Anterior knee pain is one of the most common (up to 40%) complaint from patients, active or sedentary who are attending a sports injury clinic.
Patellofemoral pain is defined as pain in front of the knee, around or behind the knee cap (patella) usually aggravated by activities that load the patellofemoral joint such as ascending or descending stairs, jumping, running and squatting (Crossley et al., 2016)
Most young patients have no structural damage to their patellofemoral joint and their symptoms are caused by a functional imbalance. Some patients have structural changes such as chondral and osteochondral degenerative changes and some patients suffer with overuse injuries of the extensor mechanism (tendonitis and insertional tendinosis) or patella instability (Petersen et al, 2014).
Older patients usually present with established patellofemoral osteoarthritis.
Despite the high prevalence of patellofemoral pain there are few published guidelines to help clinicians recommending an evidence based treatment for their patients.
It is unsure as to exactly the reason why patients have patellofemoral pain but the latest scientific research indicate towards contributing factors being patella maltracking, dynamic valgus, muscular dysfunction, foot disorders and psychological factors (Petersen et al, 2014).
The consensus statement from the 4th International Patellofemoral Pain Research Retreat in 2016 include four main treatment recommendations.
1. Exercise-therapy is recommended to reduce pain in the short, medium and long term, and improve function in the medium and long term.
2. Combining hip and knee exercises is recommended to reduce pain and improve function in the short, medium and long term, and this combination should be used in preference to knee exercises alone.
3. Combined interventions are recommended to reduce pain in adults with patellofemoral pain in the short and medium term.
4. Foot orthoses are recommended to reduce pain in the short term.
Many studies have found that Exercise-therapy is the key component to patellofemoral rehabilitation. A robust body of evidence (60 high & moderate quality published papers and systematic reviews including meta-analysis) reports significant pain reduction and improvement in function with Exercise-therapy compared to control, placebo interventions in the short and medium time to follow up. The existing evidence also highlights the importance of long term management for these patients.
Combined interventions included exercise therapy, patellar taping, patellar mobilisations and prescription of foot orthoses. This approach was found to reduce pain in the short and medium term and reduce pain among adolescents in the longer term (Barton et al., 2015)
This evidence underpins the approach we take in our clinic towards the patients with anterior knee pain and patellofemoral pathology and the treatment we recommend those patients.
We offer our patients a multimodal approach to rehabilitating patellofemoral pain in order to reduce pain and improve function in the short, medium and long term.
The Patellofemoral Pain Pathway
Our aims are to firstly diagnose and educate our patients.
Knowledge is power regarding patellofemoral pain and we understand that patient education is a key component to ensure compliance, avoid overloading and attain a quick referral for further intervention if and when required.
As a knee surgeon and as a specialist knee physiotherapist, we understand that patellofemoral pain is difficult to treat. We emphasise that regular, specific exercise and in particular following a specific strength & conditioning program is the most common treatment for patellofemoral pain.
Patients with more severe presentation and who are resistant to conservative measures often need anti-inflammatory medication, and in some cases an intra-articular injection.
For patients who are not improving their symptoms despite a rigorous conservative treatment as described above, Mr. Vioreanu recommends a surgical procedure called an iliotibial band (ITB) release. The ITB release is a simple, minimally invasive and effective day case surgical procedure that through a small (less than 2 cm) incision lengthens the iliotibial band and as a consequence releases the pressure from the patellofemoral joint.
The surgery along with the recommended immediate postoperative rehabilitation program provides a window of opportunity for patients to engage in the further more structured rehabilitation in order to return to their desired level of activities.
You can download here our Patellofemoral Pain Rehabilitation Protocol
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