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Current Reviews in Musculoskeletal Medicine
Published in: Current Reviews in Musculoskeletal Medicine 4/2019

01-12-2019 | Non-Operative Management of Anterior Knee Pain (M Fredericson and T Besier, Section Editors)

Update of Risk Factors, Diagnosis, and Management of Patellofemoral Pain

Authors: Daniel Sisk, Michael Fredericson

Published in: Current Reviews in Musculoskeletal Medicine | Issue 4/2019

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Abstract

Purpose of Review

Patellofemoral pain is the most common cause of anterior knee pain. The purpose of this review is to examine the latest research on risk factors, physical examination, and treatment of patellofemoral pain to improve accuracy of diagnosis and increase use of efficacious treatment modalities.

Recent Findings

The latest research suggests patellofemoral pain pathophysiology is a combination of biomechanical, behavioral, and psychological factors. Research into targeted exercise therapy and other conservative therapy modalities have shown efficacy especially when used in combination. New techniques such as blood flow restriction therapy, gait retraining, and acupuncture show promise but require further well-designed studies.

Summary

Patellofemoral pain is most commonly attributed to altered stress to the patellofemoral joint from intrinsic knee factors, alterations in the kinetic chain, or errors in training. Diagnosis can be made with a thorough assessment of clinical history and risk factors, and a comprehensive physical examination. The ideal treatment is a combination of conservative treatment modalities ideally individualized to the risk factors identified in each patient. Ongoing research should continue to identify biomechanical risk factors and new treatments as well as look for more efficient ways to identify patients who are amenable to treatments.
Literature
1.
2.
3.
Heino BJ, Powers C. Patellofemoral stress during walking in persons with and without patellofemoral pain. Med Sci Sports Exerc. 2002;34:1582–93.
4.
Brechter J, Powers C. Patellofemoral joint stress during stair ascent and descent in persons with and without patellofemoral pain. Gait Posture. 2002;16:115–23.PubMed
5.
Wirtz A, Willson J, Kernozek T, Hong D. Patellofemoral joint stress during running in females with and without patellofemoral pain. Knee. 2012;19:703–8.PubMed
6.
Chen Y, Powers C. Comparison of three-dimensional patellofemoral joint reaction forces in persons with and without patellofemoral pain. J Appl Biomech. 2014;30:493–500.PubMed
7.
Pattyn E, Verdonk P, Steyaert A, Vanden Bossche L, Van den Broecke W, Thijs Y, et al. Vastus medialis obliquus atrophy. Am J Sports Med. 2011;39:1450–5.PubMed
8.
Giles L, Webster K, McClelland J, Cook J. Atrophy of the quadriceps is not isolated to the vastus medialis oblique in individuals with patellofemoral pain. J Orthop Sports Phys Ther. 2015;45:613–9.PubMed
9.
Lankhorst N, Bierma-Zeinstra S, van Middelkoop M. Risk factors for patellofemoral pain syndrome: a systematic review. J Orthop Sports Phys Ther. 2012;42:81–A12.PubMed
10.
Pappas E, Wong-Tom W. Prospective predictors of patellofemoral pain syndrome. Sports Health: A Multidisciplinary Approach. 2012;4:115–20.
11.
12.
Cowan S, Hodges P, Bennell K, Crossley K. Altered vastii recruitment when people with patellofemoral pain syndrome complete a postural task. Arch Phys Med Rehabil. 2002;83:989–95.PubMed
13.
Voight M, Wieder D. Comparative reflex response times of vastus medialis obliquus and vastus lateralis in normal subjects and subjects with extensor mechanism dysfunction. Am J Sports Med. 1991;19:131–7.PubMed
14.
Pal S, Besier T, Draper C, Fredericson M, Gold G, Beaupre G, et al. Patellar tilt correlates with vastus lateralis: vastus medialis activation ratio in maltracking patellofemoral pain patients. J Orthop Res. 2012;30:927–33.PubMed
15.
Pal S, Draper C, Fredericson M, Gold G, Delp S, Beaupre G, et al. Patellar maltracking correlates with vastus medialis activation delay in patellofemoral pain patients. Am J Sports Med. 2010;39:590–8.PubMedPubMedCentral
16.
Briani R, de Oliveira SD, Pazzinatto M, Ferreira A, Ferrari D, de Azevedo F. Delayed onset of electromyographic activity of the vastus medialis relative to the vastus lateralis may be related to physical activity levels in females with patellofemoral pain. J Electromyogr Kinesiol. 2016;26:137–42.PubMed
17.
Souza R, Draper C, Fredericson M, Powers C. Femur rotation and patellofemoral joint kinematics: a weight-bearing magnetic resonance imaging analysis. J Orthop Sports Phys Ther. 2010;40:277–85.PubMed
18.
Powers C, Ward S, Fredericson M, Guillet M, Shellock F. Patellofemoral kinematics during weight-bearing and non-weight-bearing knee extension in persons with lateral subluxation of the patella: a preliminary study. J Orthop Sports Phys Ther. 2003;33:677–85.PubMed
19.
Hetsroni I, Finestone A, Milgrom C, Sira D, Nyska M, Radeva-Petrova D, et al. A prospective biomechanical study of the association between foot pronation and the incidence of anterior knee pain among military recruits. J Bone Joint Surg Br. 2006;88-B:905–8.
20.
Boling M, Padua D, Marshall S, Guskiewicz K, Pyne S, Beutler A. A prospective investigation of biomechanical risk factors for patellofemoral pain syndrome. Am J Sports Med. 2009;37:2108–16.PubMedPubMedCentral
21.
Reischl S, Powers C, Rao S, Perry J. Relationship between foot pronation and rotation of the tibia and femur during walking. Foot Ankle Int. 1999;20:513–20.PubMed
22.
Powers C, Berke G, Clary M, Fredericson M. Patellofemoral pain: is there a role for orthoses? PM&R. 2010;2:771–6.
23.
Powers C. The influence of altered lower-extremity kinematics on patellofemoral joint dysfunction: a theoretical perspective. J Orthop Sports Phys Ther. 2003;33:639–46.PubMed
24.
Dowling G, Murley G, Smith M, Munteanu S, Collins N. Dynamic foot function as a risk factor for lower limb overuse injury: a systematic review. J Sci Med Sport. 2014;18:e110.
25.
Van Cant J, Pineux C, Pitance L. Hip muscle strength and endurance in females with patellofemoral pain: a systematic review with meta-analysis. International journal of Sports Phsyaical Therapy. 2014;9(5):564–82.
26.
Prins M, van der Wurff P. Females with patellofemoral pain syndrome have weak hip muscles: a systematic review. Australian J Physiotherapy. 2009;55:9–15.
27.
Rathleff M, Rathleff C, Crossley K, Barton C. Is hip strength a risk factor for patellofemoral pain? A systematic review and meta-analysis. Br J Sports Med. 2014;48:1088.PubMed
28.
29.
Souza R, Powers C. Differences in hip kinematics, muscle strength, and muscle activation between subjects with and without patellofemoral pain. J Orthop Sports Phys Ther. 2009;39:12–9.PubMed
30.
Neal B, Barton C, Birn-Jeffery A, Morrissey D. Increased hip adduction during running is associated with patellofemoral pain and differs between males and females: a case-control study. J Biomech. 2019;91:133–9.PubMed
31.
Merican A, Amis A. Anatomy of the lateral retinaculum of the knee. J Bone Joint Surg Br. 2008;90-B:527–34.
32.
Hudson Z, Darthuy E. Iliotibial band tightness and patellofemoral pain syndrome: a case-control study. Man Ther. 2009;14:147–51.PubMed
33.
Schoots E, Tak I, Veenstra B, Krebbers Y, Bax J. Ultrasound characteristics of the lateral retinaculum in 10 patients with patellofemoral pain syndrome compared to healthy controls. J Bodyw Mov Ther. 2013;17:523–9.PubMed
34.
Kang S, Choung S, Park J, Jeon H, Kwon O. The relationship between length of the iliotibial band and patellar position in Asians. Knee. 2014;21:1135–8.PubMed
35.
Merican A, Amis A. Iliotibial band tension affects patellofemoral and tibiofemoral kinematics. J Biomech. 2009;42:1539–46.PubMed
36.
Lack S, Anthony L, Noake J, Brennan K, Zhang B, Morrissey D. Medial and lateral patellofemoral joint retinaculum thickness in people with patellofemoral pain: a case-control study. J Ultrasound Med. 2018;38:1483–90.PubMed
37.
Witvrouw E, Lysens R, Bellemans J, Cambier D, Vanderstraeten G. Intrinsic risk factors for the development of anterior knee pain in an athletic population: a two-year prospective study. Am J Sports Med. 2000;28:480–9.PubMed
38.
Smith A, Stroud L, McQueen C. Flexibility and anterior knee pain in adolescent elite figure skaters. J Pediatr Orthop. 1991;11:77–82.PubMed
39.
Piva S, Goodnite E, Childs J. Strength around the hip and flexibility of soft tissues in individuals with and without patellofemoral pain syndrome. J Orthop Sports Phys Ther. 2005;35:793–801.PubMed
40.
Post W, Dye S. Patellofemoral pain: an enigma explained by homeostasis and common sense. Am J Orthop. 2017;46:92–100.PubMed
41.
Dye S, Chew M. The use of scintigraphy to detect increased osseous metabolic activity about the knee. J Bone Joint Surg. 1993;75:1388–406.
42.
Draper C, Fredericson M, Gold G, Besier T, Delp S, Beaupre G, et al. Patients with patellofemoral pain exhibit elevated bone metabolic activity at the patellofemoral joint. J Orthop Res. 2011;30:209–13.PubMedPubMedCentral
43.
dos Santos A, Nakagawa T, Serrão F, Ferber R. Patellofemoral joint stress measured across three different running techniques. Gait Posture. 2019;68:37–43.PubMed
44.
Willson J, Ratcliff O, Meardon S, Willy R. Influence of step length and landing pattern on patellofemoral joint kinetics during running. Scand J Med Sci Sports. 2015;25:736–43.PubMed
45.
Macera C. Predicting lower-extremity injuries among habitual runners. Arch Intern Med. 1989;149(2565–2568):69.
46.
Marti B, Vader J, Minder C, Abelin T. On the epidemiology of running injuries. Am J Sports Med. 1988;16:285–94.PubMed
47.
Nielsen R, Parner E, Nohr E, Sørensen H, Lind M, Rasmussen S. Excessive progression in weekly running distance and risk of running-related injuries: an association which varies according to type of injury. J Orthop Sports Phys Ther. 2014;44:739–47.PubMed
48.
Fredericson M, Patellofemoral pain syndrome, O’Connor F, Wilder R, Nirschl R. Textbook of running medicine. New York: McGraw-Hill, Medical Pub. Division; 2001. p. 169–79.
49.
Lopes Ferreira C, Barton G, Delgado Borges L, dos Anjos RN, Politti F, Garcia Lucareli P. Step down tests are the tasks that most differentiate the kinematics of women with patellofemoral pain compared to asymptomatic controls. Gait Posture. 2019;72:129–34.PubMed
50.
Fredericson M, Yoon K. Physical examination and patellofemoral pain syndrome. Am J Phys Med Rehabil. 2006;85:234–43.PubMed
51.
Brattström H. Shape of the intercondylar groove normally and in recurrent dislocation of patella: a clinical and X-ray anatomical investigation. Acta Orthop Scand. 1964;35:1–148.
52.
Aglietti P, Insall J, Cerulli G. Patellar pain and incongruence. Clinical Orthopaedics and Related Research &NA. 1983:217–24.
53.
Caylor D, Fites R, Worrell T. The relationship between quadriceps angle and anterior knee pain syndrome. J Orthop Sports Phys Ther. 1993;17:11–6.PubMed
54.
Draper C, Chew K, Gold G, Fredericson M. Comparison of quadriceps angle measurements using short-arm and long-arm goniometers. PM&R J. 2011;3(2):111–6.
55.
Boden B, Pearsall A, Garrett W, Feagin J. Patellofemoral instability: evaluation and management. J Am Acad Orthop Surg. 1997;5:47–57.PubMed
56.
Nunes G, Stapait E, Kirsten M, de Noronha M, Santos G. Clinical test for diagnosis of patellofemoral pain syndrome: systematic review with meta-analysis. Physical Therapy in Sport. 2013;14:54–9.PubMed
57.
Fredericson M, Powers C. Practical management of patellofemoral pain. Clin J Sport Med. 2002;12:36–8.PubMed
58.
•• Collins N, Barton C, van Middelkoop M, et al. 2018 Consensus statement on exercise therapy and physical interventions (orthoses, taping and manual therapy) to treat patellofemoral pain: recommendations from the 5th International Patellofemoral Pain Research Retreat, Gold Coast, Australia, 2017. Br J Sports Med. 2018;52:1170–8 Consensus statement recommendations for treatment modalities for patellofemoral pain based on literature review of studies up to 2018. PubMed
59.
• Kooiker L, Van De Port I, Weir A, Moen M. Effects of physical therapist–guided quadriceps-strengthening exercises for the treatment of patellofemoral pain syndrome: a systematic review. Journal of Orthopaedic & Sports Physical Therapy. 2014;44:391-B1 Systematic review showing the benefit of generalized quadriceps strengthening in treatment of patellofemoral pain.
60.
Mason M, Keays S, Newcombe P. The effect of taping, quadriceps strengthening and stretching prescribed separately or combined on patellofemoral pain. Physiother Res Int. 2010;16:109–19.PubMed
61.
Powers C. Rehabilitation of patellofemoral joint disorders: a critical review. J Orthop Sports Phys Ther. 1998;28:345–54.PubMed
62.
Fredericson M. Lift less and gain more muscle with blood flow restriction training. Men's Health. 2019.
63.
• Giles L, Webster K, Mc Clelland J, Cook J. Quadriceps strengthening with and without blood flow restriction in the treatment of patellofemoral pain: a double-blind randomised trial. Br J Sports Med. 2017;51:1688–94 A randomized control trial showed short-term benefits of blood flow restriction therapy adjunct to traditional quadriceps strengthening. PubMed
64.
Syme G, Rowe P, Martin D, Daly G. Disability in patients with chronic patellofemoral pain syndrome: a randomised controlled trial of VMO selective training versus general quadriceps strengthening. Man Ther. 2009;14:252–63.PubMed
65.
Yip S, Ng G. Biofeedback supplementation to physiotherapy exercise programme for rehabilitation of patellofemoral pain syndrome: a randomized controlled pilot study. Clin Rehabil. 2006;20:1050–7.PubMed
66.
Bennell K, Duncan M, Cowan S, McConnell J, Hodges P, Crossley K. Effects of vastus medialis oblique retraining versus general quadriceps strengthening on vasti onset. Med Sci Sports Exerc. 2010;42:856–64.PubMed
67.
Crossley K, Cowan S, McConnell J, Bennell K. Physical therapy improves knee flexion during stair ambulation in patellofemoral pain. Med Sci Sports Exerc. 2005;37:176–83.PubMed
68.
Fukuda T, Melo W, Zaffalon B, Rossetto F, Magalhães E, Bryk F, et al. Hip posterolateral musculature strengthening in sedentary women with patellofemoral pain syndrome: a randomized controlled clinical trial with 1-year follow-up. J Orthop Sports Phys Ther. 2012;42:823–30.PubMed
69.
70.
Nakagawa T, Muniz T, Baldon R, Dias Maciel C, de Menezes RR, Serrão F. The effect of additional strengthening of hip abductor and lateral rotator muscles in patellofemoral pain syndrome: a randomized controlled pilot study. Clin Rehabil. 2008;22:1051–60.PubMed
71.
Rogan S, Haehni M, Luijckx E, Dealer J, Reuteler S, Taeymans J. Effects of hip abductor muscles exercises on pain and function in patients with patellofemoral pain. J Strength Cond Res. 2018;1.
72.
Keays S, Mason M, Newcombe P. Three-year outcome after a 1-month physiotherapy program of local and individualized global treatment for patellofemoral pain followed by self-management. Clin J Sport Med. 2016;26:190–8.PubMed
73.
Moyano F, Valenza M, Martin L, Caballero Y, Gonzalez-Jimenez E, Demet G. Effectiveness of different exercises and stretching physiotherapy on pain and movement in patellofemoral pain syndrome: a randomized controlled trial. Clin Rehabil. 2012;27:409–17.PubMed
74.
• Roper J, Harding E, Doerfler D, Dexter J, Kravitz L, Dufek J, et al. The effects of gait retraining in runners with patellofemoral pain: a randomized trial. Clin Biomech. 2016;35:14–22 A randomized control trial showing gait retraining to be helpful for knee pain and alteration of biomechanics.
75.
Esculier J, Bouyer L, Dubois B, Fremont P, Moore L, McFadyen B, et al. Is combining gait retraining or an exercise programme with education better than education alone in treating runners with patellofemoral pain? A randomised clinical trial. Br J Sports Med. 2017;52:659–66.PubMed
76.
Davis I. Optimising the efficacy of gait retraining. Br J Sports Med. 2017;52:624–5.PubMed
77.
Collins N, Bisset L, Crossley K, Vicenzino B. Efficacy of nonsurgical interventions for anterior knee pain. Sports Med. 2012;42:31–49.PubMed
78.
Espí-López G, Serra-Añó P, Vicent-Ferrando J, Sánchez-Moreno-Giner M, Arias-Buría J, Cleland J, et al. Effectiveness of inclusion of dry needling in a multimodal therapy program for patellofemoral pain: a randomized parallel-group trial. J Orthop Sports Phys Ther. 2017;47:392–401.PubMed
79.
Rathleff M, Petersen K, Arendt-Nielsen L, Thorborg K, Graven-Nielsen T. Impaired conditioned pain modulation in young female adults with long-standing patellofemoral pain: a single blinded cross-sectional study. Pain Medicine. 2015:pnv017.
80.
Noehren B, Shuping L, Jones A, Akers D, Bush H, Sluka K. Somatosensory and biomechanical abnormalities in females with patellofemoral pain. Clin J Pain. 2016;32:915–9.PubMedPubMedCentral
81.
Rathleff M, Roos E, Olesen J, Rasmussen S, Arendt-Nielsen L. Lower mechanical pressure pain thresholds in female adolescents with patellofemoral pain syndrome. J Orthop Sports Phys Ther. 2013;43:414–21.PubMed
82.
Maclachlan L, Collins N, Matthews M, Hodges P, Vicenzino B. The psychological features of patellofemoral pain: a systematic review. Br J Sports Med. 2017;51:732–42.PubMed
83.
Smith B, Moffatt F, Hendrick P, Bateman M, Selfe J, Rathleff M, et al. Barriers and facilitators of loaded self-managed exercises and physical activity in people with patellofemoral pain: understanding the feasibility of delivering a multicentred randomised controlled trial, a UK qualitative study. BMJ Open. 2019;9:e023805.PubMedPubMedCentral
Metadata
Title
Update of Risk Factors, Diagnosis, and Management of Patellofemoral Pain
Authors
Daniel Sisk
Michael Fredericson
Publication date
01-12-2019
Publisher
Springer US
Published in
Current Reviews in Musculoskeletal Medicine / Issue 4/2019
Electronic ISSN: 1935-9748
DOI
https://doi.org/10.1007/s12178-019-09593-z

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