What is Patellofemoral Pain Syndrome? Patellofemoral Pain Syndrome is a spectrum of processes all characterized by retropatellar pain (behind the kneecap) or peripatellar pain (around the kneecap) arising from overuse and overload of the patellofemoral joint or from biomechanical or muscular changes in this joint.

Causes Softening of the cartilage behind the patella(Chondromalacia) Malalignment of patella Tightening of tissue around patella Overuse of patellofemoral joint – Occurs when the pressure between the patella and its contact points on the femur increase as the knee is bent. Overload – Typically affects inactive patients who suddenly increase activity and stress to the joint. Large Quadriceps Angle

Other Contributory Causes

Biomechanical problems Includes pes planus (pronation of the foot), pes cavus (supination of the foot), hyperpronation, tibial torsion, patellofemoral malalignment, femoral anteversion, and leg length discrepancies.

Muscular dysfunction problems Includes weakness of the quadriceps, tight iliotibial bands, tight hamstrings, weakness or tightness of the hip muscles, or tight calf muscles.

Extrinsic Risk Factors Includes poor technique, low quality sports, or a poorly designed or intensive training program.

Patient population most commonly affected by this condition? Commonly occurs in adolescents and young adults, who regularly participate in high-impact sporting activities, such as running, basketball, and football. Most commonly found in women

Diagnosis The diagnosis of Patellofemoral Pain Syndrome is dependent on findings from the patient’s medical history and physical examination. Diagnosis of Patellofemoral Pain Syndrome is divided into three general categories: – Presence of cartilage damage – Variable cartilage damage – Normal cartilage Patellofemoral Pain Syndrome can be difficult to diagnose; however, x-rays can confirm or refine a suspected clinical diagnosis.

Clinical Presentation Physical exam findings consistent with Patellofemoral Pain Syndrome include the following: – Pain is elicited by compression of the patella into the trochlear groove while the leg is extended – Gradual or acute onset of anterior knee pain – Pain behind or around the kneecap Pain is exacerbated by running, squatting, jumping, prolonged sitting, or ascending/descending stairs – Catching sensation under the patella

Clinical Presentation Patients with Patellofemoral Pain Syndrome classically present as either: – Retropatellar pain (pain behind the kneecap) – Peripatellar pain (pain around the kneecap)

Clinical Presentation Signs: – Soft tissue swelling – Effusion – Bruising – Restricted joint movement – Patellofemoral deformities – Tenderness – Reduced weight-bearing ability

Examination A careful examination should be performed in both the prone and supine positions. Systematic palpation should be used to reproduce the patient’s complaint and localize areas of tenderness. A weight-bearing examination should also be done to assess obesity, atrophy, leg length, knee alignment, torsional deformities, and foot position. The patient should also be examined for effusion, soft tissue swelling, bruising, and position, size, and shape of patella.

Physical examination will include the following measurements:

– Pronation – Patellar mobility – Patellar tracking

– Q-angle measurement – Medial and lateral translation – Quadriceps flexibility test

– Obers test – Hip extensor rotator muscle strength test – Hughston’s test: This test is used to rule out presence of Plica syndrome

Goals of treatment Reduce Inflammation Reduce pain Increase muscle strength and endurance Restore movement and function

Non-operative Treatment

Physical Therapy Strengthening exercises – Focus on Quadriceps and Hip Abductors Stretching exercises – Focus on Quadriceps, Hamstring, Iliotibial Band, and Gastrocnemius Modalities – Icepacks and Ultrasound can be used to reduce pain and inflammation Evaluation of footwear – Careful choice of footwear can minimize the risk of developing the condition and alleviating existing pain

Pharmacotherapy NSAIDs – Used to reduce pain and inflammation

Operative Treatment

Arthroscopic Surgery Used to examine the articular cartilage surrounding the patella and the patellofemoral groove and smooth off any rough surfaces.

Lateral Release Surgery Used to re-correct the alignment of the patella by cutting the ligaments on the outside of the patella.

What is the outcome of treatment? Refer to orthopedic surgeon if condition is severe enough to require surgery Physical therapy – Improve lower extremity strength – Improve lower extremity flexibility Prognosis: Good

Prevention Avoid high impact activities that will exacerbate the condition – Walking up stairs – Squatting Use appropriate athletic shoe with proper arch support

References Ferri: Ferri’s Clinical Advisor 2011, 1 st Edition. Copyright © 2010 Mosby, An Imprint of Elsevier. Lazoff, Marie. First Consult. Elseiver Inc. Copyright © 2011