Rehab of PFPS Thurs AM Conf 10/2010

1. Rehab of PFPS Thurs AM Conf 10/2010 Michael A. Shaffer PT, ATC, OCS

2. Midterm/ ITBS Time

3. T/ F Questions • “Patellofemoral pain” is one of the most common musculoskeletal diagnoses. • Patellofemoral pain is a complex, multifactorial problem.

4. T/ F Questions • Patellofemoral pain responds reliably well to rehabilitation. • Certified Athletic Trainers and Physical Therapists provide rehabilitation.

5. T/ F Questions • The ideal rehabilitation program for a complex, multifactorial problem like patellofemoral pain is hard to define. • “Genius” is hard to define.

6. Therefore….. Athletic Trainers and Physical Therapists are geniuses!!

7. Thank you.

8. The evolution of a clinician….. • “So what is our patellofemoral pain protocol?” • “We don’t have ONE. We’ll never have one. No two PFPS rehabilitations are the same.”

11. Uh oh, first sign of trouble …..

12. Midterm time…..M/C Which of these people has PF pain?

13. Midterm Time…...Short Answer • When rehabilitating/ requesting rehabilitation for someone with PF pain, I most often utilize/ request…….? (List your top 3)

14. Top 3 ? • Quad strengthening • VMO facilitation • Stretching (based upon need) • Quadriceps • Lateral structures • Hamstrings • Posterior calf (Soleus) • Hip abductor strengthening • Taping/ Bracing • Arch supports

15. When the PT’s “cover” clinic…. • Referral hangs outside door • Evaluate and Treat • Evaluate and Return to IOSMR • Evaluate and Coordinate with PT close to home

16. When the PT’s “cover” clinic…. • Referral hangs outside door • Evaluate and Treat • Evaluate and Return to IOSMR • Evaluate and Coordinate with PT close to home

17. The evolution of a clinician……. • Evaluation AND Treatment • Pt expectation • My view of the profession • Tools in the toolbox • Timing and rationale → and dosing → and “buy in”

18. The evolution of a clinician…… • Evaluation • Observation • Foot position, Tibial varum, leg length, atrophy • Palpation • Patellar position, patellar tracking, quadriceps “tone” • ROM (Flexibility) • Quad, Hamstrings, “lateral structures” , calf • Strength • SLR x 3, Quads- No • Functional • Squat, Lunges (Stacy V)

19. The evolution of a clinician……. • Now, for PFPS, just treatment • “Pattern recognition” • More on this later • Assumptions • Focused treatment • Treatment guides eval

20. Treatment Approach for PFPS Phase 1 Everyone gets QS/ SLR x 4 And some stretching “It may not be exactly right, but it’s never wrong” “Get on base, don’t swing for the fence” Phase 2 “Groucho Marx” Therapy “Hey doc it hurts when I do this.” Ok let’s do that or something similar Phase 3 Return to activity Phase 4 Long term plan

21. Best Case Scenario • Visit 1 • QS, SLR, Stretching, Wall Sits • Visit 2 (1 week later) • 30-50% better • Step ups • Isotonics (ham curls, light leg press, hip) • Visit 3 (1 week- 2 weeks later) • ~ 70% better • CV Exercises • Talk about progression to running (prn) • Visit 4 (3-4 weeks after I/E) • “How’s running going?”……OK great, here’s how to progress your HEP, have a nice life

22. Rule of 70’s “at least 70% of patients will feel at least 70% better within 2-3 weeks of starting rehabilitation”

23. The remaining 30% …….

24. The tale of Roy McAvoy • “I can make that shot” • “I know you can, but not right now” • You’re in good shape after 2….. but you’re staring at a 12

25. PFPS History Lesson Part 1My summary of 20 years of PFPS PT Rx. Lit. • Because most patients improve with PT, it is unethical (maybe “unthinkable”) to include a control group • 2 treatment groups • Both improve • Equally!!.....arrrgh • VMO Facil., OKC vs. CKC, Conc. Vs. Ecc. , Taping vs. Bracing, Bracing vs. Orthotics

26. n = 131 14- 40 y.o. (X=24 y.o.) ~ 2/3 female BMI ~ 23 ~ 70% Sx. < 6 mos ~ 60% bilateral Sx. Pain 4/10 rest 6/10 with activity 2009:339:b4074

27. Supervised Rehab vs. Info + HEP (“standard care”) • 9 visits over 6 weeks • Progressive resistance every 2 weeks • Quadriceps, Adductors, Gluteal strengthening • Stretching • Balance

28. “Improved” but not “recovered”

29. Are they “needy” or “kneedy”Sensory Mapping of the Knee Dye et al AJSM 1998

30. PFPS- A selective history/ update (Part 2) • VMO Weakness • Quad strengthening • VMO Facilitation • Differences in timing of VMO / VL – PFPS vs. non. • Just one more risk factor • McConnell’s Critical Test / Taping • Just tape it • When the foot hits the ground …..must control the midfoot • Try some OTC inserts

31. But the results are stable……the understanding is not “So what is our patellofemoral pain protocol?” “We’re not sure, but patients keep getting better anyway”.

33. October is National PT Month

34. October is National PT MonthHappy PT Month!!

35. Just in case you were interested….The green lining perhaps Supervised Rehab (9 visits/ 6 weeks vs. Info + HEP

36. Where do we go from here? • “PFPS School ” at CRWC • Women aged 18-50 • Information • Anatomy, Epidemiology, Natural History (young woman’s disease) • Exercise • Stretching (Q, H, C, Lateral) • Strengthening (Quads, Hip adductors/ abductors) • Instruction for taping (kinesiotaping) • Encouragement • Keep exercising • Call us if • Sx. not at least 50% better after 4 weeks

37. “Other” groups Level 6 Evidence – One guy’s opinion • Men with CMP- Stretching! • Patellar Tendonitis – Eccentrics, Aggressive quadriceps and hip abductor strengthening • UI athletes with CMP- • Muscle Imbalances - • Full, Static and Dynamic Eval • Address specific imbalances – specific exercises • Remember where you are “in season”- set expectations accordingly • Don’t assume strong quadriceps (if you only have 1 bullet)

38. Thank You. Institute of Orthopedics Sports Medicine, and Rehabilitation

49. Exam findings most often associated with Patellofemoral Pain ….. • Quadriceps weakness • VMO dysfunction • Tight lateral structures • Pes Planus • Hip Abductor weakness • Increased Q angle

50. Occam