Current ConceptsCurrent Concepts in in

Patellofemoral Pain Syndrome:Patellofemoral Pain Syndrome:Treatment and RehabilitationTreatment and Rehabilitation

Dale J. Buchberger, MS, PT, DC, CSCS, DACBSPDale J. Buchberger, MS, PT, DC, CSCS, DACBSPVice-President, American Chiropractic Board of Sports PhysiciansVice-President, American Chiropractic Board of Sports Physicians

Chiropractic Consultant, Auburn Doubleday's (Single-A affiliate Washington Nationals)Chiropractic Consultant, Auburn Doubleday's (Single-A affiliate Washington Nationals)

Chiropractic consultant, Syracuse University AthleticsChiropractic consultant, Syracuse University Athletics

Chiropractic consultant, New York Jets FootballChiropractic consultant, New York Jets Football

Strength and Conditioning Coordinator Auburn Stingrays Swim TeamStrength and Conditioning Coordinator Auburn Stingrays Swim Team

NUHS HomecomingOakbrook, Il USAOakbrook, Il USA

June 11, 2011June 11, 2011

Thank youThank you

Dr. Winterstein and Shawna McDonoughDr. Winterstein and Shawna McDonough

for the invitation to presentfor the invitation to present

1.1. Discuss the prevalence and consequences of Discuss the prevalence and consequences of common lower extremity (LE) injuries.common lower extremity (LE) injuries.

2.2. Review Patho-anatomy of Patellofemoral pain Review Patho-anatomy of Patellofemoral pain syndrome (PFPS)syndrome (PFPS)

3.3. Review the LE kinematic chain.Review the LE kinematic chain.

4.4. Summarize the results of research regarding PFPS Summarize the results of research regarding PFPS and its relationship to hip and knee function.and its relationship to hip and knee function.

5.5. Describe how a functional squat can be used as an Describe how a functional squat can be used as an assessment tool.assessment tool.

Objectives

Patello-femoral Pain Syndrome Patello-femoral Pain Syndrome (PFPS)(PFPS)

Where do we start?Where do we start?

Iliotibial Band Friction Iliotibial Band Friction Syndrome (ITBFS)Syndrome (ITBFS)

– Most common cause of Most common cause of lateral knee pain in runnerslateral knee pain in runners

– Incidence rate as high as Incidence rate as high as 22.2%22.2%

Fredericson M, Weir A. Practical management of iliotibial band friction syndrome in runners. Clinical journal of Sports Medicine. 2006; 16: 261-268.

Prevalence of Common LE InjuriesPrevalence of Common LE Injuries

ACL SprainsACL Sprains

– More common in female More common in female athletes compared to malesathletes compared to males

– ~70-80% of ACL injuries ~70-80% of ACL injuries result from result from non-contact mechanismsmechanisms

Jacobs CA, Uhl TL, Mattacola CG, Shapiro R, Rayens WS. Hip abductor function and lower extremity landing kinematics: Sex differences. Journal of Athletic Training. 2007; 42: 76-83.

Prevalence of Common LE InjuriesPrevalence of Common LE Injuries

Patellofemoral Pain Patellofemoral Pain Syndrome (PFPS)Syndrome (PFPS)

– Diagnosed more frequently Diagnosed more frequently in females than malesin females than males

– ~25%~25% of knee pain evaluated of knee pain evaluated in a sports injury clinicin a sports injury clinic

Robinson RL, Nee RJ. Analysis of hip strength in females seeking physical therapy treatment for unilateral patellofemoral pain syndrome. Journal of Orthopedic & Sports Physical Therapy. 2007; 37: 232-238.

Prevalence of Common LE InjuriesPrevalence of Common LE Injuries

Lateral Ankle SprainsLateral Ankle Sprains

– Most frequently injured joint Most frequently injured joint in athletics and daily lifein athletics and daily life

– 70-80%70-80% of ankle sprains are of ankle sprains are inversion-type sprainsinversion-type sprains

Friel K, McLean N, Myers C, Caceres M. Ipsilateral hip abductor weakness after inversion ankle sprain. Journal of Athletic Training. 2006; 41: 74-78.

Hootman JM, Dick R, Agel J. Epidemiology of collegiate injuries for 15 sports: summary and recommendations for injury prevention initiatives. Journal of Athletic Training. 2007; 42: 311-9.

Prevalence of Common LE InjuriesPrevalence of Common LE Injuries

PainPain Short- term and long-term disabilityShort- term and long-term disability Decreased exercise participationDecreased exercise participation Leading cause of osteoarthritisLeading cause of osteoarthritis Significant public health costSignificant public health cost

Emery CA, Rose SM, McAllister JR, Meeuwisse WH. A prevention strategy to reduce the incidence of injury in high school basketball: A cluster randomized controlled trial. Clinical Journal of Sports Medicine. 2007; 17:17-24.

Consequences of LE InjuriesConsequences of LE Injuries

ITBFS ITBFS

– ↓↓ hip abductor strength results hip abductor strength results inin» ↑↑peak femoral adduction momentspeak femoral adduction moments» ↓↓ pelvic stability during stance pelvic stability during stance

phasephase

– Overtraining + weakness of hip Overtraining + weakness of hip abductorsabductors = ITBFS = ITBFS

Fredericson M, Weir A. Practical management of iliotibial band friction syndrome in runners. Clinical journal of Sports Medicine. 2006; 16: 261-268

What the Evidence ShowsWhat the Evidence Shows

ACL Sprains & PFPSACL Sprains & PFPS– Predisposition to injury due to LE alignment:Predisposition to injury due to LE alignment:

» Wide pelvisWide pelvis

» ↑↑ femoral anteversionfemoral anteversion

» ↑↑ genu recurvatum genu recurvatum

» ↑↑ genu valgumgenu valgum

» External tibial rotationExternal tibial rotation

» Forefoot pronationForefoot pronation

Bonci CM. Assessment and evaluation of predisposing factors to anterior cruciate ligament injury. Journal of Athletic Training. 1999; 34: 155-164.

What the Evidence ShowsWhat the Evidence Shows

ACL Sprains & PFPSACL Sprains & PFPS (continued)(continued)– ↑↑hip abductor strength hip abductor strength = = ↓↓

knee valgus when landing knee valgus when landing from a jumpfrom a jump

– Activation of quadriceps and Activation of quadriceps and hamstrings is improved with hamstrings is improved with ↑↑ hip muscle activity hip muscle activity

» Big motor; no frame syndromeBig motor; no frame syndrome

Jacobs CA, Uhl TL, Mattacola CG, Shapiro R, Rayens WS. Hip abductor function and lower extremity landing kinematics: Sex differences. Journal of Athletic Training. 2007; 42: 76-83.

What the Evidence ShowsWhat the Evidence Shows

Chronic Lateral Ankle SprainsChronic Lateral Ankle Sprains

– Weakness in hip abductors on the Weakness in hip abductors on the involved sideinvolved side

– Rehab protocols need to address Rehab protocols need to address proximal stabilityproximal stability

Friel K, McLean N, Myers C, Caceres M. Ipsilateral hip abductor weakness after inversion ankle sprain. Journal of Athletic Training. 2006; 41: 74-78.

What the Evidence ShowsWhat the Evidence Shows

The lower extremity kinematic chainThe lower extremity kinematic chain

Relationship of LE Injury to Relationship of LE Injury to Hip and Knee StabilityHip and Knee Stability

Functional Squat ExamFunctional Squat Exam

Common PatternsCommon Patterns

-Tight posterior leg (Correct this fault then reassess)-Tight posterior leg (Correct this fault then reassess)– Achilles tendon, gastroc-soleus complexAchilles tendon, gastroc-soleus complex– Tib post, flexor digitorum, flexor hallicus lgTib post, flexor digitorum, flexor hallicus lg

-Weak lumbar extensors with contracted hip flexors.-Weak lumbar extensors with contracted hip flexors. -Strong gluts with weak lumbar extensors and -Strong gluts with weak lumbar extensors and

contracted hip flexors (contracted hip flexors (athletic presentationathletic presentation))– *Complete Kinetic chain dysfunction: tight lower leg, tight *Complete Kinetic chain dysfunction: tight lower leg, tight

hip flexors, weak lumbar extensors and weak gluteus hip flexors, weak lumbar extensors and weak gluteus maximus/mediusmaximus/mediusHarding FV, et al. Significant side to side differences in Joint Moments During Squatting. MSSE 2002; Harding FV, et al. Significant side to side differences in Joint Moments During Squatting. MSSE 2002; 34:5, S21534:5, S215

FOOT/ANKLE Pes planus Pes planus

– Structural Structural – Functional-correctableFunctional-correctable

Heels upHeels up Heels downHeels down Tight achillesTight achilles Normal achilles tendonNormal achilles tendon

– **Adequate DF of the ankleAdequate DF of the ankleBuchberger DJ. Functional assessment and management of the lower extremity in clinical practice. Presented at: A Somatic Senses Ltd event; February 17-18, 2007; Victoria, British Columbia, Canada

Functional Squat as an Assessment ToolFunctional Squat as an Assessment Tool

KNEES Dynamic valgusDynamic valgus

– uncorrecteduncorrected Dynamic varusDynamic varus

– Over correctionOver correction Femoral internal rotationFemoral internal rotation

– uncorrecteduncorrected Femoral external rotationFemoral external rotation

– Consider retroversionConsider retroversionBuchberger DJ. Functional assessment and management of the lower extremity in clinical practice. Presented at: A Somatic Senses Ltd event; February 17-18, 2007; Victoria, British Columbia, Canada

Functional Squat as an Assessment ToolFunctional Squat as an Assessment Tool

HIPS/PELVIS

Thighs parallelThighs parallel Thighs non parallelThighs non parallel

LUMBAR SPINE FlexedFlexed ExtendedExtended

SHOULDERS

ForwardForward

NeutralNeutral

BackBack

Buchberger DJ. Functional assessment and management of the lower extremity in clinical practice. Presented at: A Somatic Senses Ltd event; February 17-18, 2007; Victoria, British Columbia, Canada

Functional Squat as an Assessment ToolFunctional Squat as an Assessment Tool

Additional Patterns Additional Patterns

Foot PronationFoot Pronation– Hip, foot or both?Hip, foot or both?– Structural pes planusStructural pes planus

Valgus knee motionValgus knee motion– Dynamic Knee ValgusDynamic Knee Valgus

» Weak abductorsWeak abductors» Poor eccentric control of Poor eccentric control of

adductorsadductors

What’s wrong with this squat?What’s wrong with this squat?

QuickTime™ and aYUV420 codec decompressor

are needed to see this picture.

Alignment for the AssessmentAlignment for the Assessment

Line the medial malleolus with the lateral edge Line the medial malleolus with the lateral edge of the acromionof the acromion

No verbal or tactile cueing on the initial squatNo verbal or tactile cueing on the initial squat– If the heels come up; VC to keep them downIf the heels come up; VC to keep them down– If dynamic valgus TC to correct alignmentIf dynamic valgus TC to correct alignment

» If pes planus corrects with correction of dynamic If pes planus corrects with correction of dynamic valgus=functional pes planusvalgus=functional pes planus

Location of patellofemoral painLocation of patellofemoral pain

AnteriorAnterior PosteriorPosterior MedialMedial LateralLateral

Traditional HypothesisTraditional Hypothesis

The patella tracks laterallyThe patella tracks laterally Patella malalignedPatella malaligned Increased patellofemoral joint (PFJ) compression and Increased patellofemoral joint (PFJ) compression and

shear forces during movementshear forces during movement May or may not result in abrasion of the retropatellar May or may not result in abrasion of the retropatellar

cartilagecartilage– Primarily a functional diagnosisPrimarily a functional diagnosis– Excludes anatomical obstruction such as synovial plicae, Excludes anatomical obstruction such as synovial plicae,

OA, etc.OA, etc.

Powers JOSPT 1998Powers JOSPT 1998Lee JOSPT 2003Lee JOSPT 2003

PresentationPresentation

Usually anterior or anterolateral knee painUsually anterior or anterolateral knee pain worse with going up and down stepsworse with going up and down steps worse with sitting for long periodsworse with sitting for long periods crepitus more than notcrepitus more than not difficulty coming out of a squatting difficulty coming out of a squatting

maneuvermaneuver– 21-40% of the population (possibly more today)21-40% of the population (possibly more today)

Brody and Thein JOSPT Brody and Thein JOSPT 19981998

EtiologyEtiology

Once thought to be Once thought to be primarily a soft tissue primarily a soft tissue disorder secondary to disorder secondary to patellar tracking disorderpatellar tracking disorder– Contracture of the lateral Contracture of the lateral

retinaculumretinaculum

– Weakness of the VMOWeakness of the VMO

– Increased Q-angleIncreased Q-angle

– Pes PlanusPes Planus

Brody and Thein JOSPT 1998Brody and Thein JOSPT 1998

Brier 1998

Anatomical etiologies of PFPSAnatomical etiologies of PFPS

Pinching or irritation of the Pinching or irritation of the infrapatellar fat padinfrapatellar fat pad

Plicae SyndromePlicae Syndrome Chondromalacia patella Chondromalacia patella

secondary to degeneration of secondary to degeneration of the patellar hyaline cartilagethe patellar hyaline cartilage

Degeneration secondary to Degeneration secondary to instabilityinstability

Powers JOSPT Powers JOSPT 19981998

Synovial PlicaSynovial Plica

Predisposing factors v. etiologiesPredisposing factors v. etiologies

Increased Q (quadriceps) Increased Q (quadriceps) angleangle

Underdevelopment of the Underdevelopment of the femoral condyles or patellafemoral condyles or patella

Patella alta (high riding)Patella alta (high riding) Weak VMO; poor timing Weak VMO; poor timing

with VLwith VL Tight lateral retinaculum, Tight lateral retinaculum,

vastus lateralis and/or ITBvastus lateralis and/or ITB

Hip weaknessHip weakness– Dynamic valgusDynamic valgus

– Femoral IRFemoral IR

– Functional pes planusFunctional pes planus

Structural pes planusStructural pes planus Changes in Changes in intensity intensity level level

of trainingof training Training errorTraining error

Souza and Powers AJSM 2009, Robinson JOSPT 2007, Lee JOSPT 2003, Lloyd-Ireland JOSPT 2003

Patellar Orthopedic testsPatellar Orthopedic tests

Waldron's - chondromalaciaWaldron's - chondromalacia Clarke’s Patellar grind - retropatellar irritationClarke’s Patellar grind - retropatellar irritation Figure 4 - popliteus tendonFigure 4 - popliteus tendon Medial plicae test - plicaMedial plicae test - plica Plicae stutter - advanced plicaPlicae stutter - advanced plica Patellar Apprehension - instabilityPatellar Apprehension - instability

Current thoughts Current thoughts

Patellofemoral syndrome or Patellofemoral syndrome or femoralpatellar syndrome???femoralpatellar syndrome???

Kinetic chain breakdown starts in the Kinetic chain breakdown starts in the hiphip– Weakness of the hip extensors, abductors Weakness of the hip extensors, abductors

and external rotatorsand external rotators» Allows for dynamic femoral valgus and IRAllows for dynamic femoral valgus and IR

• The femoral groove moves medially as the The femoral groove moves medially as the patella “appears” to move laterallypatella “appears” to move laterally

Lloyd-Ireland JOSPT 2003, Powers JOSPT 2003, Robinson and Nee JOSPT 2007, Souza AJSM 2009

Suggested Program of Management Suggested Program of Management for for

Patellofemoral Pain Syndrome (PFPS)Patellofemoral Pain Syndrome (PFPS)

Management InterventionsManagement Interventions

GoalsGoals– Reduce painReduce pain– Restore ROM: Restore ROM:

» Quads and Hip flexorsQuads and Hip flexors» DF of the ankleDF of the ankle

– Functional strengthFunctional strength» Open chain: hipOpen chain: hip» Closed chain: hip/kneeClosed chain: hip/knee

– Functional controlFunctional control» kinetic chain reduce dynamic valgus in kinetic chain reduce dynamic valgus in

SLSSLS» ADL’s, IADL’s, recreational, ADL’s, IADL’s, recreational,

occupational, athleticoccupational, athletic

Manual TherapyManual Therapy

Directed to the:Directed to the: – Psoas, IliacusPsoas, Iliacus

– Lateral Patellar RetinaculumLateral Patellar Retinaculum

– VMO and SartoriusVMO and Sartorius

– ITB (TFL and Glut med/min)ITB (TFL and Glut med/min)

– Biceps Femoris (Myofascial kinetic chain through the Biceps Femoris (Myofascial kinetic chain through the STL/DSL and piriformis muscle)STL/DSL and piriformis muscle)

» Various manual techniques are available: Various manual techniques are available: • ARTART®, SASTM, SASTM®, GISTM, GISTM®, F.A.S.T., F.A.S.T.®, MET, MFR, etc, MET, MFR, etc

• Rollers for home/supportive careRollers for home/supportive care

– Various density foam rollers, PVC PipeVarious density foam rollers, PVC Pipe

Kinetic chainKinetic chain

Joint Mobilization and Joint Mobilization and HVLAHVLA– peripheral jointsperipheral joints

» ankle, footankle, foot

» SI jointsSI joints

OrthoticsOrthotics– pes planuspes planus

» Functional versus structuralFunctional versus structuralSports Illustrated 2005

Cliborne JOSPT 2004

VMO?VMO?

ProgressionProgression– Open chainOpen chain

» Hip Series (6 moves)Hip Series (6 moves)» Clam shellsClam shells» Straight knee ball bridgesStraight knee ball bridges

– Closed chainClosed chain» BridgingBridging» Ball TablesBall Tables» Side walksSide walks

• w/wo bandw/wo band

» Ball Squats with bandBall Squats with band» Balance LungesBalance Lunges

Butcher, et al Butcher, et al JOSPT 2007JOSPT 2007

Flat BridgeFlat Bridge

Feet closer to the buttocks Feet closer to the buttocks increase Gluteusincrease Gluteus– As comfortable ROM in the As comfortable ROM in the

knee improves move the feet knee improves move the feet closer to the buttocks.closer to the buttocks.

Good early PWB activity Good early PWB activity with functional applicationwith functional application

Regain knee F/ERegain knee F/E

Clam ShellClam Shell

Always consider Always consider three three points of contactpoints of contact for for side posture exercisesside posture exercises– HeadHead– BackBack– SacrumSacrum

Elevated (Couch) BridgeElevated (Couch) Bridge

BOSU BridgeBOSU Bridge

Straight knee bridgeStraight knee bridge

Lift bum

Depress abdomen

Toes pointed to ceiling, can vary for chosen affect

Vary arm position for stability

-Can add HS curl later

Hold 3-6 seconds

Bent Knee Ball BridgeBent Knee Ball Bridge

6-Move Hip Series: Open chain6-Move Hip Series: Open chain

Short arc abduction (SAABD)Short arc abduction (SAABD) Hip flexion/extensionHip flexion/extension Long arc abduction (LAABD)Long arc abduction (LAABD) BicycleBicycle Circles: clockwise/counterclockwiseCircles: clockwise/counterclockwise

– Perform all 6 motions consecutivelyPerform all 6 motions consecutively– Start with 5 reps of each (30 total) and progress to Start with 5 reps of each (30 total) and progress to

30 reps of each (180 total)30 reps of each (180 total)

Short arc abductionShort arc abduction

Strengthen Hip Strengthen Hip AbductorsAbductors

Open chain Open chain proprioception and pelvic proprioception and pelvic controlcontrol– Three points of contactThree points of contact

Femoral acetabular Femoral acetabular motionmotion– Avoid lumbar lateral Avoid lumbar lateral

flexionflexion

Hip Flexion/ ExtensionHip Flexion/ Extension

Knee to 90 degrees of hip/knee flexion

Extend hip/knee

3 points of contact

Keep Femur and Tibia parallel to floor during all motion

Hip/knee Flexion

Hip/knee Extension

Long Arc Hip AbductionLong Arc Hip Abduction

Hip abductorsHip abductors– +30 degrees+30 degrees

Pelvic controlPelvic control– Avoid lumbar Avoid lumbar

lateral flexionlateral flexion CORE stabilityCORE stability Dynamic Dynamic

flexibility of Hip flexibility of Hip AdductorsAdductors

BicycleBicycle

Hip/knee flexion

Extend knee BEFORE extending hip

Extend hip last in a long lever sweeping motion

Maintain 3 points of contact

Keep femur and tibia parallel to the floor

Circles: Clockwise/counterclockwiseCircles: Clockwise/counterclockwise

Point toe

Perform CW/CCW circles as though you are drawing circles with a pen attached to you big toe

Perform motions as smooth as possible

Maintain 3-points of contact

Ball TableBall Table

Shoulders in center of ball

Head resting on ball

Knees forward

Feet straight ahead

Squeeze bum

Depress abdomen

Hold 3-6 sec

Side to side walksSide to side walks

Watch shoulder movements

Patient will have the tendency to move the contralateral shoulder in the opposite direction of the lead leg.

Ex: left leg moves to the left stretching the band and the right shoulder dips down to the right

Shoulder should stay parallel to the floor and move in the same direction as the lead leg.

Ball SquatBall Squat

GlutsGluts Lumbar and thoracic Lumbar and thoracic

extensorsextensors Good if patient has Good if patient has

limited ankle DFlimited ankle DF– Teaches form and Teaches form and

techniquetechnique

Ball squat with bandBall squat with band

Add the band to ball squat to increase stimulation of hip abductors and reduce dynamic valgus at the knees

Balance Lunge or Split SquatBalance Lunge or Split Squat

Quad/Gluteus Quad/Gluteus strengthstrength

Quad/Psoas Quad/Psoas FlexibilityFlexibility

ProprioceptionProprioception Pelvic controlPelvic control Promote balance Promote balance

in SLSin SLS

What’s wrong with this patient?What’s wrong with this patient?

QuickTime™ and aYUV420 codec decompressor

are needed to see this picture.

ConclusionsConclusions

The hip is gaining acceptance as a functional etiology The hip is gaining acceptance as a functional etiology of PFPSof PFPS

Both open and closed chain exercise programs maybe Both open and closed chain exercise programs maybe effective in the rehabilitation of patients with PFPSeffective in the rehabilitation of patients with PFPS

If a If a passivepassive structure is restricted there is usually an structure is restricted there is usually an activeactive tissue not keeping up with it’s end of the tissue not keeping up with it’s end of the bargainbargain

SAQ/LAQ only used in cases of quadriceps SAQ/LAQ only used in cases of quadriceps deficiency (either elderly, TKA, etc.)deficiency (either elderly, TKA, etc.)

Souza AJSM 2010, Robinson JOSPT 2007, Witvrouw AJSM 2004

QuestionsQuestions

Thank You!Thank You!

2006-2007 and 2008-2009 Stingray Sportsmanship award recipient; 2010-2011 High-point trophy winner

In Loving MemoryIn Loving Memory of Lyle J. Buchberger of Lyle J. BuchbergerThanks for everything! Love ya dad!Thanks for everything! Love ya dad!

May 30, 1928 - January 12, 2009May 30, 1928 - January 12, 2009

Shoulder Made SimpleShoulder Made Simple® ®

Dale J. Buchberger, MS, PT, DC, CSCS, DACBSP®Dale J. Buchberger, MS, PT, DC, CSCS, DACBSP®Active Physical Therapy Solutions PCActive Physical Therapy Solutions PC

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If you have any questions you can email Dr. Buchberger at:If you have any questions you can email Dr. Buchberger at:

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