Saturday, April 5, 2014

Patellofemoral Pain Syndrome

I thought we could take a little break from this crazy focus on perinatal fitness and do a blog on patellofemoral pain syndrome. But, just so you know, pregnant women get this too!

What is PFPS?

Patellofemoral Pain Syndrome is anterior knee pain in the area of the patella that is also referred to as “runner’s knee.” PFPS is a diagnosis of exclusion where other etiologies for knee pain should be eliminated by your physician on physical exam. For the practitioners out there, patients present with anterior knee pain involving the patella and surrounding retinaculum (see figure). They often complain of a “giving way” sensation that is actually secondary to muscle insufficiency or sudden pain. Patients may describe something known to practitioners as +theater sign—after being seated for a long period of time, patients experience frontal knee pain upon standing.

What causes this?

Patellofemoral pain syndrome is caused when the patella does not track correctly as the knee is being bent and straightened. Improper tracking leads to cartilage damage and worsening pain and inflammation. It’s very common in people who focus mainly on one sport in high volumes and is also very common in adolescent girls, likely secondary to increased Q angle that we talked about in the ACL blog. Specifically, when the knee is bent,
the 4 muscles of the quadriceps and the supporting muscles of the knee joint have to fire in balance to pull the patella in a straight line along the groove formed by the femur and tibia. In PFPS, the most common example of imbalance of muscle strength is that the lateral structures of the knee (vastus lateralis, iliotibial band, and lateral retinaculum) are tight and the vastus medialis oblique muscle on the medial (inside) of the knee is weak.

Physical Exam:

On examination, patients have tenderness to palpation on the medial and/or lateral patella, and there will be no meniscal tear signs (negative McMurray’s) or ligament instability (negative anterior drawer or Lachman test). On squat test, you will see valgus deviation of the knee, indicating weakness of the hips and quadriceps muscles. If this is a chronic problem, you may see atrophy of vastus medialis oblique on physical exam.

What can you do if you think you have PFPS:

See your doctor for a physical exam and to rule-out any serious knee pathology. Once diagnosed, treatment involves exercises to improve strength in the hips and quadriceps muscles and to increase flexibility in the quadriceps and hamstrings. It is also important to ice post-activity to help with inflammation that causes pain. NSAIDs like ibuprofen (Advil/Motrin) or naproxen (Aleve) can be taken to help reduce inflammation and pain. Relative rest from activities that worsen the pain is recommended until strength and flexibility enables the athlete to return to sport/play/recreation. BUT, you can’t just sit on the couch all day because you will experience +theater sign! ;) So, light biking or elliptical 3 x a week for 20-30 minutes to start is recommended to improve circulation and active range of motion of the knee joint, followed by some of the strengthening and flexibility exercises in the following links or prescribed by your PT or MD. Also, ask yourself, when was the last time you changed your workout/running shoes? If you’re running, you need a new pair every 300 to 500 miles or every 6-12 months. (I added the “to 12 months” part because I am the worst about this and don’t get new shoes often enough.) Orthotics may also be indicated if you are an overpronator.

My fave exercises for this:

v  Warm-up/range of motion: 20-30 minutes light stationary bicycle
v  Flexibility: IT band, quad, and hamstring stretches
v  Strength: quad sets/squeeze, bridges, planks
o   Quad sets – tighten quad muscles while you straighten the knee (can do these watching TV!)
o   Abduct knees on bridge and squeeze exercise ball to recruit abductors
o   Extending a single leg at a time on bridge and adducting leg on side plank can make these more challenging as you get stronger

v  ICE! Ice is the best exercise because you get to do it watching TV and relaxing ;) It’s also great medicine and if you do this, you might not need NSAIDs!


Uptodate hand-out for patients:

Just a disclaimer: I think I am taking a maternity leave from this blog sometime soon. I am feeling really pregnant but still running up to 6 miles on days when I feel good (don't be too impressed- on other days I run maybe 2 miles, go for a walk, or just stretch and go to bed!), now starting to enter month 9. Baby will be arriving any day over the next few weeks, so it may be a while before the next post, but look forward to some great stuff on post-partum exercise circa summer 2014.