – effecEvely reduce force, stabilize, and produce force – mulEplanar control
Treatment • Single leg funcEon is important in ADLs – requires: • quadriceps strength • core/hip/pelvic stability • confidence
– precursor to return to funcEonal acEviEes • cycle on and off of SL
Return to FuncEonal AcEviEes • ObjecEves: – Return to funcEonal acEviEes • • • •
re-‐assess Y Balance Test™ Overhead and SL squat Eccentric Step-‐down Test Anterior Knee Pain Scale
25
11/18/13
Return to FuncEonal AcEviEes • Single leg squat – NM control – Strength – Endurance • > 1 min with resistance with good control to begin landing/jogging progression
Return to FuncEonal AcEviEes • Demonstrate good control in: • Stairs • ascending/descending
• Squatting • DL and SL
• Progress to: hmp://bjsportmed.com/content/41/11/723/ F1.large.jpg
• Jogging/Running • Athletic Activities
Return to FuncEonal AcEviEes
26
11/18/13
Return to FuncEonal AcEviEes • Restore ROM – patella, fat pad, Ebiofemoral, quads/hip flexors – consider PFJ rxn forces
• Re-‐establish glute, core, and quad funcEon – strength, NM control, and muscle endurance
• Progress SL funcEon – within envelope of patellofemoral funcEon
References • Arendt E. Knee injury pamerns among men and women in collegiate basketball and soccer players -‐ NCAA data and review of literature. Am J Sports Med. 1995;23(6):294-‐701. • Bjordal JM. Epidemiology of anterior cruciate ligament injuries in soccer. Am J Sports Med. 1997;25(3):341-‐345. • Olestad BE, Holm I, Aune AK, Gunderson R, Myklebust G, EngebretsenL, Fosdahl MA, Risberg MA. Knee funcEon and prevalence of knee osteoarthriEs a]er anterior cruciate ligament reconstrucEon: a prospecEve study with 10 to 15 years of follow-‐up. Am J Sports Med. 2010;38(11):2201-‐2210. • Gwinn DE, Wilckens JH, McDevim ER, Ross G, Kao TC. The relaEve incidence of anterior cruciate ligament injury in men and women at the United States Naval Academy. Am J Sports Med. 2000;28(1):98-‐102.
References • Koga H, Nakamae A, Shima Y, et al. Mechanisms for noncontact anterior cruciate ligament injuries. Am J Sports Med. 2010;38(11):2218-‐2225. • Dye SF, Vaupel GL, Dye CC. Conscious neurosensory mapping of the internal structures of the human knee without intra-‐arEcular anesthesia. Am J Sports Med. 1998;26:773-‐777. • Paterno MV, Rauh MJ, Schmim LC, Ford KR, Hewem TE. Incidence of contralateral and ipsilateral anterior cruciate ligament (ACL) injury a]er primary ACL reconstrucEon and return to sport. Clin J Sport Med. 2012;22 (2):116-‐121. • Engebretsen L, Arendt E, Frims HM.Osteochondral lesions and cruciate ligament injuries. MRI in 18 knees. Acta Orthop Scand. 1993;64:434–436. • Steadman JR, Dragoo JL, Hines SL, Briggs KK. Arthroscopic release for symptomaEc scarring of the anterior interval of the knee. Am J Sports Med. Sep 2008;36(9):1763-‐1769.
27
11/18/13
References • Barrack RL, Lund PJ, Munn BG, Wink C, Happel L. Evidence of reinnervaEon of free patellar tendon autogra] used for anterior cruciate ligament reconstrucEon. Am J Sports Med. 1997;25(2):196-‐202. • Marumo K, Saito M, Yamagishi T, Fujii K. The "ligamenEzaEon" process in human anterior cruciate ligament reconstrucEon with autogenous patellar and hamstring tendons. Am J Sports Med. 2005;33(8):1166-‐1173. • Palmieri-‐Smith RM, Thomas AC, Wojtys EM. Maximizing quadriceps strength a]er ACL reconstrucEon. Clin Sports Med. 2008;27(3):405-‐424. • Snyder-‐Mackler L, De Luca PF, Williams PR, Eastlack ME, Bartolozzi AR. Reflex inhibiEon of the quadriceps femoris muscle a]er injury or reconstrucEon of the anterior cruciate ligament J Bone Joint Surg Am. 1994;76(4):555-‐560.
References • Snyder-‐Mackler L, Delimo A, Bailey SL, Stralka SW. Strength of the quadriceps femoris muscle and funcEonal recovery a]er reconstrucEon of the anterior cruciate ligament. A prospecEve, randomized clinical trial of electrical sEmulaEon. J Bone Joint Surg Am. 1995;77(8):1166-‐1173. • Distefano LJ, Blackburn JT, Marshall SW, Padua DA. Gluteal muscle acEvaEon during common therapeuEc exercises. J Orthop Sports Phys Ther. 2009;39(7):532-‐540. • Ekstrom RA, Donatelli RA, Carp KC. Electromyographic analysis of core trunk, hip, and thigh muscles during 9 rehabilitaEon exercises. J Orthop Sports Phys Ther. 2007;37(12):754-‐762. • Plisky PJ, Rauh MJ, Kaminski TW, Underwood FB. Star Excursion Balance Test as a predictor of lower extremity injury in high school basketball players. J Orthop Sports Phys Ther. 2006;36(12):911-‐919.
References • Souza RB, Powers CM. Differences in hip kinemaEcs, muscle strength, and muscle acEvaEon between subjects with and without patellofemoral pain. J Orthop Sports Phys Ther. 2009;39(1):12-‐19. • Norris B, Trudelle-‐Jackson E. Hip -‐ and thigh-‐muscle acEvaEon during the Star Excursion Balance Test. J Sport Rehabil. 2011;20(4):428-‐441. • Vezina MJ, Hubley-‐Kozey CL. Muscle acEvaEon in therapeuEc exercises to improve trunk stability. Arch Phys Med Rehab. 2000;81(10):1370-‐1379. • Fairclough J, Hayashi K, Toumi H, et al. Is ilioEbial band syndrome really a fricEon syndrome. J Science and Med Sport. 2007;10:74-‐76. • Von Porat A, Roos EM, Roos H. High prevalence of osteoarthriEs 14 years a]er anterior cruciate ligament tear in male soccer players: a study of radiographic and paEent relevant outcomes. Ann Rheum Dis. 2004;63:269-‐273. • Ekdahl M, Wang JHC, Ronga M, Fu FH. Gra] healing in anterior cruciate ligament reconstrucEon. Knee Surg Sports Traumatol Arthrosc. 2008;16:935-‐947.
28
11/18/13
References • Messina DF, Farney WC, DeLee JC. The incidence of injury in Texas High School basketball. Am J Sports Med. 1999;27(3):294-‐299. • Duthon VB, Barea C, Abrassart S, Fasel JH, Fritschy D, Menetrey J. Anatomy of the anterior cruciate ligament. Knee Surg Sports Traumatol Arthrosc. 2006;14(3):204-‐213. • Boling M, Padua D. RelaEonship between hip strength and trunk, hip, and knee kinemaEcs during a jump-‐landing task in individuals with patellofemoral pain. Int J Sports Phys Ther., 2013; 8(5):661-‐ 669.
29
The Patellofemoral Joint: Func%onal Assessment and Treatment Craig Garrison, PhD, PT, ATC, SCS Ben Hogan Sports Medicine Fort Worth, TX
Agenda • • • •
Epidemiology Mechanism of Injury Anatomy and Biomechanics PresentaEon • Anterior Knee Pain, Fat Pad Syndrome, Patellar Instability, Plica Syndrome
• FuncEonal Assessment • Treatment • Return to FuncEonal AcEviEes
Epidemiology • Incidence of PFPS in sports med clinics 25% • 9% in students (17-‐21 y/o) in PE • 43% in army recruits during 6 wks of training – Callaghan and Selfe, Phys Ther Sport, 2007 – Andersen and Herrington, Clin Biomech, 2003 – Witrouv E et al., Am J Sports Med., 2000 – Thijs Y, et al., Clin J Sport Med., 2007
1
11/18/13
Epidemiology • 60% of parEcipants w/ PFPS in ex program – symptoms a]er 1 yr • Clark DI, et al., Ann rheum Dis., 2000
• PFPS sx present 5 yrs a]er dx • Blond L, et al., Acta Orthop Belg., 1998 • Kannus P, et al., J Bone Joint Surg Am., 1999
Epidemiology • 1525 parEcipants from USNA – followed for PFPS -‐ 2.5 yrs – incidence rate 22/1000 person-‐years – females 2.23x more likely to develop PFPS than males • Boling M, et al. Scan J Med Sci Sports., 2010
Mechanism of Injury • Insidious onset – Anterior Knee Pain – sicng – stair climbing/descending – running – squacng
www.moveforwardPT.com
2
11/18/13
Mechanism of Injury • Repeated stresses across joint – valgus and IR – incr. ant. Ebial translaEon (knees over toes) • patellar instability and plica Syndrome
Anatomy • Patellofemoral Joint
Anatomy • Envelope of FuncEon – Fat pad – Joint capsule • peripatellar synovial lining
– Osseous metabolic acEvity – Plicae
3
11/18/13
Anatomy
Dye et al., Am J Sports Med, 1998
Anatomy • Patella – posterior surface covered by arEcular carElage – divided by verEcal ridge (30% also have a 2nd verEcal ridge medially) • medial, lateral, and odd facets
Biomechanics • Patella – funcEon – anatomic eccentric pulley – ability of patella to perform funcEon depends upon its mobility – movements?
4
11/18/13
Biomechanics • Patellofemoral Joint – 0° = no patellar contact with the trochlea – 15 ° to 20 ° = iniEal contact w/ trochlea – contact area (patellar surface and trochlear surface) ↑s from 0 ° to 60 ° – *contact area remains constant from 60° to 90° – contact area ↓s a]er 90°
Biomechanics
Biomechanics
5
11/18/13
Biomechanics • Patellofemoral Joint ReacEon Forces – Stress = F/A • snowshoe ex.
– very limle PF compression in full extension – closed chain – PFJ stress ↑s from 0° to 90° • ↓s from 90° to 120°
Stress
0°
120° Flexion Angle
Biomechanics • Patellofemoral Joint ReacEon Forces – open chain – PFJ stress ↑s from 90° to Stress 0° • ↑ in contact stress unEl ~ 25°
0°
120° Flexion Angle
Biomechanics • Females with PFPS demonstrate > medial femur rotaEon during SL squat b/n 45° and 0° than controls – altered PF kinemaEcs related to excessive femoral rotaEon rather than lateral patella rotaEon • Souza et al., JOSPT, 2010
6
11/18/13
Biomechanics • Anterior Interval – fat pad displaces posteriorly during flexion • pressure from patellar tendon
– fat pad displaces anteriorly during extension Steadman et al., AJSM, 2008
Biomechanics • Q-‐Angle – IntersecEon of the line of quadriceps pull and the line from the middle of the patella to the center of the Ebial tuberosity – Male and female differences
Biomechanics
7
11/18/13
Biomechanics • Femoral adducEon • Increased hip adductor moment • Knee valgus – hip abductor strength a predictor of frontal plane moEon (Claiborne et al., 2006)
Biomechanics • Frontal plane projecEon angle (knee valgus) during SL squat (45°) – knee angle closely associated with Hip ER strength (Willson et al., Med Sci Sports Exerc, 2006)
Biomechanics
8
11/18/13
Biomechanics “Top-Down Approach”
• Transverse Plane – Femoral IR → Ebial IR → rotaEon of the talus → calcaneal eversion – At the knee • squinEng patella or frog-‐eyed patella • femoral anteversion and retroversion *
Biomechanics • In weight-‐bearing condiEons, the femur rotates underneath the patella – moving toward terminal knee extension (18° to 0°)
Powers et. al., 2003
Biomechanics • Femoral rotaEon and movement toward the midline of the body can influence the knee – patellar alignment • patella tethered w/in the quadriceps tendon and therefore, does not have to follow the femur • PF dysfuncEon may be due to the femur rotaEng under the patella (Powers, 2003)
9
11/18/13
PresentaEon • Patellofemoral Pain (tradiEonal anterior knee pain) • Patellar instability • Fat pad syndrome • Plica syndrome
PresentaEon PFPS • SubjecEve Exam – – past history – MOI – Anterior Knee Pain Scale (AKPS) • correlated with PFP
– anterior/retropatellar knee pain • with prolonged sicng, stairs (down worse than up) • squacng, kneeling, hopping, running • symptoms not related to trauma
PresentaEon PFPS • ObjecEve Exam – – pain on palpaEon – decreased flexibility hamstrings, hip flexors – decreased strength • hip abducEon, extension, external rotaEon, knee extension – decreased peak eccentric hip abducEon torque – decreased avg. concentric and eccentric hip ER torque » Boling et al., J Athl Train, 2009
10
11/18/13
PresentaEon PFPS • ObjecEve Exam – Patellofemoral Pain • + Eccentric Step Test • Sn. 42, Sp. 82
PresentaEon PFPS • Decreased hip strength is related to increased frontal plane moEon at the knee and trunk in paEents with PFPS – 15 paEents w/ PFPS performed jump landing – eccentric hip strength of hip abd and ER
Boling and Padua, Int J Sports Phys Ther., 2013
PresentaEon PFPS • Runners with PFPS demonstrate weaker hip abd. strength than controls • Significant correlaEon b/n peak hip adducEon angle and hip abductor strength at end of run • No associaEon b/n arch height and peak knee adducEon angle – Dierks et al., J Orthop Sports Phys. Ther, 2008
11
11/18/13
PresentaEon
Patellar Instability Predisposing Factors for Patellar Instability (dislocation/subluxation)
• Other Factors
• Anatomical
– Hx. TraumaEc dislocaEon
– Patella dysplasia – Shallow trochlear groove (DysplasEc femoral trochlea) – Femoral anteversion – Genu Valgum – Patella alta – Large Q angle – Pes Planus – Generalized ligamentous laxity – Weak VMO – Tight lateral so] Essues (ITB/lateral reEnaculum)
PresentaEon
Patellar Instability • Diagnosing Patellar Instability – SubjecEve ExaminaEon • Thorough history is a must! • Does the paEent have predisposing anatomic factors? • DifferenEate giving way (instability or muscle inhibiEon) from subluxaEon of patella – “Feels like something jumps out of place or gets hung up”
• How many Emes have they dislocated or subluxed? – Frequent vs. one Eme acute traumaEc?
PresentaEon
Patellar Instability • Diagnosing Patellar Instability – ObjecEve ExaminaEon • Tenderness to palpaEon of medial patellar reEnaculum, proximal or distal patellar poles • Medial and Lateral patellar joint play
PATELLAR TILT LINES
– 50% or greater patellar width over LFC = patellar instability
+ Patellar Apprehension Test (Fairbank’s sign)
• Sn. 32, Sp. 86
12
11/18/13
PresentaEon
Patellar Instability • Diagnosing Patellar Instability – Surgical ConsideraEons • MPFL provides 50% -‐ 60% so] Essue resistance to patellar translaEon LeGrande, Sports Med Arthroc Rev, 2007
PresentaEon
Patellar Instability • Diagnosing Patellar Instability – Surgical ConsideraEons • reconstrucEon of the MPFL w/ semitendinosus, gracilis, quads tendon, syntheEc gra]s LeGrande, Sports Med Arthroc Rev, 2007
PresentaEon
Patellar Instability
• Diagnosing Patellar Instability – Surgical ConsideraEons
• competent gra] will withstand loads assoc. with normal joint moEon • moEon loss related to dissecEon and MPFL gra] locaEon Fithian, Clinics in Sports Medicine, 2010
13
11/18/13
PresentaEon
Patellar Instability • Acute and Post-‐op Patellar DislocaEon – Post-‐op – limitaEon of knee ROM up to 4 weeks – AssisEve devices as needed • Tru-‐Pull brace
– ModaliEes as indicated – PreventaEve bracing or taping – OrthoEcs (decrease foot over-‐pronaEon, reduce Q-‐angle, leg length discrepancy)
PresentaEon
Fat Pad Syndrome • SubjecEve – entrapment of fat pad 2° poor l/e kinemaEcs – anterior interval scarring • post-‐op or trauma-‐related
– significant pain generator • substance-‐P nerve fibers
www.bonesmart.org
PresentaEon
Fat Pad Syndrome
Steadman et al., Am J Sports Med., 2008
14
11/18/13
PresentaEon Plica Syndrome • Background – incidence of 18.5 to 80% – infrapatellar plica most common – incidence high in males and females (20s and 30s) • may be present in children or adolescents
– elicited w/ strenous physical acEvity or increase in acEvity
Schindler, Knee Sports Traumatol Arthrosc., 2013
PresentaEon Plica Syndrome • SubjecEve – non-‐specific anterior or anteromedial knee pain • popping or snapping w/ flexion
– intermiment, dull aching pain • aggravated by patellofemoral loading acEviEes
– pliability of synovial Essue is altered • inflammatory process -‐ synoviEs
Schindler, Knee Sports Traumatol Arthrosc., 2013
PresentaEon Plica Syndrome • ObjecEve – increased TTP medial jt line or proximal at anteromedial capsule – mild to moderate quads atrophy – altered l/e kinemaEcs • decreased hip and core strength
– pliability of synovial Essue is altered – medial patellar plica test • sensiEvity – 89.5% • specificity – 88.7% – Kim et al., Arthroscopy, 2007
Schindler, Knee Sports Traumatol Arthrosc., 2013
15
11/18/13
PresentaEon Plica Syndrome • Treatment – surgical resecEon or excision – correcEon of altered l/e kinemaEcs – hip and core strength
Schindler, Knee Sports Traumatol Arthrosc., 2013
FuncEonal Assessment
FuncEonal Assessment • Overhead Squat – breakout: • hands behind head • manually assisted
• Single Leg Squat • Y Balance Test™ • RDL
• SI joint assessment • Patellar Mobility – fat pad
• Fibular Head Mobility – anterior – posterior
– DL – SL
16
11/18/13
FuncEonal Assessment • Overhead Squat – breakout: • hands behind head • manually assisted
FuncEonal Assessment • Single Leg Squat – common faults/ deviaEons • • • • •
knee valgus knees forward of toes contralateral pelvic drop forward or lateral trunk heels raised/excessive ST pronaEon
FuncEonal Assessment • SL squat has the highest muscle acEvaEon for gluteus medius and maximus – compared to FSU, DLS – Gmed = 65.6 – Gmax = 47.4 • decreased acEvity with valgus load
• Lubahn et al., IJSPT, 2011
17
11/18/13
FuncEonal Assessment • Y Balance Test™ – components • anterior • posteromedial • posterolateral
– comparison b/n involved and un-‐involved
FuncEonal Assessment • Y-‐Balance Test™ – reliable test (.82 to .87) – anterior reach distance of > 4cm = 2.5x more likely to injure l/e
Plisky et al., JOSPT, 2006
FuncEonal Assessment • Y-‐Balance Test™ – normalized composite reach distance ≤ 94% associated with l/e injury Plisky et al., JOSPT, 2006
18
11/18/13
FuncEonal Assessment • RDL – DL S • assess eccentric hamstring funcEon and core NM control • *compensaEons at hip and spine
FuncEonal Assessment • SI joint assessment – pelvic asymmetry • muscle inhibiEon • increased PF compressive forces
– SI joint dysfuncEon increased tension across fat pad via ITB • Fairclough et al., Journal of Science and Medicine in Sport, 2007
FuncEonal Assessment • Patellar Mobility – patella – fat pad
19
11/18/13
FuncEonal Assessment • Fibular Head Mobility – anterior • decreased flexion
Anterior fibular glide
FuncEonal Assessment • Fibular Head Mobility – posterior • decreased knee extension
Posterior fibular glide
Treatment
20
11/18/13
Treatment • ObjecEves: – Restore ROM – Re-‐establish glute, core, and quad funcEon – Progress SL funcEon – Return to funcEonal acEviEes
Treatment • ObjecEves: – Restore ROM • • • •
patella fat pad Ebiofemoral quads/hip flexors muscle length
Inferior patellar glide
Treatment • ObjecEves: – Restore ROM • fat pad – limit flexion/extension – quadriceps inhibiEon
Inferior pole Epping
21
11/18/13
Treatment • Patellar and Fat Pad MobilizaEons – to avoid joint compression • Ahmad et al., Am J Sports Med., 2008
Treatment • Quads/hip flexors muscle length tension relaEonship
Treatment • ObjecEves: – Re-‐establish gluteal, core, and quad funcEon • top-‐down control
22
11/18/13
Treatment • Proximal exercises are effecEve for PFPs – decrease pain – improve funcEon – Peters JSJ, Tyson NL. Int J Sports Phys Ther. 2013
– exercises may improve and proximal and distal alignment – Meira EP, Brummit J. Sports Health, 2011; Lee SP, et al. Gait Posture, 2012
Treatment
Importance of Core Stability
• An unstable COM secondary to hip or core weakness – can place additional stress on the tissues to counteract the perturbations Powers, CSM, 2005 Garrison et al., J Sport Rehab, 2005
Treatment
RelaEonship between the Hip and Knee Hip ER strength a risk factor for l/e injury (Leetun et al., 2004 Females w/ PFP and excessive hip and knee movement (Mascal et al., 2004)
23
11/18/13
Treatment Establish hip/core control
Boren et al., Int J Sports Phys Ther. 2011
Ekstrom RA, et al., J Orthop Sports Phys Ther. 2007 DiStefano et al., J Orthop Sports Phys Ther., 2009
Treatment • Quadriceps acEvaEon – RestoraEon of knee extension: • > quadriceps recruitment – may have full PROM, but limited in terminal strength
• preparaEon for single leg tolerance
Treatment • Evidence-‐based recommendaEon for exercise in paEents w/ PFPS – daily exercise of 2-‐4 sets of 10 or more – 6 or more weeks – Harvie D, et al. J MulFdiscip Healthc, 2011.
24
11/18/13
Treatment • ObjecEves: – Progress SL funcEon • NM control of SL – demonstrate good l/e kinemaEcs – effecEvely reduce force, stabilize, and produce force – mulEplanar control
Treatment • Single leg funcEon is important in ADLs – requires: • quadriceps strength • core/hip/pelvic stability • confidence
– precursor to return to funcEonal acEviEes • cycle on and off of SL
Return to FuncEonal AcEviEes • ObjecEves: – Return to funcEonal acEviEes • • • •
re-‐assess Y Balance Test™ Overhead and SL squat Eccentric Step-‐down Test Anterior Knee Pain Scale
25
11/18/13
Return to FuncEonal AcEviEes • Single leg squat – NM control – Strength – Endurance • > 1 min with resistance with good control to begin landing/jogging progression
Return to FuncEonal AcEviEes • Demonstrate good control in: • Stairs • ascending/descending
• Squatting • DL and SL
• Progress to: hmp://bjsportmed.com/content/41/11/723/ F1.large.jpg
• Jogging/Running • Athletic Activities
Return to FuncEonal AcEviEes
26
11/18/13
Return to FuncEonal AcEviEes • Restore ROM – patella, fat pad, Ebiofemoral, quads/hip flexors – consider PFJ rxn forces
• Re-‐establish glute, core, and quad funcEon – strength, NM control, and muscle endurance
• Progress SL funcEon – within envelope of patellofemoral funcEon
References • Arendt E. Knee injury pamerns among men and women in collegiate basketball and soccer players -‐ NCAA data and review of literature. Am J Sports Med. 1995;23(6):294-‐701. • Bjordal JM. Epidemiology of anterior cruciate ligament injuries in soccer. Am J Sports Med. 1997;25(3):341-‐345. • Olestad BE, Holm I, Aune AK, Gunderson R, Myklebust G, EngebretsenL, Fosdahl MA, Risberg MA. Knee funcEon and prevalence of knee osteoarthriEs a]er anterior cruciate ligament reconstrucEon: a prospecEve study with 10 to 15 years of follow-‐up. Am J Sports Med. 2010;38(11):2201-‐2210. • Gwinn DE, Wilckens JH, McDevim ER, Ross G, Kao TC. The relaEve incidence of anterior cruciate ligament injury in men and women at the United States Naval Academy. Am J Sports Med. 2000;28(1):98-‐102.
References • Koga H, Nakamae A, Shima Y, et al. Mechanisms for noncontact anterior cruciate ligament injuries. Am J Sports Med. 2010;38(11):2218-‐2225. • Dye SF, Vaupel GL, Dye CC. Conscious neurosensory mapping of the internal structures of the human knee without intra-‐arEcular anesthesia. Am J Sports Med. 1998;26:773-‐777. • Paterno MV, Rauh MJ, Schmim LC, Ford KR, Hewem TE. Incidence of contralateral and ipsilateral anterior cruciate ligament (ACL) injury a]er primary ACL reconstrucEon and return to sport. Clin J Sport Med. 2012;22 (2):116-‐121. • Engebretsen L, Arendt E, Frims HM.Osteochondral lesions and cruciate ligament injuries. MRI in 18 knees. Acta Orthop Scand. 1993;64:434–436. • Steadman JR, Dragoo JL, Hines SL, Briggs KK. Arthroscopic release for symptomaEc scarring of the anterior interval of the knee. Am J Sports Med. Sep 2008;36(9):1763-‐1769.
27
11/18/13
References • Barrack RL, Lund PJ, Munn BG, Wink C, Happel L. Evidence of reinnervaEon of free patellar tendon autogra] used for anterior cruciate ligament reconstrucEon. Am J Sports Med. 1997;25(2):196-‐202. • Marumo K, Saito M, Yamagishi T, Fujii K. The "ligamenEzaEon" process in human anterior cruciate ligament reconstrucEon with autogenous patellar and hamstring tendons. Am J Sports Med. 2005;33(8):1166-‐1173. • Palmieri-‐Smith RM, Thomas AC, Wojtys EM. Maximizing quadriceps strength a]er ACL reconstrucEon. Clin Sports Med. 2008;27(3):405-‐424. • Snyder-‐Mackler L, De Luca PF, Williams PR, Eastlack ME, Bartolozzi AR. Reflex inhibiEon of the quadriceps femoris muscle a]er injury or reconstrucEon of the anterior cruciate ligament J Bone Joint Surg Am. 1994;76(4):555-‐560.
References • Snyder-‐Mackler L, Delimo A, Bailey SL, Stralka SW. Strength of the quadriceps femoris muscle and funcEonal recovery a]er reconstrucEon of the anterior cruciate ligament. A prospecEve, randomized clinical trial of electrical sEmulaEon. J Bone Joint Surg Am. 1995;77(8):1166-‐1173. • Distefano LJ, Blackburn JT, Marshall SW, Padua DA. Gluteal muscle acEvaEon during common therapeuEc exercises. J Orthop Sports Phys Ther. 2009;39(7):532-‐540. • Ekstrom RA, Donatelli RA, Carp KC. Electromyographic analysis of core trunk, hip, and thigh muscles during 9 rehabilitaEon exercises. J Orthop Sports Phys Ther. 2007;37(12):754-‐762. • Plisky PJ, Rauh MJ, Kaminski TW, Underwood FB. Star Excursion Balance Test as a predictor of lower extremity injury in high school basketball players. J Orthop Sports Phys Ther. 2006;36(12):911-‐919.
References • Souza RB, Powers CM. Differences in hip kinemaEcs, muscle strength, and muscle acEvaEon between subjects with and without patellofemoral pain. J Orthop Sports Phys Ther. 2009;39(1):12-‐19. • Norris B, Trudelle-‐Jackson E. Hip -‐ and thigh-‐muscle acEvaEon during the Star Excursion Balance Test. J Sport Rehabil. 2011;20(4):428-‐441. • Vezina MJ, Hubley-‐Kozey CL. Muscle acEvaEon in therapeuEc exercises to improve trunk stability. Arch Phys Med Rehab. 2000;81(10):1370-‐1379. • Fairclough J, Hayashi K, Toumi H, et al. Is ilioEbial band syndrome really a fricEon syndrome. J Science and Med Sport. 2007;10:74-‐76. • Von Porat A, Roos EM, Roos H. High prevalence of osteoarthriEs 14 years a]er anterior cruciate ligament tear in male soccer players: a study of radiographic and paEent relevant outcomes. Ann Rheum Dis. 2004;63:269-‐273. • Ekdahl M, Wang JHC, Ronga M, Fu FH. Gra] healing in anterior cruciate ligament reconstrucEon. Knee Surg Sports Traumatol Arthrosc. 2008;16:935-‐947.
28
11/18/13
References • Messina DF, Farney WC, DeLee JC. The incidence of injury in Texas High School basketball. Am J Sports Med. 1999;27(3):294-‐299. • Duthon VB, Barea C, Abrassart S, Fasel JH, Fritschy D, Menetrey J. Anatomy of the anterior cruciate ligament. Knee Surg Sports Traumatol Arthrosc. 2006;14(3):204-‐213. • Boling M, Padua D. RelaEonship between hip strength and trunk, hip, and knee kinemaEcs during a jump-‐landing task in individuals with patellofemoral pain. Int J Sports Phys Ther., 2013; 8(5):661-‐ 669.
29
