1. Patellofemoral Pain Syndrome

2. Anatomy

3. Anatomy – patellofemoral joint
Patella (convex) articulates with trochlea of femur (concave)
Bony lesions may be present in PFPS e.g. degenerative/fracture
Patella is sesamoid bone, embedded within quadriceps/patella tendon
Associated soft tissue structures commonly affected in PFPS:
Anterior synovial tissues
Anterior knee joint capsule
Suprapatellar plica
Fat pad
Bursae
Medial patellofemoral ligament
Retinaculum
Quadriceps/patella tendon
ITB

4. Pathophysiology
Loss of osseous or peripatellar soft tissue homeostasis due to overload or high frequency of load to bone/soft tissues
Potential neural involvement
Excessive pressure of lateral structures stimulates release of substances that produce growth of new nerves and blood vessels e.g. Substance P, Vascular Endothelial Growth Factor (VEGF)
Similar to tendinopathy?

5. What Causes Pain? Anatomical Source Description of Pain
Anterior synovial tissues, retinaculum, fat pad and capsules
Severe pain accurately localized
Capsular Margins, femoral condyles
Poorly localized moderate pain
Articular cartilage of patella
No pain (even with stage 2-3 chondramalacia patella)
(Dye et al., 1998)

6. Mechanism of Injury Traumatic Overuse
Compression – falling onto knee, impact of patella into trochlea
Twisting – subluxation/dislocation of patella
Overuse
Biomechanical overload
Biological overload (i.e not allowing tissue to recover)

7. Classification Patellar Compression Syndrome Patellar Instability
Excessive Lateral Pressure Syndrome
Global Patellar Pressure Syndrome
Patellar Instability
Chronic Patellar Subluxation
Acute Patellar Dislocation
Recurrent Patellar Dislocation
Biomechanical Dysfunction
Direct Patellar Trauma
Articular Cartilage Lesion (isolated)
Fracture
Fracture/dislocation
Articular Cartilage Lesion with associated malalignment
Soft Tissue Lesions
Suprapatella Plica
Fat Pad Syndrome
Medial Patellomfemoral Ligament Pain
Iliotibial Band Friction Syndrome
Bursitis
Overuse Syndromes
Tendinitis (tendinopathy)
Apophysitis
Osteochondritis Dessicans
Neurologic Disorders
Reflex Sympathetic Dystrophy
Sympathetically maintained pain

8. Patella Compression Syndrome- Excessive Lateral Pressure Syndrome
Patella is squeezed by surrounding soft tissue
If surrounding soft tissue is ‘tight’ the patella looses its mobility
Excessive pressure of the lateral structures can cause lateral retinacular pain
Pain can occasionally be medially as the structures are on constant stretch
Can eventually lead to degeneration of the lateral facet of the patella
Restriction in medial glide of patella resulting in lateral tilt

9. Patella Compression Syndrome- Excessive Lateral Pressure Syndrome

10. Patella Compression Syndrome- Global Patellar Pressure Syndrome
Both Medial and Lateral retinaculum are tight
Develops due to fibrosis of tissues following trauma or immobilization
Global restriction in patella range of movement
Knee pain is reported globally around the patella

11. Lower Extremity Biomechanical Dysfunction
Biomechanical dysfunction at the low back, hip, tibia and ankle can change the kinematics of the knee
This alters the patellofemoral joint stress and can cause pain

12. Do they happen in combination?
Excessive lateral pressure syndrome can occur because of biomechanical dysfunctions
The following presentation is going to assume this is the classification as treatment options will vary for all the different types
See Wilk et al., 1998 for more information on the management of each classification

13. Subjective
Insidious onset (generally, global patella compression syndrome is usually traumatic)
History of overloading tissues (increase in activity/training duration, intensity, frequency and/or inadequate rest)
Ill defined ache localized anterior knee
Sharp pain occasionally
Aggs: squatting, running, walking down slopes, sitting for long periods (theatre goers knee), stairs
Giving way
Pain inhibition of quads
Patella laterally dislocating

14. Objective Pain on palpation patella facets
Restricted ankle dorsiflexion
Continued pronation during gait
Restricted hip flexion/abduction/internal rotation
Restricted tibial internal rotation
Reduced quadriceps strength
Reduced hip extension/abduction strength
Painful squatting, stepping, lunge
Valgus collapse at knee

15. Special Tests Patella tracking and tilt is unreliable
(Song et al., 2011)
Specific Tests are not useful
(Nunes et al., 2013)
Assessing medio-lateral patellar position ONLY reliable and valid test available
(Smith et al., 2009)

16. Further Investigations
Bone scintigraphy - can possibly detect changes in osseous metabolism.
X-ray – not often useful, except if bony trauma
MRI – useful to guide treatment only in certain cases e.g. joint effusion
Ultrasound – to detect soft tissue lesions?
Further investigation commonly ineffective at facilitating diagnosis or guiding treatment.
Findings on investigation do not necessarily correlate with symptoms.

17. Management Multimodal Physiotherapy is key
Mixture of manual therapy AND correct rehabilitation
Control of overloading to allow biological tissue to repair e.g if running for 9 miles causes pain – only run 8 miles
Ensure adequate time for recovery between training sessions
Surgery should not be considered as lateral release has POOR outcomes

18. Management Goal of therapy is to
Reduce overload to tissues, but maintaining sufficient load to prevent deloading
Promote healing/restoration of homeostasis
Reduce pain and odema if present
Restore ROM
Restore motor control and strength
Improve biomechanics/address movement impairments
Improve neuromuscular control and proprioception
Prepare for return to sport/full function

19. Conservative Management
Manual therapy
Reduce swelling/effusion, reduce pain, restore normal mobility
Taping
Offload irritated tissues, alter muscle activity, change arthrokinematics? Limited supporting evidence
Orthotics
Offload irritated tissues, alter biomechanics
Barefoot running
Retrain running mechanics, reduce PFJ stress

20. Conservative Management
Exercise
Arguably the most important component of physiotherapy management.
Manual therapy, taping, orthotics should be used to facilitate pain free exercise.
Exercise selection based on assessment findings
Mobility – restore full ROM of ankle, knee, hip
Restore motor control
quads/VMO e.g. SQs, SLR, IRQ
Lumbopelvic control

21. Conservative Management
Exercise
Strengthening (initially in ranges of minimum PFJ stress
Quads
leg press 0-45° knee flexion, leg ext 45-90° knee flexion, gradually increasing ROM
Step up, step down, lateral step-up (without knee valgus)
Glutes – external rotation/abduction
Clam, monster band walks
Focus on concentric and eccentric strength
Gradually increase ROM and then load
Progress to squat, lunge, lateral lunge, deadlift

22. Conservative Management
Exercise
Proprioception & neuromuscular control
Balance, change of direction, controlled jumping & landing
Gait retraining
May be required to improve biomechanics/reduce PFJ stress
Specific drills to prepare for return to normal activities/sport

23. Surgical - Management
Not recommended due to poor outcomes e.g. lateral release