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Optimizing knee health: .Managing Patellofemoral Pain Syndrome and Patellar tendinopathy
- 1. Strategies for managing patellofemoralpain syndrome and quadricep/patellar tendinopathy Talha Younus Khan Assistant Manager Department of Physiotherapy & Rehabilitation Services The Aga Khan University Hospital.
- 2. In this presentation,you will gain valuable insights into the effective management of patellofemoral pain syndrome and quadricep/patellar tendinopathy. We will explore comprehensive treatment and rehabilitation strategies designed to alleviate pain, restore function, and enhance the overall quality of life for those affected by these conditions. Our aim is to equip you with evidence-based approaches and practical techniques that can be seamlessly integrated into your clinical practice.
- 3. Updated Facts Aboutthe Knee for Rehab Professionals. Prevalence of Knee Pain: • Knee pain is one of the most common musculoskeletal complaints, affecting over 25% of adults at some point in their lives. It is a leading cause of disability, significantly impacting quality of life and mobility. Rising Incidence of Knee Injuries: • The incidence of knee injuries, particularly related to overuse and sports, has been steadily increasing. With more people engaging in physical activities, the demand for effective knee injury prevention and rehabilitation is higher than ever. Economic Impact: • The economic burden of knee disorders is substantial, with billions of dollars spent annually on treatment, rehabilitation, and lost productivity. Effective management strategies are crucial to reducing these costs.
- 4. Advancements in Treatment: Recentadvancements in physiotherapy, regenerative medicine, and surgical techniques have significantly improved outcomes for knee conditions. Early intervention and tailored rehabilitation programs are key to achieving the best results. Importance of a Multidisciplinary Approach: Managing knee conditions often requires a multidisciplinary approach, involving physiotherapists, orthopedic surgeons, sports medicine specialists, and other healthcare professionals. Collaborative care ensures comprehensive treatment plans and better patient outcomes. Focus on Prevention: Preventive strategies, including strength training, flexibility exercises, and proper biomechanics, play a crucial role in reducing the risk of knee injuries. Educating patients on these practices is essential for long-term knee health. Role of Technology: Innovative technologies, such as wearable devices, motion analysis systems, and tele-rehabilitation, are transforming how knee conditions are assessed and treated. These tools enhance precision in diagnosis and customization of treatment plans.
- 5. Epidemiology of PatellarTendinopathy and Quadriceps Tendinopathy Patellar tendinopathy presents as pain at the inferior pole of the patella. Up to 14% of recreational and 45% of elite jumping athletes experience symptoms at any given time. Conversely, quadriceps tendinopathy presents as pain at the superior pole of the patella, with symptoms most pronounced with deep knee flexion. The initial onset of symptoms is usually related to an acute incident involving high levels of eccentric quadriceps loading, which occurs, for example, with knee flexion when landing from a rebound in basketball. However, symptoms are typically preceded by a period of excessive load. Although few studies have examined the prevalence of quadriceps tendinopathy, the prevalence estimates range from 0.2% to 2% in athletic populations. Among athletes with extensor mechanism pain, up to 1 in 4 experience pain at the superior pole of the patella. https://www.jospt.org/journal/jospt Journal of Orthopaedic & Sports Physical Therapy Published Online:August 31, 2019Volume49Issue9
- 6. What is thedifference between patellofemoral pain and patellar tendinopathy? The patellofemoral joint may also be the cause of anterior knee pain among jumping athletes. Patellofemoral-related pain is generally located diffusely around the patella compared with the typically localized inferior pole of the patella in patellar tendinopathy.
- 7. Patellofemoral pain syndrome(PFPS) • Patellofemoral pain syndrome (PFPS) is knee pain under or around your kneecap (patella). Healthcare providers also sometimes call PFPS runner’s knee. • Your patella is the bone at the front of your knee joint. It helps your quadriceps muscle move your leg, protects your knee, and supports lots of important muscles, tendons and ligaments. • “Patellofemoral” is the medical term for the connection between your patella and your thigh bone (femur). Usually, your patella fits into a groove in your femur and slides smoothly along that space when you move your knee. If you have PFPS, something may affect how your patella moves and make it painful. • People usually develop PFPS over time. It can affect one or both of your knees at once.
- 8. Patellofemoral Pain Syndrome(PFPS) is an umbrella term used for pain arising from the patellofemoral joint itself, or adjacent soft tissues. It is a chronic condition that tends to worsen with activities such as squatting, sitting, climbing stairs, and running. Historically it has been referred to as anterior knee pain but this is misleading as the pain can be felt in all aspects of the knee (including the popliteal fossa). Symptoms can develop slowly over time or brought on acutely. PFP tends to reoccur after 2 years in 40% of cases. The differential diagnosis of PFPS include chondromalacia patellae and patellar tendinopathy.
- 9. Clinically Relevant Anatomy: Theknee consists of two major joints, the tibiofemoral joint and the patellofemoral joint. In this case, the problem will be localized in the patellofemoral joint: The patella sits within the femoral groove; the fascies articularis patellae (posterior side) is covered with cartilage that glides over the cartilage of the anterior part of the femoral condyles (femoral groove). In this synovial joint movement and gliding creates minimal resistance due to the synovial fluid which is present around the knee and produced by the membrane synovialis, the internal part of the joint capsule during movement. Several bursae also produce synovial fluid within the capsule. The knee capsule is attached all around the patella, so only the fascies articularis patellae and femoralis are in contact with the synovial fluid. The collateral ligaments are merged with the capsule and they contributed in joint stability. On the anterior side of the patella between the patellar tendon (which is attached to the patella) and the skin, there is an extra bursa (prepatellaris) which is normally not in contact with the knee capsule and ensures a better gliding of the patellar tendon. There is a similar bursa (infrapatellaris) at the level of the tuberositas tibiae. When the knee is inflamed, these bursae can become hyperproductive (swollen). This is possible related to increase of anterior knee pain. Although each ligament has its own responsibility in supporting and protecting the knee, ligaments also provide assistive support to other ligaments. But the two ligaments that are most associated with PFPS are the two collateral ligaments (lateral and medial), because they are merged with knee capsule.
- 10. Epidemiology /Etiology PFPS canbe due to a patellar trauma, but it is more often a combination of several factors (multifactorial causes): overuse and overload of the patellofemoral joint, anatomical or biomechanical abnormalities, muscular weakness, imbalance or dysfunction. It’s more likely that PFPS is worsened and resistive to treatment because of several of these factors. Excessive overload and abnormal tracking of the patella are the main reasons behind PFP symptoms One of the main causes of PFPS is the patellar orientation and alignment. When the patella has a different orientation, it may glide more to one side of the facies patellaris (femur) and thus can cause overuse/overload (overpressure) on that part of the femur which can result in pain, discomfort or irritation. There are different causes that can provoke such deviations. The hip kinematics can also influence the knee and provoke PFPS. A study has shown that patients with PFPS displayed weaker hip abductor muscles that were associated with an increase in hip adduction during running.
- 11. Muscular etiologies ofPFPS Etiology Pathophysiology Weakness in the quadriceps It may adversely affect the PF mechanism. Strengthening is often recommended. Weakness in the medial quadriceps It allows the patella to track too far laterally. Strengthening of the VMO is often recommended. Tight iliotibial band It places excessive lateral force on the patella and can also externally rotate the tibia, upsetting the balance of the PF mechanism. This can lead to excessive lateral tracking of the patella. Tight hamstrings muscles It places more posterior force on the knee, causing pressure between the patella and the femur to increase. Weakness of tightness in the hip muscles Dysfunction of the hip external rotators results in compensatory foot pronation. Tight calf muscles It can lead to compensatory foot pronation and can increase the posterior force on the knee.
- 12. Characteristics/Clinical Presentation: Patient's usuallypresent with the complaint of anterior knee pain that is aggravated by activities that increase patellofemoral compressive forces such as: ascending/descending stairs, sitting with knees bent, kneeling, and squatting.
- 13. Differential Diagnosis • Differentdisease can provoke anterior knee pain, without being PFPS: • Chondromalacia Patellae • Hoffa's pad syndrome • Iiotibial band friction syndrome • Sinding-Larson-Johansson syndrome • Patellar tendinitis • Osteoarthritis in the knee • Chondral lesions • medial meniscus tears • Medial overload syndrome • Popliteal Cyst (Baker's Cyst) • ACL (anterior cruciate ligament) tear • PCL injury/rupture • Referred pain from the hip joint (e.g. slipped epiphysis in adolescents, FAI in young adult, OA) • Referred pain from lumbar spine
- 14. Clinical Signs Cook etal suggest a positive diagnosis of patellofemoral pain syndrome when: Both pain on muscle contraction and pain on squatting are present. 2 out of 3 of the following are present - pain on muscle contraction and/or pain on squatting and/or pain on palpation. 3 out of 3 are present - pain on muscle contraction, pain on squatting and pain on kneeling
- 15. Physical Therapy Management Commoninterventions for the treatment of PFPS are listed below: Manual Therapy open vs. closed chain exercises Quadriceps strengthening Patellar Taping Orthotics Proximal Muscle strengthening Modalities Education • There is largest body of evidence supports the use of exercise therapy in improving pain and function in the short, medium and long-term. International consensus recommends the combination of hip and knee exercise to be used in preference to knee exercise alone. • International experts suggest the use of foot orthoses, patellar taping or manual therapy as adjuncts to exercise therapy. • Joint mobilization and electrophysical agents are not recommended for treatment in PFPS.
- 16. Exercise Therapy Strengthening ofthe Quadriceps is a key in the rehabilitation program: Pain-free exercises are very important when treating PFPS. Isometric exercises while the knee is fully extended (patella has no contact with condyles) can be used at the beginning of the therapy, because it minimizes stress on the patellofemoral-joint while reinforcing the Quadriceps. Closed kinetic chain exercises (CKC) VS Open kinetic chain (OKC) exercises: CKC are more functional than OKC and they provoke lower patellofemoral joint stress, particularly in the terminal ranges of full extension (0° to max 40° knee flexion). Therefore exercises should be practiced within this range and pain-free. Vastus medialis obliquus (VMO): Training of the VMO muscle is appropriate in some PFPS patients but not all. Assessment of the vmo should assess firing, cross-sectional muscle mass, endurance capabilities, and ability to fire at different knee angles, and used functionally. Hip muscles training: Rehabilitation program for PFPS should also incorporate strengthening exercises of the hip abductors and lateral rotators. It has been proven that the pain during daily activities was lower and functionality was greater when knee exercises are combined with hip exercises.
- 17. Proprioceptive training: It hasbeen proven that the proprioceptive quality in the knee of patients with PFPS is decreased. Even with unilateral PFPS, the proprioception is decreased in both knees (pathological and nonpathological knee)! Therefore proprioceptive training (pain- free exercises!) of the knee should be part of the rehabilitation program. Kinesio Taping for PFPS: Does taping help PFPS? An increase in quadriceps muscle force can directly heighten the patellofemoral joint reaction force during gait, so patellar taping is very important for the treatment of PFPS. The technique is intended to improve patellar orientation within the trochlear groove, thus improving patellar tracking.
- 18. Quadricep/Patellar Tendinopathy Patellar tendinopathy isa source of anterior knee pain, characterized by pain localized to the inferior pole of the patella. Pain is aggravated by loading and increased with the demand on the knee extensor musculature, notably in activities that store and release energy in the patellar tendon.
- 19. PREVALENCE: The prevalence ofthis condition in elite volleyball and basketball players has been found to be over 40 percent. While certain intrinsic risk factors for patellar tendinopathy have been identified, such as gender, weight and body mass index, the most significant risk factor appears to be training load (i.e. an extrinsic risk factor). Patellar tendinopathy is a common disorder in athletes who participate in sports that require jumping such as volleyball and basketball and has been labeled “jumper’s knee.” It is also commonly seen in athletes involved in sports such as track and field, gymnastics, and tennis. However, quadriceps and patellar tendinopathy can occur in any individual who is active, especially those who may have recently increased their physical activity.
- 20. Clinically Relevant Anatomy Thequadriceps muscles are connected to the inferior pole of the patella by the common quadriceps tendon through a sesamoid bone, the patella. The patellar ligament then connects the bottom of the patella to the tibial tuberosity. The force generated from the quadriceps muscles acts through the patellar as a pulley, causing the knee to extend.
- 21. Common causes ofquadriceps tendinopathy: 1. Overuse: Repetitive stress on the quadriceps tendon from activities like jumping, running, or squatting can lead to tiny tears in the tendon. 2. Sudden increase in activity: Rapidly increasing the intensity or duration of your workouts can put too much strain on the quadriceps tendon. 3. Muscle imbalances: Weak or tight hamstrings can put increased stress on the quadriceps tendon. 4. Improper training techniques: Poor form during jumping or squatting can increase the risk of quadriceps tendinopathy. 5. Patellofemoral malalignment: If your kneecap doesn’t track properly in the groove on your femur, it can put additional stress on the quadriceps tendon.
- 22. Common symptoms ofquadriceps tendinopathy: • Pain just above the kneecap, often described as dull and aching. • Pain that worsens with activity, especially jumping, squatting, running downhill, or climbing stairs. • Stiffness in the knee, especially in the morning. • Swelling or tenderness around the kneecap. • Weakness in the quadriceps muscles. • Difficulty straightening the knee.
- 23. Pathological Process Cook &Purdam described a continuum model of tendon pathology with three distinct stages: 1. Reactive tendinopathy. A non-inflammatory proliferative response in the cell and matrix, occurs with acute tensile or compressive overload. Clinically, reactive tendinopathies occur with unaccustomed physical activity or acute overload and also after a direct blow (e.g. a direct fall onto the patellar tendon). 2. Tendon disrepair. The continued attempt of tendon healing following the reactive stage but with greater matrix breakdown. There is an increase in the number of cells present in the matrix, resulting in an increase in protein production (proteoglycan and collagen). Clinically, this stage of the pathology is seen in chronically overloaded tendons and appears across a spectrum of ages and loading environments. 3. Degenerative tendinopathy. Degenerative tendinopathy is characterized by areas of cell death due to apoptosis, tenocyte exhaustion or exhaustion. There are large areas of the matrix that are disordered and filled with matrix breakdown products, little collagen and vessels. This stage is primarily seen in the older person. Load is considered to be the primary stimulus which drives tendon health forward and back along the continuum.
- 24. Clinical Presentation: Patellar tendinopathy,is one of many potential diagnoses for a patient presenting with anterior knee pain. There is considered to be two defining clinical features: 1. Pain localized to the inferior pole of the patella. 2. Load-related pain that increases with the demand on the knee extensors, notably in activities that store and release energy in the patellar tendon.
- 25. Diagnostic Procedures: Knee examination Dose-dependentpain. Deficits in energy-storage activities can be assessed clinically by observing jumping and hopping. Stiff-knee vertical jump-landing strategy may be used by individuals with a past history of patellar tendinopathy. Examination of the complete lower extremity is necessary to identify relevant deficits at the hip, knee, and ankle/foot regions. Atrophy, reduced strength, malaligned foot posture, quadriceps and hamstring inflexibility, reduced ankle dorsiflexion have been associated with patellar tendinopathy and should also be assessed. Patellar tendon imaging does not confirm patellar tendon pain, as pathology observed via ultrasound imaging may be present in asymptomatic individuals.
- 26. •Medical Management •Non-steroidal anti-inflammatorydrugs •Corticosteroid injections •Surgical treatment •Physiotherapy Management
- 27. Physiotherapy Management: Physiotherapy isa vital component in the management of quadriceps tendinopathy. Phases of Rehabilitation: 1. Initial phase Pain management • Ice: Applying ice packs wrapped in a towel to the painful area for 15-20 minutes at a time, several times a day, can help reduce inflammation and pain. • Electrotherapy: Modalities like ultrasound or interferential current may be used to further reduce pain and promote healing. • Structural support: Taping or bracing could be used to provide support and offload the tendon. •Gentle range of motion exercises: Maintaining gentle movement will prevent stiffness and promote blood flow to the area. Physiotherapist will guide through the appropriate exercises to start the healing process.
- 28. Tendinopathy Taping: Many athletessay they experience less pain when wearing a strap (anecdotal evidence). However, there is currently little scientific evidence for the effectiveness of a patellar strap and sports tape in patellar tendinopathy. De Vries provides a nice summary of hypotheses for these potential effects but concludes by saying more research is needed to confirm these hypotheses: •Increases the patella-patellar tendon angle and reduce the effective length of the patellar tendon, this might reduce the strain on the tendon. •Improve the proprioception and hereby helps to protect the joint from re- injury or it might change the sensory input. An increased sensitization in patients with patellar tendinopathy, this low pain threshold might be influenced by the Taping/strap and could therefore result in a decrease in the amount of pain that is perceived. •By reducing the load on the tendon, the taping may improve the balance between load and load capacity in the long term. A gradually increasing load in which a small amount of pain is allowed is thought to be important for
- 29. 2. Gradual strengthening: •Isometricexercises: Once pain eases, isometric exercises, where you contract the quadriceps muscle without moving the knee, can be introduced. •Eccentric exercises: These exercises involve lengthening the quadriceps muscle under load, like controlled lowering in a squat, and are particularly effective in promoting tendon healing. Progressive strengthening: As pain improves, gradually increase the intensity and duration of exercises, incorporating resistance bands, weights, or bodyweight exercises like squats, lunges, and step-ups. Role of ShockwaveTherapy in PatellarTendinitis: Shockwave therapy, also known as Extracorporeal ShockwaveTherapy (ESWT), has emerged as a valuable treatment option for managing patellar tendinitis, particularly in cases where traditional therapies have been insufficient.
- 30. 3. Return toActivity • Functional training: Specific exercises targeting activities you enjoy, like jumping or running, will be incorporated to safely return you to your preferred sport or activity. • Stretching: Maintaining flexibility in the quadriceps, hamstring, and calf muscles is crucial to prevent recurrence.
- 31. How long doesquadriceps tendinopathy take to heal? The specific timeline for recovery will vary depending on the severity of injury and adherence to the treatment plan. Generally, improvement can be expected within several weeks in mild cases and several months or longer in severe cases.
- 32. 1 Prevention of quadriceps tendinopathy 2 Gradually increase the intensityand duration of your workouts. 3 Warm up before and cool down after exercise. 4 Strengthen the muscles around your knee, including the quadriceps, hamstrings, and calves. 5 Use proper form during exercise. 6 Wear supportive shoes. 7 Listen to your body and take rest days when needed. Prevention of quadriceps tendinopathy
- 33. Case Studies andReal-Life Examples Case Study 1: Patellofemoral Pain Syndrome in a Young Athlete • Patient Profile: A 16-year-old female soccer player presented with anterior knee pain that worsened during activity, particularly while running and climbing stairs. • Assessment: Clinical examination revealed a positive patellar grind test and pain with patellar compression. Imaging ruled out structural abnormalities. • Treatment: A multimodal approach was adopted, including quadriceps strengthening, hip abductor exercises, and patellar taping. Neuromuscular re-education focused on proper lower extremity alignment during sports activities. • Outcome: After 8 weeks, the patient reported a significant reduction in pain and returned to sports without restrictions. A follow-up at 6 months showed no recurrence of symptoms. • Key Takeaway: Early intervention with a focus on biomechanical correction and muscle strengthening is crucial in managing PFPS in young athletes.
- 34. Case Study 2:Chronic PatellarTendinopathy in a Recreational Runner • Patient Profile: A 32-year-old male recreational runner presented with chronic patellar tendinopathy, characterized by localized pain at the inferior pole of the patella, which was exacerbated by running and jumping. • Assessment: Ultrasound confirmed the diagnosis, revealing degenerative changes and thickening of the patellar tendon. • Treatment: The patient underwent a structured eccentric loading program combined with isometric exercises to reduce pain and improve tendon function. Shockwave therapy was introduced to enhance tendon healing. • Outcome: Over a 12-week period, the patient experienced a marked improvement in pain and tendon strength. He gradually returned to running, following a graded return-to-sport protocol. • Key Takeaway: Eccentric loading exercises, combined with adjunct therapies like shockwave, are effective in treating chronic patellar tendinopathy.
- 35. Evidence-Based Research Highlights 1.Eccentric vs. Isometric Exercise for Tendinopathy Management •Study: A randomized controlled trial (RCT) compared the effectiveness of eccentric exercises versus isometric exercises in managing patellar tendinopathy. •Findings: The study found that both eccentric and isometric exercises significantly reduced pain and improved function, but eccentric exercises were more effective in improving tendon structure and strength over time. •Implications: This research supports the use of eccentric exercises as a cornerstone of rehabilitation for patellar tendinopathy, particularly in athletes. 2. The Role of Hip Strengthening in Patellofemoral Pain Syndrome •Study: A systematic review examined the role of hip abductor and external rotator strengthening in patients with PFPS. •Findings: The review concluded that incorporating hip strengthening exercises leads to better outcomes in pain reduction and functional improvement compared to quadriceps strengthening alone. •Implications: Clinicians should include hip strengthening in the rehabilitation programs for PFPS to address potential biomechanical contributors to knee pain.
- 36. 3. Shockwave Therapyfor Chronic Patellar Tendinopathy: •Study: An observational study assessed the effectiveness of extracorporeal shockwave therapy (ESWT) in patients with chronic patellar tendinopathy who were unresponsive to conventional treatments. •Findings: The study reported significant pain reduction and functional improvement in patients who received ESWT, with effects lasting up to 12 months post-treatment. •Implications: ESWT is a viable option for patients with chronic patellar tendinopathy, especially when other interventions fail. 4. Biomechanical Interventions in Patellofemoral Pain Syndrome: •Study: A biomechanical analysis explored the impact of gait retraining on patients with PFPS. •Findings: The study demonstrated that altering running mechanics, such as increasing step rate and reducing hip adduction, led to a significant reduction in knee pain and improved running economy. •Implications: Gait retraining should be considered in the management of PFPS, particularly for runners and active individuals.
- 37. Q&A: We inviteyou to ask questions and share insights as we continue to advance our collective understanding and treatment of these common yet challenging knee conditions. Thank you