​Kembara Xtra - Medicine -Patellofemoral Pain Syndrome

​Kembara Xtra - Medicine -Patellofemoral Pain Syndrome 
Pain in or near the patella that worsens with greater patellar loading (such as prolonged squatting, kneeling, or climbing/descending stairs), which is not due to any other conditions.
Synonyms include chondromalacia patellae, runner's knee, and anterior knee or retropatellar pain syndrome.
impacted system(s): musculoskeletal


Epidemiology 
Prevalence
Incidence in the United States was about 6% between 2007 and 2011.
- Patients made up 55% of females. In a military population, prevalence was 12% in males and 15% in females, with the Southern region of the United States having the highest number of instances.

Pathophysiology and Etiology 

increased, frequently multivariate patellofemoral joint loading
Patellar malalignment or maltracking; abnormal structure (such as patella alta; trochlear dysplasia); asymmetry, weakness, or tightness in the quadriceps; and tightness in the hamstrings.Increased internal rotation of the hip joint; a tight lateral retinaculum; patellofemoral joint laxity; and altered tibiofemoral joint mechanics

Risk Factors include activities like running, squatting, and climbing stairs as well as a sudden increase in activity. Other risk factors include female gender, dynamic valgus, patellar instability, quadriceps weakness, and foot abnormalities like pes pronatus and rearfoot eversion. In adolescents, increased hip adduction strength may also indicate increased activity level.

Prevention 

stretching and strengthening activities, especially for the quadriceps' terminal extension and the hip abductors

Overuse, knee ligament damage or surgery, patellar tendinopathy, protracted synovitis, and iliotibial band friction syndrome are associated conditions.

Diagnosis An accurate history to distinguish between pain and instability (pain quality, location, swelling, giving way, locking, grinding, inciting events, overuse, changes in activity/training, and history of trauma) Most common symptom: diffuse anterior knee pain made worse by or after physical activity Pain when squatting, walking over uneven terrain, running, or going up or down stairs


clinical assessment 
Check for effusion and the range of motion (ROM) of the knee.
Palpation: discomfort when the medial or lateral patellar margins are touched.
Put one hand over the patella and push it inferiorly while the patient is supine. This is known as the compression test or "patellar grind test." Ask the patient to exercise their quadriceps; any discomfort they experience while doing so is consistent with PFPS; any grinding noises they make could be a sign of chondromalacia in the patellofemoral joint.
80% of PFPS patients will experience pain during the single-leg squat movement. Additionally useful in evaluating for dynamic valgus
A positive test result for the patellar apprehension test is when discomfort or apprehension is present with passive patellar displacement when the patient is supine and the knee is flexed to 30 degrees. Specific (86-92%) but not sensitive for PFPS (7-32%)
The passive patellar tilt test involves holding the patella and lifting the lateral edge of the patella off the lateral femoral condyle to check for a tight lateral retinacular constraint. The patient is supine with the knee extended.
Though specific (92%) but not sensitive for PFPS (42%)
Gait and posture can reveal any imbalances that may be a factor in PFPS, such as femoral internal rotation, hip height, scoliosis, and quadriceps atrophy.
Evaluation of the wearer's footwear may reveal pes pronatus or rearfoot eversion, which may be causes of PFPS.


Differential diagnosis includes the following conditions: Prepatellar bursitis, patellar and quadriceps tendinopathy, Chondromalacia patellae, patellofemoral arthrosis, patellar subluxation and dislocation, knee ligamentous and meniscal pathology, Iliotibial band syndrome, Plica syndrome, osteochondral defect, osteochondritis dissecans, Sinding-Larsen-Johansson syndrome, O

Laboratory Results: None were reported. Imaging is typically not required to diagnose PFPS. To assess patellar tilt and rule out alternative causes of anterior knee pain, plain films with four views of the knee are advised if imaging is necessary due to severity, atypical symptoms, or symptom persistence despite treatment:
lateral, merchant, or dawn
- Posteroanterior and anteroposterior tunnel views while standing
To grade patellar malalignment, a CT scan might be employed.
It's possible that radiographic findings and symptoms are unrelated.
Tests in the Future & Special Considerations
Until late stages, when the posterior patellar surface becomes uneven and cartilage loss is audible on radiographs, radiographic pictures may be normal.

Management 
The gold standard is conservative therapy, which includes NSAIDs, physical therapy, and rehabilitation.
Strength, flexibility, and range of motion (ROM) improvement are the main objectives of therapy in order to practice proper motion.
Knee extensors, core muscles, and hip abductors and external rotators should be the main emphasis of supervised therapy.
 Hip and knee flexor and quadriceps stretches, especially proprioceptive neuromuscular facilitation stretches.


Acetaminophen or NSAIDs for pain management. Oral glucosamine, chondroitin sulfate, and hyaluronic acid injections are not frequently advised for the treatment of patellofemoral discomfort due to a lack of evidence.


Problems to Refer 
Referral for surgery after exhausting all other options.
Rarely is surgery necessary.
Recalcitrant instances may have psychosocial problems, such as depression or abuse. In these circumstances, a referral to a mental health care provider may be required.


Further Therapies 
Combination therapy, which includes manual therapy or patellar taping in addition to an exercise regimen, may be helpful.
Ankle and foot orthoses might provide some short-term comfort, but there isn't enough solid data to back their use over the long haul.

Surgery The first line of defense is exercise therapy.
 Surgical realignment of the patella is recommended for patients with a tight lateral retinaculum and lateral patellar tilt.
 Cartilage resurfacing/restoration for patients with a patellofemoral joint cartilage defect


Continued Care 
• Inform the patient about the significance of joining and adhering to an exercise program designed specifically for them with a physical therapist.
 Give the patient a list of physical therapy clinics nearby.

PFPS may not be self-limiting and may develop into a chronic condition.
Long-term PFPS is not linked to structural patellofemoral joint OA, although it is connected with patellofemoral pain lasting longer than 12 months.

---