Anterior Knee Pain Sportseminar

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16.10.2013 1 Orthopädie Patellofemoral Pain - etiology, risk factors, conservative therapy Florian Dirisamer

Transcript of Anterior Knee Pain Sportseminar

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Orthopädie

Patellofemoral Pain - "etiology, risk factors, conservative therapy Florian Dirisamer

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Patellofemoral Pain what are the difficulties?

„…, no other area of orthopaedic surgery has an iatrogenic failure rate as great as that for patients with chronic anterior knee pain.“

Scott F. Dye

Orthopädie

Patellofemoral Pain Incidence of anterior knee pain

Berkes et al. 1999

n= 41078

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Patellofemoral Pain Incidence of anterior knee pain

Berkes et al. 1999

Orthopädie

Patellofemoral Pain Incidence of anterior knee pain

Berkes et al. 1999

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Patellofemoral Pain Where does the pain come from?

!   Targets for conservative Treatment

!   Cartilage?

!   Hyaluronic Acid, Glucosaminesulfate, Chondroitine Sulfate

!   NSAIDS, Analgetics, Steroids

!   Bone? !   unloading (Bracing, Taping, Immobilization)

!   NSAIDS, Analgetics, Steroids

!   Soft tissue? !   Strengthening, Detonisation, functional training, Taping, ...

!   NSAIDS, Analgetics, Steroids

Orthopädie

Patellofemoral Pain Etiopathogenic Base

!   Tissue Homeostatic Theory (Scott Dye, 1990s)

!   > 50% positive bone scan with intense uptake

!   histologic similar to a stress fracture

!   peripatellar soft tissue alterations (Hoffa, retinacula, synovium)

!   neurophysiologic and biochemical adaptions

normal lymphocyte infiltration

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Patellofemoral Pain Envelope of function

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Patellofemoral Pain Envelope of function

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Patellofemoral Pain Envelope of function

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Patellofemoral Pain Envelope of function

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Patellofemoral Pain Functional Deficits

!   define the functional deficit!

!   proximal approach

!   trunk stability

!   hip abductors

!   external rotators

!   knee approach

!   internal rotation during midstance

!   extension deficit during gait

!   VMO atrophy

!   distal approach

!   hyperpronation + tibial internal rotation

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Patellofemoral Pain proximal approach Background

!   good function of hip abductors and external rotators essential for functional static control of leg during weightbearing

!   deficits in trunk control:

!   may lead to loss of pelvic stability

!   decrease of rotatory hip control

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Patellofemoral Pain proximal approach Background

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Patellofemoral Pain proximal approach Background

poor hip abductors/external rotators

femoral adduction

internal rotation

predisposition for lateral maltracking

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Patellofemoral Pain proximal approach Therapy

Earl, J. E., & Hoch, A. Z. (2011). A Proximal Strengthening Program Improves Pain, Function, and Biomechanics in Women With Patellofemoral Pain Syndrome.

Phase I improve volitional control of hip and core muscles

Phase II restore reflex contractions and perturbations

Phase III restore pattern generated movements

Orthopädie

Patellofemoral Pain proximal approach Therapy

!   sensomotoric principle:

!   from easy to complex, from low functional to functional

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Patellofemoral Pain knee approach Background

!   Bracing/McConell Taping

!   Goal: pain reduction during exercising/ADLs

!   by reducing the soft tissue stress

!   no evidence for improvement of patella tracking during weight bearing

!   timing of vasti contraction improves (VMO+VL synchronized)

Aminaka, N., & Gribble, P. A. (2005). A systematic review of the effects of therapeutic taping on patellofemoral pain syndrome Journal of athletic training, 40(4), 341–351.

Derasari, A., Brindle, T. J., Alter, K. E., Alter, K. E., Sheehan, F. T., & Sheehan, F. T. (2010). McConnell Taping Shifts the Patella Inferiorly in Patients With Patellofemoral Pain: A Dynamic Magnetic Resonance Imaging Study. Physical therapy, 90(3), 411–419.

Cowan, S. M. (2006). Patellar taping does not change the amplitude of electromyographic activity of the vasti in a stair stepping task. British journal of sports medicine, 40(1), 30–34.

Orthopädie

Patellofemoral Pain knee approach Background

!   VMO/VL Balancing

!   evidence for neuromuscular imbalance VMO/VL

!   EMG activity: normally 1:1, patients with AKP 0,8:1

!   VMO strengthening or VL weakening (Botox)

!   improvement significantly higher in Botox group (pain and function)

!   evidence for effectiveness of VMO training

!   neuromuscular reeducation should happen!

Aminaka, N., & Gribble, P. A. (2005). A systematic review of the effects of therapeutic taping on patellofemoral pain syndrome Journal of athletic training, 40(4), 341–351.

Singer, B. J., Singer, B. J., Silbert, P. L., Silbert, P. L., Song, S., Song, S., Dunne, J. W., et al. (2011). Treatment of refractory anterior knee pain using botulinum toxin type A (Dysport) injection to the distal vastus lateralis muscle: a randomised placebo controlled crossover trial. British journal of sports medicine, 45(8), 640–645.

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Patellofemoral Pain distal approach Background

hyperpronation

tibial internal rotation

increase of functional Q-angle

predisposition for lateral maltracking

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Patellofemoral Pain distal approach Background

!   kinematics of the foot paralell to tibal rotation

!   hyper-/prolonged pronation causes higher/longer tibial internal rotation

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Patellofemoral Pain distal approach therapy

!   prefabricated foot orthoses provide significate improvement in pain and function

!   hind foot 4° varus wedging and arch support

!   the more effect the more pronation prior to treatment

Barton, C. J., Menz, H. B., & Crossley, K. M. (2011). The immediate effects of foot orthoses on functional performance in individuals with patellofemoral pain syndrome. British journal of sports medicine, 45(3), 193–197.

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Patellofemoral Pain Conclusion

!   results of conservative approach limited but not that bad

!   early stage of OA ideal to improve functional deficits

!   respect individual envelope of function

!   realistic patient expectations needed

!   end stage arthritis

!   functional rehab program postop

!   a home training programme sustains the patients individual responsibility and lowers the doctors accountability for the problem

Earl, J. E., & Hoch, A. Z. (2011). A proximal strengthening program improves pain, function, and biomechanics in women with patellofemoral pain syndrome The American journal of sports medicine, 39(1), 154–163

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Thanks for your attention


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