Written by David Pope. Based on the interview on the Physio Edge podcast episode 33 How to treat anterior knee pain with Kurt Lisle

Transcription

1 Written by David Pope Based on the interview on the Physio Edge podcast episode 33 How to treat anterior knee pain with Kurt Lisle Copyright David Pope 2015 Page 1

2 Subjective The patient story will help to guide your objective examination, diagnosis and ultimately. Here are some specific clues within the history that will guide you towards different structures 1. Infrapatellar fat pad Infrapatellar fat pad doesn t tend to refer to other areas - causes localised pain medial and/or lateral to the patellar tendon, inferior to the patella. May be worse in extension where it is getting pinched, e.g. Standing in hyperextension, whereas PFJ doesn t tend to get sore standing with the knee in extension. Fat pad may be irritated with kneeling e.g. Builder or carpet layer Fat pad irritation may also exist in combination with other painful structures e.g. PFJ, so if you have positive tests for the fat pad, continue your examination to identify all structures contributing to the pain experience 2. Patellar tendinopathy Patellar tendinopathy has focal pain on the inferior pole of the patellar commonly, but pain may sometimes be over the mid tendon 3. Patello Femoral Joint (PFJ) patterns The PFJ can refer pain to the posterior knee and inferior knee. The PFJ is often aggravated by squatting, lunging, up down stairs, hills, kneeling on it, sitting, and is relieved by rest 4. PFJ Behaviour - There is no real night pain, but patients may report some short term morning pain relieved with activity. Both PFJ and patellar tendinopathy can result from increased activity Patellar tendon and PFJ can be aggravated by similar activities It is really important to identify the activities that flare up their pain e.g. Doing stair climbs with their personal trainer, doing hill running What have they Copyright David Pope 2015 Page 2

3 changed in their training program? This will help guide your treatment program and activity modification 5. Objective Assessment Use an on-bed examination first to avoid stirring up the knee Check for effusion present. If it is only the patellar tendon that is affected there won t be an effusion, but if they have PFJ or chondral damage they may have some effusion. Fat pad - you may see some effusion or thickening of the fat pad, more commonly in females than males Active and passive extension - may reproduce pain in the fat pad, but passive extension does not load up the PFJ or Patellar tendon. Resisted Inner range extension on the side of the bed may enable you to locate the site of their pain, and they may be more able to be specific about the location of the pain in this position compared to functional tests e.g. The squat Check the ligaments for past injury or laxity, and patellar stability for differences side to side from previous injury Check ROM Meniscal tests should also be included as this may cause AKP Check how the patellar is moving through range of movement,e.g. If it is moving uniformly or if they are getting a catch between 90F to full Ext (over the side of the bed) Hand held dynamometry (HHD) - check for side to side strength differences in quadriceps, hamstrings, glute max and glue medius Using Surface EMG (semg) - place the EMG sensors over the middle of Vastus Medialis muscle belly. Test for activity between right and left in different ranges e.g. 15, 30, 45, 90 Extension. Copyright David Pope 2015 Page 3

4 6. Resisted isometric muscle tests Resisted Inner range extension on the side of the bed may enable you to locate the site of their pain, and they may be more able to be specific about the location of the pain in this position compared to functional tests e.g. squat 7. Specific palpation Palpate * tendon attachments e.g. If it is the whole tendon, and the medial or lateral parts of the tendon. * Fat pad - medial and lateral to the tendon over the fat pad, up towards the inferior pole of the patellar, and down closer to the tibial tuberosity (still off the patellar tendon * Palpate the fat pad in extension, and also in 90 degrees flexion * PFJ - medial and lateral aspects of the patellar You are also pushing through the retinaculum, which may be painful. It is very difficult to palpate the trochlear groove The fat pad may be tender medially and/or laterally, commonly it is tender medially AND laterally, but it may be painful on either the medial or lateral side The patellar tendon when palpated in extension is in a relaxed position, so may be less painful in this position Osgood-Schlatters will have tenderness over the Tibial Tubercle 8. The importance of through assessment Create a routine for knee assessment e.g. medial to lateral, and assess each of the structures to ensure you do not miss something. Copyright David Pope 2015 Page 4

5 9. Functional tests If the person is getting pain with a squat or lunge, you can asses their squat or lunge to see if you can identify any neuromuscular control issues around the hip, pelvis, foot and ankle, if correcting their technique improves their pain Other functional tests you may perform include: Stairs - what do they do on the stairs, difference between sides. You can video this Jumping and landing techniques Running Step-downs off a high step are often better than a single leg squat Sit to stand is a highly functional activity Cycling Squat - important factors what is happening around the knee. Is knee staying in line with their foot and ankle, is the knee moving side to side e.g. Medially or laterally. Is the knee movement happening with dynamic valgus, e.g. The femur is moving into IR/ER, or Hip abd/add Is the patellar moving up and down in the trochlear groove At what point does the person get their pain e.g. 30, 60, 90 F Copyright David Pope 2015 Page 5

6 Is there a catching or giving way at a point in range, which could give you clues that there is PFJP, PF pathology on the retropatellar surface or the trochlear groove, chondral tear, flap tear, osteochondral defect, and possibly the meniscus. The patient may describe pain behind the patellar, which gives you a clue that this may be PFJ in origin Proximal to the knee- e.g. trunk LF, pelvic tilt, IR/ER/Abd/Add of the hip and femur Foot - restriction to DF 10. PFJ Pain Tie in their subjective history of when they get their pain, and use these activities in their objective examination. You may be able to identify if you are able to change their pain quickly e.g. If a patient has pain with squatting, and you correct their form, you are looking to achieve an improvement in their pain with the new movement strategy Performing functional tests first may aggravate the whole knee and make it more difficult to identify the structures that are causing pain PF Grind test - this test is not a very sensitive test, it compresses quite a number of structures. Can be used if you are unable to locate the persons symptoms 11. Imaging Imaging may be performed if they: Have a highly likely chondral injury e.g. A flap tear causing catching Have had good physio treatment in the past with little result Have a large knee effusion Are professional athletes or amateur athletes that have a competition coming up Copyright David Pope 2015 Page 6

7 You will often get a lot of information from your assessment, and you will often manage these initially with conservative management, so imaging is not always required, even in the above situations. If a patient has an acute injury, or a suspected subluxation or dislocation it is a very good idea to get an MR XR can be used if the patient has a suspected subluxation/ dislocation, has a lot of difficulty weight bearing, as it is often quicker to get than MR 12. Factors that may load the PFJ Walking on a bent knee e.g. From a previous injury Patellar sitting laterally may affect the forces going through the PFJ in functional tasks High or low riding patellar Lack of muscular size on one side compared to the other, and still pushing the knee through sport or activity Hypo mobile PFJ - assessed with accessory mobilisation Hypermobile person - stand in hyperextension The way they control jumping and landing Soft tissue flexibility - e.g. In the Quadriceps may increase the compressive forces on the PFJ Hip and pelvis, foot and ankle control Their functional tasks e.g. How they serve, how they jump and land Copyright David Pope 2015 Page 7

8 13. Treatment of PFJP Minimise their aggravating activities e.g. No hill running, just running on the flat Load modification - look at everything they are doing and modify e.g. run every 2 3 days instead of every day What is their occupation - kneeling as a carpenter may load the knee more than sitting Use alternatives e.g. if squat is painful, take out squats. Change their squats e.g. Not so deep, or how they squat Running - shorter stride, or improve hip and pelvis control Use video and mirror feedback 14. Exercise prescription If strength is decreased in e.g. their glue max on HHD, work on strength. There is no point working on strength if they have full strength on testing. Use semg biofeedback on the quads. Activate quads with EMG in different ranges Non WB, then taking it into a functional task. Increased semg activity should also cause a change in their pain levels Start with low level activation exercises for quads e.g. Non functional activation such as bed exercises and move quite quickly to weight bearing exercises e.g. Controlled squats, leg presses, Perform unilateral exercises e.g. 1 leg legpress, Don t use squats (1 or 2 leg) in the early phase of rehab, instead use single leg exercises or other exercises Standing crab walk exercises with Theraband can improve glute activation Use single leg WB to improve hip/pelvis control Copyright David Pope 2015 Page 8

9 Start squats with small range of movement to get Vastus Medialis activation Start leg presses with a small range of movement. You may be able to use a larger range of movement in a single leg legpress with a small weight in a larger range without aggravating the knee Find exercises that do not aggravate their knee Fat pad and PFJ are often very irritable, you need to monitor that they are not doing exercises that are stirring it up. Make sure they understand the need to monitor their pain e.g. When gardening, working Highly irritable PFJP may take quite a while to settle down e.g. A number of weeks, because we place a lot of load on this joint every time we move 15. Taping Use taping in the middle of the season to help get them through the season If they get pain with their squat, tape an area to see if you can get a change in their pain during function (in this case, squatting) Tape only one area at a time e.g. Hip or foot and reassess their movement and pain Tape is a way to get some muscle activation to achieve what the tape is doing, it is not something to do forever 16. Other consideration Saphenous nerve and other neurodynamic issues may cause symptoms in the ant-medial knee. You can palpate the adductor canal for tenderness and reproduction of their pain to identify saphenous nerve involvement Superior Tib-fib joint - treatment of this area may resolve some anterior knee pain Antero-superior knee pain may be from irritated plicae and surgery may resolve these. These are superior thickenings in the capsule that gets irritated as they go through flexion-extension e.g. Cycling for 30 minutes and then you can Copyright David Pope 2015 Page 9

10 feel them. These patients do not have general knee pain, it is a very specific pain, and you may need to get them to the point that it is painful with minutes running or cycling before you can identify it. To differentiate from a quads tendinopathy, get them to perform their aggravating activity, then reassess for pain medial and lateral to the quads tendon 17. Red flags Always ask your red flag questions e.g. Night pain, weight loss Neuromas don t show up easily on scans. Keep this in mind if it is not responding to treating Copyright David Pope 2015 Page 10