Thurs AM Conf 10/2010
Michael A. Shaffer
PT, ATC, OCS

Midterm/ ITBS Time

T/ F Questions
 “Patellofemoral pain” is one of the most common musculoskeletal diagnoses.
 Patellofemoral pain is a complex, multifactorial problem.

T/ F Questions
 Patellofemoral pain responds reliably well to rehabilitation.
 Certified Athletic Trainers and Physical
Therapists provide rehabilitation.

T/ F Questions
 The ideal rehabilitation program for a complex, multifactorial problem like patellofemoral pain is hard to define.
 “Genius” is hard to define.

Therefore…..
Athletic Trainers and
Physical Therapists are geniuses!!

Thank you.

The evolution of a clinician…..
 “So what is our patellofemoral pain protocol?”
 “We don’t have ONE. We’ll never have one. No two
PFPS rehabilitations are the same.”

Uh oh, first sign of trouble …..

Midterm time…..M/C
Which of these people has PF pain?

Midterm Time…...Short Answer
 When rehabilitating/ requesting rehabilitation for someone with PF pain, I most often utilize/ request…….? (List your top 3)

Top 3 ?
 Quad strengthening
 VMO facilitation
 Stretching (based upon need)
 Quadriceps
 Lateral structures
 Hamstrings
 Posterior calf (Soleus)
 Hip abductor strengthening

Taping/ Bracing
 Arch supports

When the PT’s “cover” clinic….
 Referral hangs outside door
 Evaluate and Treat
 Evaluate and Return to IOSMR
 Evaluate and Coordinate with PT close to home

When the PT’s “cover” clinic….
 Referral hangs outside door
 Evaluate and Treat
 Evaluate and Return to IOSMR
 Evaluate and Coordinate with PT close to home

The evolution of a clinician…….
 Evaluation AND Treatment
 Pt expectation
 My view of the profession
 Tools in the toolbox
 Timing and rationale → and dosing → and “buy in”

The evolution of a clinician……
 Evaluation
 Observation
 Foot position, Tibial varum, leg length, atrophy
 Palpation
 Patellar position, patellar tracking, quadriceps “tone”
 ROM (Flexibility)
 Quad, Hamstrings, “lateral structures” , calf
 Strength
 SLR x 3, Quads- No
 Functional
 Squat, Lunges (Stacy V)

The evolution of a clinician…….
 Now, for PFPS, just treatment
 “Pattern recognition”
 More on this later
 Assumptions
 Focused treatment
 Treatment guides eval

Treatment Approach for PFPS
 Phase 1
 Everyone gets QS/ SLR x 4
 And some stretching
 “It may not be exactly right, but it’s never wrong”
 “Get on base, don’t swing for the fence”

Phase 2
 “Groucho Marx” Therapy
 “Hey doc it hurts when I do this.”
 Ok let’s do that or something similar
 Phase 3
 Return to activity
 Phase 4
 Long term plan

Best Case Scenario
 Visit 1
 QS, SLR, Stretching, Wall Sits
 Visit 2 (1 week later)
 30-50% better
 Step ups
 Isotonics (ham curls, light leg press, hip)
 Visit 3 (1 week- 2 weeks later)
 ~ 70% better
 CV Exercises
 Talk about progression to running (prn)
 Visit 4 (3-4 weeks after I/E)
 “How’s running going?”……OK great, here’s how to progress your HEP, have a nice life

Rule of 70’s
“at least 70% of patients will feel at least
70% better within 2-3 weeks of starting rehabilitation”

The remaining 30% …….

The tale of Roy McAvoy
 “I can make that shot”
 “I know you can, but not right now”
 You’re in good shape after 2…..
but you’re staring at a 12

PFPS History Lesson Part 1
My summary of 20 years of PFPS PT Rx. Lit.
 Because most patients improve with PT, it is unethical (maybe “unthinkable”) to include a control group
 2 treatment groups
 Both improve
 Equally!!.....arrrgh
 VMO Facil., OKC vs. CKC, Conc. Vs. Ecc. ,
Taping vs. Bracing, Bracing vs. Orthotics

2009:339:b4074
 n = 131
 14- 40 y.o. (X=24 y.o.)
 ~ 2/3 female
 BMI ~ 23
 ~ 70% Sx. < 6 mos
 ~ 60% bilateral Sx.
 Pain
 4/10 rest
 6/10 with activity

 Supervised Rehab vs.
Info + HEP (“standard care”)
 9 visits over 6 weeks
 Progressive resistance every 2 weeks
 Quadriceps, Adductors, Gluteal strengthening
 Stretching
 Balance

“Improved” but not “recovered”

Are they “needy” or “kneedy”
Sensory Mapping of the Knee
Dye et al AJSM 1998

PFPSA selective history/ update (Part 2)
 VMO Weakness
 Quad strengthening
 VMO Facilitation
 Differences in timing of VMO / VL – PFPS vs. non.
 Just one more risk factor
 McConnell’s Critical Test / Taping
 Just tape it
 When the foot hits the ground …..must control the midfoot
 Try some OTC inserts

But the results are stable……the understanding is not
 “So what is our patellofemoral pain protocol?”
 “We’re not sure, but patients keep getting better anyway”.

October is National PT Month

October is National PT Month
Happy PT Month!!

Just in case you were interested….
The green lining perhaps
Supervised Rehab (9 visits/ 6 weeks vs. Info + HEP

Where do we go from here?
 “PFPS School ” at CRWC
 Women aged 18-50
 Information
 Anatomy, Epidemiology, Natural History (young woman’s disease)
 Exercise
 Stretching (Q, H, C, Lateral)
 Strengthening (Quads, Hip adductors/ abductors)
 Instruction for taping (kinesiotaping)
 Encouragement
 Keep exercising
 Call us if
 Sx. not at least 50% better after 4 weeks

“Other” groups
Level 6 Evidence – One guy’s opinion
 Men with CMP- Stretching!
 Patellar Tendonitis – Eccentrics, Aggressive quadriceps and hip abductor strengthening

UI athletes with CMP-
 Muscle Imbalances -
 Full, Static and Dynamic Eval
 Address specific imbalances – specific exercises
 Remember where you are “in season”- set expectations accordingly
 Don’t assume strong quadriceps (if you only have 1 bullet)

Thank You.
Institute of Orthopedics Sports Medicine, and Rehabilitation

Exam findings most often associated with
Patellofemoral Pain …..
 Quadriceps weakness
 VMO dysfunction
 Tight lateral structures
 Pes Planus
 Hip Abductor weakness
 Increased Q angle

Occam

The evolution of a practice????
 Does it even need to be focused treatment?

Treatment Algorithm
 Options
 Treat the worst first
 Shotgun
 Top- down
 Ground- up

Check your baggage at the door
 “What is our PFPS protocol?”- Ned Amendola, MD
 No two PFPS rehabs alike
 Quadriceps weakness
 Weak hip abductors, tight posterolateral hip, and pronation
 Balance the forces (M/L)
 1 + 1 = 4
 Relief of Sx.
 Examination Treatment (S.V.)

What is PFPS?
 Chondromalacia Patella
 Patellar Tendonitis
 Patellar Instability
 Fat pad Syndrome

Pre-patellar bursitis
 Plica syndrome

Patellofemoral Anatomy
 Retinaculi
 Note interdigitations

Patellofemoral Anatomy
 Retropatellar Anatomy
 Articular cartilage
 7 mm thick
 Facets

Patellofemoral Articulation
Reinold et al JOSPT 2006

Patellofemoral Anatomy
 VMO Insertion
 Only dynamic medial stabilizer

Patellofemoral Anatomy
 Q angle
 Or……. “it’s not me, it’s you” http://www.youtube.com/watch?v=U8TnhNxKNlU

Q angle is symmetric i.e. it doesn’t change
Rauh et al JOSPT 2007

Predisposing Factors
 Hip
 Femoral Torsion
 Hip abductor weakness
 ITB tightness
 Knee
 Q Angle
 Lateral retinaculum tightness
 Lateral tilt
 Lateral positioning
 VMO dysfunction
 Foot/ Ankle
 Midfoot pronation
 Soleus Tightness

Predisposing Factors
 Hip
 Femoral Torsion (Anteversion)
 Hip abductor weakness
 ITB tightness
 Knee
 Q Angle
 Lateral retinaculum tightness
 Lateral tilt
 Lateral positioning
 VMO dysfunction
 Foot/ Ankle
 Midfoot pronation
 Soleus Tightness

Predisposing Factors
 Hip
 Femoral Torsion
 Hip abductor weakness
 ITB tightness
 Knee
 Q Angle
 Lateral retinaculum tightness
 Lateral tilt
 Lateral positioning
 VMO dysfunction
 Foot/ Ankle
 Midfoot pronation
 Soleus Tightness

Predisposing Factors
 Hip
 Femoral Torsion
 Hip abductor weakness
 ITB tightness
 Knee
 Q Angle
 Lateral retinaculum tightness
 Lateral tilt
 Lateral positioning
 VMO dysfunction
 Foot/ Ankle
 Midfoot pronation
 Soleus Tightness

Examination
 Hip
 Femoral Torsion
 Craig’s Test
 Frontal plane technique
 Hip abductor weakness
- 26% - 36%
Lloyd Ireland JOSPT 2003

Examination
 Hip
 Femoral Torsion
 Craig’s Test
 Frontal plane technique
 Hip abductor weakness
- 26% - 36%
Lloyd Ireland JOSPT 2003

Hip Abduction Strength
B’ween Groups
Robinson JOSPT 2007
Piva JOSPT 2005

Examination
 Knee
 Q Angle
 Lateral retinaculum tightness
 Patellar tilt/ lateral positioning
 Patellar Glide
 VMO dysfunction
 Quad set
 OKC Knee extension

Patellar Position
 Palpation of patellar position
Fitzgerald and McClure PT 1995
Tomishch JOSPT 1996
Watson JOSPT 1999

Examination
 Ankle/ Foot
 Midfoot pronation
 Navicular drop test
 Look/ see test
 Soleus/ Posterior Ankle Tightness
 Bilateral squat vs. Wall squat or tilt board squat
 “I have never been able to squat right”

Examination
 Soleus/ Posterior Ankle Tightness
 Bilateral squat vs. Wall squat or tilt board squat
 “I have never been able to squat right”

Examination Reliability
 30 patients with PFPS
 2 paired PT’s
ICC’s
Piva BMC Musculoskeletal Disorders 2006

Examination Findings
 “Normative” values for PFPS
 SEM’s
Piva BMC Musculoskeletal Disorders 2006

Progressions -
Phase 2
 The myth of contact area
 Greater contact area with > Flexion

Progressions -
Phase 2
 The myth of contact area
 Greater contact area with > Flexion

The Myth of Contact Area
So then why do my knees hurt when I do this?
Besier et al JOR 2005

Progressions -
Phase 2
 The myth of contact area
 Peeing in the ocean

The Myth of Contact Area
Location of the Lesion
 Patellofemoral Joint
 Trochlea, patellar undersurface
 Extension = superior patella
 Flexion = more patellar contact
BUT….
 Site of lesion
 Quadriceps loading
 Shin angle

Treatment Algorithm
 “It hurts when I go down stairs”
 Translation
 Eccentrics hurt
 Quadriceps Loading
 Phase 1
 QS, SLR x 4, Stretching (Quads)
 Phase 2
 Shuttle! → Leg press
 Front step ups → Front Step Up and BACK downs →
Dynamic lateral step downs → Front step downs

Treatment Algorithm
 “It hurts when I squat”
 Translation
 Quadriceps loading
 Soleus Tightness
 Phase 1
 QS, SLR x 4, Soleus stretching
 Phase 2
 Shuttle → Leg press (fast transition)
 Wall sits
 OKC Knee extension Multi- angle isometrics

Phase 2 Supplements
 Patellar mobilizations
 Lateral retinacular stretching
 Medial glides – but medial counterpressure
 PROM
 Thomas test stretching
 2 versions
 VMO facilitation

Selective Atrophy of the VMO?
 NO!
 Selective Training?
 Hip adduction
 Origin off Adductors
 But……
 Reports of exercises with adduction …….conflicting
 Bands vs. balls
 Anecdotal reports

Can you selectively train the VMO?
 SAQ (OKC terminal ext)?
 No
 Lieb and Perry
 Basmajian
 Hallen et al
 Jackson/ Merrifeld
 Reynolds et al
 Salzman et al.
JBJS 1968, JBJS 1971
Anat Rec 1971
Acta Orthop Scand 1967
Med Sci Sport Exe 1972
Am J Phys Med 1983
Clin Orthop 1993

Can you selectively train the VMO?
 Quad exercises
 No
 Cerny
 LaPrade
 Vaatainen et al
 Mirzabeigi et al
Phys Therapy 1995
JOSPT 1998
Int J Sports Med 1995
AJSM 1999

Can you selectively train the VMO?
 Biofeedback
 Yes
 Cowan et al Med Sci Sport Ex 2002
 No
 Dursun et al Arch Phys Med Rehabil 2001

Can you selectively train the VMO?
 Hip Adduction
 Yes
 Hanten and Schulthies
 Hodges and Richardson
 No
 Karst and Jewett
 Grabiner
 Cerny
 Laprade
Phys Ther 1990
Scand J Rehab
Med 1993
Phys Ther 1993
Eur J Exp
Musculoskel Res 1993
Phys Ther 1995
JOSPT 1998

Can you selectively train the VMO?
 Internal Tibial Rotation
 Yes
 Laprade et al.
 No
 Hanten and Schulthies
 Cerny
Phys Ther 1998
Phys Ther 1990
Phys Ther 1995

Can you selectively train the VMO?
 “….it would appear that isolated recruitment or strengthening of the VMO through selected exercises may not be a realistic goal and any emphasis on selective strengthening of the
VMO would most likely translate into a general quadriceps strengthening program.”
 Powers JOSPT 1998

Don’t speed through this section!
 Hip adduction
 Force pulling laterally placed at the knee
 Vs. Isometric hip adduction
 Anecodotal reports??

When to use taping/ bracing

Is taping/ bracing effective?
 To decrease pain?
 Yes
 McConnel
 Gerrard
 Finestone (RCT)
 Moller and Krebs
 Palumbo
 Bockrath et al
 Grace
 Powers
 Crossley et al
 Greenwald et al
 Ng and Cheng
 Cochrane 2003 (Taping)
 Wilson et al. (!!)
 No
 Miller (RCT)
 Kowall (RCT)
Aust J Physiotherap 1986
Clin Orthop 1989
Clin Orthop 1993
Arch Orthop Trauma Surg 1986
AJSM 1981
Med Sci Sports Exerc 1993
JOSPT 1997
JOSPT 1997
Clin J Sport Med 2001
Clin Orthop 1996
Clinical Rehabilitation 2002
JOSPT 2003
Am J Knee Surg 1997
AJSM 1996

Is taping/ bracing effective?
 For changing patellar position?
 Yes
 Shellock et al J Mag Res Imag 1994
 Yes, but not maintained after ex
 Larsen AJSM 1995
 Yes, but only at rest (vs. AROM)
 Muhle et al AJSM 2000
 NO
 Bockrath Med Sci Sports Ex 1993

Is taping/ bracing effective?
 On VM/ VL activation?
 Yes
 Gilleard
 No
 Cerny
Phys Ther 1998
Phys Ther 1995

When to use taping/ bracing
 Critical test
 Manual medialization of patella
 My preferred method
 Correct tilt
 Correct glide (bunch skin)
 Watch compression
 Split tape prn

Patellar Taping
Unilateral Step Down
Wilson et al JOSPT 2003

Taping….temporary
Bracing……long term

When to use orthotics
 Pronation, Femoral IR, Increased Q angle
 Gross and Foxworth JOSPT 2003
 Caucasians in Iowa

Phase 4 – Continued Exercise

Phase 4 – Continued Exercise
 Incorporate your treatment into their routine
 Gym
 Isotonics
 + coronal plane!
 Home exercise
 Wall sits, Planks
 Swiss Balls
 Ball squats, Bridges

Thank you. No, really, thank you.