Editorial
Guy G. Simoneau
This special issue provides clinical commentaries, case reports, and research data that should be of interest to all individuals treating patients with patellofemoral joint dysfunction. While it is in no way the final perspective on this issue, it is a collection of work that offers one more important contribution to the evolution of the rehabilitation techniques intended to address patellofemoral pain. As pointed out by several contributors in this special issue, it is unlikely that one intervention approach will be the answer for all patients with ‘‘anterior knee pain.'' We are still in need of a systematic and valid examination/evaluation approach that will guide decision making toward the most effective method of intervention for each patient with patellofemoral joint pain. Hopefully, contributions such as the ones found in this special issue will continue to bring us closer to a time when individuals with patellofemoral joint pain can expect their therapists to provide them with evidenced-based rehabilitation programs specific to their conditions.
J Orthop Sports Phys Ther. 2003; 33(11):637-638.
Key Words: patellofemoral joint dysfunction, treatment
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Clinical Commentary
Christopher M. Powers
Although patellofemoral pain (PFP) is recognized as being one of the most common disorders of the lower extremity, treatment guidelines and underlying rationales remain vague and controversial. The premise behind most treatment approaches is that PFP is the result of abnormal patellar tracking and/or patellar malalignment. Given as such, interventions typically focus on the joint itself and have traditionally included strengthening the vastus medialis oblique, taping, bracing, soft tissue mobilization, and patellar mobilization. More recently, it has been recognized that the patellofemoral joint and, therefore, PFP may be influenced by the interaction of the segments and joints of the lower extremity. In particular, abnormal motion of the tibia and femur in the transverse and frontal planes may have an effect on patellofemoral joint mechanics. With this in mind, interventions aimed at controlling hip and pelvic motion (proximal stability) and ankle/foot motion (distal stability) may be warranted and should be considered when treating persons with patellofemoral joint dysfunction. The purpose of this paper is to provide a biomechanical overview of how altered lower-extremity mechanics may influence the patellofemoral joint. By addressing these factors, better long-term treatment success and prevention may be achieved.
J Orthop Sports Phys Ther. 2003;33(11):639-646.
Key Words: knee, patella, patellofemoral, pain
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Case Report
Catherine L. Mascal, Robert F. Landel, Christopher M. Powers
Study Design: Case report. Objective: To describe an alternative treatment approach for patellofemoral pain. Background: Weakness of the hip, pelvis, and trunk musculature has been hypothesized to influence lower-limb alignment and contribute to patellofemoral pain. Two patients who had a chief complaint of patellofemoral pain and demonstrated lack of control of the hip in the frontal and transverse planes during functional movements were treated with an exercise program targeting the hip, pelvis, and trunk musculature. Methods and Measures: The patients presented in these 2 case reports did not exhibit obvious patellar malalignment or tracking problems; however, on qualitative assessment, both demonstrated excessive hip adduction, internal rotation, and knee valgus during gait and while performing a step-down maneuver. In addition, both patients exhibited weakness of the hip abductors, extensors, and external rotators, as demonstrated by hand-held dynamometry testing. Treatment in both cases occurred over a 14-week period and focused on recruitment and endurance training of the hip, pelvis, and trunk musculature. Functional status, pain, muscle force production, as well as subjective and objective assessment of lower-extremity kinematics during gait and a step-down maneuver were assessed preintervention and postintervention. Results: Both patients experienced a significant reduction in patellofemoral pain, improved lower-extremity kinematics during dynamic testing, and were able to return to their original levels of function. Gluteus medius force production improved by 50% in patient A and 90% in patient B, while gluteus maximus force production improved 55% in patient A and 110% in patient B. Objective kinematic improvements in the step-down task also were demonstrated in patient A. Conclusion: Assessment and treatment of the hip, pelvis, and trunk musculature should be considered in the rehabilitation of patients who present with patellofemoral pain and demonstrate abnormal lower-extremity kinematics.
J Orthop Sports Phys Ther. 2003;33(11):642-660.
Key Words: case study, knee pain, lower-extremity rehabilitation, therapeutic exercise
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Clinical Commentary
Michael T. Gross, Judy L. Foxworth
Foot orthoses often are prescribed for patients with patellofemoral pain. The purpose of this clinical commentary is to review the theoretical and research basis that might support this intervention and to provide our own clinical experience in providing foot orthoses for these patients. Literature is reviewed regarding (1) the effects of foot orthoses on pain and function, (2) the relationship between foot and lower-extremity/patellofemoral joint mechanics, (3) the effects of foot orthoses on lower-extremity mechanics, and (4) the effects of foot orthoses on patellofemoral joint position. The literature and our own clinical experience suggest that patients with patellofemoral pain may benefit from foot orthoses if they also demonstrate signs of excessive foot pronation and/or a lower-extremity alignment profile that includes excessive lower-extremity internal rotation during weight bearing and increased Q angle. The mechanism for foot orthoses having a positive effect on pain and function for these patients may include (1) a reduction in internal rotation of the lower extremity; (2) a reduction in Q angle; (3) reduced laterally-directed soft tissue forces from the patellar tendon, the quadriceps tendon, and the iliotibial band; and (4) reduced patellofemoral contact pressures and altered patellofemoral contact pressure mapping. Foot orthoses may be a valuable adjunct to other intervention strategies for patients who present with the previously stated structural alignment profile.
J Orthop Phys Ther. 2003;33(11):661-670.
Key Words: function, kinematics, knee pain, lower extremity, patella
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Research Report
Mary Lloyd Ireland, John D. Willson, Bryon T. Ballantyne, Irene S. Davis
Study Design: Cross-sectional. Objectives: To determine if females with anterior knee pain are more likely to demonstrate hip abduction or external rotation weakness than a similar, asymptomatic, age-matched control group. Background: Diminished hip strength has been implicated as being contributory to lower-extremity malalignment and patellofemoral pain. The identification of reliable and consistent patterns of weakness in this population may help health care professionals establish a more effective treatment plan. Methods and Measures: Hip abduction and external rotation isometric strength measurements were recorded for the injured side of 15 female subjects with patellofemoral joint pain (mean ± SD age, 15.7 ± 2.7 years; age range, 12-21 years). These were compared with strength measurements from the corresponding hip of 15 age-matched female control subjects (mean ± SD age, 15.7 ± 2.7 years; age range, 12-21 years). All strength measurements were made using hand-held dynamometers. Results: Subjects with patellofemoral pain demonstrated 26% less hip abduction strength (P<.001) and 36% less hip external rotation strength (P<.001) than similar age-matched controls. Conclusions: The results indicate that young women with patellofemoral pain are more likely to demonstrate weakness in hip abduction as well as external rotation than age-matched women who are not symptomatic.
J Orthop Sports Phys Ther. 2003;33(11):671-676.
Key Words: anterior knee pain, hip abduction, hip external rotation, knee, patella
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Research Report
Christopher M. Powers, Samuel R. Ward, Michael Fredericson, Marc Guillet, Frank G. Shellock
Study Design: Single-group, repeated-measures design. Objective: To compare patellofemoral joint kinematics during weight-bearing and non–weight-bearing knee extension in persons with lateral subluxation of the patella. Background: The only previous study to quantify differences in patellofemoral joint kinematics during weight-bearing and non–weight-bearing tasks was limited in that static loading conditions were utilized. Differences in patellofemoral joint kinematics between weight-bearing and non–weight-bearing conditions have not been quantified during dynamic movement. Methods and Measures: Six females with a diagnosis of patellofemoral pain and lateral subluxation of the patella participated. Using kinematic magnetic resonance imaging, axial images of the patellofemoral joint were obtained as subjects extended their knees from 45° to 0° during non–weight-bearing (5% body weight resistance) and weight-bearing (unilateral squat) conditions. Measurements of patellofemoral joint relationships (medial/lateral patellar displacement and patellar tilt), as well as femur and patella rotations relative to an external reference system (ie, the image field of view), were obtained at 3° increments during knee extension. Results: During non–weight-bearing knee extension, lateral patellar displacement was more pronounced than during the weight-bearing condition between 30° and 12° of knee extension, with statistical significance being reached at 27°, 24°, and 21°. No differences in lateral patellar tilt were observed between conditions (P = .065). During the weight-bearing condition, internal femoral rotation was significantly greater than during the non–weight-bearing condition as the knee extended from 18° to 0°. During the non–weight-bearing condition, the amount of lateral patellar rotation was significantly greater than during the weight-bearing condition throughout the range of motion tested. Conclusions: The results of this study demonstrated that lateral patellar displacement was more pronounced during non–weight-bearing knee extension compared to weight-bearing knee extension in persons with lateral patellar subluxation. In addition, the results of this investigation suggest that the patellofemoral joint kinematics during non–weight-bearing could be characterized as the patella rotating on the femur, while the patellofemoral joint kinematics during the weight-bearing condition could be characterized as the femur rotating underneath the patella.
J Orthop Sports Phys Ther. 2003;33(11):677-685.
Key Words: magnetic resonance imaging, patellar tracking, patellofemoral joint
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Clinical Commentary
Thay Q. Lee, Garrett Morris, Rick P. Csintalan
Fixed rotation of either the femur or tibia has a significant influence on the patellofemoral joint contact areas and pressures. This is due to the anatomic asymmetry in the knee with respect to all planes, as well as the laterally directed force vector that naturally exists in bipedal lower-limb biomechanics. Specifically, femoral rotation results in an increase in patellofemoral contact pressures on the contralateral facets of the patella, and tibial rotation results in an increase in patellofemoral contact pressures on the ipsilateral facets of the patella. This difference can be elucidated when one considers that rotation of the femur is biomechanically different than rotation of the tibia. For both tibial and femoral rotations, the patella’s distal attachment to the tibial tubercle influences the direction of patellar movement. The biomechanical evidence reviewed in this manuscript suggests that the determining factor in patellofemoral pathology is the derangement of normal joint mechanics. However, despite considerable experimental data supporting this position, there also are theories that suggest otherwise. This illustrates a very important point in patellofemoral joint pathology, where no one factor may be the sole defining etiology. Instead, the patellofemoral joint is one of the most complex diarthrodial joints in the body and there are a number of etiologic factors that can lead to pathology. This should be considered for developing repair and rehabilitation strategies.
J Orthop Sports Phys Ther. 2003;33(11):686-693.
Key Words: contact pressure, femur, knee, patellofemoral joint, tibial rotation
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