The Physio edge podcast with David pope. This week they interview Kurt Lisle about anterior knee pain. Here is our synopsis:
One of the things they empahasized right off the bat was that patellofemoral pain not only refers about the knee but also below or most importantly posterior to the knee. The fat pad had a tendency to refer more locally where is other structures can refer to other areas.
Aggravating factors for patello femoral dysfunctional pain tends to be flexion or activities involving flexion as well as compression of the knee and rest is in alleviating factor.
The fat pad pain tends to be to either side of the patellar tendon and sometimes directly under it. This can be aggravated by standing, particularly with the knee and hyperextension, which compresses the fat pad.
Patellar tendon pain tends to remain at the inferior pole of the patella on the tendon whereas patellofemoral pain has a tendency to refer more.
Physical examination pearls:
Patellar tendonopathy alone generally does not have effusion present where as the patellofemoral or fat pad injury may.
Is there pain in passive hyperextension? This generally can mean fat pad injury or potential he ligamentous injury.
Visually you may palpate a thickened fat pad, particularly in females.
Pain with passive motions generally points away from patellar tendon.
Dialing in as to where and when they are having their pain is an important part of the functional evaluation.
Kurt likes to do a table top examination first to ensure functional integrity of the knee before jumping right to functional tasks. His concerns are (which are valid) is the knee up to the task you’re about to ask it to do? Good advice here. He emphasizes the need to be systematic and consistent in your examination, no matter how you examine them. Develop a routine that you follow each and every time. He recommends passively looking at the knee in extension and 90° flexion.
There is a discussion on functional movement about the hip and pelvis, knee, and foot and ankle. Emphasis is made, for example at the knee, as to “is the knee moving medially and laterally or are the femur and tibia rotating mediately or laterally” in which is precipitating the pain?
“Catching” of the patella is often due to patellofemoral pathology such as a subchondral defect, slap tear of the chondral surface, or abnormalities of the trochlea of the femur.
Advanced imaging strategies are also discussed with a brief overview of some of the things to look for.
Finally treatment strategies were discussed. It is emphasized that identifying the specific activity or change activities that’s causing any pain he’s made as well as activity modification. We were happy to hear that footwear and its role in knee as well as hepatology was discussed as well as looking at occupational contributions to the pain.
There was emphasis on exercise specificity particularly with respect to if the problem was unilateral not giving “blanket” exercises for both knees but rather concentrating on the symptomatic side.
A discussion on the use of EMG and activation patterns was also entertained with some good clinical pearls here. More marked rather than subtle changes and activation side to side seem to be more clinically significant. In other words, with respect training, can they achieve similar levels of activation on each side with a similar activity (for example isometric knee extension with the leg bent 60°).
The judicious use of tape from a functional testing standpoint was interesting. Emphasis was made that tape is not a cure and will merely a tool.
All in all and informative, concise podcast with some great clinical pearls and a nice review of the knee and patellofemoral pain.