Patellofemoral pain syndrome (pfps)
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pathomechanivs of patellofemoral pain syndrome
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Patellofemoral pain syndrome (pfps)
- 1. PATHOMECHANICS OF PATELLOFEMORAL PAIN SYNDROME (PFPS) By- Priyanka Urkurkar Priyanka Urkurkar 24-feb-13
- 2. contents PATELLOFEMORAL ANATOMY BIOMECHANICS JOINT PAIN PATHOMECHANICS Priyanka Urkurkar 24-feb-13
- 3. Anatomy of patellofemoral joint Patella is the flat triangularly shaped largest sesamoid bone in the body • It is embedded within the quadriceps muscles Priyanka Urkurkar 24-feb-13
- 4. Posterior articular surface Divided by a vertical ridge Medial facet lateral facet odd facet Priyanka Urkurkar 24-feb-13
- 5. Priyanka UrkurkarAttachments of the patella 24-feb-13
- 6. Joint congruence Patella has much smaller articular surface than its femoral counterpart. Thus it is one of the most incongruent joints of the body. In an extended knee joint congruency is minimal. Stability is affected mainly by vertical position of patella Priyanka Urkurkar 24-feb-13
- 7. Also, vertical position of the patella is related to the patellar tendon Insall-Salviti index : length of patellar tendon to the length of patella is approximately 1:1 Patella alta : abnormally high position of patella on femoral sulcus. Patella baja : patella sits lower than normal on femoral sulcus and positioned more inferiorly Priyanka Urkurkar 24-feb-13
- 9. Biomechanics of Patellofemoral joint Priyanka Urkurkar 24-feb-13
- 11. Motion of the patella Flexion and extension Priyanka Urkurkar 24-feb-13
- 13. Medial and lateral patellar tilt Priyanka Urkurkar 24-feb-13
- 14. Medial and lateral rotation of the patella Priyanka Urkurkar 24-feb-13
- 15. Patellofemoral joint stress PFJ can undergo very high stress during typical activities of daily living. PFJ reaction force is influenced by both quadriceps force and knee angle. During knee flexion and extension patella is pulled superiorly by quadriceps tendon and inferiorly by patellar tendon. Priyanka Urkurkar 24-feb-13
- 16. Combination of these pulls produces posterior compressive forces of patella on femur It varies with knee flexion Priyanka Urkurkar 24-feb-13
- 17. In extension, there is small contact area between patella and femur. Minimal posterior compressive vectors of vastus medialis and vastus laterails muscles maintains low joint stress Priyanka Urkurkar 24-feb-13
- 18. Frontal plane Patellofemoral joint stability It is unique in its potential for Frontal plane instability near full extension Degenerative changes resulting from PFJ stress Relative stability depends on Transverse stabilizers longitudinal stabilizers Priyanka Urkurkar 24-feb-13
- 19. Longitudinal stabilizers Quadriceps tendon Patellar tendon Patello – tibial ligament capsule It provides medial lateral stability of patella in knee flexion Priyanka Urkurkar 24-feb-13
- 20. 24-feb-13 Patellar tendon Quadrice ps tendon Articular capsule Priyanka Urkurkar
- 21. Transverse stabilizers Superficial portion of extensor retinaculum Medial and lateral patellofemoral ligament attach the patella to the adductor tubercle medially and IT band laterally. Large lateral lip of the femoral sulcus Priyanka Urkurkar 24-feb-13
- 22. Quadriceps Force Vector The quadriceps force vector includes forces from the fiber orientation of vastus lateralis (VL) - composed of two force vector components , othe vastus lateralis longus (VLL) ovastus lateralis obliquus (VLO). Privyaanksa tUurksurkianr termedius (VI), 24-feb-13
- 23. rectus femoris (RF), vastus medialis (VM) – composed of two force vector components the vastus medialis longus (VML) vastus medialis obliqus(VMO) Priyanka Urkurkar 24-feb-13
- 25. Patellar tracking The patellofemoral joint functions to increase the efficiency of knee extensor mechanism by : Increasing the distance of the extensor apparatus from the axis of the knee Increasing the length of the quadriceps moment arm Turning the force of quadriceps directed obliquely superiorly and slightly laterally into a strict vertical force Priyanka Urkurkar 24-feb-13
- 26. Tracking of the patella is mainly due to configuration of femoral condyles and contracting surfaces of the patella. And, to a lesser extent due to Q angle. If underlying bony structural alignment is poor, prognosis of the treatment is likely to be poor. Priyanka Urkurkar 24-feb-13
- 28. Patella Maltracking The patella sits at the front of the knee, and with knee flexion and extension it normally runs up and down the middle of a groove in the front of the knee, called the trochlear groove. For various reasons the patella can track out of its groove (usually pulled laterally). This is called patellar maltracking. Priyanka Urkurkar 24-feb-13
- 30. It is usually an overuse type injury, but can be a result of trauma to the knee (subluxation or dislocation) With patellar maltracking, patella will rub, and there forces on the articular cartilage surfaces (in the patellofemoral joint) will be increased. This can cause pressure overload and pain, and eventually the articular cartilage can suffer increased wear and tear. Priyanka Urkurkar 24-feb-13
- 32. The Q - angle The direction of quadriceps force produces a measure known as Q – angle Increases with femoral anteversion and/ or external tibial torsion Priyanka Urkurkar 24-feb-13
- 33. Q – angle for male and female •The average angle is • 15.8 ± 4.5 for females •11.2 ± 3.0 for men Priyanka Urkurkar 24-feb-13
- 34. Above 15 degrees is considered excessive in men Above 17 degrees is considered excessive in females This is indicative of severe patellar malalignment. Priyanka Urkurkar 24-feb-13
- 35. What is patellofemoral pain syndrome ?? It’s a preferred term used to describe peripatellar and retro patellar pain Synonyms Patello femoral joint pain Anterior knee pain Chondromalacia patella Priyanka Urkurkar 24-feb-13
- 36. patellofemoral pain syndrome Usually young ( adolescents) and active Young athletes Pain on sitting (movie-goer sign) Middle aged Female > Male (2.2 times) Priyanka Urkurkar 24-feb-13
- 37. Clinical signs of PFPS Signs PFPS Onset running, stair/step activity particularly eccentric component Pain peripatellar and/or posterior, hard to describe Tenderness peripatellar or inferior pole, may not be palpable Crepitus often present in severe cases Giving way due to quads weakness or pain EffusioPrniyanka Urkurkar occasional but small 24-feb-13
- 38. Click clunk often in older athlete Knee ROM decreased in severe cases Patellar mobility dec. medial glide due to tight lateral retinaculum VMO wasting VMO/ VL imbalance and altered timings Effect of activity pain increases with inc. in activity Priyanka Urkurkar 24-feb-13
- 39. How does PFJ load results in patellofemoral pain ?? Injury to PFJ musculoskeletal tissues by supraphysiological load Single maximal load Lower magnitude repetitive load Cascade of events occur Inflammation of the peripatellar bone stress synovium Priyanka Urkurkar 24-feb-13
- 40. Patello femoral joint pain Increase in PFJ load causes patellofemoral pain. Priyanka Urkurkar 24-feb-13
- 41. Extrinsic load is created by ground reaction forces Is moderated by – Body mass Speed of gait Surfaces foot wear Priyanka Urkurkar 24-feb-13
- 42. Intrinsic load is conceptualized as patella tracking Factors influence patella tracking Remote Local Priyanka Urkurkar 24-feb-13
- 43. REMOTE FACTORS Femoral internal rotation Knee valgus Tibial rotation Subtalar pronation Muscle strength Muscle inflexibility LOCAL FACTORS Patella position Soft tissue tension Neuromuscular components of the medial and lateral vasti Priyanka Urkurkar 24-feb-13
- 44. Contributing factors for PFPS 1. Remote factor Increased femoral -structural: femoral anteversion internal rotation -weak external rotators and hip abductors -ROM deficit in the hip Increased Knee valgus -structural: genu varum, tibial varum,, coxavarum -weak hip external rotators, abductors, quadriceps and hamstrins Subtalar pronation Muscle flexibility -rectus femoris, TFL, quads, Priyanka Urkurkar hamstrings and gastocne2m4-fieub-s13
- 46. VMO weakness Contributes to poor tracking of the patella Allows vastus lateralis to pull the patella laterally Priyanka Urkurkar 24-feb-13
- 47. Tight Lateral Patellar Retinaculum: Causes lateral tilt of the patella Lateral patellar facet compression Pain in lateral aspect of knee Non-contact of the medial patellar facet Chondromalacia of medial patellar facet Priyanka Urkurkar 24-feb-13
- 48. Pes planus Foot pronation is a combination of eversion, dorsiflexion and abduction of the foot Hyper pronation with a secondary increase in transverse plane motion of the tibia leads to eccentric loading of the patella Priyanka Urkurkar 24-feb-13
- 49. This includes overuse of vastus lateralis and underuse of VMO Thus, it causes compensatory internal rotation of tibia or femur Upsets the patellofemoral mechanism Leading to patellofemoral pain Priyanka Urkurkar 24-feb-13
- 50. Priyanka Urkurkar Pronated feet 24-feb-13
- 51. Pes Cavus High-Arched or supinated foot. Compared with a normal foot, a high-arched foot provides less cushioning for the leg when it strikes the ground. This places more stress on the patellofemoral mechanism, particularly when a person is running. Causing the patella shift more laterally Priyanka Urkurkar 24-feb-13 Am Fam Physician. 1999 Nov 1;60(7):2012-2018.
- 53. 2. Local factors Patella position Patella position structural observation Lateral displacement -patella displaced laterally - restricted medial glide Lateral tilt -difficult to palapate lateral border -high medial border -increases with passive medial glide Posterior tilt -inferior pole displaced posteriorly, -difficult to palpate due to infrapatellar fat pad Rotation -long axis of the patella is not parellal with long axis of femur Patella alta - high riding patella Priyanka Urkurkar 24-feb-13
- 55. Soft tissue contribution Soft tissue contribution structural observation Tight lateral structures lateral displacement or tilt Compliant medial structures lateral displacement or tilt Vasti neuromuscular control Vasti neuromuscular control structural observation Reduced quads activity reduced ms. Bulk of quads Delayed onset of VMO reduced ms. bulk of VMO relative to VL Reduced magnitude of VMO reduced ms, bulk of VMO Relative to VL Altered reflex response reduced ms. bulk of VMO Priyanka Urkurkar 24-feb-13
- 56. Knee health follows a neat algebraic equation: feet + hips = knees. It just so happens that athleticism’s algebraic equation goes like this: feet + hips = athleticism. Priyanka Urkurkar 24-feb-13
- 58. 24-feb-13 summary Anatomy patellofemoral joint Biomechanics of patellofemoral joint Patellofemoral pain syndrome Priyanka Urkurkar
- 59. Poor Control of Hip Rotation Tight Muscles (e.g. iliotibial band) Femoral Anteversion Tibial Torsion Excessive Pronation Post- Surgery Post knee injury Post patellar subluxatio n Primary dysfunction Secondary dysfunction Vastus medialis obliques dysfunction Abnormal Biomechanics Tight lateral structures (e.g. iliotibial band, lateral retinaculum) Abnormal Patellar Tracking Distance running steps/stains Excessive pressure on squats patellofemoral joint Patellofemoral syndrome Increased Q angle Patella alta summary Priyanka Urkurkar 24-feb-13
- 60. references Brukner P, Khan K. Clinical Sports Medicine. 3rd Edition. Zuluaga M, Briggs C et al. Sports Physiotherapy: Applied Science and Practice. Levangie PK, Norkin CC. Joint Structure and Function: A Comprehensive Analysis Kapandji IA. The physiology of the joints: Lower extremity Neumann DA. Kinesiology of the musculoskeletal system: foundations for physical rehabilitation 24-feb- 13 Priyanka Urkurkar
Notas del editor
- Most of the patella also have the second vertical ridge towards the medial border that separates the medial facet from extreme medial edge known as odd facet of the patella.
- Posterior surface of the patella sits on the femoral sulcus in the extended knee on the anterior aspect of the distal sulcus.
- Superior aspect of the femoral sulcus is less developed as compared to the inferior
- At 30 degrees, the area of patellofemoral contact is approximately 2.0cm2. At 90 degrees of knee flexion contact area triples, increasing up to 6.0cm2. The contact area initially is small and gradually increases as the joint become more congruent. At 90 degrees of flexion, patella moves laterally . When the patella sits in the femoral sulcus in the extended knee, only the inferior pole of the patella is making contact with the femur. As the knee begins to flex, the patella slides down the femur, increasing the surface contact area. In this manner, the first consistent contact between the patella and the femur occurs along the inferior margin of both the medial and lateral facets of the patella at 10 to 20 of knee flexion. As tibiofemoral flexion progresses, the contact area increases and shifts from the initial inferior location on the patella to a more superior position. As the contact area shifts superiorly along the posterior aspect of the patella, it also spreads outward to cover the medial and lateral facet. By 90 of knee flexion, all portions of the patella have experienced some (although inconsistent) contact, with the exception of the odd facet. As flexion continues beyond 90, the area of contact begins to migrate inferiorly once again as the smaller odd facet makes contact with the medial femoral condyle for the first time. At full flexion, the patella is lodged in the intercondylar groove, and contact is on the lateral and odd facets, with the medial facet completely out of contact
- When femur is fixed and tibia is flexing. Patella is pulled down and under the femoral condyles. Ending with the apex of patella pointing posteriorly in full knee flexion. The sagittal plane movement of the patella as the patella travels down the intercondylar groove of the femur is termed as patellar flexion.
- In addition to flexion and extension patella rotates around longitudinal axis and tilts around an anterposterior axis. Rotation around longitudinal axis is termed as medial or lateral patellar tilt
- It is like patellar tilt.. It is necessary in order for the patella to remain seated in the femoral condyles as the femur undergoes axial rotation on the tibia. Because the inferior aspect of the patella is tied to the tibia through patellar tendon.
- This is the rationale for the use of SLR as a way of improving quadriceps strength without creating or exacerbating patellofrmoral joint stress
- In extended knee instability is a problem because patella sits in the shallow femoral sulcus.
- Medial lateral stability through increased PFJ compression
- This retinaculum further
- During active extension, the patella glides superiorly. If this glide is restricted, quadriceps function is compromised, and passive knee extension may be lost. During active tibiofemoral flexion, the patella glides inferiorly. As knee flexion is initiated, the patella shifts medially as it is pushed by the larger lateral femoral condyle and as the tibia medially rotates with unlocking of the knee. As knee flexion proceeds past 30, the patella may shift slightly laterally or remain fairly stable, inasmuch as the patella is now firmly engaged within the femoral condyles.
- The condition is much more common in females.
- Increases with femoral anteversion and/ or external tibial torsion
- Chondromalacia patellae includes problems related only to articular cartilages. Anterior knee pain syndrome includes the group of problems including problems in bursa, tendons, plica, retinacula etc.
- Female wid inc. Q angle normal lateralization of patella and dec. activity Boys wid normal Q angke increased lateralization of patella (malalignment) inc activity
- Increase in magnitude of PFJ load will (e.g higher training volume, increased speed of running, or bounding) this may overload PFJ structures sufficiently to initiates painful process.
- a movement of patella within the femoral trochlea
- Weakness of hip external rotators: may allow for excessive femoral internal rotation during the stance phase leads to increased contact pressure between the lateral femoral condyle and the lateral facet of the patella repetitive nature of running may lead to PFPS Weakness of hip abductors: allows for excessive femoral adduction during the stance phase of running lead to valgus (abducted) knee Knee valgus is believed to increase lateral forces acting on the patella Iliopsoas and Hamstring: increases knee flexion angle in running thus increases the patellofemoral joint reaction forces in stance Gastrocnemius: increases knee flexion in running increases the flexion torque creates compensatory foot pronation and can increase the posterior force on the knee
- Typical foot pronation during the heel contact/weight acceptance phase of gait, is characterized by eversión of the calcaneus. This motion causes the talus to both plantar flex and rotate inwardly, taking the tibia with it. During supination, which occurs after shock absorption/loading response, these trends reverse as body weight shifts over the foot, and the knee becomes tenninally extended (screw-home mechanism). It is hypothesized that excessive pronation would cause increased calcaneal eversión and as a result, exaggerated internal rotation of the talus and tibia. In this scenario, as the foot attempts to supinate, the excessive rotation of tibia/talus would delay the external tibial rotation needed to facilitate knee extension. Consequently, to achieve full knee extension, the femur would have to compensate by internally rotating more than normal, the lateral tracking of patella would increase, patellofemoral contact force would be exaggerated, and knee pain would follow.