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Patellofemoral Pain Syndrome

Patellofemoral disorders – a range of conditions which include Patellofemoral Pain Syndrome ( PFPS ) Also known by other names as runner’s knee , retropatellar pain syndrome , lateral facet compression syndrome , idiopathic anterior knee pain.

 

” Pain occurring around or behind the patella that is aggravated by atleast one activity that loads the patella during weight bearing on a flexed knee ” ( Crossley et al 2016 consensus statement from the 4th International Patellofemoral Pain Research Retreat Manchester )

 

common cause of knee pain in adolescents and adults < 60 one of the most common cause of knee pain seen in primary care ,orthopedics , sport setting , physiotherapy Patella-femoral knee injuries – constitute > 25 % of cases in orthopedic clinics PFS affects women more than men , ratio of 2 : 1 Estimated prevalence of 23 % in the general population in the UK Most commonly diagnosed knee condition in young individuals with knee pain

 

likely to be multifactorial PF jt junction – a complex interaction between static and dynamic structures that involve the entire lower extremity as the patella tracks in the trochlea involves 6 anatomic areas (1) subchondral bone (2) synovium (3) retinaculum (4) skin (5 ) nerve and (6) muscle Four major contributing factors thought to be important are Malalignment of the lower extremity and or patella Muscular imbalance of the lower extremity Overactivity / Overload Trauma

 

Risk factors -female sex female athletes ( particularly high risk ) participation in recreationally running or military training risk factors could also be intrinsic or extrinsic intrinsic risk factors which are modifiable include weak muscles ( hip abductors , external rotators , vastus medialis ) ; inflexibility of the iliotibial band , quadriceps , hamstring and gastro – soleus tendons ; foot over pronation ; increased joint forces with heel strike non- modifiable intrinsic factors include patella alta ( high riding patella ) , femoral anteversion , pes planus , age , gender and race extrinsic factors include training errors or overtraining , inappropriate running shoes , uphill training and hard playing surface.

 

Pain around or behind patella , which is aggravated by at least one activity that loads the patellofemoral jt during weight bearing on a flexed knee as squatting , stair ambulation , jogging / running , hopping / jumping.

 

A -crepitus or grinding sensation emanating from the PFjt during knee flexion movements B – tenderness on the patellar facet palpation C – small effusion D – pain on sitting , rising on sitting , or straightening the knee following sitting.

 

ROM is usually normal feel for the medial and lateral facets of patella patellar mobility may or may not be normal pain during squatting is highly sensitive ( no single test is diagnostic ) and PFP is evident in 80 % of people who are positive for this test tests with limited evidence
- patellar grinding and apprehension tests
- knee range of motion and effusion large effusions , erythema , increased warmth – should prompt you to consider an alternative diagnosis inspect gait and posture pain is nor present when the PF jt is not subject to loading or is being nor compressed for e.g when sleeping , standing or resting observe shoe wear pattern – excess wear on medial aspect may suggest pes pronatus.

 

Diagnosis is clinical with based on history and clinical examination History should cover aspects as
- date of symptom onset
- mechanism of injury ( if any ) or antecedent events
- location and quality of pain
- exacerbating and relieving factors
- relevant past history ( e.g previous knee surgery )
- occupational demands
- recreational activities
- foot wear Onset of pain can be slow or develop acutely Pain may be uni or bilateral Poorly localised behind or around the patella and may be of achy pr sharp in character Some patients may describe a giving way or a catching sensation PFPS is considered a diagnosis of exclusion Plain radiograph is reserved for cases which fail to improve to r/o conditions as bipartite patella , osteoarthritis , loose bodies , fracture XR findings do not correlate well with the presenting complain If requesting XR ask for weight bearing PA , weight bearing lateral and sunrise view Advanced imaging as MRI , musculoskeletal US and CT are usually not indicated and used to evaluate other pathology.

 

Retropatellar or peripatellar pain -Pain can be reproduced in the peripatellar or retropatellar region when squatting. Stair climbing , prolonged sitting or other functional activities which load the PFJ in a flexed position , Excluding other conditions which can also cause anterior knee pain

 

Articular cartilage injury Bone tumours Chondromalacia patella Pain localized in infrapatellar fat region ( Hoffa disease ) Iliotibial band syndrome Lateral patellar compression syndrome Loose bodies Osgood – Schlatter disease Osteochondritis dissecans Patellar instability / subluxation Patellar stress fracture Patellar tendinopathy Patellofemoral osteoarthritis Pes anserine bursitis Plica syndrome Prepatellar bursitis Quadriceps tendinopathy Referred pain ( for e.g lumbar spine , hip ) Symptomatic bipartite patella

 

No good guideline to follow for management Conservative management is the standard treatment Treatment can be split into 2 phases














 Several intervention are available which include education , exercise , taping , braces , foot arthroses , soft tissue manipulation and acupuncture Exercise – a combination of hip and knee targeted exercises Physiotherapy options as
- close chain strengthening exercises
- education and advice
- open chain strengthening exercises
- taping
- stretches Adjunctive interventions as foot arthroses , bracing , taping and injectibe therapies

 

long term prognosis may be poor ( described earlier as benign self limiting condition ) chronic pain – about 71 % to 91 % of patients may report chronic pain up to 20 yrs after the initial diagnosis increased risk of developing PF osteoarthritis ( possibly ) weight gain ( increased BMI ) higher than expected levels of disability PFP impacts function , ability to participate in leisure time activities , work , sport and reduces QoL

 

presence of any red flags no improvement following 3-6 months of extensive conservative management diagnostic uncertainty or worsening symptoms surgical treatment is considered in rare cases and involves principally one of three interventions patellar alignment , patellar resurfacing and patellar arthroplasty

REFERENCES

  1. Bump JM, Lewis L. Patellofemoral Syndrome. [Updated 2022 Feb 18]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK557657/
  2. Barton CJLack SHemmings S, et al The ‘Best Practice Guide to Conservative Management of Patellofemoral Pain’: incorporating level 1 evidence with expert clinical reasoning
  3. Patellofemoral Pain Clinical Practice Guidelines Linked to the International Classification of Functioning, Disability and Health From the Academy of Orthopaedic Physical Therapy of the American Physical Therapy Association J Orthop Sports Phys Ther. 2019;49(9):CPG1-CPG95. doi:10.2519/jospt.2019.0302
  4. Patellofemoral Syndrome Author(s): William F. Micheo, MD, Jose L. Rios Russo, MD, ATC, Richard Fontanez, MD, Gerardo Miranda-Comas, MD Originally published: July 20, 2012 Last updated: December 15, 2020 Patellofemoral Syndrome | PM&R KnowledgeNow (aapmr.org)

  5. Crossley KMStefanik JJSelfe J, et al 2016 Patellofemoral pain consensus statement from the 4th International Patellofemoral Pain Research Retreat, Manchester. Part 1: Terminology, definitions, clinical examination, natural history, patellofemoral osteoarthritis and patient-reported outcome measures
  6. Gaitonde DY, Ericksen A, Robbins RC. Patellofemoral Pain Syndrome. Am Fam Physician. 2019 Jan 15;99(2):88-94. PMID: 30633480.Patellofemoral Pain Syndrome – PubMed (nih.gov)

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