Patellofemoral pain; classification and PT management

Despite a number of studies, ‘patellofemoral pain syndrome’, previously described as the” black hole of orthopedics” by Dr. Scott Dye, is still one of the most irritable condition causing dysfunctions for patients and confusion for clinicians. Although non-operative treatment has established as the initial form of treatment for patellofemoral disorders, there is a lack of consensus on the most effective clinical guideline for patellofemoral pain. As a result, this condition is still frustrating many times for both patients and clinicians with poor outcomes.

In a clinic, patients present with different characteristics of anterior knee pain or patellofemoral pain which leads to the fact that patellofemoral pain arises from various sources and thus contributing to different forms of pain or disorder. Therefore, patellofemoral pain syndrome sounds to be such a vague term and definitely the rehabilitation program for the patients mostly differ according to the source and nature of the disorder. The most critical component of treating patellofemoral pain is an accurate diagnosis.

The classification of Patellofemoral dysfunction and treatment guideline

Wilk et al. (1998) proposed a classification system for patellofemoral dysfunction which made the differential diagnosis of PFPS more accurate and the treatment strategies more specific to the cause of patellofemoral pain. This publication is a worthy read.

Patellar compression syndromes

This is a condition of the overconstrained patella on trochlea due to the tight surrounding soft tissue causing restrictions on patellar mobility. This compression and reduced mobility can lead to articular cartilage damage.

Excessive lateral pressure syndrome

• Unilateral compression of the patella due to the tightness of lateral retinacular tissue.
• A patient complains of lateral retinaculum pain mainly at the insertion of Vastus lateralis.
• Occasional pain over the medial peripatellar region mainly due to soft tissue stretching.
• Laterally shifted or tilted patella and decreased medial glide.
• Pain mainly on stair climbing, squatting or stooping down.
• Atrophy of Vastus medialis oblique muscle (VMO).

         Treatment

• Stretching of lateral retinaculum with joint mobilization or medial glide/tilt of the patella.
• Patellar taping to correct the excessive lateral tilt of patella if present.
• Stretching of iliotibial band, hamstrings, and quadriceps. Mainly tightness of IT Band results in lateral tilting of the patella.
• Quadriceps strengthening mainly the VMO muscle to improve patellar stabilization.
• Avoiding extremes of motion, both extension and flexion, to reduce patellar compression until the normal patellar mobility is restored. Patients to reduce stair ambulation and deep knee squatting activities.
• Instruct patient to avoid repetitive activities like bicycling especially in extremes ROM.

Global Patellar pressure syndrome

• Excessive compression of the patella within trochlea due to the tightness of both medial and lateral retinacular soft tissues.
• Develops secondary to direct blow/trauma to the patella, immobilization due to fracture treatment or knee surgeries like ACL reconstructions. Compression develops due to the formation of arthrofibrosis or fibrosis within the surrounding retinaculum.
• Chief complain of diffuse anterior knee pain around the patella.
• Cardinal feature is the global loss of patellar mobility. The patella is restricted in both medial and lateral direction with superior or inferior restrictions as well.
• Patients usually present with disuse atrophy of quadriceps and tightness of ITB, hamstrings, and quads as well.

          Treatment

• Patellar mobilization in all direction focussing to improve most restricted direction first.
• Soft tissue mobilization to reduce both medial and lateral retinacular soft tissue.
• Stretching and strengthening of quadriceps, hamstrings, hip flexors, gastrocnemius, and ITB.
• Frequent knee AROM exercises throughout the day.
• Patellar compressive motions like deep squats, stairs, bicycling resisted terminal knee extensions are discouraged until improved patellar mobility is achieved. Similarly, patellar taping or bracing is also discouraged to enhance frequent patellar mobility.