This month’s edition of International Journal of Sports Physical Therapy is dedicated to Patellofemoral Pain Syndrome.
Original level of evidence: 5
See Lamen’s overview of the examination of the Patellofemoral joint.
Original Article and Abstract can be found here. EXAMINATION OF THE PATELLOFEMORAL JOINT
Intro – PFPS (Patello Femoral Pain Syndrome) accounts for up to 25% of all sports injuries. No single special test used to diagnose, process of elimination and patient history is extremely important.
History – PFPS is a nonspecific complaint that associated with multiple conditions. This includes compressive issues, instability, biomechanical dysfunction, direct patellar trauma, soft tissue lesions, overuse syndromes, osteochondritis dissecans, and neurologic disorders. Compressive can be described as by aching, exacerbated when the knee is flexed for extended periods of time. Patients with patellar instability c/o symptoms as knee slipping, giving way, giving out, about to give. Instability may not be a macrotraumatic or patellar dislocation. Biomechanical issues as increased knee valgus, increased hip adduction and Tibial abduction or foot pronation can be complaints of pain that is localized to the anterior knee. These symptoms are made worse with mal-alignment syndrome in the classic presentation of internally rotated femur, externally rotated tibia and pronated foot. Direct patellar trauma is often treated in the acute phase and painful as a result of potential fractures, dislocations, and associated articular cartilage lesions, such as Osteochondritis Dissecans. Soft tissue lesions include plica syndrome, fat pad syndrome (Hoffa’s Syndrome), and bursitis. Soft tissue tendon disorders present with pain along a tendon or its attachment. Pain can be aggravated with activity, quick movements, deceleration, and jumping. A common apophyseal injury in teenagers involving the patella is Sindig-Larsen Johannsen’s Syndrome. Overuse injuries occur when training type, frequency, duration or intensity exceeds the body’s healing response. Common in in athletes such as runners, cyclists, weight lifters. Osteochondritis dissecans can create PFPS symptoms that are deep in the knee with c/o of pain more retropatellar. Patellar dislocations can result in an OCD lesion. However because these lesions are behind the patella they are often very painful with reported primary location of pain is peri-patellar. Consistent knee effusion, difficulty with weight bearing may indicate need for medical imaging.
Physical Exam Observation – Start with the Standing Observation – alignment, patella position, observation should be anterior and lateral, assess Q-Angle abnormalities, Leg Length measurements, foot posture. Excessive pronation can be visualized in barefoot standing.
Dynamic movement assessments – Step down test – Step down from a 20 cm box 5-10 times with arms crossed on chest until heel touches the floor. Assessing for trunk and pelvis deviations, hip add and IR are likely, and knee alignment (varus/valgus) relative to foot. Also watch for hands to uncross to help complete movement. Lateral step down test – standing on 15 cm step requires knee bend to 60 degrees to touch uninvolved heel to the ground. Single leg squat test – 80% of PFP is evident in 80% of people who are positive. Gait.
Examination for hypermobility – Beighton Index. Seated exam – Seated in tripod position at edge of table perform palpation and assess passive and active patellar tracking. Strength testing in sitting – hip flx, hip ER, hip IR, knee extension.
Supine exam – Clear referral joints such radicular symptoms. Lumbar, SI, and hip, and local palpation. Objective measures such as AROM and PROM of the knee, hip, and ankle. Passive patella mobility in 30 degrees of flexion to best assess. (towel under knee).
Flexibility tests – 90/90, long sit HS, Thomas Test. Special Testing- Banks Sign or Apprehension for patella dislocation, moving patella apprehension test. Lateral deep retinacular tightness is common in those with PFPS. Lateral retinacular structures also include attachments from the IT band and the lateral patellofemoral and patellotibial ligaments. The force vectorof these tissues is more posterior than lateral causing a compressive force and why when tight they create more of a tilt vs lateral glide. The patellar tilt test assesses deep retinacular fibers. This test is performed with the knee in full extension. With the patella in the trochlea groove at 30-40 degrees of flexion creating tension of the deep retinacular fibers. If the patient’s patella does not tilt back to neutral it is indicative of excessive lateral tightness and the potential to have excessive lateral pressure syndrome. Comparing to contralateral side is extremely important. The patella should tilt 15 degrees with both medial and lateral tilts.
Neurological exam – Stork test in standing, looking again for alignment and potential Trendelenburg sign. Quick Myotome and Dermatome testing. Side lying exam – Flexibility testing and strength with hip abd and hip add. Prone exam – Prone Knee bend or Ely’s test to assess for pain and Quad tightness. Strength testing – hip extension both knee straight and in flexion, knee flexors. Functional testing – 2-legged jump, single-leg hop, Lower Extremity Functional Test (LEFT), and then functional specificity testing.
Imaging – X-ray, MRI (especially if OCD is suspected) Conclusions – PFPS is a complex pathology that is critical to use a systematic examination including careful review of both proximal and distal factors that could be contributing to this problem –