Physiotherapy as primary treatment approach for Patellofemoral Pain Syndrome

Patellofemoral Syndrome, often referred to as PFPS, is a condition that commonly affects the knee joint. Patellofemoral Syndrome occurs when there is an imbalance or dysfunction in the way the patella moves within the femoral groove. This results in pain, discomfort, and sometimes a grating sensation during activities that involve bending the knee, such as walking, running, or climbing stairs.

In a healthy knee, the patella moves smoothly within its groove, guided by the surrounding muscles, ligaments and tendons. However, when PFPS strikes, the movement is abrupt and gliding does not occur properly. This leads  to irritation, inflammation, and pain around the knee joint.

Remember, PFPS can be frustrating, but it's a condition that can be managed and even resolved with the right treatment choice. As a physiotherapist the goal is to work on strengthening the muscles around the knee, improving flexibility, and correcting any movement patterns that might be contributing to the problem. 

 

Signs and symptoms of Patellofemoral Syndrome (PFPS)

• Knee Pain which is dull ache or a sharp stabbing is felt behind the patella
• Pain increases with activities that involve bending the knee, such as walking, running, squatting, or going up and down stairs.
• Some individuals may notice a crepitus
• Swelling around the knee joint
• Stiffness in the knee joint is seen making it difficult to extend or flex the knee.
• Weakness of the quadriceps muscles
• Pain may worsen after sitting for extended periods of time
• Tenderness around the patella
• Reduced activity of daily living due to pain

 

Risk factors associated with Patellofemoral Syndrome

• Weakness or tightness in the quadriceps increases the risk of PFPS.
• Individuals with poor lower limb biomechanics, such as increased pronation (excessive inward rolling of the feet) or a high Q-angle (the angle between the hip and knee), may be more prone to PFPS.
• Ligament sprains or meniscal tears can lead to altered joint mechanics and cause PFPS.
• Improper Footwear cause insufficient shock absorption thus increasing the impact on the knee joint during activities.
• Repetitive knee flexion and extension can strain the knee joint and contribute to PFPS.
• Females are more susceptible.
• Sports activities that involve frequent jumping, squatting, or running, such as basketball, volleyball etc. increases the risk.
• Not incorporating warm-up before physical activity.
• Being overweight increase weight bearing on joint which  contribute to pain and dysfunction.

 

Diagnosing Patellofemoral Syndrome (PFPS)

Clinical Tests

Patellar Tilt Test (Clark's Test):

1. The patient is positioned supine down with his knee extended.
2. The therapist places his hand on the upper part of the patella and applies pressure in lateral direction (towards the outer side of the knee) while asking the patient to gently contract their quadriceps.
3. A positive test is indicated by pain or discomfort under the patella, which suggests abnormal patellar tracking.

Patellar Apprehension Test:

1. The patient lies prone with his knee extended.
2. The therapist gently pushes the patella laterally (toward the outer side of the knee) while observing the patient's reaction.
3. A positive test result occurs when the patient shows apprehension or discomfort as if he is guarding against the patella dislocating.

Patellar Grind Test (Clarke's Sign):

1. The patient is supine lying with the knee extended.
2. The therapist places his thumb or fingers just above the patella and applies downward pressure while asking the patient to contract his quadriceps while extending the knee.
3. Pain or discomfort under the patella during this maneuver is considered a positive test result.

Step-Down Test:

1. This functional test assesses how the patella behaves during activities.
2. The patient stands on a step or platform and performs a controlled step-down movement, typically with one leg at a time.
3. The physiotherapist observes for any abnormal patellar tracking, pain, or instability during the movement.

Single-Leg Squat Test:

The patient is asked to perform a single-leg squat while the therapist observes their knee alignment, tracking, and any signs of pain or instability.

Biomechanical Assessment:

It is crucial to analyze the patient's gait and lower limb alignment to identify any biomechanical issues contributing to PFPS.

Pelvic Tilt and Lumbopelvic Control:

Assess the patient's pelvic alignment during walking. Look for excessive anterior or posterior pelvic tilt, as poor lumbopelvic control can affect lower limb biomechanics.

Hip, Knee, and Ankle Motion:

Observe the range of motion at the hip, knee, and ankle joints during walking. Pay attention to hip adduction, knee valgus (knock-knee), and ankle pronation or supination.

Step Length and Cadence:

Measure step length and cadence (step rate) to identify any asymmetries or abnormalities.

Foot Strike Pattern:

Determine the patient's foot strike pattern (heel strike, midfoot strike, forefoot strike) during the gait cycle.

The Relationship with PFPS:

The relationship between foot strike patterns and PFPS is complex, and the impact of foot strike on PFPS varies from person to person. Some individuals with PFPS may benefit from altering their foot strike pattern to reduce excessive stress on the knee joint. Here are some considerations:

• Heel Strikers with PFPS: Heel strikers may be at a higher risk of PFPS due to the impact forces transmitted through the heel and up the leg. Transitioning to a midfoot or forefoot strike pattern might help reduce these forces.
• Midfoot and Forefoot Strikers with PFPS: These individuals may already have a foot strike pattern that is potentially less stressful on the knee joint. However, other biomechanical factors, such as hip and knee alignment, muscle imbalances, and gait mechanics, can still contribute to PFPS.

Treatment Plan

Range of Motion Exercises:

ROM exercises help in addressing any knee stiffness and improve flexibility. Few examples are listed below

• Knee Flexion and Extension
• Heel Slides
• Ankle Pumps
• Seated Knee Circles
• Hip Flexor Stretch

 

Strengthening Exercises:

These exercises focus on strengthening the muscles around the knee, especially the quadriceps, hamstrings, and gluteus muscles. It is important to progress the exercises as the patient's strength improves.

• Quad isometrics
• Straight Leg Raises
• Terminal Knee Extension
• Step-Ups – as if climbing a staircase
• Lateral Leg Raises
• Clamshells
• Bridging exercise

 

Stretching Exercises:

Stretching can help reduce muscle imbalances and improve knee alignment. The muscles to be targeted are listed below:

• Quadriceps Stretch
• Hamstring Stretch
• Calf Stretch
• Iliotibial Band (ITB) Stretch
• Hip Flexor Stretch
• Butterfly Stretch
• Piriformis Stretch
• Gastrocnemius Stretch

Patellar Mobilization:

Techniques like patellar mobilization is used by the physiotherapists to improve patellar tracking.

Patellar Glides:

• Supine Glide: The patient lies prone with the knee extended. The therapist uses his hands to gently guide the patella in an upward and downward motion, within the femoral groove.
• Medial and Lateral Glide: Similar to the supine glide, but with the therapist applying gentle pressure to move the patella medially (toward the inside of the knee) and laterally (toward the outside of the knee).

 

Patellar Tilt Correction:

In this technique, the therapist uses his hands to guide the patella into its proper alignment, reducing any lateral tilt or mal-tracking. The patient may be in a sitting or lying position with the knee slightly flexed.

 

Mobilization with Movement (MWM):

MWM involves applying a gentle sustained force while the patient performs a specific movement. For patellar mobilization, the therapist may use a hands-on technique to guide the patella while the patient performs exercises like knee flexion and extension.

 

Patellar Distraction:

This technique involves applying gentle upward traction to the patella to relieve pressure and improve alignment within the femoral groove. The patient is usually in a sitting or supine position.

Patellar Mobilization with Soft Tissue Release:

In conjunction with patellar mobilization, the therapist may incorporate soft tissue techniques to release tight or adhered structures around the knee joint, such as the quadriceps and iliotibial band (ITB).

Other Methods:

Taping Techniques:

Patellar taping can be used to provide temporary support and improve patellar tracking. Techniques like McConnell taping or Kinesio taping may be employed by a skilled physiotherapist.

Patellar Mobilization Devices:

Some physiotherapists use specialized devices or tools designed for patellar mobilization. These tools can provide controlled and precise mobilization of the patella.