Patellofemoral dysfunction..

[guru_utkarsh]

Hey, Got this patient.. she is a 14 yr old girl.. complaining of anterior knee pain on descending stairs, squatting, sitting cross legged, jumping.. the patellla presents as tilted medially, quads are weak, skyline view x ray of patella shows medial tilting, no problem at the hips and femur is normally positioned..
Wat i the best way for treatment.. i've started with ice, TENS, taping the patella by displacing it laterally, strengthening the quads, stretching hamstrings and medial patellar structures..

"Post taping the activities of squatting and descending stairs had 50% pain relief.."

Am i on the right track.. plz rectify and suggest..
Also how helpful is taping as a long term treatment method.. will a brace to place patella in neutral position help?? thanks..

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[guru_utkarsh]

hey.. for further help i'm attaching X-Rays.. plz reply soon.. its urgent..
1. Skyline patellar digital
2. Whole femur digital
3. Knee AP/ LAt normal x ray

[shinydan]

hi.its cool.u r in the right track.i don think so any thing else you have to add in this initial phase.strenghten the hams too. i don know whether you started with that. patellar baring brace will help a lot too. i don think so she can do taping always.anyways taping is best.give concentration to the lateral structures, even the itband.is there a lot of tenderness in the proximal part of patella with resisted knee extn?

[junior_physiotherapist]

Hi All,

First of all what is her diagnosis ?? what is the cause of her problem!!!?

Any way ..as she seems being have a chondromalicia,!
In addition to the above u have to use with her grade one of
gentle joint -play oscillation may inhibit the pain..then u can make a progess.

Also let her do quad sets not to the point that increases irritability,then u can progress to SLR .

Remember to make adaptation to reduce amount of knee flexion and patellar compression whem she moves from flexion to extension in activities such as standing up from sitting or stair climbing .Instruct the patient to minimize stair climbing ,to use elevated seats on commodes,and to avoid deep-seated or low chairs.

Hope these could help u!

Regards

[jwilso]

the patient is 14. when is she going to use a comode? the x-rays didnt look too bad to me. Has she got any weakness in her hip, femoralanteversion,tibial torsion etc. is she flat footed?. there could be another reason for her maltracking.

[guru_utkarsh]

when is she going to use a comode?

Wat do u mean by that..

And femur aint atnteverted.. but i sure need help with it.. i'm not too gud at assessing femoral and tibial torsions..

And yes the quads are pretty weak..hams a lil tight.. i'm stretching the medial structures as well..
And wat bout the ITB.. i need to strengthen the abductors and stretch adductors or wat..
If any book, article on patellar maltracking and lower limb mechanics then do tell.. i'm not that gud at it.. though tryin my level best..
thanks..

[sdkashif]

You seems to be on right track. For a review about the patellfemoral dysfunction, have a look over.

Patellofemoral pain with malalignment or Biomechanical dysfunction.

This include problems that cause an increased functional Q angle such as femoral anteversion, external tibial torsion, genu valgum and foot hyper pronation. There may be a tight lateral retinaculum, weak VMO, Patella Alta, Patella baja, dysplastic femoral trachlea. There is usually abnormal patellar tracking andf there may be descordent firing of quadriceps.

Patellofemoral Pain with out Malalignment.

These include many subcategories that cause anterior knee pain.

Soft Tissue Lesions which include Plica Syndrome, Fat Pad Syndrome, Tendinitis of patellar or quadriceps tendons, Iliotibial band friction syndrome, prepatellar bursitis.

Tight Medial and lateral retinacula or patellar pressure syndrome.

Osteochondritis Dissecans or patella or femoral trochlea.

Traumatic Patellar chonromalacia.

Patellofemoral Osteoarthritis.

Apophysitis.

Symptomatic Bipartite patella.

Trauma.


Common Impairments:

Impairments that may be associated with patellofemoral Dysfunction include:

Weakness, inhibition, or poor recruitment or timing of vastus medialis oblique

Overstretched medial retinaculum

Restricted lateral retinaculum, IT band or fascial structures around the patella

Decreased medial gliding or medial tipping of patella

Pronated foot

Pain in the retron patellar region

Tight gastrocnemius, soleus, hamstring or rectus femoris muscles

Irritated patellar tendon or subpatellar fat pad

Patellar crepitus, swelling or locking

Management:

Protection Phase:

When symptoms are acute treat as any joint problem with modalities, rest, gentle motion and muscle setting exercies in pain free range or positions. Pain and joint effusion inhibit the quadriceps so it is imperative to reduce the irritating forces. Splinting the patella with a brace a tap may unload the joint and relieve the irritating forces.

Controlled Motion and Return To Function Phase:

When the signs of inflammations are no longer present, mamangementis directed towards corecting the biomechnical forces that may be contributing to the impairments. Suggestions for correcting the faulty patellar alignment or tracking follow.

Increase flexibility of lateral fascia and insertion of IT Band.

Use tap to realign the patella and apply a prolonged stretch as well as maitain alignment of patella for non stressful training.

Identify any tightened muscles that could be contributing to faulty mechanics and establish a stretching programme. Increase the knee flexion and extension by stretching exercises emphasize the muscles that cross two joints.

Train and strengthen the function control of Knee extension in the Non weight bearing position.

As a progression train and strengthen the function control of knee extension in the partial weight bearing and full weight bearing positions.

Modify the biomechanical stresses. If the pateint has a foot pronation, a foot orthosis may relive it. Assess lower limb Mechanics and modify any faulty patterns.

Educate the patient. Untill the knee is symptom free, the patient should avoids the positions and activities that provoke the condition.

Avoid stair climbing and descending untill muscles are strengthened to a level at which they can function without symptoms.

The patient should not sit with bent excessively for long periods.

Use a home exercise programme to reinforce the training and instruct patient how to safely progress.