Current Concepts in Patellofemoral Pain Syndrome: Treatment and Rehabilitation - Dale J. Buchberger
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Current Concepts in Patellofemoral Pain Syndrome: Treatment and Rehabilitation by Dale J. Buchberger, MS, PT, DC, CSCS, DACBSP.
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Current Concepts in Patellofemoral Pain Syndrome: Treatment and Rehabilitation - Dale J. Buchberger
- 1. Current Concepts in Patellofemoral Pain Syndrome: Treatment and Rehabilitation Dale J. Buchberger, MS, PT, DC, CSCS, DACBSP Vice-President, American Chiropractic Board of Sports Physicians Chiropractic Consultant, Auburn Doubleday's (Single-A affiliate Washington Nationals) Chiropractic consultant, Syracuse University Athletics Chiropractic consultant, New York Jets Football Strength and Conditioning Coordinator Auburn Stingrays Swim Team NUHS Homecoming Oakbrook, Il USA June 11, 2011
- 2. Thank you Dr. Winterstein and Shawna McDonough for the invitation to present
- 4. Patello-femoral Pain Syndrome (PFPS)
- 5. Where do we start?
- 22. What’s wrong with this squat?
- 29. Synovial Plica
- 33. Suggested Program of Management for Patellofemoral Pain Syndrome (PFPS)
- 41. BOSU Bridge
- 42. Straight 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
- 43. Bent Knee Ball Bridge
- 46. Hip 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
- 48. Bicycle 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
- 49. Circles: 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
- 50. Ball Table Shoulders in center of ball Head resting on ball Knees forward Feet straight ahead Squeeze bum Depress abdomen Hold 3-6 sec
- 51. Side 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.
- 53. Ball squat with band Add the band to ball squat to increase stimulation of hip abductors and reduce dynamic valgus at the knees
- 55. What’s wrong with this patient?
- 57. Questions
- 58. Thank You! 2006-2007 and 2008-2009 Stingray Sportsmanship award recipient; 2010-2011 High-point trophy winner
- 59. In Loving Memory of Lyle J. Buchberger Thanks for everything! Love ya dad! May 30, 1928 - January 12, 2009
Notas del editor
- It is nice to be back and to have the opportunity to speak for my alma mater. For those of you that knew me in school; you’re saying’ “What the hell is he doing up there?” I have two explanations: First: I ‘m a late bloomer Second: I was young I needed the money!
- I will apologize ahead of time for my bizarre presentation style. Sometimes I speak in random movie lines; it is up to you to decide if it is part of the presentation or a random movie line! On that note; ponder this during the next 90 minutes, Zoolander is to _________ as Space balls is to Star Wars.
- The learning objectives for the presentation today include: AS ABOVE
- ITBFS hasw been reported as the most common cause of lateral knee pain in runners and has been theorized to result from repetitive friction of the ITB sliding over the lateral femoral condyle. The incidence of ITBFS has been reported to be as high as 22.2% of all LE injuries in runners.
- ACL injuries are more common in females than males. This is due to a variety of factors including LE alignment and strength differences which will be discussed shortly. It has been reported that ~70-80% of all ACL injuries in females result from non-contact mechanisms. This finding is significant because prevention may play a key role in lowering this number. Data from the NCAA has found that the majority of ACL injuries for females occurred in women’s basketball and soccer, and for men in football mostly due to contact mechanisms. Due to these findings there has been in a wealth of research in the prevention of ACL injuries, especially in females.
- The diagnosis of PFPS encompasses retropatellar and or peripatellar knee pain. It is a diagnosis which is also more common in females than males and for some of the same reasons as ACL injuries which will be discussed shortly. A study by Devereaux and Lachman revealed that ~25% of all individuals with knee pain who were evaluated in a sports injury clinic were given the diagnosis of PFPS.
- The ankle is the most frequently injured joint in both sports and daily life. Data from the NCAA Injury Surveillance System showed that ankle ligament sprains were the most common injury over 15 sports, accounting for 15% of all reported injuries. 70-80% of ankle sprains are lateral, or inversion type sprains.
- The immediate result of LE injuries are pain and short term disability. Other consequences include long term disability and decreased participation in sports. Injuries have been found to be the leading reason people stop their involvement in sports & physical activity. Therefore, prevention of injury or complete recovery from injury is crucial to keep people active. Physical activity is known to decrease the risk of cardiovascular disease, obesity and diabetes, all of which are associated with higher mortality and morbidity and a significant cost to our health care system. Sports injuries are also a leading cause of the development of OA, especially knee and ankle injuries. Evidence shows that 12-20 years following a knee injury involving the meniscus and/or ACL, more than 50% will have knee OA in comparison with 5% in the uninjured population. The cost to treat LE injury conservatively, or operatively as well as the increased incidence of OA and disease associated with inactivity results in significantly high health care costs.
- You can get a better understanding of the kinematic chain with this picture. You can see how weakness of the hip abductors results in the pelvis dropping which causes an increase in femoral adduction in the frontal plane. In regards to ITBFS, this causes the ITB to pulled against the lateral femoral condyle, resulting in injury. Research has shown that ITBFS occurs when the is weakness of the hip abductors and the runner is in a phase of overtraining. Therefore, one of the main components in treatment is to strengthen the hip abductors.
- As mentioned previously, there are differences seen in LE alignment and strength in females as compared to males which results in a predisposition to ACL injuries and PFPS. This is not to say that men can’t display similar LE posture as we see here, however it is more commonly seen in females. The wider pelvis that females exhibit result in other changes down the LE such as: AS LISTED ABOVE. It is the external rotation of the tibia which is believed to strain the ACL against the lateral femoral trochlea increasing the chances of injury and it is also associated with increased lateral retropatellar contact pressure, which is a commonly accepted risk factor for PFPS.
- Studies have shown that when cutting, landing, squatting and running females exhibit greater hip adduction, hip IR, knee valgus and less knee flexion, as demonstrated in this picture. As we just discussed this alignment places greater stress on the ACL and PF joint. Studies have also suggested that there are greater eccentric demands placed on the hip abductors and ER in females versus males during running. When strength was tested in females with PFPS and ACL injury it was found that they had weakness of their hip abductors, external rotators and in some cases hip extensors. Thus, it makes sense that strengthening these muscle groups should result in less ACL injury and PFPS, and the research has shown just that. A study by Jacobs et al revealed that ↑ hip abductor strength resulted in ↓ knee valgus displacement when landing from a jump. Another study showed that activation of quadriceps and hamstrings is improved when there is an ↑ hip muscle activity. Taken all together, the vast majority of studies which evaluated the relationship of hip strength to injury suggest that LE prevention should include a strengthening program of the hip and knee, specifically hip abductors, ER and extensors.
- As with what was found with the ITBFS, ACL injuries and PFPS, studies have shown that lateral ankle sprains; especially chronic ankle sprains are associated with weak hip abductors. The authors cited on this slide state that weakness of the hip may result in chronic loss of stability or compensation throughout the LE kinematic chain which contributes to repeated injury at the ankle. Thus, strengthening the proximal musculature is key to reducing repeated injury at the ankle.
- The motion which occurs in the joints of the LE when a person is standing can be explained by the concept of the kinematic chain. When in a weight bearing position, the joints in the leg are linked together into a series of joints so that motion at one of the joints in the series is accompanied by motion at an adjacent joint. For example, as demonstrated by this slide, when a person bends both knees to squat, there must also be motion at both the ankle and hip joints. This concept is useful for assessing joint motion as well as the how injury affects joint movement. A change in the function or structure of one joint in the leg will usually cause a change in the function or structure immediately adjacent to the affected joint or at a more distal joint. This concept will be revisited throughout the rest of the presentation as we discuss how proximal stability at the hip affects both the knee and ankle.
- As mentioned previously when discussing the kinematic chain, a squat maneuver can be used to assess how motion in one joint affects another. A squat, or what we refer to as a functional squat is a quick way to assess the flexibility and strength throughout the LE. I will briefly run through the variety of things to look for and what they may indicate when assessing a patient’s ability to perform a functional squat, starting at the feet and going up. The first step is to place the patient in a “start position” in order to have a consistency when assessing or reassessing the move. This position when looking at the patient from the front, is an imaginary straight line drawn from the medial malleous to the lateral edge of the acromion process of the shoulder, with toes out at a 10 degree angle. First, assess the feet for pes planus, or flat feet. This can be structural or functional. Structural pes planus will not be altered by any amount of strengthening, orthotics are a way to provide external support to the arches to temporarily correct this deformity. Functional pes planus often occurs with dynamic knee valgus (everything falls inward). If this can be corrected if the dynamic knee valgus is decreased then hip strengthening will help decrease this occurrence. The next thing to look for is tight heel cords. If the achilles tendon is tight, a few things may happen: either the heels will come off the floor, or if the patient forces the heels down, the lumbar spine will flex and shoulders will come forward, or lastly they will actively contract their ankle dorsiflexors or toe extensors so you will see their toes come off the floor or anterior tibialis tendon stand out. With a normal heel cord, the heels will stay down without any of these compensations occurring.
- Next, take a look at the knees. Dynamic knee valgus is the most common thing that will happen and this usually occurs with internal femoral rotation and functional pes planus which indicates weakness of the hip external rotators and hip abductors. Dynamic knee varus and femoral external rotation occurs less often and is usually the result of weakness at the hip so that the patient “pre-positions” themselves consciously to avoid other compensations. You want to correct for this by placing pressure at the lateral knees while they squat and re-assess what happens.
- As for the hips and thighs, with normal flexibility and strength of the lower extremity the patient should be able to squat until the thighs are parallel to the ground. If there is weakness of the gluteals a patient won’t be able to get their thighs parallel. As mentioned before an increase in lumbar flexion indicates a tight achilles tendon, but may also be a sign of tight hip flexors and/or weak back extensors and is usually accompanied with forward shoulders. If the back is overly extended with the shoulders back they may have a sway back, or excessive amount of lordosis.
- Hip series and clam shells against wall with three (3) points of contact Balance lunge requires adequate psoas/quadriceps flexibility to perform correctly
- I’ve tried to make the process simple and efficient. That doesn’t mean you can’t make the process more complicated; that’s easy!