Patellofemoral pain: Using evidence to inform practicesemrc.blogs.latrobe.edu.au › ... ›...

Presenters

Kay Crossley: La Trobe

Natalie Collins: UQBill Vicenzino: UQChristian Barton(KC): La Trobe

Follow us on Twitter! @iPFRR17

Patellofemoral pain: Using evidence to inform

practice

Part AEvidence related to:

Defining PFP ; impairments; treatments – DISCUSSION

Part BPractice: Cases – applying

evidence to manage PFP- DISCUSSION


Patellofemoral pain: Using evidence to inform

practice

Patellofemoral pain:Overview

KAY M CROSSLEYBAppSc (physio); PhD

APA Sports PhysiotherapistProfessor,

La Trobe University

Important PFP resources: PFP Retreat

JOSPT, 2010, 40(3):A1-16

JOSPT, 2012, 42(6):A1-20

BJSM, 2014, 48(6):411-414

Clinical Symposium

Brisbane, 22 July 2017


5th International Patellofemoral Pain Research Retreat

Gold Coast, 18-20 July 2017

Important PFP resources

http://www.latrobe.edu.au/sport-and-exercise-medicine

Dr Michael RathleffDr Christian Barton

@kaymcrossley@natj_collins@Bill_Vicenzino@DrChrisBarton@LaTrobeSEM

@MichaelRathleff@rwilly203


Br J Sports Medicine 2016: 6;50:839–843.

Br J Sports Medicine 2016: 6;50:8344-852.

Overview

PFP in adolescents PFP in adults PFJ OA in adults

1. What is PFP

i. Terminology

ii. Definitions

iii. Clinical exam

iv. Natural history

2. Impact of PFP across the lifespan

What is patellofemoral pain

Br J Sports Medicine 2016: 6;50:839–843.

TerminologyWhat is patellofemoral pain?


Patellofemoral pain is the preferred term, and is a synonym for other terms including: (1) PFP syndrome; (2) chondromalacia patella; (3) anterior knee pain and/ or syndrome; and (4) runner’s knee.

What is patellofemoral pain?


Additional criteria (not essential): • Crepitus or grinding sensation emanating from the

patellofemoral joint during knee flexion movements• Tenderness on patellar facet palpation• Small effusion• Pain on sitting, rising on sitting, or straightening the

knee following sitting

Defining patellofemoral pain- pain around or behind the patella, (can be medial,

lateral or infrapatellar; can be non-specific or vague)- aggravated by at least one activity that loads the

patellofemoral joint during weight bearing on a flexed knee

- (eg, squatting, stair ambulation, jogging/ running, hopping/jumping).

Clinical examinationWhat is patellofemoral pain?


Clinical examination is the cornerstone to diagnose BUT….there is no definitive clinical test to diagnose

The best available test is anterior knee pain elicited during a squatting manoeuvre: ……PFP is evident in 80% of people who are positive on this test.Additional tests (limited evidence):

- Tenderness on palpation of the patellar edges ……….(PFP is evident in 71–75% of people with this finding).

Tests with limited diagnostic usefulness:Patellar grinding and apprehension tests (eg, Clarke’s test) have low sensitivity and limited diagnostic accuracy for PFPKnee range of motion and effusion.

Incidence/ prevalenceWhat is patellofemoral pain?


PFP is common in young adolescents, with aprevalence of 7–28%, and incidence of 9.2%.

Few studies have evaluated prevalence or incidence in other populations, except in the military, where the annual incidencein men is 3.8% and in women is 6.5%, with a prevalence of 12% in men and 15% in women.

Specialisation in a single sport was associated with a relative risk (1.5: 95% CI: 1.0 to 2.2) of PFP incidence, relative to multisport athletes

PFP across the lifespan

asymptomatic PFP

adolescents young adults

Sandow et al, 1985, JBJS (Br), 67(1):36-8Nimon et al, 1994, J Pediatr Orthoped 18(1):118-22

asymptomatic PFP PFJ OA

adolescents young adults older adults

Age 40-50: radiographic PFJ OA in 26% (isolated PFJ) & 29% (PFJ + TFJ) with chronic AKP Hinman et al, 2014, Arth Care Res, 66(8):1252-7




Retrospective case-control study: PF arthroplasty more likely to report adolescent AKP (22%) vs. medial unicompartmental knee

arthroplasty (6%); OR 4.4 (95% CI 1.8 to 10.6) Utting et al, 2005, Knee, 12(5):362-5


continuum of PFJ disease





Impact of PFP across the lifespan



1. PFP is not a benign or self-limiting condition

2. Adolescents with PFP have poor care-seeking behaviour

3. Adolescents with PFP may become less physically active

4. Subgroup of people with PFP have a poor prognosis

Sandow et al, 1985, JBJS (Br), 67(1):36-8Nimon et al, 1994, J Pediatr Orthoped 18:118-22

Schipof et al 2014, Osteoarthrit Cart, 22:631-8

Crepitus may be an early sign of PFJ OA

59% had sought medical treatment, 18% currently under medical treatment

Rathleff et al, 2013, BMC Musc Dis, 14:225

Age 26 ± 7 years: lower weekly physical activity vs. controls (344 vs. 536 mins/week)

Rathleff MS et al, 2014, KSSTA, 22(10):2301-7

Unfavourable recovery: 55% at 3 mths, 40% at 12 mths; 60% at 5 years

Collins N et al, 2013, BJSM, 47(4):227-33Lankhorst N et al, BJSM in press

Ledingham et al, 1993, Ann Rheum Dis, 52(7):520-6Duncan et al, 2006, Rheumatol, 45:757-60

lateralTFJ

medial TFJ

PFJ

10%

24%

50%

1%

8%

6%

1%

5. Most common knee joint compartment affected by OA



PFJ osteophytes significantly associated with pain (not TFJ)Kornaat et al, 2006, Radiol, 239(3):811-7

6. More potent source of symptoms than TFJ OA


Reduced patella cartilage volume associated with increased pain & poorer function (not femoral or

tibial) Hunter et al, 2003, Osteoarthritis

Cart, 11(10):725-9


7. Limitations of current surgical strategies for PFJ OA


Implications of PFP across the lifespan



1. Consider prevention strategies for adolescents

2. Take adolescent knee pain seriously– appears to be the start of a chronic condition

3. Patellofemoral pain in adults appears to be the start of a chronic condition

4. Stopping transition and persistence of symptoms may require treatments to address PFJ load

Clinical Symposium

Brisbane, 22 July 2017


5th International Patellofemoral Pain Research Retreat

Gold Coast, 18-20 July 2017

Patellofemoral pain: Using evidence to inform practicesemrc.blogs.latrobe.edu.au › ... ›...

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