In
the articles reviewed regarding conservative versus surgical
management of patellofemoral pain, all of the articles suggested
conservative management should be the first attempt. This statement
is based on the fact that the cause of patellofemoral pain syndrome
is uncertain and can be caused by an array of possible dusfunctions.
Calpur et al (2002) reported that surgical intervention should be
performed as the last option after conservative management has
failed. Physical therapists can treat conservatively until
improvements are no longer apparent, then referral for diagnostic
imaging may be necessary to identify another possible cause.
Physical therapy may not be able to correct anatomical
misalignments; therefore, patients with these types of dysfunctions
would be candidates for surgical interventions. According to Bruce
and Stevens (2004), patient’s reported full satisfaction with the
rotational osteotomies of the femur and tibia, however, the outcome
measures used in this study were not valid, reliable or functionally
related. Based on the poor research design of the two surgical
articles, the benefits of surgical outcomes remain questionable.
Patellofemoral pain would be best treated with conservative
interventions. A treatment program including both open kinetic chain
(OKC) and closed kinetic chain (CKC) exercises focusing on hip
flexion strength has shown to decrease pain (Tyler et al, 2006). The
study also noted that improvements in flexibility of iliotibial band
(ITB) and iliopsoas muscles contributed to decreased patellofemoral
pain. However, it remains to be determined whether a treatment
protocol that exclusively focuses on hip flexion strengthening and
ITB and iliopsoas stretching would prove more effective in the
treatment of patellofemoral pain than the comprehensive protocol
used in this study. Witvrouw et al (2000) reported no significant
differences in improvements between OKC compared to CKC exercises
with both types of exercise improving pain, function, strength and
muscle length.
If patients are willing to participate in an exercise program,
patellar taping as performed in the study by Whittingham (2004),
would be an effective adjunctive therapy to aid in improving acute
patellofemoral pain. If tape is applied correctly, patellar taping
is a safe addition to an exercise program consisting of
strengthening and stretching and can be beneficial for physical
therapists to try with their patients. However, physical therapists
need to reinforce to their patients that taping is not a cure and
adherence to their home exercise program is essential. Another
possible adjunct to the exercise program is foot orthoses. Physical
therapists may be able to use the following three predictions in
their decision to recommend an off-the-shelf foot orthotic: forefoot
valgus alignment of greater than equal to 2°,
passive great toe extension of less than or equal to 78°,
and navicular drop of less than or equal to 3 mm (Sutlive et al,
2004). Seventy-two percent of the 45 subjects reported at least a
50% decrease in pain with orthotic use and activity modification.
However, the navicular drop and forefoot to rearfoot alignment
measurements have low interrater reliability, in addition to the
lack of a control group in the study. Therefore, activity
modification may have given a false sense of improvement when using
the orthotic. With this in mind, an educational approach similar to
that of patellar taping is needed. Orthotics should not cause any
serious negative effects in patients and for that reason can be used
as an adjunct to physical therapy. Again, patients need to
understand that orthotic or tape use alone will not decrease their
pain or dysfunction completely.
Last revised: June 1, 2009
by Krista Formanek, DPT
References:
1. Calpur O, Tan L, et al. Arthroscopic mediopatellar
plicaectomy and lateral retinacular release in mechanical patellofemoral
disorders. Knee Surg Sports Traumatol Arthrosc. 2002; 10:177-183.
2. Bruce WD, Stevens PM. Surgical Correction of Miserable Malalignment
Syndrome. J Pediatr Orthop. 2004; 24(4):392-396.
3. Tyler TF, Nicholas SJ, et al. The Role of Hip Muscle Function in the
treatment of patellofemoral pain syndrome. Am J Sports Med. 2006;
34:630-636.
4. Sutlive TG, Mitchell SD, et al. Identification of individuals with
patellofemoral pain whose symptoms improved after a combined program of foot
orthosis use and modified activity: A preliminary investigation. Phys Ther.
2004; 84: 49-61.
5. Witvrouw E, Lysens, et al. Open versus closed kinetic chain exercises for
patellofemoral pain. Am J Sports Med. 2000; 28(5):687-694.
6. Whittingham M, Palmer S, et al. Effects of aping on pain and function in
patellofemoral pain syndrome: A randomized controlled trial. J Orthop Sports
Phys Ther. 2004; 34:504-510.
