Prehabilitation for Patellofemoral Pain Syndrome (PFPS)

Patellofemoral pain syndrome (PFPS) can be a real pain in the knee, but is it really a knee problem? PFPS is a common injury experienced by adults and adolescents and presents as anterior knee pain, pain in or around the patella (Lankhorst, Bierma-Zeinstra & van Middelkoop, 2012). Often pain increases when running, using stairs, kneeling, sitting or squatting (Callaghan & Selfe, 2012). PFPS is the most common diagnosis amongst runners (Aytar et al., 2011) and accounts for 25-40% of all knee injuries seen within sports injury clinics (Kannus, Aho, Järvinen & Nttymäki, 1987). Females are shown to have a 2.23 times higher incidence than males and it is theorised that q‐angle and leg strength differences between genders could be contributing factors (Boling et al., 2010; Daneshmandi, Saki, Shahheidari & Khoori, 2011). Despite its prevalence, there is still little consensus on its exact cause and subsequent treatment. When investigating the cause of pain, Dye, Stäubli, Biedert and Vaupel (1999) found that individuals reporting PFPS often had no identifiable structural abnormalities. In a systematic review by Cook, Mabry, Reiman and Hegedus (2012) looking into clinical tests for diagnosing PFPS, they concluded that the best tests are still unknown. It has been suggested that the best means of diagnosis is one of exclusion, where intra-articular pathologies, tendinopathy, bursitis, Osgood-Schlatter disease or other rare pathologies are ruled out (Lankhorst et al., 2012). A recent cross-sectional observational study found altered patella tendon reflex excitability in females with PFPS. The authors (Pazzinatto et al., 2019) suggested this as a possible clinical test.

To effectively prevent or treat PFPS, it is important to try and understand risk factors. To date, several studies have investigated the hip muscles and their link to PFPS. In a study analysing gluteal muscle activation in female runners, Willson, Kernozek, Arndt, Reznichek and Straker (2011) found that gluteus medius (GMED) activation was delayed and shorter in duration in those experiencing PFPS. Another important finding was a moderate correlation with hip adduction (knee valgus) impacting on gait kinematics, which can also be seen during stair negotiation (Barton, Lack, Malliaras and Morrissey, 2013). More evidence was offered in a study by Neal, Barton, Birn-Jeffery and Morrissey (2019) where runners with PFPS had on average 4.9° greater peak hip adduction than controls without PFPS. Noehren, Scholz and Davis (2011) investigated the impact of gait kinematics on hip mechanics, pain and function in runners with PFPS. Using real-time gait retraining over 2 weeks, subjects were instructed to contract the gluteal muscles and maintain a level pelvis. The result was a 5° reduction in hip adduction and an 86% reduction in pain, which persisted after 1 month. Hip adduction contributing to excessive q-angle, has been identified as a risk factor for knee injury (Daneshmandi et al. (2011) and should be corrected as part of a prehabilitation programme.

When compared to quadriceps (quad) strengthening, hip strengthening has been shown to achieve positive results in a shorter time period. In a study where both were used as a rehabilitation method, pain and function improved in both groups. However, improvements were reported in the hip group after 4 weeks, compared to 8 weeks (Dolak et al., 2011). Activation and strength of the quad muscles, vastus lateralis (VL) and vastus medialis oblique (VMO) have been another large area of research when trying to understand PFPS. Using electromyographic (EMG) to measure the firing pattern of the VMO and VL, Cowan, Hodges, Bennell and Crossley, (2002) found that during sit to stand there was delayed VMO recruitment in subjects with PFPS compared to those without. However, this contradicts earlier research by Sheehy, Burdett, Irrgang and Van Swearingen (1998) who found no significant difference, when using the same method while negotiating stairs. However, changes in relative VMO-VL activation were seen in individuals descending stairs after motor control and quad strengthening exercises were used (Bennell et al., 2010). Delayed VMO activation has a significant correlation to patella maltracking in individuals with PFPS (Pal et al., 2011). Therefore, VMO and/or overall quad strengthening has been shown in many studies to be an effective treatment for PFPS (Bennell et al., 2010; Dolak et al., 2011; Eapen, Nayak & Zulfeequer, 2011; Kaya et al., 2011; Kooiker, Van De Port, Weir & Moen, 2014).

Another hypothesised risk factor is excessive foot pronation or rearfoot eversion. Barton, Bonanno, Levinger and Menz (2010) found individuals with PFPS had greater foot pronation than those without. Ferreira et al. (2018) concluded that foot pronation significantly predicted peak hip internal rotation in females during stair ascent. Barton, Menz & Crossley (2011) looked at the effectiveness of foot orthoses on pain and functional performance on individuals with PFPS. During a single leg squat, individuals with foot pronation had an immediate and significant reduction in pain. These finding are supported in earlier research looking at the role of foot orthoses as an extrinsic treatment for PFPS (Gross & Foxworth, 2003; Johnston & Gross, 2004). Kinesio taping (KT) is another commonly used extrinsic treatment for treating PFPS (Callaghan & Selfe, 2012) although the evidence of its effectiveness is debatable. A Cochrane review concluded that the outcomes were not sufficient enough to recommend KT as an effective treatment. In addition, Aytar et al., 2011 found KT was no better than placebo in improving pain and joint position. Other authors (Aminaka & Gribble, 2008; Whittingham, Palmer & Macmillan, 2004) argue that KT can be effective as part of a rehabilitation programme.

In conclusion, once all other pathologies are ruled out, non-specific anterior or prepatellar pain is classified as PFPS. The research shows that hip strengthening, VMO activation and overall quad strengthening are effective in reducing symptoms of PFPS. Foot orthoses is also effective in individuals with excessive foot pronation. Furthermore, this would suggest muscle dysfunction including delayed VMO activation, quad weakness, hip weakness, specifically GMED and foot pronation are risk factors for PFPS. There is evidence that these dysfunctions can result in knee valgus and maltracking of the patella and that this is more prevalent in females due to their increased q-angle. Therefore, a prehabilitation programme would have a focus on correct knee alignment. This can be achieved by retraining and awareness of knee position through functional movement, which is supported through corrective, strengthening exercises, foot orthoses and possibly use of KT.

In this video we will take a brief look at how to differentiate between PFPS and other, similar conditions sometimes referred to as “runner’s knee”. We will review the anatomy and function of the knee and factors that contribute to increased q-angle and patellar maltracking. Finally, how to prevent PFPS through correcting muscular imbalances by using simple exercises.

References

Aminaka, N., & Gribble, P. A. (2008). Patellar taping, patellofemoral pain syndrome, lower extremity kinematics, and dynamic postural control. Journal of athletic training43(1), 21-28.

Aytar, A., Ozunlu, N., Surenkok, O., Baltacı, G., Oztop, P., & Karatas, M. (2011). Initial effects of kinesio® taping in patients with patellofemoral pain syndrome: A randomized, double-blind study. Isokinetics and Exercise Science19(2), 135-142.

Barton, C. J., Bonanno, D., Levinger, P., & Menz, H. B. (2010). Foot and ankle characteristics in patellofemoral pain syndrome: a case control and reliability study. journal of orthopaedic & sports physical therapy40(5), 286-296.

Barton, C. J., Lack, S., Malliaras, P., & Morrissey, D. (2013). Gluteal muscle activity and patellofemoral pain syndrome: a systematic review. British journal of sports medicine47(4), 207-214.

Barton, C. J., Menz, H. B., & Crossley, K. M. (2011). The immediate effects of foot orthoses on functional performance in individuals with patellofemoral pain syndrome. British journal of sports medicine45(3), 193-197.

Bennell, K., Duncan, M., Cowan, S., McConnell, J., Hodges, P., & Crossley, K. (2010). Effects of vastus medialis oblique retraining versus general quadriceps strengthening on vasti onset. Medicine & Science in Sports & Exercise42(5), 856-864.

Boling, M., Padua, D., Marshall, S., Guskiewicz, K., Pyne, S., & Beutler, A. (2010). Gender differences in the incidence and prevalence of patellofemoral pain syndrome. Scandinavian journal of medicine & science in sports, 20(5), 725-730.

Callaghan, M. J., & Selfe, J. (2012). Patellar taping for patellofemoral pain syndrome in adults. Cochrane Database of Systematic Reviews, (4).

Cook, C., Mabry, L., Reiman, M. P., & Hegedus, E. J. (2012). Best tests/clinical findings for screening and diagnosis of patellofemoral pain syndrome: a systematic review. Physiotherapy98(2), 93-100.

Cowan, S. M., Hodges, P. W., Bennell, K. L., & Crossley, K. M. (2002). Altered vastii recruitment when people with patellofemoral pain syndrome complete a postural task. Archives of physical medicine and rehabilitation83(7), 989-995.

Daneshmandi, H., Saki, F., Shahheidari, S., & Khoori, A. (2011). Lower extremity Malalignment and its linear relation with Q angle in female athletes. Procedia-Social and Behavioral Sciences, 15, 3349-3354.

Dolak, K. L., Silkman, C., McKeon, J. M., Hosey, R. G., Lattermann, C., & Uhl, T. L. (2011). Hip strengthening prior to functional exercises reduces pain sooner than quadriceps strengthening in females with patellofemoral pain syndrome: a randomized clinical trial. journal of orthopaedic & sports physical therapy41(8), 560-570.

Dye, S. F., Stäubli, H. U., Biedert, R. M., & Vaupel, G. L. (1999). The mosaic of pathophysiology causing patellofemoral pain: Therapeutic implications. Operative Techniques in Sports Medicine, 7(2), 46-54.

Eapen, C., Nayak, C. D., & Zulfeequer, C. P. (2011). Effect of eccentric isotonic quadriceps muscle exercises on patellofemoral pain syndrome: an exploratory pilot study. Asian journal of sports medicine2(4), 227.

Ferreira, A. S., de Oliveira Silva, D., Briani, R. V., Ferrari, D., Aragão, F. A., Pazzinatto, M. F., & de Azevedo, F. M. (2018). Which is the best predictor of excessive hip internal rotation in women with patellofemoral pain: Rearfoot eversion or hip muscle strength? Exploring subgroups. Gait & posture62, 366-371.

Gross, M. T., & Foxworth, J. L. (2003). The role of foot orthoses as an intervention for patellofemoral pain. Journal of Orthopaedic & Sports Physical Therapy33(11), 661-670.

Johnston, L. B., & Gross, M. T. (2004). Effects of foot orthoses on quality of life for individuals with patellofemoral pain syndrome. Journal of Orthopaedic & Sports Physical Therapy34(8), 440-448.

Kannus, P., Aho, H., Järvinen, M., & Nttymäki, S. (1987). Computerized recording of visits to an outpatient sports clinic. The American Journal of Sports Medicine, 15(1), 79-85.

Kaya, D., Citaker, S., Kerimoglu, U., Atay, O. A., Nyland, J., Callaghan, M. & Doral, M. N. (2011). Women with patellofemoral pain syndrome have quadriceps femoris volume and strength deficiency. Knee Surgery, Sports Traumatology, Arthroscopy19(2), 242-247.

Kooiker, L., Van De Port, I. G., Weir, A., & Moen, M. H. (2014). Effects of physical therapist–guided quadriceps-strengthening exercises for the treatment of patellofemoral pain syndrome: a systematic review. journal of orthopaedic & sports physical therapy44(6), 391-402.

Lankhorst, N. E., Bierma-Zeinstra, S. M., & van Middelkoop, M. (2012). Risk factors for patellofemoral pain syndrome: a systematic review. journal of orthopaedic & sports physical therapy42(2), 81-94.

Magalhães, E., Fukuda, T. Y., Sacramento, S. N., Forgas, A., Cohen, M., & Abdalla, R. J. (2010). A comparison of hip strength between sedentary females with and without patellofemoral pain syndrome. journal of orthopaedic & sports physical therapy40(10), 641-647.

Neal, B. S., Barton, C. J., Birn-Jeffery, A., & Morrissey, D. (2019). Increased hip adduction during running is associated with patellofemoral pain and differs between males and females: A case-control study. Journal of biomechanics91, 133-139.

Noehren, B., Scholz, J., & Davis, I. (2011). The effect of real-time gait retraining on hip kinematics, pain and function in subjects with patellofemoral pain syndrome. British journal of sports medicine45(9), 691-696.

Pal, S., Draper, C. E., Fredericson, M., Gold, G. E., Delp, S. L., Beaupre, G. S., & Besier, T. F. (2011). Patellar maltracking correlates with vastus medialis activation delay in patellofemoral pain patients. The American journal of sports medicine39(3), 590-598.

Pazzinatto, M. F., de Oliveira Silva, D., Ferreira, A. S., Waiteman, M. C., Pappas, E., Magalhães, F. H., & de Azevedo, F. M. (2019). Patellar tendon reflex and vastus medialis Hoffmann reflex are down regulated and correlated in women with patellofemoral pain. Archives of physical medicine and rehabilitation100(3), 514-519.

Sheehy, P., Burdett, R. G., Irrgang, J. J., & Van Swearingen, J. (1998). An electromyographic study of vastus medialis oblique and vastus lateralis activity while ascending and descending steps. Journal of Orthopaedic & Sports Physical Therapy27(6), 423-429.

Whittingham, M., Palmer, S., & Macmillan, F. (2004). Effects of taping on pain and function in patellofemoral pain syndrome: a randomized controlled trial. Journal of Orthopaedic & Sports Physical Therapy34(9), 504-510.

Willson, J. D., Kernozek, T. W., Arndt, R. L., Reznichek, D. A., & Straker, J. S. (2011). Gluteal muscle activation during running in females with and without patellofemoral pain syndrome. Clinical biomechanics26(7), 735-740.

Wales Exercise Medicine Symposium 2018

I recently had the pleasure of attending the 2018 annual Wales Exercise Medicine Symposium with Marjon. the trip was organised by Ben Jane and attended by Vicki Evans and a strong squad of 2nd and 3rd year students and myself, a lonely 1st year.

In addition to exeriencing the rather shady Kiwi bar in Cardiff and Elliot’s razor sharp dance moves, I took away some incredible information. Here’s what I remember…

Prof. Peter Brukner – “Why are we getting fatter and sicker?”

Peter opened the Symposium with an extended version of his workshop as the original speaker was unable to attend. In true Aussie fashion, he swore and presented in a way that didn’t pull too many punches (I appreciate this style). He started by discussing the state of the nation, both ours and his own, as they’re very similar in respect to obesity and diabetes. He explained how diabetes is the largest epidemic in human history and in the last 18 years cases have tripled. In addition to this, non-alcoholic fatty liver disease is now prevalent in 1/3 people in the UK.

He talked about where we wrong… well, it was about 30 years ago, in the 80’s when the government low fat guidelines were released. A dietician involved has since admitted that the research was funded by the committee of agriculture and the guidelines were based on no evidence but instead politics. In fact, he went as far as stating that animal fat does not cause heart disease and saturated fats are ok. With low fat products, typically comes high sugar – you gotta get the flavour somewhere, right? The idea that we’ve been fooled for all these years, which has hugely impacted our health makes me really angry!

Finally, he talks about what we can do. Carb intake really depends on an individuals insulin sensitivity. However, in the obese and certainly diabetic you can assume they’re not insulin sensitive. So, a LCHF (low carb, high fat) diet is the way to go. He uses himself as a prime example in this. There was a point where he was overweight with a fatty liver. By adopting a LCHF diet, in just 3 months, he lost 13kg, reduced his ALT from 65-25 and improved his Triglyceride/HDL ratio.

Recommended Reading:

 

Dr. Aseem Malhotra – “You can’t outrun a bad diet”

Aseem continued on the same tune as Peter Brukner, discussing the incorrect idea that a low fat diet is how we should be eating and supported the idea that saturated fat is not the issue. Aseem came from a clinical background as an intervention cardiologist. His journey began when he suffered the embarrassment of giving a patience a pep talk about nutrition and life style, following a recent heart attack, as they were served a load of junk food in their hospital bed. He was asked “Dr., why are you telling me to eat one thing but then serving me another?” to which he had no answer for.

He made some interesting admissions about hospitals and the NHS. “50% of all NHS workers are obese”, “Medics learn nothing about nutrition in med school” and “have about a days worth of training on exercise prescription”. He notes how modern hospitals have a toxic food environment with branding opportunities for food companies, shops selling confectionary and trolleys even bringing sugary products to people in their beds. One study showed that people are more likely to eat junk food if they go into hospital than if they didn’t.

Aseem, like Peter promotes the idea of a LCHF diet as the way to improve the state of the nation. He references an Italian town, Pioppi where the average life expectancy is 90 years old. Unlike common belief in the UK, these Italians have a low carb diet where Spaghetti is a small starter before a main of meat or fish and veggies. With dessert being a once a week, weekend treat. He promotes his book, the Pioppi Diet, which is a science book (despite the name) and encourages pretty much cutting out all starchy carbs and sugars for the initial 21 days.

Recommended Reading:

  • Action on Sugar – BMJ
  • The Pioppi Diet – Aseem Malhotra

 

If you made it this far, you deserves this…

What does it mean to be a professional in Sport Rehabilitation.

There are many facets to being a professional in sports rehabilitation. The intention of this post is to clarify what skills and attributes are required for an existing fitness professional or personal trainer (PT) to transition into becoming effective as a Sport Rehabilitator (SR). Also, the expectations of the governing body, The British Association of Rehabilitators and Trainers (BASRaT) in regard to qualifications and conduct.

Within sports rehabilitation there are many key attributes and skills required to be effective. For an experienced PT with existing level 4 qualifications in low back pain and strength & conditioning, moving into the sport rehabilitation, many of these key attributes and skills may exist and are transferable. These might include: a basic to intermediate understanding of human anatomy and physiology (A&P), basic to intermediate ability to conduct a movement screen and postural analysis, the ability to prescribe relevant, effective and safe exercises for fitness and skills in communication, interpersonal effectiveness and organisation. These existing attributes and skills will contribute to becoming effective but alone will not qualify a professional to be a SR. BASRaT requires their members to hold a bachelor’s degree level qualification (BSc). Once this qualification has been achieved by an individual they would then be considered “a graduate level autonomous healthcare practitioner specialising in musculoskeletal management, exercise based rehabilitation and fitness” (2017 – BASRaT).

An SR’s level of A&P knowledge should be well beyond that which is basic and should be evidence-based in order to underpin their practice as alluded to by Archer and Nelson (2013:vii). With this knowledge an SR is able to offer a correct diagnosis and evaluation of an individual’s injury. Also, evidence-based knowledge of available techniques within their scope of practice should be very clear. All this should be applied knowledge supported with at least 400 hours clinical experience. Once achieved, safe, relevant and effective corrective interventions can be delivered or prescribed and clinical reasoning (CR) can be given if challenged. The importance a SR’s ability to offer CR is supported by Abrahamson et al. (2012), as is the importance of CR in the curriculum of any rehabilitation degree.

So what does being effective really refer to. Simply taking a definition of the word from Oxford University Press (2017) “Rehabilitation: the action of restoring something that had been damaged to its former condition” offers some insight. In a sporting context this would be the process of taking an injury through therapy and treatment in order to restore full function or as near to it as possible. Full function can be defined through range of movement of the affected joint, contractual force of the affective muscles, motor control of the nervous system and overall performance of the patient’s ability to complete their day to day tasks. These tasks could be as simple as walking for some individuals or a high velocity change of direction for others.

Based on the evidence, being a professional in sport rehabilitation means, in order to be effective one must have suitable education. This can be none less than a BSc in sports rehabilitation and accredited by BASRaT. Suitable experience in the form practical experience gained from placement throughout their education. Proven knowledge of human anatomy and physiology that is acceptable by the accrediting body, BASRaT and the university delivering the course. Knowledge in assessment and diagnostic tools and rehab techniques and interventions. Finally, the ability to confidently communicate, which would include receiving and delivering critical information and note taking.

References

  1. Abrahamson, E., Egan, K. and West, L. (2012) Towards a conceptual model of clinical reasoning development in an undergraduate sports rehabilitation curriculum. SportEX Medicine. Vol. 51: 16-21.
  2. Archer, P. and Nelson, L. (Eds.) (2013) Applied Anatomy & Physiology for Manual Therapists. (1st ed.) Philadelphia: Lippincott Williams & Wilkins.
  3. Oxford University Press. (2017) Oxford Living Dictionary. [Online] Available from: https://en.oxforddictionaries.com/definition/rehabilitation [accessed 24 October 2017].
  4. Designed and built by timb. 2017. Basratorg. [Online]. [12 October 2017]. Available from: https://www.basrat.org/home/roleofsportrehab.