PATELLOFEMORAL PAIN: All you need to know! (part 3)

In the previous blogs (read here and here) we talked about the multi factorial etiology of PFP and the need to focus on getting our differential right. Education is key in the management along with communication and addressing the psychosocial factors. It is mind boggling to know that up to 500 factors can contribute to development and sustaining PFP (ref). Therefore, it is recommended that, when it comes to the management of PFP, it should be a combination of more than one treatment approach focusing on strength and managing load, addressing flexibility issues and central sensitization and retraining gait mechanics and control. (ref). Demonstrating the integrated approach of interventions with proven efficacy (Lack et al, 2018)

PATIENT EDUCATION

Patient education remains the cornerstone for the management of patellofemoral pain including providing information and reassurance. It should include proper explanation of the potential contributing factors and the prognosis along with promoting self-efficacy. Addressing lifestyle factors and kinesiophobia are essential to achieve positive outcomes. (ref)

 The rehab of patient with PFP needs to be person focused keeping the multifactorial nature of the condition in mind. Emphasis should be placed on managing load and educating the patient by addressing the psychosocial factors as well as the biomechanical factors.

 IS EXERCISE THE PANACEA?

 Although there is strong evidence for exercise (ref, ref, ref), we should be mindful of the gap between research and long- term clinical outcomes. Research shows that despite all our efforts and all the exercises, 71 - 91% of individuals with PFP continue to experience recurring pain 20 years later (ref, ref) and 57% are likely to report unfavorable outcomes 5-8 years after. (ref)

 Therefore, clearly physiotherapists are missing a trick. With so much focus on ‘what’ to do, we are losing our focus on ‘how’ to do it! We are not being specific enough with our intensity, frequency and duration of our exercises. The focus is not individualistic with regards to which exercises to give for how long and to whom? What about time under tension and which exercise to give when?

We need to identify the training errors, address running gait & painful training activities along with modifying aggravating factors if we want to use movement and exercises as the way forward.

 CALM SH*T DOWN!

 Our first intention is to bring down the pain. The emphasis is on reducing the load on the patellofemoral joint for which isometrics can be a good option to start. Getting the muscles firing before hypertrophy can be a better option instead of blindly using passive therapies without any attention given to the best practice guidelines. (ref) The use of taping & braces can also be explored in patients with kinesiophobia (ref) to get them moving and participate in exercises. 

THE IMPACT OF STRENGTH

 Strengthening exercises do help but for how long? Are the results sustainable in the long term? Let’s look at some evidence. Knee targeted exercises are superior to 'wait & see' at 6 weeks (ref) but no difference in functional outcomes at 5 months (ref). Hip targeted exercises led to large reduction in pain and improvement in function but only in the short term (ref). In hip and knee vs knee exercises alone, better outcomes were reported in the short term (ref). Therefore, we need to level up our exercise game. We know that Quads are important in PFP so the goal should be to load them appropriately with leg extension (90-45) and leg press (0-45). Attempt should be made to target the glutes in different planes of movement as it is still not clear if the gluteal weakness is the effect or cause of PFP. (ref)

 WHERE DO WE START?

We need to recognize the fact that we cannot apply the same standard protocol to every patient as the cause and risk factors distinctly differ from patient to patient. We need to address the strength and endurance deficits and get specific. (ref, ref). We will never be able to implement exercise interventions to patients if we have no idea what was done or prescribed, with no idea of how many sets and reps, duration and rationale of exercises, recovery between sessions and patient compliance. Gait retraining has been shown poor long term outcomes with techniques like increasing step rate. However, increasing step rate with the option of transitioning to a non-rearfoot strike pattern provided no additional benefit of running retraining protocol compared to load management education (ref).

It has been shown that running retraining strategies are beneficial for short-term improvements in running specific PFP (ref) There is no benefits & conflictive evidence of the use of taping. (ref)

 Patellofemoral knee orthoses (knee brace, sleeve, or a patellar strap) plus exercise therapy versus exercise therapy alone did not have a meaningful impact on pain in the short term. (ref). However, if using braces allows the patient to move without fear then it might be worth exploring. Significant individual response has been reported for use of foot orthoses.(ref) clinicians should not use dry needling for the treatment of individuals with PFP. (ref)

As we always say at the BCP, communicate and listen well. Your patient is telling you the diagnosis and the possible treatment.