|
|
Patellofemoral pain
|
Logged in as: Guest
|
|
Users viewing this topic:
none
|
|
Login  | |
|
Patellofemoral pain - May 30, 2006 5:44:00 PM
|
|
|
tf8560
Posts: 47
Joined: October 21, 2004
From: miami
Status: offline
|
My patient is a 45 y/o MD who used to be an avid tennis player 2-3X/wk. no tennis last 6 mos due to bilateral knee pain just below the patella.
Eval found
1. Bilat rear foot varus (not too bad, but worth noting)
2. an approximate 1.7cm leg length discrepancy ASIS to meial maleolus L longer than R
3. Pain with resistance to the quads between 90 and 75 degrees flexion
4. significantly tight hamstrings and calf musculature.
For what its worth, I'm considering
1. Orthotics to correct LLD and rearfoot varus
2.Stretching to hamstrings/calf maybe tennis ball rolling to plantar fascia to augment
3. Hip strengthening
Thinking about TFM to patellar tendons, taping
but I mainly want to get your experience on what type of exercises directly for the knee you would consider. I know eccentrics are supposed to be beneficial, but specifically what eccentrics?
I was considering putting him on a horizontal type leg press and finding his loading tolerance weight and working him in painfree ranges.
Any help is greatly appreciated
Tom Fletcher, PT
|
|
|
|
|
Re: Patellofemoral pain - May 31, 2006 3:15:00 AM
|
|
|
PTupdate.com
Posts: 1478
Joined: October 8, 2001
From: Pittsburgh, PA USA
Status: offline
|
Tom,
Don't forget to address rectus tightness (that muscle gets ignored way to much) and also the ITB..both can certainly influence that patellar tendon. I would certainly do the TFM, perhaps pulsed US right at the site of the lesion, and perhaps iontophoresis as well (but at 6 months, probably less inflammation and more tissue dysfunction). Strengthen the quads and hip as you indicated. I just recently read an article that Jason Silvernail gave me regarding eccentric loading on a slant board versus standard step-ups/downs. Both worked well, but the slantboard patients had better continuation of improvement at 12 months.
As it is bilateral, I doubt the apparent limb difference is a major player, as the adaption of the body will be basically opposite for each limb, and his symptoms are bilateral.
John Duffy, PT OCS
[URL=http://www.PTupdate.com]www.PTupdate.com[/URL]
_____________________________
John M. Duffy, PT
Board Certified Orthopaedic Clinical Specialist
www.PTupdate.com
|
|
|
|
|
Re: Patellofemoral pain - May 31, 2006 3:20:00 AM
|
|
|
tf8560
Posts: 47
Joined: October 21, 2004
From: miami
Status: offline
|
Thanks John. Since i am a member of your site, has that article been posted?
Tom
|
|
|
|
|
Re: Patellofemoral pain - May 31, 2006 3:55:00 AM
|
|
|
Sebastian Asselbergs
Posts: 1207
Joined: September 29, 1999
From: Barrie, Canada
Status: offline
|
Second that notion of rectus femoris, and that apparent LLD, John - which is not likely to be a big factor...
I would focus a LOT on the posterior "tightness" of hams and calves - with a significant restriction there, any knee extensor strengthening or recruitment exercises will have a much harder time being effective. You may want to consider doing some neural work around sciatic components - maybe the hams are that tight because of protection of neural tissues - then again, maybe the hams have been tight for many years (possibly due to a protective adaptation) and the body simply hasn't reverted back to normal neuromuscular status.
In any case - the posterior tissues would have my attention most....(Esp. since I am a tennis player - poor- with intimate and painful knowledge of the importance of flexible posterior leg muscles...).
and check lumbar spine for flexibility and dynaimc stability - tight hams always raise a warning flag for a dysfunction there as well...
OK, just some ramblin' thoughts..
_____________________________
Mundi vult decipi
|
|
|
|
|
Re: Patellofemoral pain - May 31, 2006 6:29:00 AM
|
|
|
PTupdate.com
Posts: 1478
Joined: October 8, 2001
From: Pittsburgh, PA USA
Status: offline
|
Yes Tom, it was just done on May 10 of this year. There were some issues with the methodology of the study, which I put in the commentary. Plus, I recently tried this with a bilateral patellar tendinosis patient, and as the protocol calls for eccentric only, it gets tough because you need the other leg to concentrically return them to neutral!?
Duffy
_____________________________
John M. Duffy, PT
Board Certified Orthopaedic Clinical Specialist
www.PTupdate.com
|
|
|
|
|
Re: Patellofemoral pain - May 31, 2006 2:17:00 PM
|
|
|
ginger
Posts: 660
Joined: February 26, 2005
From: Melbourne Victoria
Status: offline
|
Hey Tom, here in Australia our emphasis is not nearly so much on exercise , as hands on manual therapies. Over the last twenty or so years I've found that a method I've labelled 'continuous mobilisation' is a very effective means to restore normal spinal facet joint mobility, along with the pain and other features associated with it. I say other features to include somatic referred pain and its cousins altered sensations and altered patterns of recruitment of distal musculature.
There was a time when I too was somewhat mystified by the PFS issue. As I worked and developed the continuous method, ( I'll explain this later) I realised that many of the musculoskeletal pain and dysfunction problems I'd been taught were of mysterious origin were revealed to be related to spinal facet joint dysfunction. In particular PFS. McConnel did brilliant work in the eighties to reveal it to be a muscle control issue to do with recruitment patterns of Vastus medialis oblique. She went further to propose a taping and exercise method that works . Unfortunately this method falls short of a cure.
What was and is regularly revealed by my assessments of those complaining of PFS is that they all , yes all, have hypomobile L3 facet joints on the side of their complained of Knee pain.
It remains obvious that a careful examamnination to test VMO function ( details on req.)and locate the problem to extracapsular issues is vital.
Method.
Mobilise L3. thats all Tom . Just mobilise L3. However when you do it ,take your time to explore the sensitive issue of resistance as you mobilise. As resistance to your passive movments falls away , so will the pain at that facet joint. within ten minutes you can test VMO function ( half squat will do ) and discover to your great surprise and delight , that the patello femoral pain is significantly reduced.
Continue to mobilise untill the resistance felt at L3 is as little as possible ( or untill your poor old thumb says uncle) and you will have gone a major step along the way to a CURE for this problem.
Don't go asking me for research , because I have not done it yet. Give me a few more years , but seriously it is as I say.
Don't wait for the paper Tom , just put your hands on L3 and give it your best. You are here at the cutting edge mate.
talk to me.
_____________________________
Ubi est mea anaticula cumminosa?
The Grand Pediculator
|
|
|
|
|
Re: Patellofemoral pain - May 31, 2006 3:21:00 PM
|
|
|
rwillcott
Posts: 436
Joined: March 20, 2006
From: Canada
Status: offline
|
Tom,
Have you checked his Thomas and Ober's Test? I would look for a tight ITB,Rectus Femoris or Iliopsoas. Also, have you checked the strength/endurance of glut med and max? These muscles can be lacking endurance and can lead to a valgus position at the knee joint with WB'ing activity.
It's also useful to perform a step-down exercise with the affected leg remaining on the step. Compare both sides and look for the amount of valgus stress at the knee.
I find the the hip is often overlooked when it comes to PFS. I would begin with a lot of glut med and max exercises in NWB and progress to WB'ing along with stretching of the the tight hip musculature such as ITB, Rec Fem and Iliopsoas.
Rob
|
|
|
|
|
Re: Patellofemoral pain - May 31, 2006 5:26:00 PM
|
|
|
tf8560
Posts: 47
Joined: October 21, 2004
From: miami
Status: offline
|
Thank you all good posts.
If what Ginger says is correct then wouldn't it reason that the LLD may be an issue? I do like the L3 mobs idea.
Also, yes I tested the hip strength and it is in my plan to address strength here as well as correcting his fot dysfunction. PS there is alot of valgus stress during the step down test.
My main question is regarding the eccentrics..because it is a bilateral problem there is no good leg to asist in the concentric portion. Any ideas John?
Also, anyone familiar with Doug Kelsey's work over in Austin Tx?
Tom
|
|
|
|
|
Re: Patellofemoral pain - June 1, 2006 3:55:00 AM
|
|
|
PTupdate.com
Posts: 1478
Joined: October 8, 2001
From: Pittsburgh, PA USA
Status: offline
|
Tom:
When looking at something bilateral, it becomes harder for a unilateral problem to be the cause...especially when the symptoms are the same. With LLD, the "longer" limb may act normal or try and shorten. The "short" limb also may act normal, or attempt to lengthen. Either way, the adjustments are opposite, so it's unlikely that you would still end up with the same condition.
As far as that eccentric program, I had the football player in again last night, and we just did standard single leg squats, permitting some pain, unilaterally. There was really no way to effectively create an eccentri-only program when dealing with two limbs
You can certainly try gingers method, but please do not short change and screw your patient and neglect treatment of the knee. There is quit a bit of evidence with regards to these standard treatments, and they are effective. There is nothing with regards to the L3 treatment. Try them both, and if he gets better, great. You may not know which one really did it, or if a combo situation occurred. Save the L3 treatment done in isolation for those where the knee program had no effect.
John Duffy, PT OCS
[URL=http://www.PTUpdate.com]www.PTUpdate.com[/URL]
_____________________________
John M. Duffy, PT
Board Certified Orthopaedic Clinical Specialist
www.PTupdate.com
|
|
|
|
|
Re: Patellofemoral pain - June 1, 2006 5:18:00 AM
|
|
|
PHSPT
Posts: 119
Joined: December 1, 2005
From: Oklahoma
Status: offline
|
John,
I am not familiar w the eccentric work your are referring to. Can you elaborate more on the type of exercises done?. similar pnt here.
thanks
Ginger,
You certainly take manual therapy seriously, i admire for your perseverance! Interesting to see the differences when it comes to interventions b/t US and Canada/Australia (would make for a good topic). keep it up, and come up w/ some papers already!!
|
|
|
|
|
Re: Patellofemoral pain - June 1, 2006 8:08:00 AM
|
|
|
silverfish
Posts: 10
Joined: June 19, 2005
From: Charlotte, NC
Status: offline
|
Ginger,
SO going by your continuous mobiliZation model, you are saying to apply pressure to the affected side. In this case would you perform general PA or perform the mobilization unilaterally? In treating a MD, he may be a willing participant in a case study to perform one method on the right and the other method on the left. Just a thought.
|
|
|
|
|
Re: Patellofemoral pain - June 1, 2006 2:26:00 PM
|
|
|
ginger
Posts: 660
Joined: February 26, 2005
From: Melbourne Victoria
Status: offline
|
As long as you listen John Duffy , just as long as you are willing to listen mate. Unfortunately if anyone were to take your advice , then any opportunity to see the immediate results I get every time will be muddied by the effect of anything done to the knees. I make this staement over and over again , but still pertinant to this as for any nother musculoskeletal situation demanding assessment/diagnosis. You must first restore normal neurological input output to the structure in order to appreciate what is referred and what is not. Were you to place the cart before the horse , then time just gets wasted on efforts related to neuralgic effects that may respond temporarily to attention , yet yield little or no lasting result. To do otherwise , to treat the structure before the spine, would be to remain ignorant of the very likely altered sensation/recruitment/pain picture.
GBPT
Mobilise each side seperately, restore normal movements and reassess the knee as you go , on each side , if only to give you confidence to preceed to the other side. Take your time, exhaust the thumb in the process if it is unused to this method ( most are , mine's tough as after many years of mobs )
Pa's are less effetive ( central PA's )
Remember the method is SAFE , the effects are IMMEDIATE, the results are as permanent as the product of attention to L3 allows . That is , for every improvement in L3 facet joint mobility there will be a positive benefit to the knee untill the inflammatory event at L3 is removed. Other factors ( assymmetry, SIJ dysfunction , soft tissue tightness etc etc , must be addresssed apropriately for full and lasting normalisation of L3 joint function to be provided)
Mobs first, John and others, makes sense, leave the knee exercises to those who are not capable of effective mobs to the central spine, you have hands, use them.
_____________________________
Ubi est mea anaticula cumminosa?
The Grand Pediculator
|
|
|
|
|
Re: Patellofemoral pain - June 1, 2006 4:11:00 PM
|
|
|
nari
Posts: 1568
Joined: November 14, 2003
From: Australia
Status: offline
|
I know we pound the same no man's land a lot, but Ginger is right - though he uses a different method than I do. To deal with muscle, ligament or most tissue deformations, treat neurally. Then the CNS/PNS does all the hard yakka for you.
O'Connell's methods gets results, but it's slow. I understand she now accepts there is a neural component to pain (?!) but do not know more than that.
Nari
|
|
|
|
|
Re: Patellofemoral pain - June 1, 2006 5:15:00 PM
|
|
|
PTupdate.com
Posts: 1478
Joined: October 8, 2001
From: Pittsburgh, PA USA
Status: offline
|
Don't worry ginger, I am quite willing to listen. However, I am NOT willing to screw a person with a $25 co-pay, or 15 PT visits per calendar year, and do something suggested by an unnamed percollator in Australia, that has nothing evidence-wise to back it up. At this time, I will do what I know works, is backed by research showing it works. Perhaps I will let the local orthos know that if someone comes in with no insurance, and therefore cannot afford/get PT, that I'd be willing to do your mobilizations on the house, and we'll see what happens. I can be quite open minded, but not on someone elses pocketbook
John Duffy, PT OCS
[URL=http://www.PTUpdate.com]www.PTUpdate.com[/URL]
_____________________________
John M. Duffy, PT
Board Certified Orthopaedic Clinical Specialist
www.PTupdate.com
|
|
|
|
|
Re: Patellofemoral pain - June 1, 2006 8:09:00 PM
|
|
|
ginger
Posts: 660
Joined: February 26, 2005
From: Melbourne Victoria
Status: offline
|
John , when the time comes to do mobs on the house as you've mentioned, I'd be only too glad to offer any info that will be of value to you and your patient. In particular perhaps a detailed description of the minutiae of the technique I recommend( continuous mobs). I'd be delighted to hear of your progress and findings.
cheers
_____________________________
Ubi est mea anaticula cumminosa?
The Grand Pediculator
|
|
|
|
|
Re: Patellofemoral pain - June 2, 2006 3:52:00 AM
|
|
|
PTupdate.com
Posts: 1478
Joined: October 8, 2001
From: Pittsburgh, PA USA
Status: offline
|
Sounds like a deal ginger!
Duffy
_____________________________
John M. Duffy, PT
Board Certified Orthopaedic Clinical Specialist
www.PTupdate.com
|
|
|
|
|
Re: Patellofemoral pain - June 3, 2006 9:51:00 AM
|
|
|
srcase
Posts: 551
Joined: November 30, 2004
From: Michigan
Status: offline
|
Ginger,
Just throwing this out there because my curious mind wants to know.....have you ever just tried manipulating the spine instead of the thumb-breaking continuous mobs??? You're theory of referred pain sounds very much like the chiropractors, or I could be wrong. Please, can anyone shed some light on this?
Sarah
|
|
|
|
|
Re: Patellofemoral pain - June 3, 2006 2:09:00 PM
|
|
|
nari
Posts: 1568
Joined: November 14, 2003
From: Australia
Status: offline
|
Sarah
Referred pain has been recognised for around 25 years; mobilising the spine to alleviate pain and often neuro changes is part of standard treatment in Australia, anyway. Even mobilising the spinal segments to relieve, and often resolve symptoms in the foot or hand or knee, etc.
What Ginger does differently is the method of continuous mobs; most PTs would have fallen in a heap if they had practised that way!
Nari
|
|
|
|
|
Re: Patellofemoral pain - June 3, 2006 2:38:00 PM
|
|
|
certMDT
Posts: 154
Joined: April 5, 2004
From: Durham, NC
Status: offline
|
Duffy -
Couldn't you just have the guy stand on the slant board in a set of parallel bars, or between two chairs? He could use his arms to assist in rising, then let go and just use one leg for the eccentric aspect. You would probably need a backpack to add weight, but that's more or less the way they did it anyway.
This has been shown to work in ~90% of appropriately selected patients, with clinical and histological studies that take this method well beyond "biologic plausability" - the excuse we use for so many of our treatments. This understanding is at the forefront of our knowledge about tissue loading and healing. I agree with John, and I'm not sure why we feel the need to look to another source for treatment.
_____________________________
Charles Sheets PT OCS Dip MDT
|
|
|
|
|
Re: Patellofemoral pain - June 3, 2006 9:22:00 PM
|
|
|
nari
Posts: 1568
Joined: November 14, 2003
From: Australia
Status: offline
|
Charles,
When you say 'appropriately selected patients' does this mean according to the diagnosis of altered patella tracking? Patients are labelled with PFS for all sorts of causes for pain around the knee. Are these ever included in a highly specific study? I don't think so. What might happen to them?
Nari
|
|
|
|
 New Messages |
 No New Messages |
 Hot Topic w/ New Messages |
 Hot Topic w/o New Messages |
 Locked w/ New Messages |
 Locked w/o New Messages |
|
 Post New Thread
Reply to Message
Post New Poll
Submit Vote
Delete My Own Post
Delete My Own Thread
Rate Posts |
|
0.094
|
Printable Version
