Patellofemoral Joint Pain

Earlier this week I shared a link to a recent paper about generalised knee pain in adolescents. It highlighted the fact that we need to be doing more to help improve pain, quality of life and general health & well-being in this age group. If you missed it, the research found that 56% of 15-19 year-olds still had knee pain, 2 years after initial reporting their symptoms (1).

The above-mentioned paper covered all knee pain conditions, so what I wanted to do is present some specific information regarding PFJ pain. It is a condition and a topic that I have a very keen interest in, as I feel that it is poorly managed – especially in teenage athletes/patients – and it can progress to the point that the patient has long term pain and disability. This is evident by research showing that 90-94% of patients have ongoing PFJ pain 4-16 years after the initial diagnosis (2). To me this is completely unacceptable, and it is obvious that their management is ineffective, nor is PFJ pain a benign or self-limiting condition.

In a nutshell, PFJ pain is characterised by a gradual onset of pain behind and around the patella. It is aggravated by squatting, stair-climbing and running and is alleviated with rest, but in some cases can present as a dull ache with prolonged sitting. Physiotherapy, patient education, orthotics, load management and strengthening & conditioning are essential features of PFJ pain management. It is reported that most people will have noticeable improvement in their pain and function within 6-12 weeks of starting a multi-modal approach, as described above, but those who are older and who have had a long history of pain will need to expect a longer recovery period.

The 2 links provided below are a MUST READ, and are an excellent overview of PFJ pain and its best management.

- Best Practice Guidelines (Barton et al, 2015)

- Patellofemoral Pain Overview (Crossley et al, 2016).

With my background in exercise science, I must admit I am biased towards a strength & conditioning approach to PFJ pain, rather than rely on passive interventions (eg. patella mobilisations, dry needling. stretching, taping, massage, orthotics, electrotherapy) to treat PFJ pain. I do acknowledge that each of them have a role to play, but none of them should be used as a stand-alone treatment, and strengthening exercises should be the priority. I have provided 4 links to papers that provide strong evidence for strengthening, in particular gluteal strengthening:

- Lower eccentric hip abductor (gluteus medius - Gmed) strength vs higher Gmed strength, was a risk factor to future PFJ pain in novice runners (3).

- Adults with PFJ pain have lower hip strength values compared to pain-free controls (4).

- Delayed and shorter duration Gmed activity was found during stair negotiation and running in patients with PFJ pain (5).

- Hip and knee strengthening exercises were superior to knee exercises alone for the treatment of PFJ pain in the short and long term (6)

Additionally, the PFJ encounters varying amounts of stress and load depending on whether the person is exercising in a weight-bearing (WB) position vs a non weight-bearing (NWB) position. This paper highlights safe rehab exercise options during open kinetic chain (NWB) vs closed kinetic chain exercise (WB) (7).

In summary, PFJ pain needs to be managed better than advising people to rest!! It is not a benign condition, and it has the potential to negatively effect function and quality of life in the long term.

I hope I have provided you with some good links to some recent literature that should guide better practice for this condition. In my opinion, we need to be assessing, treating and monitoring our patients/athletes with PFJ pain better and taking them through a multi-modal approach to treat their pain.

Like always, please feel free to comment if you think that I have missed something of importance, and please feel free to share this information to people or patients that you think could use the information.

References:

1. Rathleff MS, Rathleff CR, Olesen JL, Rasmussen S, Roos EM. Is Knee Pain During Adolescence a Self-limiting Condition? Prognosis of Patellofemoral Pain and Other Types of Knee Pain. The American journal of sports medicine. 2016 May;44(5):1165-71. PubMed PMID: 26792702. Epub 2016/01/23. eng.

2. Thomas MJ, Wood L, Selfe J, Peat G. Anterior knee pain in younger adults as a precursor to subsequent patellofemoral osteoarthritis: a systematic review. BMC musculoskeletal disorders. 2010;11:201. PubMed PMID: 20828401. Pubmed Central PMCID: PMC2944218. Epub 2010/09/11. eng.

3. Ramskov D, Barton C, Nielsen RO, Rasmussen S. High eccentric hip abduction strength reduces the risk of developing patellofemoral pain among novice runners initiating a self-structured running program: a 1-year observational study. The Journal of orthopaedic and sports physical therapy. 2015 Mar;45(3):153-61. PubMed PMID: 25627149. Epub 2015/01/30. eng.

4. Rathleff MS, Rathleff CR, Crossley KM, Barton CJ. Is hip strength a risk factor for patellofemoral pain? A systematic review and meta-analysis. British journal of sports medicine. 2014 Jul;48(14):1088. PubMed PMID: 24687010. Epub 2014/04/02. eng.

5. Barton CJ, Lack S, Malliaras P, Morrissey D. Gluteal muscle activity and patellofemoral pain syndrome: a systematic review. British journal of sports medicine. 2013 Mar;47(4):207-14. PubMed PMID: 22945929. Epub 2012/09/05. eng.

6. van der Heijden RA, Lankhorst NE, van Linschoten R, Bierma-Zeinstra SM, van Middelkoop M. Exercise for treating patellofemoral pain syndrome. The Cochrane database of systematic reviews. 2015;1:CD010387. PubMed PMID: 25603546. Epub 2015/01/21. eng.

7. Powers CM, Ho KY, Chen YJ, Souza RB, Farrokhi S. Patellofemoral joint stress during weight-bearing and non-weight-bearing quadriceps exercises. The Journal of orthopaedic and sports physical therapy. 2014 May;44(5):320-7. PubMed PMID: 24673446. Epub 2014/03/29. eng.