Patellofemoral pain syndrome – is this a top down or bottom up problem…or both? Guest blog by Simon Lack

Patellofemoral pain syndrome (PFPS) has a high prevalence within the sporting population, with one study of 2159 presentations to sports medicine clinics, reporting 5.4% incidence of PFPS, accounting for 25% of those presenting with knee pain (1).  Despite a more traditional approach to management having been well researched in a high quality RCT (2), the problem has been shown to have a high recurrence.  In a quest to unravel the mystery of long-term successful treatment outcomes, researchers have started looking above and below the knee to potentially identify more effective solutions.

Arguably started by the work of Lee et al (3) that identified that changes in femoral rotation angles have significant consequences for patellofemoral joint loading, in combination with consistently reported weakness of hip musculature in PFPS populations (4), multiple studies have looked to modify top down control through strengthening of the hip rotator muscles.  The outcomes of these studies have shown significant reductions in symptoms and increases in function particularly in weaker individuals.  In addition, better outcomes have been reported if a proximal strengthening programme is started prior to functional strengthening compared with an initial local knee-strengthening programme (5). Thus, a case is emerging in favour of a top-down treatment mechanism.

Distal to the knee a growing body of evidence supporting the use of foot orthoses in PFPS management has started to be established.  A high quality RCT that compared six weeks of physiotherapist intervention with off the shelf foot orthoses, flat inserts, multimodal physiotherapy (patellofemoral joint mobilisation, patellar taping, quadriceps muscle retraining, and education), or foot orthoses plus physiotherapy, demonstrated orthoses to be superior to flat inserts, with their use resulting in comparable outcomes to multimodal physiotherapy (6).

Further more, evidence suggests foot orthoses have the ability to change pain immediately within this population of patients (7), with a further reduction of pain experienced following a 12/52 period of orthotic wear (8).  Interventions that have the capacity to reduce pain symptoms immediately, pose a valuable tool in facilitating normal movement patterns, maximising function and minimising detrimental pain inhibition.  Hence, further emerging evidence for a bottom-up treatment mechanism.

What do you think predicts treatment success in PFPS, and why ?

Simon Lack is a Physiotherapist and current PhD student at Queen Mary University, London, currently studying the interaction of hip and foot biomechanics in the presentation and management of patellofemoral pain.

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References

1.Devereaux MD, Lachmann SM. Patello-femoral arthralgia in athletes attending a Sports Injury Clinic. Br J Sports Med. 1984 Mar;18(1):18-21.

2. Crossley K, Bennell K, Green S, Cowan S, McConnell J. Physical therapy for patellofemoral pain: a randomized, double-blinded, placebo-controlled trial. Am J Sports Med. [Clinical Trial Multicenter Study Randomized Controlled Trial Research Support, Non-U.S. Gov’t]. 2002 Nov-Dec;30(6):857-65.

3. Lee TQ, Morris G, Csintalan RP. The influence of tibial and femoral rotation on patellofemoral contact area and pressure. J Orthop Sports Phys Ther. [Research Support, Non-U.S. Gov’t Research Support, U.S. Gov’t, Non-P.H.S. Review]. 2003 Nov;33(11):686-93.

4. Prins MR, van der Wurff P. Females with patellofemoral pain syndrome have weak hip muscles: a systematic review. Aust J Physiother. 2009;55(1):9-15.

5. Dolak KL, Silkman C, Medina McKeon J, Hosey RG, Lattermann C, Uhl TL. Hip strengthening prior to functional exercises reduces pain sooner than quadriceps strengthening in females with patellofemoral pain syndrome: a randomized clinical trial. J Orthop Sports Phys Ther. 2011 Aug;41(8):560-70.

6. Collins N, Crossley K, Beller E, Darnell R, McPoil T, Vicenzino B. Foot orthoses and physiotherapy in the treatment of patellofemoral pain syndrome: randomised clinical trial. Bmj. [Comparative Study Randomized Controlled Trial Research Support, Non-U.S. Gov’t]. 2008;337:a1735.

7. Barton CJ, Menz HB, Crossley KM. The immediate effects of foot orthoses on functional performance in individuals with patellofemoral pain syndrome. Br J Sports Med. 2010 Jul 20.

8. Barton CJ, Menz HB, Crossley KM. Effects of prefabricated foot orthoses on pain and function in individuals with patellofemoral pain syndrome: a cohort study. Phys Ther Sport. 2011 May;12(2):70-5.