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Current Concepts of Patellofemoral Pain Syndrome

Introduction

Fredericson and Wolf (2005) state that the Iliotibial band syndrome is one of the major principal causes of pain experienced by athletes in the knees. According to the authors, the Iliotibial band syndrome (ITBS) occurs when the lateral femoral epicondyle and the Iliotibial band (ITB) slide against each other. In other words, ITBS occurs when the tissue (situated on the external section of the knee) sustains injuries from overuse (Fredericson & Wolf, 2005, p. 452). ITBS is caused by a number of factors such as running downhill and extreme running in a single direction. In many cases, the syndrome emerges when reduced knee flexion amplifies abrasion between the lateral epicondyle and the Iliotibial band. Thus, the Iliotibial band syndrome weakens knee extension and knee flexion among the affected athletes (Fredericson & Wolf, 2005, p. 453).

Patellofemoral pain syndrome (PFPS) is a common disorder among individuals with anterior knee pain. However, PFPS cannot be diagnosed among individuals experiencing anterior knee pain since it is caused by specific pathologies such as Hoffa’s diseases, Sinding’s lacerations, Johnson’s lacerations, and Osgood Schlatter’s lacerations. Patellofemoral (PF) is a suitable term for describing PFPS since clinicians are not able to differentiate which part of the femur or patella is damaged. The pain indicates only the symptom experienced by patients (Witvrouw et al., 2005, p. 123; Besier et al. 2005).

Statement of the Problem

Dye (2005) states that “patients with symptoms of patellofemoral pain present one of the most substantial challenges to the diagnostic and therapeutic abilities of orthopedic surgeons worldwide” (p. 100). The theory relating to the factors that cause anterior knee pain has gradually moved away from the traditional paradigm of the superlative significance of specific features (i.e. the existence of chondromalacia) to the importance of pathophysiologic aspects. The pathophysiologic processes (i.e. Amplified osseous metabolic activity of particular bone) have been reported to have more archaeological relevance (with respect to the origin of patellofemoral disorder) than the symptoms of malalignment. In addition, some patients with PFPS have also experienced peripatellar soft tissue neuromas (a condition that cannot be scientifically imaged by any modern technology). When put together, these biological conditions can be described as a loss of tissue homeostasis (Dye, 2005, p. 100). The following section presents a literature review relating to the various strategies used to treat PFPS.

Literature Review

Fredericson and Wolf (2005) have proposed several treatments and rehabilitation approaches for patients with ITBS. They assert that the initial treatment should focus on decreasing inflammation emanating from Iliotibial band friction. Other valuable modalities include ontophoresis, phonophoresis, and ice rubdown. The researchers suggest that the affected athletes should avoid aggravating activities such as downhill running, and cycling to decrease the recurrence of mechanical stress at the affected knee (Fredericson & Wolf, 2005, p. 455). The authors also propose various exercises that athletes can employ to reinforce their hip abductors.

For example, the Frontal Plane Lunges is an exercise whereby the subject assumes a standing position with the knees flexed slightly, legs spread slightly apart and abdominals curved in. The subject assumes this position until the gluteal muscles experience stress. The modified matrix exercise is also used to strengthen the hip abductors. This exercise is carried out when the subject is in an upright position. The feet must also be spread slightly apart and the abdominals are drawn in. Thereafter, the subject’s right foot assumes a 3 o’clock position while the left foot assumes a 12 o’clock position. The subject’s right arm is placed in a snatched position. Afterward, the subject attempts to simultaneously spin the hips in the direction of the left foot and relocate the load to the left foot. At the same time, the subject uses his/her left hand to reach a point between the knee and the left leg. The subject then spins the hip to the left in order to assume the initial position (Fredericson & Wolf, 2005, p. 457).

Dolak et al. (2011) performed a randomized clinical trial to establish whether hip strengthening exercise resulted in remarkable improvement among females with PFPS. The researchers compared the results with those of females who carried out quadriceps strengthening exercises. Participants were randomly divided into two groups. The first group (hip group) comprised participants enrolled in the hip strengthening exercise. The second group (quad group) comprised of participants enlisted in the quadriceps strengthening exercise (Dolak et al., 2011, p. 561).

The researchers administered the same rehabilitation exercise to both groups. The participants were required to execute an upright wall stretch, upright quadriceps stretch, and a horizontal hamstrings stretch during the entire study period. The participants were required to carry out the flexibility exercise followed by the strengthening training. The rehabilitation exercise was focused on the quadriceps and hip musculature. The rehabilitation program entailed carrying out hip and quadriceps strengthening exercises against a load equivalent to 7 percent of the total weight of the body (Dolak et al., 2011, p. 564).

According to Robinson and Nee (2007), PFPS is an orthopedic disorder that is prevalent among female athletes (p. 232). The authors state that the medical diagnosis of patellofemoral pain syndrome usually entails peripatellar knee pain that is exacerbated via extended sitting or activities that exert pressure on the patellofemoral joint (i.e. kneeling, jumping, or squatting). One of the widely acknowledged hypotheses relating to the causes of the patellofemoral pain syndrome is that anomalous patellar tracking augments stress on the patellofemoral joint and result in successive wear on the articular cartilage. It is against this backdrop that Robinson and Nee (2007) conducted a study to find out whether females in search of physical therapy for the lateral patellofemoral pain syndrome exhibited shortages in terms of hip abduction, hip extension, and hip rotation. The results were then compared with those of the non-PFPS controlled group. The researchers selected 20 participants, particularly women who had prior experience with unilateral PT joint disorder (Robinson & Nee, 2007, p. 233).

The researchers employed several criteria to select the PFPS participants. First, the selected participants were aged between 12 and 35 years. This age criterion was employed to prevent the likelihood that tibiofemoral osteoarthritis caused anterior knee pain. The second selection criterion was based on symptoms not associated with a distressing event. The third criterion was the retropatellar pain caused by physical activities such as prolonged sitting periods, squatting, and sports. The controlled group (n=10) consisted of female participants within the 12-35 age cohort and with no record of knee pathologies. Participants from both the controlled group and the PFPS group were disqualified from the study on the basis of the following reasons: prior record of knee operations, patellar dislocation, and muscular pathology. In addition, a dynamometer was used to test various characteristics of the study sample. For example, the instrument measured the isometric potency of the hip abduction, hip extension, and hip rotation. Robinson and Nee (2007) state that the dynamometer is a reliable instrument since previous studies have reported analogous correlation coefficient values after using it (p. 234).

Each participant was required to lie on one side to enable the researchers to administer the isometric strength test for hip abduction. The inspector steadied the pelvis and exerted force (with the HHD just next to the tangential malleolus). The hip extension test was administered with the participant lying on the healing table. In addition, the knee was flexed to 900. The researchers steadied the pelvis and exerted weight (with the HDD placed against the distal posterior thigh). Finally, the participant was required to sit on the periphery of the healing table with the knees and hips flexed to 900 so that the isometric strength testing of the hip external rotation could be administered (Robinson & Nee, 2007, p. 234).

In another related study, Witvrouw et al. (2005) conducted a qualitative study in order to assist doctors and clinicians in developing a non-operative therapeutic procedure for patients with patellofemoral pain (p. 122). The authors assert that the clinical diagnosis of the patellofemoral joint should not only lend credence to the identification of the malalignment in the patellofemoral joint but also the physician should strive to determine whether the muscular/non-muscular structures result in the PF malalignment. They also suggest that the quadriceps contraction should be used to examine patellofemoral malalignment. The authors quote several studies which showed that the quadriceps contraction technique revealed patellofemoral malalignment in 52 percent of the patients experiencing PFPS. Accordingly, many researchers believe that the pain in the PF joint is principally caused by the quadriceps. The authors suggest that the PF therapy should lend credence to revitalizing the quadriceps muscle. In addition, the physician must carry out a muscular assessment in order to administer this treatment protocol in an effective manner (Witvrouw et al., 2005, p. 125).

Dye (2005) conducted a thorough investigation to determine whether previous activities contributed to the appearance of the PF symptoms. He also recorded patients’ activities that aggravated pain and suggested ways to reduce them. Although the researcher does not recommend any therapeutic technique, he nonetheless suggests that patients experiencing PFPS should maintain an active life as much as possible in order to exercise the affected PF joint. The researcher notes that the PF joints can steadily endure some mild activities such as moderate bicycling and swimming which are known to improve joint range of motion, muscle tone, and muscle strength without exerting undue pressure on the damaged joint. In addition, he recommends an anti-inflammatory exercise that encompasses numerous periods of short (approximately 16 minutes) tissue cooling every day. The author also suggests that clinicians should prescribe suitable anti-inflammatory drugs for patients with patellofemoral pain syndrome to help them manage the condition (Dye, 2005, p. 106).

According to Dye (2005), patellofemoral taping is an effective technique that can substantially reduce PF joint pain. This technique usually entails tapping the skin covering the PT joint. However, a physician must be present to supervise the adoption of this technique. Dye (2005) states further that the PF joint is extremely sensitive and cannot endure any clinical technique that undermines its biomechanical and biologic features. Consequently, the author suggests that a mild technique should be employed when treating the PF joint. The main objective should be to optimize the functionality of the PF joint in a safe and sound manner. Once the functionality of the PF joint has been optimized, the patient should be encouraged to exert some weight on the joint in a steady manner. In a nutshell, the researcher recommends that the treatment intervention must conform to the biomechanical features of the affected joint (Dye, 2005, p. 107).

Feller et al. (2007) echo similar sentiments in a study that sought to review data relating to the existing knowledge of the biomechanical characteristics of the PF joints. The researchers state that surgical procedures relating to PF malalignment differ significantly. What is more, a considerable number of doctors employ a small number of techniques to rectify PT experienced by different patients. The authors suggest that a femoral rotational osteotomy is an important surgical procedure that physicians can use to address patellofemoral pain syndrome. The surgical procedure is based on the idea of inserting the trochlear groove beneath the patella as opposed to inserting the patella into the trochlear groove (Feller et al., 2007, p. 550). Amis et al. (2005) also report that a femoral rotational osteotomy is an important surgical procedure with respect to the management of PT malalignment among patients. Feller et al. (2007) observe that orthopedic surgeons must examine all the biomechanical and soft-tissue characteristics of the patella in order to manage PT malalignment effectively. The surgical procedure relating to PT malfunction must be planned well and take into account the unique anatomy of the affected joint. The researchers recommend that clinicians must have a variety of surgical options at their disposal in order to systematically deal with the biomechanical characteristics of the affected joint. The surgeons must also be alive to the fact that adjustments in the joint alignment can lead to considerable modifications in PT joint stresses (Feller et al., 2007, p. 551).

The role of the lateral release in PFPS treatment is highlighted in a study by Amis et al. (2005). However, some researchers claim that the procedure is controversial. For instance, some studies have reported that lateral release reduces patellar stability among recuperating patients. In addition, the lateral retinacular release has a limited impact on patellofemoral joint loading. It appears that arthroscopic releases usually focus on dissimilar structures (i.e. Interior layers). However, Amis et al. (2005) report that lateral release is currently used in some parts of the malfunctioning joint to rectify extreme lateral patellar tilt in a steady but sore knee. The procedure is also important in restoring patella stability. In another related study, Elias et al. (2006) noted that the reconstruction of the medial patellofemoral ligament (MPFL) using a stiff graft can dramatically improve the PF joint loading if there are small faults in the graft length (p. 1478).

In a related study, Naslund et al. (2006) investigated symptoms and experimental results among groups of patients with patellofemoral pain syndrome. The participants were categorized according to the results of their respective radiology tests. The results were later contrasted with those of the knee-fit participants. A physical therapist and an orthopedic doctor examined 80 patients suffering from patellofemoral pain syndrome. The physical therapist and the orthopedic doctor administered medical tests and analyzed previous cases of PFPS among the participants. In addition, a compression test was administered on the patella with the knee extended and the quadriceps muscles unperturbed. The participants were then requested to state whether they felt any pain during the compression exercise (Naslund et al., 2006, p. 110).

Crossley et al. (2006) carried out an RCT (randomized controlled trial) to investigate the effectiveness of physical therapy in alleviating PT pain and disability. The study aimed to evaluate whether participants (indiscriminately assigned to the physical rehabilitation cluster) achieved a higher increase in instance-stage knee flexion. The results were then compared with those of the participants in the placebo therapy cluster. The cohort of this study consisted of participants (n=40) who enlisted in the larger randomized, controlled trial. The components for the physical therapy treatment included: gluteal reinforcement, revitalizing of the PF joint via a wide range of exercises, and patella tapping to decrease PF joint pain (Crossley et al., 2006, p. 117).

Discussion

As noted above, there is no consensus regarding the best treatment approach for addressing symptoms of PFPS among patients. As of now, clinicians generally agree that a standard patellofemoral pain syndrome is missing (Christoforakis et al., 2006). Consequently, a common treatment procedure cannot be provided (Witvrouw, 2005). Nonetheless, the literature review in the preceding section has attempted to reveal some common characteristics of PFPS. They include limited elasticity of the hamstrings, quadriceps, Soleus, and gastrocnemius (Piva, Goodnite & Childs, 2005). Some studies have also demonstrated the importance of patellofemoral (Dye 2005), and placebo tapings (Crossley et al., 2006) as effective techniques that can substantially reduce the pain in PF joints. These techniques usually entail tapping the foreskin of the PT joint (subject to the guidance of a physician) in order to rectify the malalignment. According to the findings above, effective treatment of PFPS must take into account the patient’s prior experience with PFPS. Such information is crucial in determining the most appropriate remedial intervention for joint malalignment.

Dolak et al. (2011) found that the hip strengthening exercise was more effective than the quadriceps strengthening exercise in reducing pain among females experiencing patellofemoral pain syndrome. Accordingly, the researchers noted that hip strengthening is an effective technique in decreasing pain as well as enhancing the functionality of the hip musculature (Dolak et al., 2011, p. 568).

Conclusion

The findings by Dolak et al. (2011) suggest that hip strengthening exercise is an effective strategy for decreasing pain and improving the performance of the hip musculature. The participants who enrolled in the hip strengthening program reported a dramatic decrease in knee pain within a short time. On the contrary, those who underwent quadriceps strengthening exercises needed more time before attaining similar results. The researchers concluded that hip strengthening is an important exercise in reducing hip pain. Fredericson and Wolf (2005) also concur that a biomechanical technique should be adopted in the treatment of ITBS. They assert further that biomechanical techniques can effectively rectify unevenness in the lateral hip muscles. Finally, they propose that tissue strengthening and massage exercises should be used in improving triplanar movement patterns among patients with ITBS.

References

Amis, A., Oguz, C., Dejour, D., & Senavongse, W. (2005). The effect of trochleoplasty on patellar stability and tracking in-vitro. Hollywood, FL: International Society of Arthroscopy, Knee Surgery and Orthopaedic Sports.

Besier, F., Draper, E., Gold, E., Beaupre, S., & Delp, L. (2005). Patellofemoral joint contact area increases with knee flexion and weight-bearing. J Orthop Res, 23, 345-350.

Christoforakis, J., Bull, AM., Strachan, K., Shymkiw, R., Senavongse, W., & Amis, A. (2006). Effects of lateral retinacular release on the lateral stability of the patella. Knee Surg Sports Traumatol Arthrosc, 14, 273-277.

Crossley, K., Cowan, S., McConnell, J., Bennell, K. (2006). Physical Therapy Improves Knee Flexion during Stair Ambulation in Patellofemoral Pain. Medicine & Science In Sports & Exercise, 176-183.

Dolak, K., Silkman, C., Mickeon, J., Hosey, R., Lattermann, C., Uhl, T. (2011). Hip Strengthening Prior to Functional Exercises Reduces Pain Sooner Than Quadriceps Strengthening in Females With Patellofemoral Pain Syndrome: A Randomized Clinical Trial. Journal of Orthopaedic & Sports Physical Therapy, 41(8), 560-571.

Dye, F. (2005). The Pathophysiology of Patellofemoral Pain: A Tissue Homeostasis Perspective. Clinical Orthopaedics And Related Research, 436, 100–110.

Elias, J., & Cosgarea, J. (2006). Technical errors during medial patellofemoralligament reconstruction could overload medial patellofemoral cartilage: A computational analysis. Am JSports Med, 34,1478-1485.

Feller, J., Amis, A., Andrish, J., Arendt, E., Erasmus, P., & Powers, C. (2007). Surgical Biomechanics of the Patellofemoral Joint. The Journal of Arthroscopic and Related Surgery, 23(5), 542-553.

Fredericson, M., & Wolf, C. (2005). Iliotibial Band Syndrome in Runners: Innovations in Treatment. Sports Med, 35 (5), 451-459.

Naslund, J., Naslund, U., Odenbring, S., & Lundeberg, T. (2006). Comparison of symptoms and clinical findings in subgroups of individuals with patellofemoral pain. Physiotherapy Theory and Practice, 22(3), 105-118,

Piva, S., Goodnite, E., & Childs, J. (2005). Strength Around the Hip and Flexibility of Soft Tissues in Individuals With and Without Patellofemoral Pain Syndrome. Orthop Sports Phys Ther, 35, 793-801.

Robinson, R., & Nee, R. (2007). Analysis of Hip Strength in Females Seeking Physical Therapy Treatment for Unilateral Patellofemoral Pain Syndrome. Journal Of Orthopaedic & Sports Physical Therapy, 7(5), 232-238.

Witvrouw, E., Werner, S., Mikkelsen, C., Tiggelen, D., & Cerulli, G. (2005). Clinical classification of patellofemoral pain syndrome: guidelines for non-operative treatment. Knee Surg Sports Traumatol Arthrosc, 13, 122–130.

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