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Musculoskeletal 1 > Patellofemoral pain syndrome > Flashcards

Patellofemoral pain syndrome Flashcards

1
Q

Describe the patella and its role in the knee

A
  • sesamoid bone
  • increases the efficiency of the quad pull for the last 30º
  • guide for quad tendon and decreases the friction
  • boney shield for the tibiofemoral joint
  • thickest cartilage in body
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2
Q

Patella anatomy

A
  • base is superior portion
  • apex is the inferior portion
  • medial side: medial facet and odd facet
  • vertical ridge between medial and lateral facet
  • superior and inferior facets
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3
Q

Describe important lateral structures in the knee in regards to support for the patella

A
  • vastus intermedius
  • vastus lateralis
  • lateral retinaculum
  • Gerry’s tubercle (bursa underneath) insertion for IT band
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4
Q

Describe important medial structure in the knee in regards to support for the patella

A
  • vastus medialis
  • quad tendon
  • medial retainculum
  • pes anserinus
  • fat pat beneath patella ligament
  • tibial tubersoity
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5
Q

Patella contact area during
1) flexion
2) mid range
3) extension

A

1) superior patella
2) more contact
3) inferior patella
lateral tracking is normal as you go into extension

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6
Q

Normal patella position

inreguards to patella ligment

A
  • patella ligament length = patella body length
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7
Q

Patella alta

also what this looks like and what happens anatomically

A
  • patella higher than normal
  • patella ligament longer than normal
  • frog eyes in 90ºof flexion as patellae faces up and out
  • causes the patella to not be firmly in the intracondylar groove
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8
Q

Patella baja

A
  • patella lower than normal
  • patella ligament shorter than normal
  • closer to the tibial tuberosity
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9
Q

Compressive forces at the PFJ

A
  • reflects the magnitude of force through the quads
  • walking 0.5 x BW
  • ascending stairs 2.5 xBW
  • descending stairs 3.5 x BW
  • squatting 7.8 x BW
  • compression forces overtime can cause DJD
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10
Q

Chondromalacia

A
  • softening of cartilage on posterior surface of patella
  • pitted tissues, fragmented
  • may lead to DJD
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11
Q

Chondromalacia signs and symptoms

A
  • PFJ creptitis (can feel this)
  • retropatella pain w/ ROM
  • pressure
  • common in patients with high compressive forces (kneeling, seat, stairs, sitting with excessive knee flexion)
  • post trauma and surgery
  • associated with Mal-tracking compression
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12
Q

Patellar tracking

What allows tracking normally/what typically happens with mal-tracking

A
  • opposing forces keep patella in groove
  • Mal-tracking related to muscle imbalance, hyper/hypomobility
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13
Q

What structures must balance to have normal patella tracking

A
  • overall quad force
  • VMO
  • IT band
  • lateral retinacular fibers
  • medial retinacular fibers
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14
Q

Causes of patella lateral mal-tracking

A
  • muscle imbalance/weakness
  • tight lateral structures
  • laxity or tear fo medial patellar retinaculum
  • bony dysplasia
  • patella instability
  • excessive pronation
  • femoral IR torsion
  • tibial bony lateral torsion
  • knee alignment issues
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15
Q

How can muscle imbalances cause patella maltracking

A
  • VMO: doesn’t oppose pull of VL, VMO is not recruited properly
  • Weak hip ERs and abductors causes excessive femoral IR and adduction = valgus collapse
  • females > males
    female with patella femoral syndrome> weakness than females without it
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16
Q

How can tight lateral structures cause patella lateral mal tracking

A
  • lateral retinaculum and ITB
  • can pull the patella more laterally
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17
Q

How can laxity or tears in medial structures cause lateral Mal-tracking

A
  • medial patellar retinaculum
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18
Q

How can bony dysplasia cause PFS

A
  • shallow intercondylar groove of femur
  • flat or smaller lateral femoral condyle
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19
Q

Patella instability and how it cause lateral mal-tracking

A
  • patella alta
  • genu recurvatum (hyperextension)
  • not seated in intracondylar groove
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20
Q

Examples of alignment/posture that can cause lateral patella mal-tracking

A
  • pronation (excessive)
  • femoral IR torsion
  • tibial bony lateral torsion - structure
    a laterally seated tibial tubercle (similar to femoral IR)
  • knee alignment: genu valgum or Q-angle
21
Q

Q-angle

A
  • measures the quads line of pull
  • Measure ASIS to mid-patella to tibial tuberosity
  • normal 12-18º
  • larger Q-angle >18ºwith lateral subluxation results in PFPS
22
Q

Lateral retinacular release

A
  • lateral patellofemoral/tibial ligament
  • weak on medial side/sublux on lateral side = tight lateral structures
  • done to reduce PFJ lateral mal-tracking
  • arthroscopic or open procedure
23
Q

Post-op complications of lateral retinacular release

A
  • swelling, hemarthrosis
  • unsuccessful = chronic pain
  • NOT done in isolation - not effective for lateral instability
  • failure to realign patella more medially
  • long term = high recurrence of dislocation
24
Q

Proximal extensor mechanism realignement surgery

what is it and when is it preformed

A
  • medial patella femoral ligament repair/reconstruct to tighten it

Preformed if medial patelloefemoral ligament deficiency

  • 1st time acute traumatic lateral patella dislocation
  • chronic recurrent lateral instability with pain
  • excessive lateral tracking w/ VMO insufficiency
  • failed conservative management
25
Q

Surgery to tighten medial patellofemoral ligament repair/reconstruction

A
  • repair: suture tear, reattach MPFL to medial condyle and patella
  • reconstruction: autograph, allograph- hams, TFL, quad tendon
26
Q

Medial patellofemoral ligament repair/reconstruction done with any one of what procedures
- also post op complications

A
  • Vastus médiales Oblique advancement: central or distal relocation of VMO to improve length tension
  • lateral retinacular release (arthroscopic)
  • tighten medial patellotibial, patellomensical ligament
  • post op complications: infection, DVT, patella scaring, adhesions, arthrofibrosis and decrease ROM
27
Q

MPFL repair/reconstruction rehab: protection phase

Goals of rehab

A

Protection phase

  • weeks 1-4
  • control swelling/pain
  • ROM 0-90 by 4th week
  • strength of 3/5
  • gait: FWB locked brace without AD
28
Q

MPFL repair/reconstruction rehab: moderate protection phase

A
  • weeks 4-8
  • control swelling/pain
  • ROM 0-120 by 6th week
  • 0-135 by 8th week
  • strength 4-5/5
  • normalize gait
29
Q

MPFL repair/reconstruction rehab: minimum protection phase

A
  • weeks 8-12
  • functional ROM
  • 75% strength of uninvolved
  • gradual return to ADLs
  • educate on resuming normal activities
30
Q

Distal realignment of extensor mechanism

A
  • Tibial tubercle, patellar tendon medial transfer

Preformed if:

  • painful lateral tracking, retro-patellar pain
  • > 15mm distance from tibial tubercle to femoral intercondylar groove
31
Q

How does the distal realignment of extensor mechanism correct a laterally positioned tibial tubercle

A
  • transfer tibial tubercle and patellar tendon medially
  • decrease Q-angle
  • decrease lateral directed patellar forces
32
Q

distal realignment of extensor mechanism surgery complications and treatment

A
  • complications: tibial tubercle fracture, nonunion, osteomyelitis
  • Treatment: protocol to progress more gradually to allow bone healing; U/L WB 8 weeks, max quad contraction 12 weeks
33
Q

Exercise precautions for proximal or distal extensor realignment

A
  • initially in brace with ROM limits to avoid excessive flexion
  • progress Flexion ROM gradually avoiding excessive valgus
  • SLR exercise locked in brace
  • begin WB shifts in BL stance brace locked
  • progress to CC ex ROM limited unlocked brace (mini squats once 50% WB okay)
  • keep brace locked in FWB activities and ambulation until quad control
  • postpone U/L WB ex’s on involved LE without brace as protocol and healing tissue allows: 4-6 weeks soft tissue, 8 weeks for bony
  • do not preform max quad contraction for at least 12 weeks after VMO advancement or tibial tubercle osteotomy
34
Q

Patella dislocation factors

A
  • MOI external force = lateral patella dislocation
  • bony abnormalities: flat lateral condyle, shallow groove
  • weakness of VMO
  • valgus deformity with tight lateral retinaculum and stretched medial retainaculum
  • females > dislocation rates than men
  • females have a higher Q-angle, ligament laxity, weak quad (VMO), weak ERs and abductors = valgus collapse
  • recurrent dislocations: surgery to realign patella
35
Q

Patella fx

General rehab focus

A
  • ROM, WB progression depends on the type
36
Q

Types of patella fx and their treatment

A
  • non-displaced fx: extension brace 3-6 weeks, early WBAT, ROM at 4-6 weeks
  • displaced or commented fax: ORIF wire/screws, PWB initially ROM at 4-6 weeks
  • patellectomy: rare = lose pulley system, extensor quad lag and los active terminal extension
37
Q

Patellar tendonitis

What typically causes this and what can be done to treat?

A
  • jumper knee
  • repetitive jumping
  • rest , patellar tendon strap to dissipate forces for treatment
38
Q

Quad tendon rupture

A
  • usually >50 y.o
  • repair: immobilize in full extension for 6-8 weeks
39
Q

Patella tendon rupture

A
  • <40 years old
  • high energy trauma
  • history of patellar tendonitis
  • hx of steroid injections/ anabolic steroid use
  • repair - ligament sutured to bone: immobilize full extension for 6-8 weeks PWB
40
Q

Knee bursitis

A
  • overuse
  • trauma fall on knee/kneeling
  • supra patellar burse
  • pre patellar burse - housemaids
  • fat pad
  • superficial infrapatellar bursa
  • deep infra patellar bursa
41
Q

Pes anserine bursitis: ITB friction syndrome

A
  • overuse/tightness
  • ITB friction syndrome bursae
  • pes anserine bursitis
42
Q

Plica syndrome

A
  • embryonic remnant fold of synodal tissue
  • gets irritated with activity
  • located medial, inferior and superior
  • medial plica most prevalent (25-50%)
  • plica irritation, inflammation fibrotic
  • pain with palpation
43
Q

Treatment for plica syndrome

A
  • rest, refrain from aggravating activity NSADs
  • arthroscopic resection
44
Q

PFP classifications impairment/function-based

A
  1. overuse/overloading; is 1º reason of pain, PFJ loading magnitude/rate that surpasses recovery
  2. muscle deficits: hip/quad function/preformance; respond favorable to hip and knee resistance exercise
  3. movement coordination deficits: when patient presents with poorly controlled knee valgus durning a dynamic task
  4. mobility impairment: hyper/hypomobilities: excessive pronation and/or flexibility deficits in more than 1 of these: hamstrings, quads/rectus femoris, ITB, gastric/soleus, lateral retinaculum
45
Q

PFJ outcome measures

A
  • LEFS: LE functional scale
  • anteiror knee pain scale AKPS
  • PFP and osteoarthritis subscale of the knee
  • Osteoarthritis outcome score (KOOS-PF)
  • Visual analog scale
  • Eng and pierrynowski Questionarie (EPQ) to measure pain and function in patietns with PFP
46
Q

Tests that reproduce PF pain and assess LE movemtn and coordination

A
  • squatting
  • step-downs
  • single leg squats
47
Q

What to assess in potential PFPS patients in reference to body structure and function

A
  • patellar provaocation
  • patellar mobility
  • foot position (pronation)
  • hip and thigh muscule strength (valgus collapse)
  • muscle length
48
Q

How can retraining running gait help with PFPS

A
  • cuing to adopt forefoot-striking pattern reduces the need for the quads to work
  • increasing work of the quads can cause PFPS

Musculoskeletal 1 (42 decks)

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