Personality in patients with long-term patellofemoral pain syndrome

Arthroscopic Untethering of the Fat Pad of the Knee: Release or Resection of the Infrapatellar Plica (Ligamentum Mucosum) and Related Structures for Anterior Knee Pain

Anterior knee pain (AKP), a multifactorial symptom complex, can be successfully treated surgically. A specific diagnosis often cannot be made, but the pain is linked to an unrecognized common factor in most patients: the mechanical behavior of the non-isometric contents of the anterior compartment of the knee-the fat pad (FP) and infrapatellar plica (IPP). The objective of this presentation is to describe an effective arthroscopic technique that treats AKP by addressing this common factor. The operation consists of release or resection of the IPP, or ligamentum mucosum, which tethers the FP. These highly innervated tissues act together as a hydraulic shock absorber, filling the anterior compartment. They stretch and deform at the extremes of knee motion because of constraint centrally by the non-isometric IPP. These dynamic changes in shape are eliminated when the plica is released or resected. Pain perception is from perturbed nociceptive nerves: pain relief results from de-tensioning these contained nerves by untethering the fat pad. Ascribing pain causation is problematic because morphologic change, such as inflammation, fibrosis, or contracture of these structures, is only present in a minority of cases. Nonetheless, AKP is both physically linked to these central, pain-sensitive structures and relieved by this operation.

Results of isolated lateral retinacular reconstruction for iatrogenic medial patellar instability

PURPOSE

The aim of this study was to assess the outcomes of an isolated lateral retinaculum reconstruction for iatrogenic medial patellar instability (IMPI) in patients with continued pain after failed lateral retinacular release (LRR), including associated psychometric analysis.

METHODS

Pain was assessed using the visual analog scale (VAS) and disability was determined with the Lysholm scale. Psychological variables such as anxiety, depression, catastrophizing, and fear-of-movement beliefs were studied by using self-administered psychometric questionnaires.

RESULTS

All 17 patients (13 women and 4 men) in this retrospective study had undergone LRR previously for anterior knee pain or lateral patellar instability. Four patients had undergone LRR plus proximal (Insall) realignment, and one had undergone LRR plus a medial tibial tubercle transfer. After their procedures, all had disabling symptoms. All patients underwent reconstructive surgery for IMPI. At a minimum follow-up of 2 years (range, 2 to 8 years), the mean preoperative VAS score was 7.6 (range, 5 to 9) and improved to 1.9 (range, 0 to 8) at the time of final follow-up (P < .001). The mean preoperative Lysholm score was 36.4 (range, 20 to 55), and the knee was described as bad (<65 points) in all cases. Postoperatively, it improved to 86.1 (range, 70 to 94) at final follow-up (P < .001). Before surgery, 4 patients (24%) had the clinical criteria for depression, 10 (59%) had anxiety, 7 (41%) had "catastrophizing" ideas concerning pain, and all (100%) had kinesiophobia (fear of movement). After surgery, none of the patients had depression or anxiety, none had catastrophizing ideation, and only 53% had kinesiophobia.

CONCLUSIONS

Reconstruction of the deep transverse layer of the lateral retinaculum (LR) using a central strip of the iliotibial band for IMPI in patients with continued pain after failed LRR can successfully treat these severely disabled patients.

LEVEL OF EVIDENCE

Level IV, therapeutic case series.

Anterior knee pain: an update of physical therapy

Anterior knee pain is one of the most common knee problems in physically active individuals. The reason for anterior knee pain has been suggested to be multifactorial with patella abnormalities or extensor mechanism disorder leading to patellar malalignment during flexion and extension of the knee joint. Some patients complain mostly of non-specific knee pain, while others report patellar instability problems. The patients present with a variety of symptoms and clinical findings, meaning that a thorough clinical examination is the key for optimal treatment. Weakness of the quadriceps muscle, especially during eccentric contractions, is usually present in the majority of anterior knee pain patients. However, irrespective of whether pain or instability is the major problem, hypotrophy and reduced activity of the vastus medialis are often found, which result in an imbalance between vastus medialis and vastus lateralis. This imbalance needs to be corrected before quadriceps exercises are started. The non-operative rehabilitation protocol should be divided into different phases based on the patient's progress. The goal of the first phase is to reduce pain and swelling, improve the balance between vastus medialis and vastus lateralis, restore normal gait, and decrease loading of the patello-femoral joint. The second phase should include improvement of postural control and coordination of the lower extremity, increase of quadriceps strength and when needed hip muscle strength, and restore good knee function. The patient should be encouraged to return to or to start with a suitable regular physical exercise. Therefore, the third phase should include functional exercises. Towards the end of the treatment, single-leg functional tests and functional knee scores should be used for evaluating clinical outcome. A non-operative treatment of patients with anterior knee pain should be tried for at least 3 months before considering other treatment options.

Short-term effects of patellar kinesio taping on pain and hop function in patients with patellofemoral pain syndrome

Background:

Patellofemoral pain syndrome (PFPS) is the most prevalent orthopaedic condition among physically active individuals, contributing to an estimated 30% to 40% of all sports medicine visits. Techniques using Kinesio Tape (KT) have become increasingly popular; however, there has been scant research supporting its use on patients with PFPS.

Hypothesis:

The use of patellar KT to treat patients with PFPS will provide a statistically significant improvement in short-term pain and single-leg hop measures as compared with sham placement of KT.

Study Design:

Nonrandomized controlled clinical trial with repeated-measures design.

Level of Evidence:

Level 3.

Methods:

Forty-nine subjects (41 females, 8 males) between the ages of 12 and 24 years with PFPS participated in this study. Each subject underwent patellar kinesio taping with both experimental and sham applications while completing 4 functional tasks and the single-leg triple jump test (STJT). The treatment outcome was analyzed using separate paired t tests to measure improvement on a numeric pain rating scale. A 2-way, 2 × 2 analysis of variance was used to analyze the relationship between taping condition (experimental vs sham) and side (involved vs uninvolved) for STJT scores.

Results:

Separate paired t tests found step-up, step-down, and STJT pain improvement statistically significant between taping conditions. The 2-factor analysis of variance yielded a significant main effect for taping condition, but the main effect for side was not significant. The interaction between taping condition and side was significant. This showed there was little change in STJT distance between repeated measures performed on the untaped, noninvolved leg. However, subjects’ STJT distances were significantly greater for the experimental KT application than the sham application for the involved side.

Conclusion:

Patellar kinesio taping provided an immediate and statistically significant improvement in pain and single-leg hop function in patients with PFPS when compared with a sham application. However, improvement in STJT scores did not surpass the minimally detectable change value, and therefore, the clinical effectiveness of KT for improving single-leg hop function was not established in the current study.

Clinical Relevance:

Kinesio Tape provides a viable, short-term method to control pain.

Associates of physical function and pain in patients with patellofemoral pain syndrome

OBJECTIVES

To explore whether impairment of muscle strength, soft tissue length, movement control, postural and biomechanic alterations, and psychologic factors are associated with physical function and pain in patients with patellofemoral pain syndrome (PFPS).

DESIGN

Cross-sectional study.

SETTING

Rehabilitation outpatient.

PARTICIPANTS

Seventy-four patients diagnosed with PFPS.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Measurements were self-reported function and pain; strength of quadriceps, hip abduction, and hip external rotation; length of hamstrings, quadriceps, plantar flexors, iliotibial band/tensor fasciae latae complex, and lateral retinaculum; foot pronation; Q-angle; tibial torsion; visual observation of quality of movement during a lateral step-down task; anxiety; and fear-avoidance beliefs.

RESULTS

After controlling for age and sex, anxiety and fear-avoidance beliefs about work and physical activity were associated with function, while only fear-avoidance beliefs about work and physical activity were associated with pain.

CONCLUSIONS

Psychologic factors were the only associates of function and pain in patients with PFPS. Factors related to physical impairments did not associate to function or pain. Our results should be validated in other samples of patients with PFPS. Further studies should determine the role of other psychologic factors, and how they relate to anxiety and fear-avoidance beliefs in these patients.

Disability in patients with chronic patellofemoral pain syndrome: a randomised controlled trial of VMO selective training versus general quadriceps strengthening

This study was a prospective single blind randomised controlled trial to compare the effects of rehabilitation with emphasis on retraining the vastus medialis (VMO) component of the quadriceps femoris muscle and rehabilitation with emphasis on general strengthening of the quadriceps femoris muscles on pain, function and Quality of Life in patients with patellofemoral pain syndrome (PFPS). Patients with PFPS (n=69) were recruited from a hospital orthopaedic clinic and randomised into three groups: (1) physiotherapy with emphasis on selectively retraining the VMO (Selective); (2) physiotherapy with emphasis on general strengthening of the quadriceps femoris muscles (General); and (3) a no-treatment control group (Control). The three groups were then compared before and after an eight-week rehabilitation period. The Selective and General groups demonstrated statistically significant and 'moderate' to 'large' effect size reductions in pain when compared to the Control group. Both the Selective and General groups displayed statistically significant and 'moderate' and 'large' effect size improvements in subjective function and Quality of Life compared to the Control group. Knee flexion excursion during the stance phase of gait, demonstrated that there were no statistical significant differences and only 'trivial' to 'small' effect size differences between the Selective or General groups and the Control group. A large number of PFPS patients can experience significant improvements in pain, function and Quality of Life, at least in the short term, with quadriceps femoris rehabilitation, with or without emphasis on selective activation of the VMO component. Both approaches would seem acceptable for rehabilitating patients with PFPS. It may be appropriate to undertake exercises involving selective activation of the vastus medialis early in the rehabilitation process, however, clinicians should not overly focus on selective activation before progressing rehabilitation, especially in more chronic cases with significant participation restrictions.

Quantitative sensory testing of patients with long lasting Patellofemoral pain syndrome

BACKGROUND

Anterior knee pain, diagnosed as Patellofemoral Pain Syndrome (PFPS), is one of the most common musculoskeletal problems found in adolescents and young adults. There is no consensus in medical literature concerning the aetiology of the PFPS.

AIMS

To assess by means of Quantitative Sensory Testing (QST) whether patients suffering from long-lasting unilateral PFPS demonstrate somatosensory dysfunction related to afferent fibres from the local pain area.

METHODS

A descriptive non-experimental study with two independent samples, consisting of 25 men and women between 18 and 44 years of age with unilateral PFPS, and a comparable group of 23 healthy subjects. Somedic Thermotest apparatus was used to assess thresholds of thermal perception, and of heat and cold pain thresholds. Von Frey filaments were used to detect tactile sensitivity. Furthermore, quality and intensity of knee pain, symptoms and signs from a clinical neurological examination were recorded.

RESULTS

Decreased sensitivity to tactile stimulation, when tested with von Frey filaments, was demonstrated on both the painful and pain-free knee in subjects with PFPS, compared to the mean between the knees of the control group (p< or =0.001). The mean detection threshold for warmth was increased by 1.9 degrees C (p< or =0.01) in the painful knee, and 1.4 degrees C (p< or =0.01) in the non-painful knee in the PFPS group, compared to the mean of the healthy control group. The mean detection threshold for cold was increased by 1.6 degrees C (p< or =0.01) in the painful knee of the PFPS group, compared to the control group. These findings were supported by clinical sensory tests. No significant differences of mean thermal pain thresholds between the PFPS group and controls were found, and there were no significant differences in mean detection thresholds for warmth, cold or thermal pain thresholds between the painful and the non-painful knees in the PFPS group.

CONCLUSION

This study demonstrated an abnormal sensory function in the painful and non-painful knee in some individuals with long lasting unilateral Patellofemoral Pain Syndrome using Quantitative Sensory Testing supported by clinical neurological examinations. A dysfunction of the peripheral and/or the central nervous system may cause neuropathic pain in some subjects with PFPS.

Knee function and pain related to psychological variables in patients with long-term patellofemoral pain syndrome

STUDY DESIGN

Nonexperimental, descriptive study, including 2 independent samples.

OBJECTIVES

To assess the levels of mental distress and self-perceived health in subjects with long-term patellofemoral pain syndrome (PFPS) compared to a group of healthy subjects, and the relationship between knee function and knee pain to these psychological variables.

BACKGROUND

Psychological variables and those describing self-perceived health status have been given little focus in PFPS research.

METHODS AND MEASURES

One group of 25 men and women between 19 and 44 years of age with unilateral long lasting PFPS, and a control group (n = 23) of healthy subjects (age range, 18-44 years) participated in the study. Knee function was assessed with the use of the Cincinnati Knee Rating System (CKRS) and the triple jump test, and knee pain was measured by a visual analogue scale (VAS). Self-perceived health and mental distress were assessed with the Coop-Wonca Chart and the Hopkins Symptoms Checklist-25 (HSCL-25) questionnaire.

RESULTS

The mean (+/- SD) score on the Coop-Wonca Chart was 2.02 +/- 0.73 in the PFPS group, compared to 1.20 +/- 0.53 in the controls (P < .001). HSCL-25 mean (+/- SD) scores were 1.46 +/- 0.47 and 1.08 +/- 0.18 (P < .001) for the PFPS and the control group, respectively. When analyzed with correlation statistics, CKRS and VAS scores were found to correlate to those of the Coop-Wonca Chart and HSCL-25 scores.

CONCLUSION

Levels of mental distress were higher in the group with PFPS than in the control group, while levels of self-perceived health were lower. Our data indicate that the levels of knee pain and knee function correlate closely to the degree of mental distress and self-perceived health in individuals with PFPS.

Patellofemoral pain syndrome: pain, coping strategies and degree of well-being

The purpose of this study was to evaluate how patients with patellofemoral pain syndrome (PFPS) experience their pain, what coping strategies they use for the pain, and their degree of well-being. Fifty patients, 15-52 years old, with PFPS were evaluated with multidimensional pain inventory (MPI), coping strategies questionnaire (CSQ) and Spielberger state trait anxiety inventory (STAI). Reliability of the evaluation methods was established for 12 patients. Good reliability was established for all instruments except for six of the 13 scales of the MPI. Results on MPI, CSQ and STAI are in agreement with the literature on other patient groups with chronic pain. The most frequently used strategies were "coping self statements" and "ignoring sensations". High scores were found for the strategy "catastrophizing" compared with other patient groups having chronic pain. The STAI scores were in general found to be somewhat higher than the scores found in the literature on healthy subjects. It is concluded that the way patients with PFPS experience their pain, the coping strategies for pain they use and their degree of well-being, are in agreement with other patient groups who have chronic pain. Some concern is raised in terms of the high scores reported for the coping strategy "catastrophizing" .

Comparison of three standard radiologic techniques for screening of patellar subluxations

The presence of many "abnormal" types of PF joints in asymptomatic cases and the frequent unilateral complaints in morphologically symmetric joints indicate that emphasis must be placed on factors that cause "abnormal" PF joints to decompensate, rendering them symptomatic. These factors include hyperlaxity, puberty, overuse, or athletic activities. It is our conviction that full understanding of PF problems needs dynamic, three-dimensional motion analysis of patellofemoral relationships. At the present time these imaging techniques do not exist, as they require more powerful computer capacities. The absence of strict and reliable relationships between radiographic anomalies and clinical symptoms brings two reflections about the treatments in symptomatic cases: It is common sense to treat PPS by conservative methods first. Our study indicates that the goal should be to turn the symptomatic patella into an asymptomatic one, rather than correcting maltracking by vastus medialis training. The high failure rates at long-term follow-up of patellar maltracking correction by surgical methods such as lateral release and tibial tubercle transfer show us that correction of part or all of the anomalies does not always make the symptoms disappear. A nice lesson in humility for the orthopedist.

Patellofemoral pain syndrome in the female athlete

Although PFS will continue to be a therapeutic challenge, the prognosis for most female athletes is good, especially if they are motivated and compliant with their treatment program. Particularly in women, care should be taken to avoid placing too much emphasis on biomechanical variants that may not be clinically significant or correctable because such findings can reinforce a feeling that "nothing can be done." In many cases, muscle dysfunction and repetitive loading of the patellofemoral joint rather than fixed biomechanical factors contribute to the development of PFS. Nonetheless, the importance of a detailed biomechanical assessment on physical examination must not be neglected, particularly in athletes who are not improving with conservative treatment and who may become surgical candidates. A practical initial treatment program for most athletes with nontraumatic PFS begins with relative rest, quadriceps strengthening, and stretching of tight myotendinous units. The introduction of NSAIDs, orthoses, taping, knee sleeves, and more specific rehabilitative exercises should be an individualized decision based on physical findings, past treatment results, and athletic expectations. Surgical referral should be considered in cases of PFS or patellar instability refractory to prolonged maximal nonoperative treatment.

Patellofemoral pain syndrome: a review of current issues

There is no clear consensus in the literature concerning the terminology, aetiology and treatment for pain in the anterior part of the knee. The term 'anterior knee pain' is suggested to encompass all pain-related problems. By excluding anterior knee pain due to intra-articular pathology, peripatellar tendinitis or bursitis, plica syndromes, Sinding Larsen's disease, Osgood Schlatter's disease, neuromas and other rarely occurring pathologies, it is suggested that remaining patients with a clinical presentation of anterior knee pain could be diagnosed with patello-femoral pain syndrome (PFPS). Three major contributing factors of PFPS are discussed: (i) malalignment of the lower extremity and/or the patella; (ii) muscular imbalance of the lower extremity; and (iii) overactivity. The significance of lower extremity alignment factors and pathological limits needs further investigation. It is possible that the definitions used for malalignment should be re-evaluated, as the scientific support is very weak for determining when alignment is normal and when there is malalignment. Consequently, pathological limits must be clarified, along with evaluation of risk factors for acquiring PFPS. Muscle tightness and muscular imbalance of the lower extremity muscles with decreased strength due to hypotrophy or inhibition have been suggested, but remain unclear as potential causes of PFPS. Decreased knee extensor strength is a common finding in patients with PFPS. Various patterns of weaknesses have been reported, with selective weakness in eccentric muscle strength, within the quadriceps muscle and in terminal knee extension. The significance of muscle function in a closed versus open kinetic chain has been discussed, but is far from well investigated. It is clear that further studies are necessary in order to establish the significance of various strength deficits and muscular imbalances, and to clarify whether a specific disturbance in muscular activation is a cause or an effect (or both) of PFPS. The most common symptoms in patients with PFPS are pain during and after physical activity, during bodyweight loading of the lower extremities in walking up/down stairs and squatting, and in sitting with the knees flexed. However, the source of patellofemoral pain in patients with PFPS cannot be sufficiently explained. There are several types of clinical manifestation of pain, and therefore a differentiated documentation of the patient's pain symptoms is necessary. The connection between strength, pain and inhibition, as well as between personality and pain, needs further investigation. Many different treatment protocols are described in the literature and recent studies advocate a comprehensive treatment approach allowing for an individual and specifically designed treatment. Surgical treatment is rarely indicated. It is strongly suggested that, when presenting studies on PFPS, a detailed description should be provided of the diagnosis, inclusion and exclusion criteria of the patients should be specified along with a detailed methodology, and the conclusions drawn should be compared with those of other studies in the published literature. As this is not the case in most studies on PFPS found in the literature, it is only possible to make general comparisons. In order to further develop treatment models for PFPS we advocate prospective, randomised, controlled, long term studies using validated outcome measures. However, there is a strong need for basic research on the nature and aetiology of PFPS in order to better understand this mysterious syndrome.