Physiotherapy management of Anterior knee pain in runners Catherine Kwan M.Sc.(Manip Physio), BSc.(Physio), MCSP, SRP Clinical Development Lead/Extended Scope Physiotherapist Horder Healthcare, The Horder Centre

Overview • Causes/ associated factors of Patello-femoral pain syndrome (PFPS) • Diagnosing PFPS • Biomechanical analysis • Physiotherapy management of PFPS • Recent evidence • What exercises when • taping

Anterior knee pain in runners… • Running is an integral part of life for some runners • No matter what distance • “rest!” doesn’t work for them • Rehab needs to be gradual but steady, sufficiently effective to gain results

Anterior Knee pain • First of the top five running injuries • Been thought to affect up to 30% of runners • Too much, too soon, too often, too little rest

Incorporates: • Patello-femoral pain syndrome (PFPS) • Patellar tendinopathy • Infra-patellar fat pad inflammation • Patello-femoral instability • Concentrating on Patello-femoral Pain Syndrome

Case Study • 32 year old female runner • Antero-lateral knee pain of 5-6 weeks duration, gradual onset • Training for 10km run (last weekend) but didn’t do it. • Is training now for Brighton half marathon on Feb 17th, and Brighton Marathon in late March • No history of this pain or any knee pain • Took up running 2 years ago, this is the furthest she has run! • hasn’t done a half or full marathon before

Case study cont • Shoes – Brooks Adrenaline (neutral to slight pronation support) 6 months old. • Runs 4x/week - mainly on the road, also in the downs (once/week) • Runs 3 x 5 miles, 1 x 8 miles per week • No other training, minimal stretching • Works in an office – mainly sitting • Wants to continue with her training asap

• How to get her back running asap with minimal pain? • What factors are contributing to her condition? • • • •

Effective management and self management Use of cross training education Psychosocial support

WHY DOES PATELLOFEMORAL PAIN OCCUR?

Factors associated with PFPS • • • •

Lankhorst et al 2013 Systematic review to look at factors associated with PFPS Meta analysis, data from eight variables pooled Found that the following were found in subjects with PFPS – – – – – –

Larger Q angle Larger sulcus angle More patellar tilt Less hip abduction strength Less hip external rotation strength Reduced peak knee extensor torque

Why does patello-femoral pain happen? • Aetiology unknown • Repetitive limb loading • Generally accepted that the patella tracks laterally • Affected by: – Active and passive factors – Local and remote structures – Neuromotor system

Why does the patella get painful? Inflammatory reaction due to • Excessive mechanical loading of the PFJ • Causing chemical irritation to the nerve endings and synovitis • Once inflamed, the synovitis is easily aggravated • Influenced by patellofemoral joint force

Underlying factors contributing to increased PFJ forces • Dynamic Q angle – Increased laterally directed forces

• Quadriceps dominance/tightness – Increase compressive forces across the PFJ

• 10 degree change in Q angle causes 45% increase in peak joint pressure

Q angle • Dynamic Q angle is more important than static • Internal rotation of femur, adduction of femur • Internal rotation of tibia, • Excessive pronation

Patello-femoral pain syndrome

WHAT DO WE LOOK FOR?

Subjective Examination PFPS • likely to involve running, weight bearing sport • Pain around the patella • Aggravated by stairs, hills, sitting prolonged • More common in female athletes

Patella Tendinopathy • Sports involving jumping and landing • Pain is usually around inferior pole of patella, and in patella tendon • Aggravated by jumping, mid to full squat • More common in males

Objective examination • Soft tissue tightness – calf, hamstring, quadriceps, ITB complex, hip flexors, adductors and internal rotators • Muscle weakness – hip abductors, external rotators, extensors, Quadriceps especially VMO, calf • Body structure – eg femoral anteversion, tibial torsion • foot biomechanics – excessive pronation • Poor core strength and stability • Muscle recruitment patterns

Objective • • • • • • • • •

Posture Functional tests Gait analysis Range of movement Motor control Muscle strength Muscle length Palpation Taping offload

Alignment and ground reaction force

jo martin strideuk.mp4

Courtesy Stride UK

Front on alignment

From behind alignment

Patello-femoral pain syndrome

PHYSIOTHERAPY MANAGEMENT

Physiotherapy management • • • • •

Historically Multifactorial problem Individual to each athlete Many different treatment approaches Address underlying causes • • • •

Tight muscles Weakness Poor alignment Poor core

Consequences of muscle tightness • Hamstrings – knee in flexion longer in early stance phase • Calf – over-pronation causing increased tibial rotation • TFL – increased internal rotation of femur • Adductors – increased adduction of femur, contributing to increased Q angle • Quadriceps and hip flexors – increased forces on PFJ stance phase

Lengthening soft tissue • Massage/soft tissue techniques • Stretches – Hamstring, calf, quads, hip flexors, TFL/ITB, gluteals – Need to be held at least 30 seconds, 60 seconds in middle aged

• Foam rolling – – – – –

Quadriceps ITB Calf Gluteal muscles Adductors

Gluteus medius function (Gmed) • External rotator of hip • 3 distinct parts • Posterior fibres seem more significant in PFPS than anterior fibres • Its importance in PFPS is being recognised recently (Gottschalk et al 1989)

Gluteus Medius weakness and PFPS • Boling et al 2009 – increased hip IR is a risk factor for PFPS • Increased hip IR in female runners with PFPS compared with control (Noehran et al 2011, Wirtz et al 2011) • Systematic review: reduced duration of and delay in activation of Gmed in several tasks in subjects with PFPS. (Barton et al 2013) • RCT: Hip strengthening exercises + closed kinetic chain (CKC) quads reduced pain perception and increased knee strength more than CKC exercises alone (Ismael et al 2013) • Systematic review showed proximal exercises more effective than quadriceps exercises only in reducing pain and improving function in PFPS (Peters et al 2013)

Gluteus Maximus Gluteus maximus weakness • Gmax is hip abductor, external rotator and extender • Can present with overactive TFL • And weak GMed • Balance between internal and external rotation forces are altered • If Gmax is weak  greater quadriceps force needed for extensor torque

Top 5 exercises that recruit Gluteus Medius • Side plank abduction with dominant leg on bottom • Side plank abduction with dominant leg on top • Single limb squat • Clam shell • Front plank with extension (Boren et al, 2013)

Front plank with extension

The Clam

Top 5 exercises that recruit Gluteus Maximus • Front plank with extension • Gluteal squeeze • Side plank abduction with dominant leg on top • Side plank abduction with dominant leg on bottom • Single limb squat

VMO function and PFPS • Vastis medialis obliquus – part of vastis medialis • Thought to have medial pull on patella • Historically this was thought to be the reason PFPS occurs • Thought there is a delay in onset of VMO compared to vastis lateralis

Research into VMO activation • VMO predictive of patella tilt at 0 degrees and 30 degrees cross sectional area of VMO • VMO activation in squat greater in adduction than abduction, Gluteus medius activation greater in hip abduction (Dias et al 2011) • Specific and general quad strength exercises both effective in treating PFPS (Hunt et al 2009) • Addition of adduction results are inconclusive

VMO strengthening exercises • • • • • • • •

Isometric quads, good alignment Wall squats Plie squats One leg dips Step ups/downs Standing squat Lunge forwards/backwards Jump lunge

VMO strengthening • Inner range exercises • Emphasising correct alignment of the lower limb • Start with isometric in standing • Progress to squats, one leg dip, squats, lunges, • Backwards lunges

Patellar taping • Underlying principle is to correct the position of the patella (primarily tilt) • To reduce pressure on lateral facet of femur and therefore correct patellar alignment • 50% reduction for it to be effective

Evidence around taping • Very variable results through all values assessed • Taping can reduce perceived pain (Osorio et al 2013, Earl & Hoch, 2011, Aminaka & Gribble, 2008)

• increase peak knee extension force (Handfield& Cramer, 2000, Herrington 2001,Salsich et al 2002, Osario et al 2013)

• However some studies say exactly the opposite (Tunay et al 2008) • Perhaps due to different taping methods, methodology, aspects measured, etc. • There appears to be be enough evidence to suggest that it may be effective and may be included as treatment of patellofemoral pain, but results are not conclusive

Orthotics • Moderate evidence to suggest that orthotics helpp in patello-femoral pain • Off the shelf orthotics can improve VMO and gluteus medius function in controlled movements but not in vertical jump (Hertel et al 2005).

Progressing to functional rehabilitation • Push outwards against band in standing • Sideways steps • Lunging forward/back • Jump lunge • High steps • 1 leg stand up

Functional rehabilitation • Progress back into running • Reduce from 4x/week to 3x/week • One session in gym – Pilates/strength& conditioning • Intervals to start with – run/walk • Increase time running/distance • Interval training – fast/slow • Fartlek training • Cross training – spin, bike, cross trainer

Questions ?

References: Available on request