4 5981010730143450412

PAIN AND ITS ORIGINS, DIAGNOSIS AND TREATMENTS
PATELLOFEMORAL PAIN
AN EVIDENCE-BASED
CLINICAL GUIDE
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PAIN AND ITS ORIGINS, DIAGNOSIS
AND TREATMENTS
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PAIN AND ITS ORIGINS, DIAGNOSIS AND TREATMENTS
PATELLOFEMORAL PAIN
AN EVIDENCE-BASED
CLINICAL GUIDE
JAMES SELFE
JESSIE JANSSEN
AND
MICHAEL CALLAGHAN
EDITORS
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CONTENTS
Introduction What is patellofemoral pain? vii

Jessie Janssen
Section 1: What Do You Do When the Patient First Walks
Through the Door? 1
Chapter 1 Concepts of Patellofemoral Pain 3
Jessie Janssen
Chapter 2 Patients’ Emotional States and Expectations 15
Jenny McConnell
Chapter 3 Subjective Examination 21
James Selfe
Chapter 4 Red Flags and Rare Pathologies 31
James Selfe
Chapter 5 Clinical Biomechanics Assessment for
Patellofemoral Pain 49
Jim Richards
Chapter 6 Clinical Tests of Patellofemoral Pain 61
Michael Callaghan and Jessie Janssen
Section 2: Intervention 73
Introduction to Section 2: Treatment Adherence 75
Michael Callaghan
vi Contents
Chapter 7 Exercises: Stretching, Strengthening

and Proprioception 79
Michael Callaghan and Jessie Janssen
Chapter 8 Patellofemoral Taping 91
Jenny McConnell
Chapter 9 Knee Braces 101
Michael Callaghan
Chapter 10 The Use of Foot Orthoses in the Management
of Patellofemoral Pain 109
Sarah A. Curran
Chapter 11 Radiology of the Patellofemoral Joint 121
Zeid Al-Ani, Gulraiz Ahmad and Waqar Bhatti
Chapter 12 Recalcitrant Patellofemoral Pain 141
Jenny McConnell
About the Editors 149
Index 153
Introduction
WHAT IS PATELLOFEMORAL PAIN?
Jessie Janssen
Allied Health Research unit, University of Central Lancashire, Preston, UK
INTRODUCTION
How would you describe the typical case of patellofemoral pain (PFP)?
You might think of pain at the front of, around, or behind the patella in a
young active adult who participates in sport. Despite this simple description,
PFP is regarded as one of the more complex of musculoskeletal conditions,
with its aetiology, assessment and management principles varied, unclear and
controversial (Wilson 2007). The difficulty that PFP presents to clinicians is
illustrated by several descriptions of the condition such as the ‘black hole of
orthopaedics’ (Dye and Vaupel 1994) and the ‘Loch Ness Monster’
(Grelsamer et al. 2009). There are many different concepts, paradigms or
models that try to explain the cause of pain in patients with PFP (see chapter 1
for concepts of PFP), but unfortunately there is no consensus (Naslund et al.
2006). In addition there is not one clinical test that is sensitive or specific
enough to diagnose PFP, however a combination of multiple tests can indicate
(note that we don’t say ‘confirm’) that someone has PFP (Haim et al. 2006,
Nijs et al. 2006, Cook et al. 2010). More information on diagnostic tests can be
found in chapter 6.
viii Jessie Janssen
INCIDENCE OF PFP
PFP is generally considered to be a common problem yet only one study
has actually provided data on the incidence in the general population (Wood,
Muller, and Peat 2011). Wood et al. estimated that one out of 6 adults who
visits their General Practitioner in the UK does this because of a PFP problem.
Most data on the incidence of PFP come from specialised populations such as
the military (Boling et al. 2009), adolescents (Rathleff et al. 2013) and elite
athletes (Witvrouw et al. 2000), therefore published incidence rates for PFP
range widely from 3% to 40% (Callaghan and Selfe 2007). Although not
specific to PFP, we established that 34% of adults in the general population
report knee pain by responding positively to the question “have you had pain
or problems in the last year in or around the knee”? (Selfe et al. 2015).
Current evidence indicates that about 2 out of 3 patients (66%) attending
for physiotherapy with PFP are women (Selfe et al. 2016). Treatment of PFP
varies and it is quite normal that multiple therapies (multimodal approach) are
used, further information about treatment options are described in the
Intervention Chapters in Section 2 of this book.
DURATION AND SEQUELAE OF PFP

Some people regard PFP as a self-limiting and relatively trivial condition
(van Dijk and van der Tempel 2008). It affects all three domains of the
International Classification of Function (World Health Organization 2013) as
it can cause not only dysfunction, but can also limit activities and social
participation.
Several researchers have investigated how long patients suffer with PFP.
Price, Jones and Allum (2000) found that 90% of their patients had pain and
dysfunction 4 years following diagnosis (Price, Jones, and Allum 2000).
Stathopulu and Baildam (2003) confirmed this with 91% of their patients
reporting pain at least 4 years after diagnosis (Stathopulu and Baildam 2003).
At an average of 5.7 years follow-up 73% of athletes diagnosed with PFP still
had pain (Blond and Hansen 1998). These findings link with the possibility
that people with PFP might be predisposed to developing osteoarthritis when
they are older. Forty-five percent of the patients investigated with PFP were
later diagnosed with a patellofemoral joint arthritic condition (Stathopulu and
Baildam 2003). Others have asked patients undergoing uni-compartmental
Introduction ix
patellofemoral arthroplasty to remember if they had PFP when they were

younger; 22% responded positively to this question (Utting, Davies, and
Newman 2005). Currently there is insufficient evidence that a direct link exists
between PFP in younger people and PFOA at a later stage in life (Wyndow et
al. 2016).
WHAT DO WE MEAN BY PFP IN THIS BOOK?

Over the years many terms have been used to describe this condition.
Table 1 lists some of the most common terms you will read.
Table 1. Common terms for PFP
Anterior knee pain

Retropatellar pain
Patellofemoral pain
Chondromalacia patellae
Patellofemoral disorder
Extensor mechanism disorder
Patellofemoral pain syndrome
Patella malalignment syndrome
Miserable malalignment syndrome
Excessive lateral pressure syndrome
When we talk about PFP we talk about a young adult (between the age of
18 and 40 years old) who suffers from anterior or retropatellar pain when they
are sitting for a long time, going up or down the stairs, squatting, running,
kneeling, and/or hopping/jumping (Syme et al. 2009, Cook et al. 2010). We
have provided more information on this in Chapter 3, Subjective Examination.
The consensus statement from the 4th International PFP Research Retreat
(Crossley et al. 2016) states that at least one of these activities should be
provocative for a diagnosis of PFP.
x Jessie Janssen
PFP is normally diagnosed by excluding other pathologies that fall outside

the scope of this book such as those with previous knee surgery and/or
awaiting surgery for another lower limb joint problem(s), ligamentous
instability and/or internal derangement, a history of patella subluxation or
dislocation, significant joint effusion, true knee joint locking and/or giving
way, coexistent acute illness or chronic disease, bursitis, patella or iliotibial
tract tendinopathy, Osgood Schlatter’s disease, Sinding-Larsen Johansson
Syndrome, muscle tears or symptomatic knee plicae (Syme et al. 2009). Some
of these patients are best referred for orthopaedic or radiological opinion
(Acton and Craig 2000). Chapter 11 Radiology of the Patellofemoral Joint will
shed more light on the investigative options available in radiology. Women
who are pregnant or are breastfeeding are also outside of the scope of this
book as their ligaments are affected by systemic hormonal changes in their
bodies. We have not included adolescents and patellofemoral osteoarthritis
(PFOA) because these patients may have other mechanisms or pathologies
underlying their PFP and this would dilute the specific scope and usefulness of
this book.
Another area of contention which lies outside the scope of this book is
around the optimal outcome measure to use with patients suffering from PFP
as currently no consensus exists. In the last 15 years a number of outcome
measures have been used in PFP trials, such as the Kujala scale (anterior knee
pain scale), functional index questionnaire, numeric pain rating scale, and the
global rating of change scale (Crossley et al. 2004). A new outcome measure
has been developed by an international consortium which might become the
preferred measure for those with PFOP and PFOA (Crossley et al 2017).
IMPORTANCE OF RESEARCH INTO PFP

In 2010 the Chartered Society of Physiotherapy in the UK (Chartered
Society of Physiotherapy 2010) launched the Musculoskeletal Research
Priority Project and investigating the clinical and cost effectiveness of
physiotherapy for patients with PFP emerged as the third highest priority topic
(Chartered Society of Physiotherapy 2010). Only the exploration of
interventions to increase patients’ adherence and the prescription of exercise
were deemed higher priorities (Chartered Society of Physiotherapy 2010).
Interestingly, these first two topics are also crucial for patients with PFP as
well and are discussed in Section 2 of this book.
Introduction xi
EDITORIAL STYLE
We have divided the book into two sections in attempt to mirror the real
world of clinical practice. Section 1 focuses on what you do when the patient
first walks through the door in terms of establishing what the patient’s problem
and how it affects them. Section 2 mainly focuses on interventions but goes
onto consider options for radiological investigation and closes with some
thoughts about recalcitrant PFP. We have edited this book to ensure
consistency of the information across the chapters, which have been written by
a variety of experts. However, we have not edited the style of writing from
each of our contributors as we wanted to preserve their ‘voices’ so that the
reader could gain an insight into the kind of clinical advice each would give if
they were stood in the clinic with you. In addition throughout this book
examples are given of dynamic tests or exercises, we recommend looking
these up online as a still photograph would not do these examples justice.
Lastly we would like to remind our readers that it is important to work
within your scope of practice. For example some contributors refer to
prescriptions for analgesia and foot orthoses, but this is only possible if this
falls within the remit of your practice in your country.
REFERENCES
Acton, D., and Craig, D. 2000. "Should I scan or should I scope?" The Knee 7
(4):245-248.
Blond, L., and Hansen, L. 1998. "Patellofemoral pain syndrome in athletes: a
5.7-year retrospective follow-up study of 250 athletes." Acta
Orthopaedica Belgica 64 (4):393-400.
Boling, M. C., Padua, D. A., Marshall, S. W., Guskiewicz, K., Pyne, S., and
Beutler, A. 2009. "A prospective investigation of biomechanical risk
factors for patellofemoral pain syndrome: the Joint Undertaking to
Monitor and Prevent ACL Injury (JUMP-ACL) cohort." American
Journal of Sports Medicine 37 (11):2108-16.
Callaghan, M., and Selfe, J. 2007. "Has the incidence of prevalence of
patellofemoral pain in the general population in the the United Kingdom
been properly evaluated?" Physical Therapy in Sports. 8:37–43.
Chartered Society of Physiotherapy. 2010. "Physiotherapy research priority
project: musculoskeletal topics." Chartered Society of Physiotherapy.
xii Jessie Janssen
Cook, C., Hegedus, E., Hawkins, R., Scovell, F., and Wyland, D. 2010.
"Diagnostic accuracy and association to disability of clinical test findings
associated with patellofemoral pain syndrome." Physiotherapy Canada
62 (1):17-24.
Crossley, K. M., Bennell, K. L., Cowan, S. M., and Green, S. 2004. "Analysis
of outcome measures for persons with patellofemoral pain: which are
reliable and valid?" Archives of Physical Medicine and Rehabilitation 85
(5):815-22.
Crossley K. M., Macri E. M., Cowan S. M., Collins N. J., Roos E. M. 2017.
The patellofemoral pain and osteoarthritis subscale of the KOOS (KOOS-
PF): development and validation using the COSMIN checklist. British
Journal of Sports Medicine. 3. doi: 10.1136/bjsports-2016-096776.
Crossley, K. M., Stefanik, J. J., Selfe, J., Collins, N. J., Davis, I. S., Powers, C.
M., McConnell, J., Vicenzino, B., Bazett-Jones, D. M., Esculier, J. F.,
Morrissey, D., and Callaghan, M. J. 2016. "2016 Patellofemoral pain
consensus statement from the 4th International Patellofemoral Pain
Research Retreat, Manchester. Part 1: Terminology, definitions, clinical
examination, natural history, patellofemoral osteoarthritis and patient-
reported outcome measures." British Journal of Sports Medicine 50
(14):839-43.
Dye, S. F., and Vaupel, G. L. 1994. The pathophysiology of patellofemoral
pain. Sports Medicine and Arthroscopy Review (2): 203–210.
Grelsamer, R., Moss, G., Ee, G., and Donell, S. 2009. "The patellofemoral
syndrome; the same problem as the Loch Ness Monster?" The Knee 16
(5):301-2.
Haim, A., Yaniv, M., Dekel, S., and Amir, H. 2006. "Patellofemoral pain
syndrome: validity of clinical and radiological features." Clinical
Orthopaedics and Related Research 451:223-8.
Naslund, J., Naslund, U. B., Odenbring, S., and Lundeberg, T. 2006.
"Comparison of symptoms and clinical findings in subgroups of
individuals with patellofemoral pain." Physiotherapy Theory and Practice
22 (3):105-18.
Nijs, J., Van Geel, C., Van der auwera, C., and Van de Velde, B. 2006.
"Diagnostic value of five clinical tests in patellofemoral pain syndrome."
Manual Therapy 11 (1):69-77.
Price, A. J., Jones, J., and Allum, R. 2000. "Chronic traumatic anterior knee
pain." Injury 31 (5):373-8.
Rathleff, M. S., Samani, A., Olesen, J. L., Roos, E. M., Rasmussen, S.,
Christensen, B. H., and Madeleine, P. 2013. "Neuromuscular activity and
Introduction xiii
knee kinematics in adolescents with patellofemoral pain." Medicine &

Science in Sports & Exercise 45 (9):1730-9.
Selfe, J., Dey, P., Richards, J., Cook, N., Chohan, A., Payne, K., and Masters,
R. S. 2015. "An exploration of the association between the reporting of
musculoskeletal pain in the knee and the propensity for conscious control
of movement." Clinical Rehabilitation 29 (1):95-100.
Selfe, J., Janssen, J., Callaghan, M., Witvrouw, E., Sutton, C., Richards, J.,
Stokes, M., Martin, D., Dixon, J., Hogarth, R., Baltzopoulos, V., Ritchie,
E., Arden, N., and Dey, P. 2016. "Are there three main subgroups within
the patellofemoral pain population? A detailed characterisation study of
127 patients to help develop targeted intervention (TIPPs)." British
Stathopulu, E., and Baildam, E. 2003. "Anterior knee pain: a long-term follow-
up." Rheumatology (Oxford) 42 (2):380-2.
Syme, G., Rowe, P., Martin, D., and Daly, G. 2009. "Disability in patients
with chronic patellofemoral pain syndrome: a randomised controlled trial
of VMO selective training versus general quadriceps strengthening."
Utting, M. R., Davies, G., and Newman, J. H. 2005. "Is anterior knee pain a
predisposing factor to patellofemoral osteoarthritis?" The Knee 12
(5):362-5.
van Dijk, CN., and van der Tempel, WM. 2008. "Patellofemoral pain
syndrome." British Medical Journal 337:a1948.
Wilson, T. 2007. "The measurement of patellar alignment in patellofemoral
pain syndrome: are we confusing assumptions with evidence?" Journal of
Orthopaedic & Sports Physical Therapy 37 (6):330-41.
Witvrouw, E., Lysens, R., Bellemans, J., Cambier, D., and Vanderstraeten, G.
2000. "Intrinsic risk factors for the development of anterior knee pain in
an athletic population. A two-year prospective study." American Journal
of Sports Medicine 28 (4):480-9.
Wood, L., Muller, S., and Peat, G. 2011. "The epidemiology of patellofemoral
disorders in adulthood: a review of routine general practice morbidity
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World Health Organization. 2013. "How to use the ICF: A practical manual
for using the International Classification of Functioning, Disability and
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xiv Jessie Janssen
Wyndow, N., Collins, N., Vicenzino, B., Tucker, K., and Crossley, K. 2016.
"Is There a BiomechanicalLink Between Patellofemoral Pain and
Osteoarthritis? A Narrative Review." Sports Medicine. 46(12):1797-1808
SECTION 1: WHAT DO YOU DO WHEN
THE PATIENT FIRST WALKS THROUGH
THE DOOR?
In: Patellofemoral Pain ISBN: 978-1-53611-780-6
Editors: J. Selfe, J. Janssen et al. © 2017 Nova Science Publishers, Inc.
Chapter 1
CONCEPTS OF PATELLOFEMORAL PAIN
Jessie Janssen
Allied Health Research unit, University of Central Lancashire, Preston, UK
INTRODUCTION
Over the last 40 years, researchers and clinicians have developed multiple
concepts to explain the underlying cause(s) for patellofemoral pain (PFP). All
have produced evidence supporting their concepts, but all have also been
criticised as they do not paint a full picture of PFP. As mentioned in the
introduction chapter these multiple concepts reflect the complicated nature of
PFP. Neither clinicians nor researchers agree which best reflects the condition
(Domenech, Sanchis-Alfonso, and Espejo 2014). Currently the most widely
accepted concept about the origin of PFP is that malalignment of the patella
causes pain (Powers et al. 2012, Wilson 2007), however which underlying
structure is affected is still unknown. Looking at PFP from a clinical
perspective rather than trying to identify the exact affected structures has been
the recent focus, but a merging of these two concepts might be the best
approach. In this chapter, we will first take you through concepts based on
structural changes, then we will continue to explain the concepts that are based
in clinical practice.
Keywords: structural concepts, clinical concepts

4 Jessie Janssen
Structural Concepts
 Subchondral bone deformation

 Intramedullary pressure changes
 Lateral retinacular neuroma
 Infrapatellar fat pad
 Tissue homeostasis
 Neural Model
Clinical Concepts
 Multimodal treatment
 Targeted treatment based on subgroups
 Cold knees/ischaemia
 Psychosocial factors
STRUCTURAL CONCEPTS: DUE TO OVERLOADING

THE PATELLA-THIS WAS CALLED
CHONDROMALACIA PATELLAE
Until the late 20th century patellofemoral pain (PFP) was usually explained
by a softening of the cartilage on the posterior side of the patella, due to
overloading of the patella, this was called chondromalacia patellae. Even
though chondromalacia patellae is still a diagnosis, a clear link between
softening of the cartilage and PFP has not been established (Sanchis-Alfonso
2010).
After the 1980’s the concept of malalignment of the patella became
prominent. The forces upon the patella are extremely high and the contact
areas between the patella and the femur very small, this leads to high joint
reaction forces acting on the patella. In a healthy patella the joint reaction
forces are higher than in a healthy hip joint (Ahmed, Burke, and Yu 1983) and
can reach 7-8 times a person’s bodyweight when squatting (Reilly and
Martens 1972) (see chapters 2 and 5 for more information). It was (and is)
thought that a patella that does not track well within the trochlear grove will be
exposed to higher forces and is therefore more likely to become a source of
pain or the structures around it will become painful. These structures could be
Concepts of Patellofemoral Pain 5
any richly innervated tissue in contact with the patella, such as the medial and
lateral retinaculum or the infrapatellar fat pad. It is important to note that the
concept of malalignment has been criticised as it was discovered that those
whose patellae are malaligned do not exhibit any symptoms, and others who
do have PFP do not have malaligned patellae (Sanchis-Alfonso 2010).
The following four structural concepts are based upon patella
malalignment.
Subchondral Bone Deformation
In 1976 Goodfellow et al. hypothesised that people with PFP developed

‘lesions’ in the subchondral bone (the bone underlying the calcified cartilage
(Madry, van Dijk, and Mueller-Gerbl 2010)) of the odd facet of the patella
(Goodfellow, Hungerford, and Woods 1976). The odd facet is positioned on
the posterior side of the patella on the medial side. The cartilage itself stayed
smooth, but the subchondral bone was thought to become spongy and less able
to deal with the forces that acted upon it. Because subchondral bone is richly
innervated, pain can be experienced from this area. This concept also
explained why some people ‘grow out’ of their pain, as it was thought that the
smooth intact cartilage could regenerate the underlying bone (Goodfellow,
Hungerford, and Woods 1976).
Intramedullary Pressure Changes
Intramedullary pressure is the internal pressure within the bone marrow.

Bone marrow pressure in the patella is raised when the external pressure on
the bone is increased, which is the case when a patella is malaligned.
However, because of the shape and size of the patella the pressure is difficult
to release and the pressure continues to rise. Release of the high
intramedullary pressure in the patella can only happen through the
extraosseous veins, but these are easily blocked by, for example, knee flexion.
This might explain why so many people with PFP experience pain when they
have been sitting for a long time, the so called ‘movie goers sign’ (Dye 2005).
Therefore, in contrast to the subchondral bone deformation it is not the
mechanical force that is the issue, but the raised intramedullary pressure within
the patella (Arnoldi 1991). People with PFP have been found to have higher
intramedullary pressure than those without PFP, however this is very difficult
6 Jessie Janssen
to measure and therefore the concept has encountered some resistance

(Macnicol 1995). The higher pressure is thought to cause oedema in the patella
and this might be responsible for causing cellular degeneration and also pain.
Lateral Retinacular Neuroma
The lateral retinaculum is a passive support structure located on the lateral

side of the patella and its function is to stabilise the patella during daily
activities. When the patella is malaligned chronic injury occurs to the small
nerves in the lateral retinaculum. These traumatised nerves form neuromata
which can cause spontaneous pain. This concept has been highly popular with
surgeons as it allowed them to perform a lateral retinaculum release. However
it has become less popular over the years as the results of a lateral release were
unpredictable, people’s patellae became unstable (Merican, Kondo, and Amis
2009) and pain returned within three years in a number of people. Lateral
releases can still be indicated but only when people have a tight lateral
retinaculum in addition to a rotated tilted patella (Fulkerson 2002) and for PFP
or patellofemoral instability if these are due to tight lateral structures and all
other conservative treatment has been exhausted.
Infrapatellar Fat Pad
The infrapatellar (Hoffa’s) fat pad lies just underneath the patella and is
the largest adipose tissue structure in a human joint (Eymard and Chevalier
2016). Despite the fact that the exact function of the fat pad is currently
unknown what the exact function is of the infrapatellar fat pad, it may play a
role in the biomechanics of the knee or act as a store for reparative cells after
injury (Dragoo, Johnson, and McConnell 2012). The fat pad is richly
innervated and therefore susceptible to producing pain (Dragoo, Johnson, and
McConnell 2012). Inflammation of the infrapatellar fat pad is called Hoffa’s
disease (Hoffa 1904) and the swollen fat pad is thought to become impinged
between the tibia and the femur (Eymard and Chevalier 2016) and this can
present clinically as PFP.
Tissue Homeostasis
The concept of tissue homeostasis encompasses much more than just

patella malalignment. It studies the balance of the internal environment of a
person’s body (Dye et al. 1999). Due to external factors the internal
environment around the patella changes constantly, for example when
someone is sitting down or running a marathon. Tissue homeostasis is the
stage when this balance is kept and therefore there are no symptoms of
inflammation such as pain, tenderness, swelling and warmth. The outer limits
of the balance are called the envelope of function (Dye 2005). When the
balance is lost because a person has overused body structures by overloading
or repetitive tasks, people break through the envelope of function and run the
risk of structural changes if they continue. We have used the word body
structures here, because in contrast to the previous concepts, tissue
homeostasis is not concerned about which structures are affected. Any richly
sensory innervated tissue in close contact with the patella might be the cause
of the pain (Aigner et al. 2001). When tissues are damaged the envelope of
function is lowered as only lower loading will be pain free. This often leads to
the situation where people are not able to conduct their daily activities as their
loading capacity is diminished, leading to a vicious circle of pain, reduced
activity and chronic symptoms. These functional limitations which occur
without any structural changes can be captured well within the ICF framework
of the WHO, which takes a person centred approach by taking activity and
participation levels into account.
Neural Model
The neural model combines the lateral retinaculum neuroma concept with
tissue homeostasis, as it proposes that the vascular balance in the lateral
retinaculum has been lost in a subgroup of people with PFP. When someone
flexes and extends their knee repeatedly the blood vessels in the lateral
retinaculum bend and stretch and the area supplied by the blood vessel is
deprived of oxygen (Sanchis-Alfonso 2010). As a result neural growth factor
(NGF) will be released. As the name suggests, NGF will lead to an increase of
nerve innervation, in this case a hyper innervation, and the release of
Substance P (Malcangio et al. 1997), which in turn causes pain. It has been
shown that people with very painful PFP have a higher number of nerves in
the lateral retinaculum (Sanchis-Alfonso et al. 2000, 2005) and have more
8 Jessie Janssen
NGF in this area (Sanchis-Alfonso, Rosello-Sastre, and Revert 2001) than

people with less painful PFP.
CLINICAL CONCEPTS
The following clinical concepts have been developed to improve
treatment, they do not explain the underlying causes of PFP.
Multimodal Treatment
The most current clinically used pathway for treating people with PFP is a
multimodal approach (Barton et al. 2015). In this approach the physiotherapist
rehabilitates the patient with a number of different treatment modalities
simultaneously. The treatments can include strengthening exercises, stretching
exercises, manual therapy, taping, acupuncture and the supply of foot orthoses.
In the multimodal approach the physiotherapist chooses the combination of
these treatments which are likely to be most beneficial for the patient with
PFP. Multimodal treatment has been proven to be more successful in reducing
pain and increasing function than control treatment in the short term (up to 3
months follow up) (Collins et al. 2012, van der Heijden et al. 2015).
Targeted Treatment Based on Subgroups
An alternative to the multimodal approach is to use a targeted approach in

which only those treatments which are targeted to a specific dysfunction,
identified by the clinician, are used. This approach is based on the concept that
subgroups exist within the PFP population (Selhorst et al. 2015, Keays,
Mason, and Newcombe 2015, Selfe et al. 2016). The 1st International
Patellofemoral Research Retreat (Davis and Powers 2010) recognised that
proximal, local and distal factors are likely to be important. This proposes that
local factors such as patellofemoral joint mechanics and surrounding tissues
can cause PFP, but additionally there are also factors proximal and distal to the
knee. The proximal factors focus on the hip, pelvis, and trunk whereas the
distal factors mainly focus on foot and ankle mechanics (Powers et al. 2012).
For example from a distal perspective additional tibial internal rotation could
be a factor influencing PFP (Witvrouw et al. 2014). From a proximal point of
view additional hip adduction and/or internal rotation of the hip have been
seen in women with PFP, less so in men (Witvrouw et al. 2014). Selfe et al.
(2016) found that three clinical subgroups exist. One subgroup was described
as ‘strong,’ and the two remaining subgroups had both weak quadriceps and
hip abductor muscles, however one of the subgroups had more pronated feet
whereas the other subgroup had tighter leg muscles (see Chapters 6 and 7 for
more on subgroups). Further research is being planned to identify if these
groups also respond better to targeted treatment.
Cold Knees/Ischaemia
This concept is based on torsion of the blood vessels in the knee (similar
to the neural model) can lead to ischemia in and around the knee. Some people
with PFP experience more pain when in a cold environment (Sandow and
Goodfellow 1985). Fifteen out of 46 patients with anterior knee pain caused by
a trauma said that cold weather increased their pain (Price, Jones, and Allum
2000). In addition, 14 out of 77 patients with anterior knee pain who felt that
their legs were cold in warm surroundings, also functioned less and made less
improvement with regards to pain compared to others who did not have cold
legs in warm surroundings (Selfe et al. 2003). Selfe et al. reported that female
AKP patients with cold knees presented with a smaller skin fold, were less
active and had a history of trauma to their knees (Selfe et al. 2010). The
existence of this group still needs to be verified.
Psychosocial Factors
Studies on low back pain have demonstrated that psychosocial factors

influence outcome. This may also the case for people with PFP. Chapters 2
and 3 explain more about the clinical implications of these factors. In 1993
Carlsson and co-workers compared the personalities of people with PFP to
people without PFP and found that people with PFP were more depressed,
hostile and had a more passive attitude than their peers who did not have PFP
(Carlsson et al. 1993). They also suggested that people who did not respond to
non-operative treatment such as physiotherapy could be referred to a pain
clinic. Piva et al. in 2009 treated 74 people with PFP and measured physical
outcomes such as hip abductor and quadriceps strength, and additionally fear
avoidance (Piva et al. 2009). Their aim was to identify which of these
10 Jessie Janssen
measures predicted pain and functional outcome. Fear avoidance towards

physical activity was the only factor that predicted whether pain and function
would improve or not. This led to the development of a subgrouping system in
which fear avoidance was taken into account (Selhorst et al. 2015). Currently
there is still a gap in the literature around psychosocial factors in PFP and
more research needs to be done in this area (Witvrouw et al. 2014).
CONCLUSION
This chapter has presented several biological that have been developed to
explain PFP. None of the concepts individually can fully explain PFP
symptoms and mechanisms. Patella malalignment remains the main focus of
the structural concepts for PFP. As a result alternative clinical concepts such
as subgrouping are being proposed to guide treatment.
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Aigner, T., Hemmel, M., Neureiter, D., Gebhard, P. M., Zeiler, G., Kirchner,
T., and McKenna, L. 2001. "Apoptotic cell death is not a widespread
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Arnoldi, C. C. 1991. "Patellar pain." Acta orthopaedica Scandinavica.
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Barton, C. J., Lack, S., Hemmings, S., Tufail, S., and Morrissey, D. 2015.
"The 'Best Practice Guide to Conservative Management of Patellofemoral
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British Journal of Sports Medicine 49(14):923-34.
Carlsson, A. M., Werner, S., Mattlar, C. E., Edman, G., Puukka, P., and
Eriksson, E. 1993. "Personality in patients with long-term patellofemoral
pain syndrome." Knee Surgery Sports Traumatology Arthroscopy 1 (3-
4):178-83.
Collins, N. J., Bisset, L. M., Crossley, K. M., and Vicenzino, B. 2012.

"Efficacy of nonsurgical interventions for anterior knee pain: systematic
review and meta-analysis of randomized trials." Sports Medicine 42
(1):31-49.
Davis, IS., and Powers, C. 2010. "Patellofemoral Pain Syndrome: Proximal,
Distal, and Local Factors—An International Research Retreat." Journal
of Orthopaedic & Sports Physical Therapy 40 (3):A1-A48.
Domenech, J., Sanchis-Alfonso, V., and Espejo, B. 2014. "Changes in
catastrophizing and kinesiophobia are predictive of changes in disability
and pain after treatment in patients with anterior knee pain." Knee
Surgery Sports Traumatology Arthroscopy 22 (10):2295-300.
Dragoo, J. L., Johnson, C., and McConnell, J. 2012. "Evaluation and treatment
of disorders of the infrapatellar fat pad." Sports Medicine 42 (1):51-67.
Dye, S. F. 2005. "The pathophysiology of patellofemoral pain: a tissue
homeostasis perspective." Clinical Orthopaedics and Related Research
(436):100-10.
Dye, S. F., Stäubli, H. U., Biedert, R. M., and Vaupel, G. L. 1999. "The
mosaic of pathophysiology causing patellofemoral pain: Therapeutic
implications." Operative Techniques in Sports Medicine 7:46–54.
Dye, S. F., and Vaupel, G. L. 1994. The pathophysiology of patellofemoral
pain. Sports Medicine and Arthroscopy Review (2): 203–210.
Eymard, F., and Chevalier, X. 2016. "Inflammation of the infrapatellar fat
pad." Joint Bone Spine 83 (4):389-93.
Fulkerson, J. P. 2002. "Diagnosis and treatment of patients with patellofemoral
pain." American Journal of Sports Medicine 30 (3):447-56.
Goodfellow, J., Hungerford, D. S., and Woods, C. 1976. "Patello-femoral joint
mechanics and pathology. 2. Chondromalacia patellae." The Journal of
bone and joint surgery. British volume 58 (3):291-9.
Hoffa, A. 1904. "The influence of the adipose tissue with regard to the
pathology of the knee joint." Journal of the American Medical
Association: 795–6.
Keays, S. L., Mason, M., and Newcombe, P. A. 2015. "Individualized
physiotherapy in the treatment of patellofemoral pain." Physiotherapy
Research International 20 (1):22-36.
Macnicol, M.F. 1995. The problem knee. Second edition ed. Oxford:
Butterworth-Heinemann.
Madry, H., van Dijk, C. N., and Mueller-Gerbl, M. 2010. "The basic science of
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Malcangio, M., Garrett, N. E., Cruwys, S., and Tomlinson, D. R. 1997. "Nerve
growth factor- and neurotrophin-3-induced changes in nociceptive
threshold and the release of substance P from the rat isolated spinal cord."
The Journal of neuroscience 17 (21):8459-67.
Merican, A. M., Kondo, E., and Amis, A. A. 2009. "The effect on
patellofemoral joint stability of selective cutting of lateral retinacular and
capsular structures." Journal of Biomechanics 42 (3):291-6.
Piva, S. R., Fitzgerald, G. K., Wisniewski, S., and Delitto, A. 2009.
"Predictors of pain and function outcome after rehabilitation in patients
with patellofemoral pain syndrome." Journal of Rehabilitation Medicine
41 (8):604-12.
Powers, C. M., Bolgla, L. A., Callaghan, M. J., Collins, N., and Sheehan, F. T.
2012. "Patellofemoral pain: proximal, distal, and local factors, 2nd
International Research Retreat." Journal of Orthopaedic & Sports
Physical Therapy 42 (6):A1-54.
pain." Injury 31 (5):373-8.
Reilly, D. T., and Martens, M. 1972. "Experimental analysis of the quadriceps
muscle force and patello-femoral joint reaction force for various
activities." Acta Orthopaedica Scandinavica 43 (2):126-37.
Sanchis-Alfonso, V. 2010. "Pathophysiology of anterior knee pain." In
Patellofemoral pain, instability, and arthritis, edited by Dejour D. Arent
E. A. Zaffagnini S, pp 1-16. Berlin: Springer.
Sanchis-Alfonso, V., Rosello-Sastre, E., and Revert, F. 2001. "Neural growth
factor expression in the lateral retinaculum in painful patellofemoral
malalignment." Acta Orthopaedica Scandinavica 72 (2):146-9..
Sanchis-Alfonso, V., Rosello-Sastre, E., Revert, F., and Garcia, A. 2000.
"Immunohistochemical analysis for neural markers of the lateral
retinaculum in patients with isolated symptomatic patellofemoral
malalignment. A neuroanatomic basis for anterior knee pain in the active
young patient." American Journal of Sports Medicine 28 (5):725-31.
Sanchis-Alfonso, V., Rosello-Sastre, E., Revert, F., and Garcia, A. 2005.
"Histologic retinacular changes associated with ischemia in painful
patellofemoral malalignment." Orthopedics 28 (6):593-9.
Sandow, M. J., and Goodfellow, J. W. 1985. "The natural history of anterior
knee pain in adolescents." The Journal of bone and joint surgery. British
volume 67 (1):36-8.
Selfe, J., Harper, L., Pedersen, I., Breen-Turner, J., Waring, J., and Stevens, D.
2003. "Cold legs: a potential indicator of negative outcome in the
rehabilitation of patients with patellofemoral pain syndrome." The Knee

10 (2):139-43.
Selfe, J., Sutton, C., Hardaker, N. J., Greenhalgh, S., Karki, A., and Dey, P.
2010. "Anterior knee pain and cold knees: a possible association in
women." The Knee 17 (5):319-23.
Selhorst, M., Rice, W., Degenhart, T., Jackowski, M., and Tatman, M. 2015.
"Evaluation of a treatment algorithm for patients with patellofemoral pain
syndrome: a pilot study." International Journal of Sports Physical
Therapy 10 (2):178-88.
van der Heijden, R. A., Lankhorst, N. E., van Linschoten, R., Bierma-Zeinstra,
S. M., and van Middelkoop, M. 2015. "Exercise for treating
patellofemoral pain syndrome." Cochrane Database of Systematic
Reviews 1:CD010387.
Wilson, T. 2007. "The measurement of patellar alignment in patellofemoral
pain syndrome: are we confusing assumptions with evidence?" Journal of
Orthopaedic & Sports Physical Therapy 37 (6):330-41. doi:
10.2519/jospt.2007.2281.
Witvrouw, E., Callaghan, M. J., Stefanik, J. J., Noehren, B., Bazett-Jones, D.
M., Willson, J. D., Earl-Boehm, J. E., Davis, I. S., Powers, C. M.,
McConnell, J., and Crossley, K. M. 2014. "Patellofemoral pain: consensus
statement from the 3rd International Patellofemoral Pain Research Retreat
held in Vancouver, September 2013." British Journal of Sports Medicine
48 (6):411-414.
Chapter 2
PATIENTS’ EMOTIONAL STATES

AND EXPECTATIONS
Jenny McConnell
McConnell Institute, Mosman,
New South Wales, Australia
INTRODUCTION
Patients visit a physiotherapist because they are experiencing pain. They
may also be concerned about giving way, swelling, clicking or altered
sensation in the absence of pain, but generally speaking pain is the motivation
for coming to the physiotherapist. Patients usually do not present for treatment
to correct internal rotation of the femur or pronated feet, unless they are having
patellofemoral symptoms.
Keywords: self-management, adherence, desensitisation, communication
SELF-MANAGEMENT JOURNEY
The presence of pain decreases muscle activity, timing and endurance, as
well as altering movement patterns (Hodges et al. 2009). As pain is a cortical
experience, extrinsic factors such as fear of pain, stress and anxiety (Van de
Kar and Blair 1999, Juhn et al. 1999) can amplify the pain experience for the
16 Jenny McConnell
patient and the contribution of these factors must be understood if

physiotherapists are to satisfactorily improve individuals with any
musculoskeletal pain. As musculoskeletal conditions are not generally ‘cured’,
physiotherapy should be regarded as a journey towards self-management for a
patient. This involves you, the physiotherapist getting ‘buy in’ from the
patient, so it is imperative at the first consultation that you explain to the
patient what has happened, why it has happened and what you and the patient
can do together to improve the symptoms. This means the patient must be
aware from the outset that musculoskeletal problems can be self-managed very
successfully but will often return unless the patient is prepared to keep doing
their ‘body management strategies’ (the word ‘exercise’ conjures up a very
negative concept to many patients) to keep their symptoms at bay. You
therefore need to take a detailed subjective examination of the patient’s
problem, finding out details about where the pain is, what increases and
decreases it and when it started, if possible establishing a cause for the pain
(see Chapter 3). In short, your role is to listen to the patient, as you will glean a
great deal about the symptoms from your subjective examination. Sometimes
you may have to dig a little deeper when determining causative factors. For
example when the patient states they have done nothing and the pain just
started, you could ask have they moved house, started a gym programme,
changed their training routine, changed jobs or changed their footwear. In
Australia for example increased knee and lower extremity problems often
occur during summer when some people, particularly females wear sandals
and thongs (flip flops), as the foot is not well supported. The resulting altered
alignment of the lower extremity results in pain.
EXPLANATION TO THE PATIENT ABOUT THE REASONS

FOR SYMPTOMS
During the initial examination you need to discuss with the patient the
effect of intensity and frequency of load on joints and what happens when
their threshold is exceeded i.e., outside the envelope of function (See Chapter
5). If you are seeing a patient with knee pain, you need to explain to that
patient that during walking 0.5x body weight goes through the knee, 3-4 x
body weight through the knee on stair ascent and descent, 7-8x body weight in
squatting and 8-10x body weight with running (see Chapter 5). Once the
Patients’ Emotional States and Expectations 17
patient has pain, their function decreases because pain reduces quadriceps
activity.
In turn the load through the joint increases as the muscle is no longer
supporting the joint, which in turn causes more knee pain. This can result in
fear of pain, causing a decrease in quadriceps activity, resulting in lateral
tracking of the patella and of course more knee pain. Explaining the
importance of breaking this negative pain and dysfunction cycle is critical to
obtaining the patient’s understanding about their symptoms. This background
information will further strengthen the patient’s confidence in you, and
enhance treatment adherence.
MINIMISING OCCURRENCE OF COMPLEX REGIONAL

PAIN SYNDROME
At this stage in the consultation, you have an opportunity to identify any
signs of complex regional pain syndrome (CRPS), as early recognition will
alleviate some potential future problems (see Chapter 4). If the patient appears
apprehensive about being touched over the knee and you see that the skin is
more mottled around the knee or there is a decrease in temperature around the
knee, then you should ask the patient to gently feel the temperature difference
around their knee. Once the patient has felt this difference, you can explain to
the patient about centralisation of pain and the concept of why minimal
mechanical stimuli are interpreted by the brain as being painful. I do this by
using an analogy of an electric stove, which I explain keeps cooking the food
even when the stove is turned off, (i.e., the patient’s nervous system is tuned,
so that it responds to all stimuli as if they were painful). The only way the
patient can diminish this, is to consciously ‘turn off’ the input by desensitising
the area.
To decrease the hypersensitivity around the knee, the patient is shown a
desensitising regime, which involves rubbing the knee with different textures
in a circular then a stroking fashion. The procedure needs to be performed for
up to 5 minutes every day. Several textures can be found in the clinic such as
cotton wool, pot scourer pad, TubigripTM, and a piece of Thera-Band, and
should be given to the patient to take home, so they can maintain the daily
regime. I find that desensitising usually takes about a month. If you try to
direct traditional physiotherapy treatment such as quadriceps strengthening
exercises to the knee at this stage the symptoms will worsen.
18 Jenny McConnell
RELIEVING THE PAIN

The most powerful way to ensure adherence and ultimately success of
treatment is for you to relieve the patient’s symptoms. Relief of the patient’s
symptoms can be achieved very quickly and successfully, by taping the
patient’s knee to unload the painful tissues and promote a more optimal
positioning of the patella on the femur. Knee taping is covered separately in
Chapter 8. If you can significantly reduce the patient’s pain, the patient is
usually then very willing to start their home programme of muscle training.
The home programme should be easy for the patient to do, requiring minimal
or no equipment.
If the home programme is onerous or the patient cannot see that the
training is effective, then the patient will not participate and their symptoms
will not improve. Recent evidence of the long-term outcome of treatment for
adolescents with PFP, who were supposedly compliant with a multimodal
exercise programme, was fairly poor, but it was found that the majority of
adolescents did not perform their home-exercises correctly two weeks after
their initial instruction (Faber et al. 2015). Thus, you need to check the
patient’s home programme very regularly and emphasise to them that it is like
cleaning their teeth, so should be performed at least daily, if not twice daily,
when they are on maintenance and their symptoms have settled. As many
patients often stop their maintenance programme because their pain has gone,
in my opinion it is imperative that you check their progress every 6 or 12
months, to reinforce the importance of keeping their muscle training in peak
condition so their symptoms do not return. In musculoskeletal physiotherapy,
we need a paradigm shift in how we manage patients and need to adopt the
dental model of prevention, particularly in this current era of escalating health
care costs.
SUMMARY
Patients are invariably motivated by pain when they decide to seek help
from a physiotherapist. However, engagement in the subsequent rehabilitation
is moderated by a wide variety of psychosocial variables. It is essential to get
patient ‘buy in’ to the rehabilitation programme from day one.
Patients’ Emotional States and Expectations 19
REFERENCES
Faber, M., Andersen, M. H., Sevel, C., Thorborg, K., Bandholm, T., and
Rathleff, M. 2015. "The majority are not performing home-exercises
correctly two weeks after their initial instruction-an assessor-blinded
study." PeerJ 3:e1102.
Hodges, P. W., Mellor, R., Crossley, K., and Bennell, K. 2009. "Pain induced
by injection of hypertonic saline into the infrapatellar fat pad and effect on
coordination of the quadriceps muscles." Arthritis & Rheumatology 61
(1):70-7.
Juhn, S. K., Li, W., Kim, J. Y., Javel, E., Levine, S., and Odland, R. M. 1999.
"Effect of stress-related hormones on inner ear fluid homeostasis and
function." American Journal of Otolaryngology 20 (6):800-6.
Van de Kar, L. D., and Blair, M. L. 1999. "Forebrain pathways mediating
stress-induced hormone secretion." Frontiers in Neuroendocrinology 20
(1):1-48.
Chapter 3
SUBJECTIVE EXAMINATION
James Selfe
Department of Health Professions,
Manchester Metropolitan University, Manchester, UK
INTRODUCTION
Patellofemoral pain (PFP) is usually described in many textbooks a
diagnosis of exclusion i.e., when everything else has been ruled out it is worth
considering the patellofemoral joint as being the source of the symptoms.
Typically PFP patients will complain of activities that load the
patellofemoral joint such as
 Squatting
 Kneeling
 Ascending/descending stairs and slopes
 Prolonged sitting
In fact these activities have almost become accepted as pathognomic for

PFP, however it is common for patients with other types of knee problems to
also complain of pain during these activities (Callaghan, Selfe, and Dey 2009).
Clinicians therefore need to thoroughly explore the full history of the
condition and not rely exclusively on a small number of items before reaching
a clinical diagnosis of PFP.
22 James Selfe
The subjective examination has a number of functions to;
 Rule out Red Flags (Chapter 4)

 Establish likely causes of pain and/or dysfunction,
 Determine modifiable and non-modifiable factors, which help to focus
treatment planning
 Understand the patient’s motivation for attending physiotherapy and
their willingness (or sometimes lack of it) to engage in rehabilitation
Keywords: subjective examination, modifiable and non-modifiable factors,

patient’s motivation
WHEN AND HOW DID PAIN START?

In the majority of patients, between 80-90% (Selfe 2010, Selfe et al. 2016)
the onset of symptoms is insidious. A traumatic onset of PFP is more likely to
be associated with a poor outcome. According to Price, Jones and Allum
(2000) few patients with a traumatic onset will improve beyond 2 years and
improvement in symptoms beyond this time is considered unlikely. Traumatic
onset PFP also seems to be more associated with cold knees than insidious or
gradual onset PFP (see Chapter 4 for cold knees). If there has been any
twisting/pivoting or rapid acceleration/deceleration involved in the injury then
it is much less likely to be primarily a patellofemoral problem.
CURRENT PAIN
When discussing pain levels with PFP patients the two most useful
questions are
‘What is your current pain right now’

‘What has your usual or average level of pain been in the last week (7
days)’
The best method of recording the patient’s responses to these questions is

on an 11 point Numeric Pain Rating Scale (NPRS) where 0 is no pain and 10
is the worst pain imaginable. This is easy for patients to understand and does
Subjective Examination 23
not require any calculations by therapists to derive a score. The NPRS used in
this way also has the advantage of being able to be used over the telephone or
can easily be adapted for use on mobile and other electronic devices if
required.
WHERE IS THE PAIN?

Bilateral pain occurs in over 50% of patients (Selfe et al. 2001), in
bilateral cases it is common to find that one leg is worse than the other. Asking
patients where the pain is located is often not that helpful as typically patients
with PFP will describe a diffuse dull ache often interspersed with periods of
sharp pain somewhere in the vicinity of the patella. When asked to localise the
pain patients will often use a vague sweeping hand gesture around the anterior
knee and will be unable to put their finger on a specific painful area.
To highlight the variability in patient’s report of pain the following pain
locations were recorded from 119 knees in a group of PFP patients (Selfe et al.
2001).
 Intrapatellar 5%
 Suprapatellar 11%
 Infrapatellar 20%
 Medial 17%
 Lateral 20%
 Retropatellar 17%
 Popliteal fossa 10%
Referred pain, particularly to the lateral side of the knee, from proximal
structures such as the hip, lumbar spine and altered neural dynamics is also
fairly common and screening questions for these areas should therefore also be
routinely included in the subjective examination of PFP. Any reports of
generalised joint pain should also be investigated, Stathopulu and Baildam
(2003) reported that 45% of their PFP patients, for whom PFP was the first
recorded musculoskeletal problem, were later diagnosed with other arthritic
conditions (see Chapter 4 for Reactive Arthritis).
24 James Selfe
PREVIOUS HISTORY
PFP is often refractory to treatment and can persist for many months and
in some cases many years. Previous treatment is often reported by patients as
unsuccessful. Commonly patients will report that no one has ever have
managed to reproduce their pain during a clinical examination and that
previous physical testing was unable to demonstrate any abnormalities. If the
patient reports having undergone knee surgery this often increases the
likelihood of PFP due to inhibition of the quadriceps through either pain or
swelling. Many PFP patients will have had negative arthroscopies, paradoxically
this can sometimes cause an increase in pain, probably due to trauma of the fat
pad which is richly innervated (Eivazi and Selfe 2008). During arthroscopy
without intra-articular anaesthesia it has been reported that the infrapatellar fat
pad is exquisitely sensitive to mechanical loading (Dye, Vaupel, and Dye 1998).
LOCKING AND GIVING WAY

Reports of locking or giving way tend to suggest the problem is more
likely to be associated with internal tibiofemoral derangement due to a
meniscus or loose body, these types of problems are more common in older
age groups and associated with degenerative or traumatic processes. Very
rapid, transient, painful catching sensations are however fairly common in PFP
but these should be differentiated through careful questioning from true
locking and true giving way. According to Fulkerson and Hungerford (1990)
giving way associated with the patellofemoral joint tends to occur when
ascending stairs or walking down an incline. Whereas giving way associated
with ligamentous instability or meniscal lesions tends to occur during turning
or pivoting movements.
SITTING PAIN, NIGHT PAIN, STIFFNESS

Pain aggravated by prolonged sitting is variously termed ‘movie goer’s
knee’ or ‘the theatre sign’ and is quite common in PFP. The pain is probably
caused by a complex combination of raised intraosseous pressure and
decreased metabolite/nutrient exchange associated with static loading. A
similar mechanism is likely to occur during sleep if a foetal position is adopted
but with the additional factor that at night the body’s natural anti-
-inflammatories are at their lowest level. Knee joint stiffness is often
associated with sleep or prolonged sitting and may indicate an abnormality
within the cartilage or synovium, usually linked to an inflammatory process
(Macnicol and Steenbrugge 2012).
SWELLING
In addition to pain, there is often a low-grade effusion associated with
PFP. Spencer, Hayes, and Alexander (1984) found that 20mls of saline will
inhibit vastus medialis and 50/60mls will inhibit both rectus femoris and
vastus lateralis. Iles, Stokes, and Young (1990), suggest that any degree of
joint effusion will have an inhibitory effect on the quadriceps. This can have
profound effects on function and so any degree of minor swelling should be
actively treated. This phenomenon sometimes appears to occur at a subclinical
level where patients will report a sensation of swelling but none is found on
physical examination. Considering the knee joint is the largest synovial joint
cavity in humans and that very small amounts of swelling are capable of
significantly inhibiting the quadriceps this apparent mismatch between
subjective reporting and objective finding is unsurprising.
CREPITUS
Even in non-arthritic PFP, patients will often report a range of sounds and
sensations coming from their knee. Crepitus is graded as fine, medium or
coarse. According to Johnson et al. (1998) patellofemoral crepitus should be
considered a normal rather than a pathological finding in knee joint
assessments of females (see chapter 6). In a study of 100 healthy adult females
(mean age 47), with no lifetime history of any knee problems they found 94%
of subjects had crepitus. In comparison, in the same study they found only
45% of 110 healthy adult males (mean age 48), had crepitus. Macnicol and
Steenbrugge (2012) highlight that although crepitus is common it may provoke
considerable anxiety in some patients. With this in mind although crepitus is a
non-modifiable factor time needs to be taken to explain this to patients
carefully so that they can focus positively on rehabilitation strategies aimed at
reducing pain and increasing function which are both modifiable factors.
26 James Selfe
BODY WEIGHT
The subject of weight control can be a very sensitive one and problems
associated with weight control can be associated with other underlying
emotional problems so clinicians have to proceed carefully in this area. There
are two groups of patients that this is particularly pertinent for; the overweight
and the intensive sports player. When considering overweight patients the
magnitude of loading forces on the patellofemoral joint are going to be larger
than they should it is therefore important to consider weight loss and weight
maintenance strategies as part of the rehabilitation package. There often
emerges a ‘Catch 22’ situation as one of the keys to weight loss is exercise;
however, if prescribed carelessly this may aggravate patellofemoral symptoms.
Clinicians need to plan rehabilitation activities carefully in order not to
provoke the very problem for which the patient is seeking help (see chapter 7).
The intensive sports player presents a slightly different rehabilitation
challenge. The problem is often that they have a very high calorie intake which
is fine while they are playing a lot of sport. When they have an injury they are
unable to use as many calories but often their appetite is undiminished and
they maintain a very high calorie intake which means that their weight
increases. In terms of rehabilitation this can be problematic. Another reason
that weight may increase in this group of patients is due to ‘comfort eating’
which occurs due to depressed mood because of being unable to play sport and
boredom as ‘there is nothing else to do.’
ALTERED PATELLA TEMPERATURE

A history of elevated temperature is a Red Flag for possible serious
pathology associated with an inflammatory or infective process and such a
finding probably warrants further investigation or onward referral (Chapter 4).
A discussion of Cold Knees is also presented in Chapter 4, however here it is
relevant to present the questions used to identify those patients that may have a
Cold Knee (Selfe et al. 2010).
 Do you get night pain

 In winter do you use electric blankets/hot water bottles in bed
 Do your knees feel cold even on a warm day
 Does cold weather affect your knees
 Do you wear extra tights/long johns in winter

 Would you prefer a hot water bottle or ice pack on your knee
 Traumatic onset
The most interesting response is to the hot water bottle/ice pack question.
It is usually anticipated that the Cold Knee patients will politely request a hot
water bottle. What is surprising is that instead they very strongly and definitely
reject the ice pack with responses such as ‘Don’t you come near me with that
ice pack.’ See Chapter 4 for suggested interventions for this group of patients.
ATTITUDE, EXPECTATIONS AND EMOTIONS

Many patients have very high, sometimes unrealistic expectations of what
physiotherapy will be able to do for them i.e., present a ‘Magic Wand or
Magic Bullet’ that will cure their problem. Whilst on the one hand this can be
seen as a professional compliment, these expectations need to be managed
very carefully if frustration and disappointment are to be avoided. A key
question here is ‘What do you hope to gain from physiotherapy?’ It is
important from the outset to work in partnership with the patient in order to
establish realistic and achievable aims. One of the key areas of work is around
timescales. Whilst it is obvious to therapists that a condition that has taken 12
months or more to develop is not going to be resolved in one or two 30 minute
sessions of physiotherapy, patients often have a different perspective. In rare
cases there may deeper emotional problems in patients with PFP which might
require specialist multidisciplinary input, warning signs for these include;
 Unwilling to weight bear yet joint compression painless

 Frequent report of knee giving way despite being structurally intact
 Persistent inappropriate use of walking aid
 Reports of swelling/bruising post treatment but none present at next
appointment
 Patient unable to self-care e.g., feeding or washing due to severity of
knee problem
 Over emphasis of minor joint clicking
 Report of painful restricted flexion yet able to sit pain free during
assessment
28 James Selfe
Patients may express frustration at all sorts of things such as being unable
to perform their job to the best of their ability or participate in sports or leisure
pursuits at the level they wish. It is important that even in relatively minor
musculoskeletal conditions such as PFP that the patient is treated holistically
and that a biopsychosocial approach is adopted (World Health Organization
2013).
SUMMARY
As with most musculoskeletal conditions the subjective examination is
probably more important than the objective examination. It allows the
therapist to gain a good insight into the potential causes of the presenting
problem reassuring both patient and therapist that the causes are not related to
serious pathology. It should also give the therapist a clear vision into the
patient’s world i.e., what has motivated them to seek help and what their
expectations of physiotherapy are. As discussed in the introduction patients
with PFP may be affected across all 3 domains of the ICF and so the
subjective needs to explore these thoroughly as this will help form the
foundation for a positive and successful therapeutic relationship.
REFERENCES
Callaghan, M., Selfe, J., and Dey, P. 2009. "Activity-associated pain in
patellofemoral pain syndrome: how does it inform research and practice?"
Physiotherapy 95 (4):321-2.
Dye, S. F., Vaupel, G. L., and Dye, C. C. 1998. "Conscious neurosensory
mapping of the internal structures of the human knee without intraarticular
anesthesia." American Journal of Sports Medicine 26 (6):773-7.
Eivazi, M. G., and Selfe, J. 2008. "Infrapatellar fat pad lesions: Theoretical
considerations and practical implications." Physical Therapy Reviews 13
(1):11-16.
Fulkerson, J, and Hungerford, D. 1990. "Chapter 11, Reflex Sympathetic
Dystrophy and Chronic Pain." In Disorders of the patellofmoral joint.
Baltimore: Williams and Wilkins.
Iles, J. F., Stokes, M., and Young, A. 1990. "Reflex actions of knee joint
afferents during contraction of the human quadriceps." Clinical
Physiology 10 (5):489-500.
Johnson, L. L., van Dyk, G. E., Green, J. R., 3rd, Pittsley, A. W., Bays, B.,
Gully, S. M., and Phillips, J. M. 1998. "Clinical assessment of
asymptomatic knees: comparison of men and women." Arthroscopy 14
(4):347-59.
Macnicol, M, and Steenbrugge, F. 2012. The problem knee. 3rd ed. London:
Hodder Arnold.
pain." Injury 31 (5):373-8.
Selfe, J. 2010. "Patellofemoral pain: myths; truths; future directions."
Physiotherapy Ireland 31 (2):16-18.
Selfe, J., Harper, L., Pedersen, I., Breen-Turner, J., and Waring, J. 2001. "Four
Outcome Measures for Patellofemoral Joint Problems: Part 1
Development and validity." Physiotherapy 87 (10):507-515.
women." The Knee 17 (5):319-23.
Spencer, J. D., Hayes, K. C., and Alexander, I. J. 1984. "Knee joint effusion
and quadriceps reflex inhibition in man." Archives of Physical Medicine
and Rehabilitation 65 (4):171-7.
Stathopulu, E., and Baildam, E. 2003. "Anterior knee pain: a long-term follow-
up." Rheumatology (Oxford) 42 (2):380-2.
World Health Organization. 2013. "How to use the ICF: A practical manual
for using the International Classification of Functioning, Disability and
Health (ICF). Exposure draft for comment." WHO.
Chapter 4
RED FLAGS AND RARE PATHOLOGIES *
James Selfe
Manchester Metropolitan University, Manchester, UK
INTRODUCTION
Red Flags represent warning signs associated with serious pathology,
however serious pathology is not a single condition; it is a group of highly
heterogeneous conditions arising from different organ systems which are
associated with a wide diversity of symptoms (Lyratzopoulos, Wardle, and
Rubin 2014) (Table 4.1). Southerst, Dufton, and Stern (2012) report that well-
known Red Flags such as, previous history of cancer, no relief with rest, and
constitutional symptoms such as unexpected weight loss, fever, and fatigue
individually have high specificity but low sensitivity. Combinations of Red
Flags are therefore much more helpful; however, more work is needed to
evaluate sensitivity and specificity of such combinations to evaluate their
strength (Southerst, Dufton, and Stern 2012). Currently Red Flags individually
or in combination should be viewed as useful clinical sign posts to raise the
index of suspicion as to the possibility of the presence of serious pathology;
Red Flags would generally fail if they were used as binary classification tests
within a classical diagnostic testing process. It is reassuring that malignancy is
*
Images kindly supplied by Waqar Bhatti, Department of Radiology, University Hospital South
Manchester NHS Trust, Manchester, UK.
32 James Selfe
a rare finding at the knee but should be considered, especially in the elderly
and in those with unremitting pain (Chapman 2000).
Table 4.1. Red Flags for the knee (NICE, Chapman 2000)
Red Flags Possible pathology

 Hot (calor) Infection (septic arthritis)
 Painful (dolor) (Pain at night or at rest)
 Red (rubor) specific risk factors for joint
 Swollen (tumour) appeared acutely, infection include
over less than 24 hours  Recent knee surgery
 Fever  Rheumatoid arthritis
 Nausea  Intravenous drug use
 Vomiting  Immunosuppression, e.g.,
 Systemically unwell diabetes, use of long-term
 Loss of appetite corticosteroids, alcoholism
 Absence of trauma  Septicaemia
 Bone pain, Tumour
 Increasing, persistent, or unexplained,
tenderness, or swelling, especially if it
is not in the knee joint itself but
adjacent to the knee
 Pain at night or at rest
 Unexplained weight loss
 Previous history of cancer
 Sudden onset of pain (may indicate a
pathological fracture, but can also
occur in osteonecrosis)
 In adults, any palpable lump that is
any of the following
- larger than about 5 cm in diameter
- deep to fascia
- fixed or immobile
- painful
- increasing in size (possible soft
tissue sarcoma)
Red Flags and Rare Pathologies 33
Red Flags Possible pathology

 Persistent synovitis Inflammatory polyarthritis
 Pain that is worse at rest or during
periods of inactivity.
 Joint swelling, tenderness, and warmth
— giving a 'boggy' feel on palpation.
 Stiffness in the morning and after
inactivity that lasts more than 30
minutes
 Synovitis affecting other joints —
symmetrical synovitis of the small
joints of the hands and feet is typical
in rheumatoid arthritis.
 A history of psoriasis, inflammatory
bowel disease, or iritis (uveitis).
 Shoulder stiffness and/or pain Polymyalgia Rheumatica
 Pelvic girdle stiffness and/or pain Temporal Arteritis
 Headache
 Scalp tenderness
The following conditions although classified as serious pathology are not

considered in this chapter as they generally lie outside the target age range of
young adults, aged 18-40, which this book is specifically focussing on
 Osgood-Schlatter (11-14 year olds. Male: Female ratio = 3:1)

 Sinding-Larsen-Johansson syndrome (9-14 year olds)
 Sleeve fracture (12-13 year olds)
 Epiphyseal injury (Male: Female ratio = 2:1)
 Slipped Capital Femoral Epiphysis (SCFE), (11-17 year olds)
Keywords: red flags, serious pathology, clinical vigilance
OSTEOCHONDRITIS DESSICANS
Estimated Incidence
Osteochondritis Dessicans occurs in 2 per 1000 of the population and

affects males two or three times more commonly than females (Macnicol and
34 James Selfe
Steenbrugge 2012). It occurs more regularly in adolescents and patients who

are very athletically active (Brier 1999).
What Is It?
A condition in which a segment of articular cartilage and subchondral

bone become fragmented and potentially displaced from the underlying bone
these can form loose bodies within the knee causing locking (Figures 4.1, 4.2,
4.3). The exact aetiology is unclear, however, possible causes have been cited
as ischaemia, repetitive microtrauma, genetic predisposition and endocrine
disorders associated with epiphyseal abnormalities (Tejwani, Ellerman, and Fu
2012). There can be a spectrum of disorders seen from articular cartilage,
articular cartilage to bone interface or more typically osteochondral lesions
involving both the cartilage and bone. The lateral aspect of the medial femoral
condyle is the most commonly affected site, followed by the lateral femoral
condyle and rarely the patella. Estimates vary that between 20-30% of cases
will develop the condition bilaterally (Tejwani, Ellerman, and Fu 2012).
Although not commonly discussed in the literature the condition may be prone
to recurrence (Davin and Selfe 2006).
Figure 4.1. Sagittal MRI: Osteochondritis along the lateral femoral trochlear groove.
Figure 4.2. Coronal MRI: Osteochondritis along the medial femoral condyle.
Figure 4.3. Sagittal MRI: Osteochondral defect along the medial femoral condyle and
detached loose body within the suprapatellar pouch.
36 James Selfe
What Could Be Confusing?

The onset of symptoms is usually insidious and symptoms are non-
specific (Davin and Selfe 2006, Brier 1999), sometimes occurring with
variable activity related effusion (Tejwani, Ellerman, and Fu 2012). Presenting
symptoms and early positive responses to treatment may be very misleading
and indicative of dysfunction in structures that are not actually responsible for
the complaint (Davin and Selfe 2006). For example in a published case study
(Davin and Selfe 2006) of a professional footballer the objective assessment of
the tibiofemoral joint gave no comparable signs and the player was diagnosed
to have a patellofemoral problem. Subsequent physiotherapy treatment of the
patellofemoral joint had a very positive effect on the symptoms and the patient
successfully completed two consecutive training sessions pain free prior to the
symptoms recurring. You should remember that in suspected cases of cases of
Osteochondritis Dessicans it is not possible, clinically, to attribute signs
specifically to the medial femoral condyle even with compression or active
loading (Davin and Selfe 2006). In the later stages of the condition patients
may present with mechanical symptoms due to unstable or displaced
fragments forming loose bodies (Tejwani, Ellerman, and Fu 2012).
Treatment/Intervention
Skeletal maturity is a significant prognostic indicator of healing. Younger
patients with metabolically active bone tend to have a better prognosis
compared to older patients with closed growth plates and decreased metabolic
bone activity (Tejwani, Ellerman, and Fu 2012). In adults the condition often
heals poorly with the onset of osteoarthritis being hastened by approximately
10 years (Macnicol and Steenbrugge 2012). A wide variety of surgical
procedures are described which include drilling, microfracture and cell
implants.
Conservative management usually consists of
 Weight control
 Activity modification
 Reduced weight bearing (possibly using crutches)
 Ice may help to relieve pain
 Stretching
 Proprioception
 Isometric strengthening exercises
Assessment/Diagnostic Tests
MRI is the imaging modality of choice when considering a diagnosis of

Osteochondritis Dessicans.
COMPLEX REGIONAL PAIN SYNDROME (CRPS)

(REFLEX SYMPATHETIC DYSTROPHY - RSD)
Estimated Incidence
Precise estimates are very hard to find however, Katz and Hungerford
(1987) report that 65% of complex regional pain syndrome (CRPS) at the knee
originates from the patellofemoral joint. The same authors go on to report that
following 700 consecutive total knee replacements there were 5 recorded cases
of CRPS which was a more common cause of complication than infection.
Macnicol and Steenbrugge (2012) report there is an important gender bias with
females being 6 times more likely to develop CRPS than males. Most cases are
preceded by some sort of trauma.
What Is It?
The condition is characterised by unprecedented levels of spontaneous

pain which initially leads to muscle wasting and joint stiffness. This very
severe pain is associated with skin hyperesthesia and the pain often interferes
with gait and disturbs sleep (Fulkerson and Hungerford 1990). The skin often
displays characteristic changes which include appearing mottled and blue and
often feeling waxy or cold or swollen when palpated (Macnicol and
Steenbrugge 2012). Changes within the bone marrow can develop and these
can appear as spotty high signal change within the bone marrow (Figure 4.4).
It is thought that efferent autonomic stimulation causes a vicious cycle of
vasomotor instability which leads to these changes (Fulkerson and Hungerford
1990).
38 James Selfe
Figure 4.4. Axial MRI scans six months apart showing spotty marrow signal change
post-trauma. This finding is non-specific and can be seen with disuse and CRPS.
CRPS occurs across a wide spectrum of severity, there is no specific

diagnostic test, however a history of recent trauma to the knee associated with
what appears to be a disproportionate pain response and skin hyperesthesia,
should alert clinicians to the possibility of CRPS. Serious pathology should be
ruled out, generally this can be through the use of axial x-ray which shows the
characteristic osteoporotic changes of CRPS, which take on a microcystic
appearance.
‘Gentleness and persistence are the key factors.’

(Fulkerson and Hungerford 1990)
For this group of patients and the cold knee patients presented in the next
section there is simply no better description of the treatment approach you
need. Activity modification may be required. In younger patients there may be
an excessive level of activity which needs to be reduced to prevent overload
physically and emotionally. In older patients a very gently graded exercise
progression is required similar to that described for the cold knees in the next
section. In CRPS there would be more emphasis on encouraging gentle weight
bearing exercises especially walking due to the additional complication of

osteoporosis. Desensitisation techniques are also required (see chapter 2).
Finally to emphasise the quote from Fulkerson and Hungerford (1990)
which started this section here is a quote from a 56 year old female patient
suffering from patella CRPS. She had previously spent a lot of time and
money travelling to some of the top knee clinics around the world.
‘I really want to thank you because you are the first person to look at my
knee who didn’t make it worse.’
Following a gentle graded exercise programme at 3 months she was able
to starting very gentle jogging which had been one of her main treatment
goals.
COLD KNEES
Estimated Incidence
Sandow and Goodfellow (1985) reported that 17% (n=9) of a sample of

adolescent females had pain that was aggravated by cold weather at an average
follow up of 4 years. Price, Jones, and Allum (2000) reported that 61% of
patients with chronic traumatic anterior knee pain had pain that was
aggravated by cold weather. Selfe et al. (2003) found 18% (n=14) patients
were classed as cold sufferers at initial assessment using therapist palpation.
Later using thermal imaging Selfe et al. (2010) found that 36% (n=21) of
patients had significantly colder knees, that this was more common in females,
associated with a significantly smaller patella skin fold, lower levels of activity
and worse pain and dysfunction scores on the Modified Functional Index
Questionnaire (MFIQ).
What Is It?
It is speculated that cold knees may be part of the CRPS spectrum of

disorders (Selfe et al. 2010). A number of investigators have suggested that
PFP may be induced by ischemia in some patients (Arnoldi 1991, Sanchis-
Alfonso and Rosello-Sastre 2003, Naslund, Walden, and Lindberg 2007).
From anatomical and biomechanical perspectives, the vessels of both the
arterial supply and venous drainage of the patella are anterior to the axis of
40 James Selfe
knee flexion. Therefore, it is possible that during flexion activities these

vessels will be subjected to stress, vascular torsion or bending which could
lead to intermittent ischaemia and hypoxia. Clinically this intermittent
ischaemia may manifest as cold and painful knees.
Currently there is no standardised clinical test for classifying patients as

having a cold knee. Attempts have been made to use thermal imaging but this
is generally too expensive for routine clinical use (Selfe et al. 2010). More
recently low cost hand held digital thermometers have been trialled
investigating a thermal index between the centre of the patella and the tibialis
anterior (Selfe et al. 2013). Preliminary unpublished PhD data suggest a lower
patella temperature difference of 6 degrees Celsius or more compared to the
tibialis anterior may be clinically important.
Suggested interventions for ‘cold’ PFP patients (Selfe 2010).

Active exercise
 Non-weight bearing range of motion exercises e.g., Cycle ergometer

on low resistance
 Gentle hydrotherapy – not swimming
 Proprioceptive exercises
 Very gradual and controlled progression onto weight bearing
exercises using a generalised functional lower limb approach e.g.,
walking on a treadmill
Passive modalities
 TubigripTM/neoprene type knee sleeves for warmth and proprioceptive

effects rather than mechanical support (ensure correct fitting to avoid
excessive compression)
 Gentle heat
 Acupuncture (Tootill et al. 2011)
Advice/counselling
 Advice about fluid intake, mild dehydration can decrease peripheral
blood flow
 Stress relief/counselling
Additionally specific desensitisation techniques are also required (see

Chapter 2).
PLICA SYNDROME
Estimated Incidence
Plicae are estimated to persist into adulthood in approximately 20% of

people (Solomon and Karachalios 2010), and are present in autopsies in 25-
33% of knees (Tejwani, Ellerman, and Fu 2012). It is unknown how many
people suffer from plica syndrome but it is reported as common in young
adults (Tejwani, Ellerman, and Fu 2012).
What Is It?
The plicae are 3 embryonic folds of synovial membrane that divide the
knee joint into separate compartments; by approximately the 12 week of intra-
uterine life they have usually been absorbed leaving a single joint cavity
(Solomon and Karachalios 2010). Pain can occur if the medial plica (Figure
4.5) becomes fibrotic, thickened and inflamed and then rubs against the
femoral condyle (Macnicol and Steenbrugge 2012, Tejwani, Ellerman, and Fu
2012). Aggravating factors include, trauma, repetitive activity and kneeling
(Tejwani, Ellerman, and Fu 2012).
Clinical findings can mimic medial meniscus tear, chondral injury or

patellar instability (Tejwani, Ellerman, and Fu 2012). The subjective
examination of patients with plica syndrome is often very similar to that of
other cases of PFP. One thing that is unusual is the report of a popping
42 James Selfe
sensation often first thing in the morning (Amatuzzi, Fazzi, and Varella 1990).
Whilst a lot of PFP patients complain of a fascinating variety of grinding,
grating, clicking and creaking sensations broadly in line with varying grades of
crepitus, popping is not a commonly reported sensation. Patients may also
report a confusing picture of typical PFP related signs such as pain on
prolonged sitting combined with non-PFP symptoms such as true giving way.
Palpation may reveal a thickened painful band of tissue medial near the
tibiofemoral joint line medial to the medial border of the patella. In cases of
inflamed medial plica a medially directed McConnell taping technique to the
patella will usually result in an acute exacerbation of pain due to the increased
pressure on the inflamed synovial tissue. A marked increase in pain in
response to this type of taping technique is of course quite the opposite of
therapeutic expectation and so needs careful consideration. MRI and
arthroscopy can aid diagnosis.
Figure 4.5. Axial MRI showing an incidental non thickened medial synovial plica.
 Activity modification i.e., reduction to decrease repetitive loading on

the inflamed structures (Solomon and Karachalios 2010).
 Local cryotherapy - Ice
 Anti-inflammatories (Solomon and Karachalios 2010).
 In recalcitrant cases the plica can be divided or removed
arthroscopically (Solomon and Karachalios 2010).
REACTIVE ARTHRITIS (REITER’S SYNDROME)

Estimated Incidence
Reactive arthritis can occur at any age, but it most commonly affects
young adults aged 20-40. Men are generally affected more than women,
particularly in cases linked to Sexually Transmitted Infections (STIs), which
are estimated to be about 10 times more common in men (NHS Choices 2015).
What Is It?
Reactive arthritis usually develops within four weeks of an infection,

typically after a STI such as chlamydia, or a bowel infection. Joint pain,
tenderness and swelling occurs usually in weight-bearing joints such as knees,
feet and ankles. Joint stiffness is common particularly in the morning. There
may also be low back and buttock pain along with swelling of the fingers and
toes (NHS Choices 2015).
There is no single test for reactive arthritis, although blood and urine tests,
genital swabs and X-rays may be used to check for infection and rule out other
causes of symptoms. During the subjective examination it is important you
clarify if swollen and painful joints have been preceded by recent episodes of
diarrhoea or problems passing urine. Reactive arthritis can sometimes involve
inflammation of the urethra (non-gonococcal urethritis). Symptoms of
44 James Selfe
urethritis can include: pain or a burning sensation during micturition, urinating

more often than usual, having a sudden urge to urinate, discharge from the
penis or vagina, and less commonly blood in the urine. Reactive arthritis may
also involve conjunctivitis. Symptoms of conjunctivitis can include: itchy, red,
watery eyes, eye pain and swollen eye lids. In rare cases, iritis can develop
where the eyes become painful, red and sensitive to light. Other symptoms of
reactive arthritis include: malaise, fever, weight loss, mouth ulcers, thick and
crumbly nails, abdominal pain with or without bouts of diarrhoea (NHS
Choices 2015).
There is currently no cure for reactive arthritis, but most people get better
in approximately six months. Treatment using non-steroidal anti-inflammatory
drugs (NSAIDs) and simple painkillers can help to relieve symptoms such as
pain and stiffness. Severe symptoms may require corticosteroids or disease-
modifying anti-rheumatic drugs (DMARDs) (NHS Choices 2015).
BONE TUMOURS
Bone tumours around the knee account for between 20-25% of all skeletal
primary neoplasias (see Table 4.2). Benign lesions tend to be small and well
marginated with no soft tissue mass adjoining them (Macnicol and
Steenbrugge 2012). Non-mechanical bone pain and night pain are significant
Red Flags for cancer and require appropriate investigation especially in
younger adults aged less than 20 (Manghan and Cool 2012). Any patient with
unremitting pain or atypical symptoms with no history of trauma associated
with systemic symptoms such as weight loss and malaise should also raise the
index of suspicion that serious pathology may be present (Manghan and Cool
2012). Progressive swelling and tenderness of either the tibia or femur should
also cause concern (Macnicol and Steenbrugge 2012). It is important to look
beyond the knee joint in the assessment of knee pain. Tumours can often be
detected in the metadiaphyseal region of the bone and it is wise to look at the
planning scout views to exclude such conditions (Figure 4.6).
Table 4.2. Cancer around the knee

(Manghan and Cool 2012)
Cancer type % of total Age range Gender Clinical signs

occurrence predominantly ratio M:F
around the affected
knee
Aneurysmal Bone 45% <20years 5:4  Painful bony
Cyst swelling
 Occasional
pathological
fracture
Chondroblastoma 35% 10-20 years 3:2  Persistent long
(Benign tumour) standing joint pain
 Effusion
Osteochondroma 35% 10-20 years 2:1  Can be
(Most common asymptomatic and
primary bone found incidentally
tumour)  Swelling
 Neurovascular
obstruction
 Bursitis
 Fracture
Osteosarcoma 60% 10-30 years 2:1  Pain (night pain or
(Most common non-mechanical
primary malignant bone pain)
bone tumour)  Swelling
 Palpable mass or
effusion
Parosteal 80% 10-40 4:5  Painless swelling
osteosarcoma
Malignant fibrous 40% 20-70 3:2  Pain
histiocytoma Peak incidence  Swelling
5th & 6th  Pathological
decades fracture
46 James Selfe
Figure 4.6. Coronal MRI: showing an aneurysmal bone cyst within the distal
femoral metadiaphyseal region.
CONCLUSION
Serious pathology at the knee is rare. However, you should remain
vigilant to this possibility, as PFP is diagnosis of exclusion typically associated
with vague signs and symptoms, which are also associated with early stage
serious pathologies.
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Selfe, J. 2010. "Patellofemoral pain: myths; truths; future directions."

Physiotherapy Ireland 31 (2):16-18.
Selfe, J., Callaghan, M., Witvrouw, E., Richards, J., Dey, M. P., Sutton, C.,
Dixon, J., Martin, D., Stokes, M., Janssen, J., Ritchie, E., and Turner, D.
2013. "Targeted interventions for patellofemoral pain syndrome (TIPPS):
classification of clinical subgroups." British Medical Journal Open 3
(9):e003795.
Selfe, J., Harper, L., Pedersen, I., Breen-Turner, J., Waring, J., and Stevens, D.
2003. "Cold legs: a potential indicator of negative outcome in the
rehabilitation of patients with patellofemoral pain syndrome." The Knee
10 (2):139-43.
women." The Knee 17 (5):319-23.
Solomon, L, and Karachalios, K. 2010. "Chapter 20: The Knee." In Apley's
System of Orthopaedics and Fractures, edited by L. Solomon, D.
Warwick and S. Nayagam. London: Hodder Arnold.
Southerst, D., Dufton, J., and Stern, P. 2012. "Multiple Myeloma presenting as
sacroiliac joint pain: a case report." The Journal of the Canadian
Chiropractic Association 56 (2):94-101.
Tejwani, S., Ellerman, J., and Fu, F. 2012. "Chapter 76: Diagnosis of non-
ligamentous knee injuries." In Mercers Textbook of Orthopaedics and
Trauma, edited by S. Sivanthum, E. Sherry, P. Warnke and D. Miller.
London: Hodder Arnold.
Tootill, I., Hayes, C., Hardaker, N., and Selfe, J. 2011. "Acupuncture for
the treatment of Patellofemoral Pain: A Single Case Experiment with an
ABA design." Journal of the Acupuncture Association of the CSP
Autumn: 99-103.
Chapter 5
CLINICAL BIOMECHANICS ASSESSMENT

FOR PATELLOFEMORAL PAIN
Jim Richards, PhD

Allied Health Research unit,
University of Central Lancashire, Preston, UK
INTRODUCTION
The patellofemoral joint must support large forces and control complex
movements during sporting activities and activities of daily living. The
capacity of the patellofemoral joint to function under these loads and
movements may be affected in a number of ways in people with
patellofemoral pain (PFP). A good understanding of the anatomy and
biomechanics of the patellofemoral joint is therefore important for clinicians
who wish to assess and treat this condition. This chapter covers the
biomechanical factors that have been associated with PFP and what we can
learn from these when considering its treatment and assessment.
Keywords: clinical biomechanics, muscle strength, stability, proprioception

50 Jim Richards
ANATOMY
The patellofemoral joint, put simply, is the articulation between the
underside of the patella and the trochlea at the distal end of the femur. Like all
joints, the surrounding soft tissues contribute to the articulation which include
the medial and lateral retinacula, the patellofemoral ligaments, the infrapatellar
(Hoffa’s) fat pad and, perhaps more than any other joint, the muscular
anatomy and the roles of the vastii. This book will not describe in detail the
anatomy of the patellofemoral joint, as this can easily be revised using the
standard textbooks and online references. However, you need to be aware of
some anatomical controversies which are pertinent to the patellofemoral joint.
One of the major controversies in patellofemoral anatomy is whether vastus
medialis (VM) can truly be subdivided into oblique (VMO) and longus (VML)
fibres based on the orientation of the muscles (Smith et al. 2009). The same is
also true for the vastus lateralis (VL) even though many anatomy textbook do
not recognise the differentiation of VL into oblique and long fibres (Vieira
2011). Although these anatomical distinctions are interesting and have created
much debate, it is still uncertain whether VMO and VML can be selectively
recruited and strengthened, whether they contribute differently to the function
of the knee or patellofemoral joint and whether they should be regarded
separately in the treatment of PFP. Another controversy is the role of the
infrapatellar (Hoffa’s) fat pad which is a large, deformable pad of adipose
tissue occupying the space between the patella, tibia and femur. For many
years this tissue was regarded as being of little importance for the knee joint.
But the fat pad is vascular and its surface is covered with highly innervated
synovial membrane and is a source of pain (Swan and Mercer 2005). It
articulates with the articular cartilage of the trochlea. The fat pad may have an
important function as a shock absorber and we also know a totally or partially
resected or even inflamed fat pad inadvertently changes patellar biomechanics
(Bohnsack et al. 2004, Bohnsack et al. 2009).
PATELLOFEMORAL JOINT FORCES

Background
Knee flexion moments are the main factor for loading on the
patellofemoral joint. These are significantly greater for closed kinetic chain
Clinical Biomechanics Assessment for Patellofemoral Pain 51
tasks involving larger knee flexion angles. For example, during stair descent
the flexion moment is nearly three times greater than stair ascent (Andriacchi
et al. 1980). For many closed kinetic chain eccentric tasks, the stance knee
starts in a relatively stable extended position and progressively moves into a
more unstable position of flexion, as controlled lowering takes place. This has
the effect of increasing the patellofemoral contact forces and pressures.
Moving into a more unstable position also requires a progressive increase in
eccentric muscular control. It is important to consider the role of the patella in
the extensor mechanism and the contact zones on the patella as the knee
moves into flexion. When moving from full extension to full flexion discrete
parts of the patella articulate with the femur, these are referred to as contact
zones. Patella contact zones have a horizontal orientation which are spread
over approximately one third of the articular surface of the patella. The contact
area move proximally towards the superior pole or base of the patella as the
knee moves from extension into flexion (Fulkerson and Hungerford 1990).
The resulting force and pressure are referred to as patellofemoral contact force
and patellofemoral contact pressure which may be estimated using the
equations and models presented by Ward and Powers (2004).
So What Does This Tell Us?
The link between knee flexion angle, knee flexion moment, patellofemoral
contact force and patellofemoral contact pressure has been used to explain the
presence of PFP in active and athletic populations (Bonacci et al. 2014). As
the knee flexion angle increases, the knee flexion moment also increases,
resulting in a greater patellofemoral contact force or patellofemoral joint
reaction force. Figure 5.1 shows someone at two different stages of a step
descent, firstly at the point where all the weight has just been transferred to the
stance limb and secondly at the point just before the swing limb makes contact
with the step below. Initially the flexion angle and moment are small resulting
in a low quadriceps, patella tendon force and patellofemoral joint reaction
force; as the person moves into greater knee flexion the moment, quadriceps
force, patella tendon force and patellofemoral joint reaction force all increase.
The patellofemoral contact pressure, or patellofemoral joint stress, depends on
the contact force and the patellofemoral contact area at the different knee
flexion angles. However, calculations of patellofemoral joint reaction force
and patellofemoral contact pressure generally only consider the sagittal plane
52 Jim Richards
forces and moments and the complexity of the effect of coronal plane and
transverse plane moments have yet to be fully explored.
Figure 5.1. Knee flexion moment, quadriceps force, patella tendon force patellofemoral
joint reaction force during a step down task.
Such loads are not just restricted to tasks such as stair descent. During
more high-risk sporting manoeuvres such as running, cutting, jumping and
landing the knee flexion moments are significantly higher leading to higher
patellofemoral contact forces and pressures. These, coupled with cumulative
loading, are a significant risk factor for tissue overload and onset of PFP in
sporting populations. This is highlighted by the fact that PFP is the most
common chronic injury in recreational runners, which is characterized by pain
and linked to the contact of the posterior surface of the patella with the femur
(Besier et al. 2005). The effect of shock absorbing insoles has been explored to
determine if it is possible to change the forces acting at the foot and to see its
effect at the knee. Sinclair, Isherwood, and Taylor (2014) found that the peak
knee flexion moment, patellofemoral contact force and patellofemoral contact
pressure were significantly reduced when running with orthoses. For a more
detailed description on the assessment and prescription of foot orthoses see

Chapter 10.
MUSCLE STRENGTH AND POWER

Background
There are several ways of assessing muscle strength and joint power, these
vary from the use of isokinetic machines to hand held dynamometers.
Isokinetic machines, such as the Cybex or Biodex allow an assessment of joint
moments, commonly referred to as torque, and power. This includes the
assessment of concentric, eccentric and isometric muscle actions, however due
to cost these are largely restricted to scientific assessment (Richards 2008).
There is growing literature on the clinical use of hand held dynamometers
(HHDs), these are significantly lower in cost and easier to use in clinical
environments. These can be used to collect isometric joint moments, which
directly relate to muscle strength in a given joint position, although to achieve
reliable data it is very important to consider the positioning and stability of the
HHD. Figure 5.2 shows the assessment of the knee extensor and hip abductors,
where measures of the maximum force exerted and the position of the force
from proximal joint are recorded to calculate the moment.
Figure 5.2a. Measurement of knee extensor moment.

54 Jim Richards
Figure 5.2b. Measurement of hip abductor moment.
Assessment of strength associated with PFP has generally focussed on

knee extensor, hip abductor and hip external rotator moments (Ireland et al.
2003, Boling et al. 2009, Selfe et al. 2016). Previous work has found
significantly weaker hip abductor, knee extensor and hip external rotator
strength (Boling et al. 2009, Ireland et al. 2003). More recently the presence of
weaker hip abductor and knee extensor strength has been shown to be a key
measure to determine different subgroups in people with PFP (Selfe et al.
2016). The mechanisms for these factors being related to PFP can be explained
by considering the interaction of the hip and tibiofemoral joint positions on the
patellofemoral joint. Knee extensor strength, in particular VM, has been
suggested as an important factor in patella tracking either to ensure a stable
tibiofemoral joint or to alter the patella position. Whereas a weakness in the
hip abductors could lead to an increase in femoral adduction which allows
dynamic valgus collapse which in turn is believed to increase the lateral force
acting on the patella (Dierks et al. 2008). Similarly, a weakness in the hip
external rotators could lead to an increase in femoral internal rotation which
would theoretically increase the contact pressure between the lateral femoral
condyle and the lateral facet of the patella (Powers 2003). For a detailed
description of common exercises for PFP see chapter 7.
POSTURAL ALIGNMENT AND DYNAMIC MALALIGNMENT

Background
Postural alignment and dynamic malalignment have been identified as risk

factors in the development of PFP. Noehren et al. (2012) observed that female
runners with PFP had greater tibial internal rotation compared with healthy
controls. In addition, Richards et al. (2015) reported that patients with PFP had
50% greater knee varus/valgus range of motion of the tibiofemoral joint than
healthy individuals during a step down task. One of the current areas of
interest is the use of proprioceptive interventions to improve dynamic
alignment through improvements in neuromuscular control. This includes an
understanding of joint control and stability during slower eccentric tasks and
more dynamic tasks. Improvements in control in tibiofemoral varus/valgus and
internal/external rotation movement have previously been demonstrated with
taping and soft bracing (Selfe et al. 2008, Selfe et al. 2011). This in turn has
been shown to change the motor unit firing in subjects with knee pain when
using therapeutic taping (Richards and Selfe 2012). The interaction of the
motor unit firing rate, common drive and motor unit recruitment presents a
variety of responses amongst individuals, potentially offering a range of
control solutions within the muscle (Lindley 2015). Changes in neuromuscular
control provides important evidence which supports the possible
proprioceptive and mechanoreceptive effects of treatments and their role in the
management of people with PFP who have poor control/knee instability. These
changes in neuromuscular control have been further supported by changes in
brain activity in the areas associated with the planning of complex
coordination tasks and unconscious aspects of proprioception when using
bracing and taping techniques (Thijs et al. 2010, Callaghan and Selfe 2012).
It is very hard to measure the movement of the patella during activities of

daily living, so much of the research conducted has considered the
tibiofemoral joint and not the patellofemoral joint. Improvements in
56 Jim Richards
varus/valgus and internal/external tibiofemoral joint stability can be achieved

through changes in neuromuscular control with proprioceptive interventions.
Such underlying control mechanisms may consequently adjust the muscle
forces and joint control which offers a tantalising glimpse into the internal
neuromuscular control mechanisms and the resulting biomechanical effect. As
with the theoretical approach to muscle strength, improvements in tibiofemoral
control may in turn allow the patella to track more effectively in the femoral
trochlear groove and therefore reduce patellofemoral contact forces and
pressures. This has been described as the ‘train on track’ analogy.
Over the last 30 years there has been considerable interest in different
conservative treatments for knee instability and a body of evidence has
emerged that confirm that low cost treatments such as taping and soft bracing
are effective at relieving pain. There is an ongoing debate about whether these
effects are mediated by enhancing proprioceptive mechanisms through
cutaneous receptors and whether these effects are sufficient to change the
neuromuscular control of joints. However, the biomechanical findings are in
general agreement with perceptions of improvement in joint stability and
reductions in pain, although the effects of bracing and taping might only be
beneficial to a subgroup of people with PFP with poor proprioception
(Callaghan et al. 2008), or poor stability.
BIOFEEDBACK AND FUTURE CLINICAL

ASSESSMENT TOOLS
EMG biofeedback provides immediate feedback to the patient and the
therapist about the level of muscle activation. EMG biofeedback training is
usually focussed on VM and VL with the view to selectively strengthening one
or other or both of these muscles with the view to improving medial-lateral
tracking of the patella in people with PFP. One example of this was the use of
biofeedback over an 8 week training programme where significant changes
were seen in the ratio between VM and VL which indicates that the use of
EMG biofeedback into physiotherapy exercise programmes can facilitate the
targeted activation of VM during daily activities (Ng, Zhang, and Li 2008).
Using three-dimensional motion analysis and biomechanical models it is now

possible to measure and assess the movements of joints in the sagittal, coronal
and transverse planes. These can be displayed alongside an avatar in real time
which can be used as biofeedback, however due to the high cost and the
complexity of this, this is beyond almost all clinical settings. It is possible to
conduct a video assessment of the movement of the knee with digital cameras
such as those that are readily available on a camera phone. This can be a useful
feedback tool for the patient and a record for the clinician. Reasonable
estimates of knee flexion and extension can be obtained. To do this the camera
should be positioned at right angles to the patient in the sagittal plane at the
same height as the knee, however the use of such video assessment can
produce substantial errors when trying to assess varus/valgus and
internal/external rotation movement of the knee and hip. It may be possible to
get an acceptable representation of varus/valgus movement over small
amounts of knee flexion with careful camera placement, however as the knee
angle increases these errors increase significantly. If a video analysis of
varus/valgus movement is required then the camera should be pointed directly
at the front of the knee in the coronal plane and the height should again be set
at the same height as the knee. Unfortunately it is not possible to get a reliable
estimate of internal/external rotation using this camera view. In the near
future, with the advent of Inertial Measurement Units (IMUs) which are now
in every smart phone, it may be possible to have accurate biofeedback using
movement data. IMUs contain tri-axial accelerometers, gyroscopes and
magnetometers from which it is possible to get a representation of joint angles,
and perhaps more importantly a direct measure of angular velocity and
acceleration in the three cardinal planes. These can be used to show, for
example, the coronal and transverse plane stability of the shank (tibial
segment) or thigh (femoral segment). As well as being a potentially useful
biofeedback tool during proprioceptive training, this would also help the
assessment of movement control and determine if a deficit exists.
SUMMARY
Looking at a biomechanical approach has allowed us to assess the
potential mechanisms of pain and injury due to altered sagittal, coronal and
transverse plane mechanics at the foot, knee and hip. This can offer a valuable
insight into the reasons why people develop PFP in the first place and into
factors that cause PFP to persist over time. A biomechanical approach also
58 Jim Richards
provides objective measures of the clinical efficacy of different interventions.

This may in future also aid the identification of clinical subgroups and help in
the assessment of the effect of different treatment options within these
subgroups.
REFERENCES
Andriacchi, T. P., Andersson, G. B., Fermier, R. W., Stern, D., and Galante, J.
O. 1980. "A study of lower-limb mechanics during stair-climbing." The
Journal of bone and joint surgery. American volume 62 (5):749-57.
Besier, T. F., Gold, G. E., Beaupre, G. S., and Delp, S. L. 2005. "A modeling
framework to estimate patellofemoral joint cartilage stress in vivo."
Medicine & Science in Sports & Exercise37 (11):1924-30.
Bohnsack, M., Klages, P., Hurschler, C., Halcour, A., Wilharm, A.,
Ostermeier, S., Ruhmann, O., and Wirth, C. J. 2009. "Influence of an
infrapatellar fat pad edema on patellofemoral biomechanics and knee
kinematics: a possible relation to the anterior knee pain syndrome."
Archives of Orthopaedic and Trauma Surgery 129 (8):1025-30.
Bohnsack, M., Wilharm, A., Hurschler, C., Ruhmann, O., Stukenborg-
Colsman, C., and Wirth, C. J. 2004. "Biomechanical and kinematic
influences of a total infrapatellar fat pad resection on the knee." American
Boling, M. C., Padua, D. A., Marshall, S. W., Guskiewicz, K., Pyne, S., and
Beutler, A. 2009. "A prospective investigation of biomechanical risk
factors for patellofemoral pain syndrome: the Joint Undertaking to
Monitor and Prevent ACL Injury (JUMP-ACL) cohort." American
Bonacci, J., Vicenzino, B., Spratford, W., and Collins, P. 2014. "Take your
shoes off to reduce patellofemoral joint stress during running." British
Callaghan, M. J., and Selfe, J. 2012. "Patellar taping for patellofemoral pain
syndrome in adults." Cochrane Database of Systematic Reviews
4:CD006717.
Callaghan, M. J., Selfe, J., McHenry, A., and Oldham, J. A. 2008. "Effects of
patellar taping on knee joint proprioception in patients with patellofemoral
pain syndrome." Manual Therapy 13 (3):192-9.
Dierks, T. A., Manal, K. T., Hamill, J., and Davis, I. S. 2008. "Proximal and
distal influences on hip and knee kinematics in runners with
patellofemoral pain during a prolonged run." Journal of Orthopaedic &

Sports Physical Therapy 38 (8):448-56.
Fulkerson, J., and Hungerford, D. 1990. Disorders of the patellofemoral joint.
2nd Edition ed. Baltimore: Williams and Wilkins.
Ireland, M. L., Willson, J. D., Ballantyne, B. T., and Davis, I. M. 2003. "Hip
strength in females with and without patellofemoral pain." Journal of
Lindley, S. 2015. "Neuromuscular and Mechanical Control of the Knee Joint
with Patellofemoral Pain." PhD.
Ng, G. Y., Zhang, A. Q., and Li, C. K. 2008. "Biofeedback exercise improved
the EMG activity ratio of the medial and lateral vasti muscles in subjects
with patellofemoral pain syndrome." Journal of Electromyography and
Kinesiology 18 (1):128-33.
Noehren, B., Pohl, M. B., Sanchez, Z., Cunningham, T., and Lattermann, C.
2012. "Proximal and distal kinematics in female runners with
patellofemoral pain." Clinical Biomechanics 27 (4):366-71.
Powers, C. M. 2003. "The influence of altered lower-extremity kinematics on
patellofemoral joint dysfunction: a theoretical perspective." Journal of
Richards, J. 2008. Biomechanics in Clinic and Research. London: Churchill
Livingstone.
Richards, J., Chohan, A., Janssen, J., and Selfe, J. 2015. "Taping and bracing
of the knee joint: a ladder of conservative intervention for patellofemoral
pain." Physiotherapy 101, Supplement 1:e1280-e1281.
Richards, J., and Selfe, J. 2012. "EMG Decomposition of Vastus Medialis and
Vastus Lateralis in Normal Subjects and Patellofemoral Patients: A New
Way of Assessing the Balance of Muscle Function?" Journal of
Orthopaedic and Sports Physical Therapy 42 (6):A46.
Selfe, J., Richards, J., Thewlis, D., and Kilmurray, S. 2008. "The
biomechanics of step descent under different treatment modalities used in
patellofemoral pain." Gait & Posture 27 (2):258-63.
Selfe, J., Thewlis, D., Hill, S., Whitaker, J., Sutton, C., and Richards, J. 2011.
"A clinical study of the biomechanics of step descent using different
60 Jim Richards
treatment modalities for patellofemoral pain." Gait & Posture 34 (1):92-

6.
Sinclair, J., Isherwood, J., and Taylor, P. J. 2014. "Effects of foot orthoses on
Achilles tendon load in recreational runners." Clinical Biomechanics 29
(8):956-8.
Smith, T. O., Nichols, R., Harle, D., and Donell, S. T. 2009. "Do the vastus
medialis obliquus and vastus medialis longus really exist? A systematic
review." Clinical Anatomy 22 (2):183-199.
Swan, A. , and Mercer, S. 2005. "Anatomy of the infrapatellar fat pad." New
Zealand Journal of Physiotherapy 33 (1):19-22.
Thijs, Y., Vingerhoets, G., Pattyn, E., Rombaut, L., and Witvrouw, E. 2010.
"Does bracing influence brain activity during knee movement: an fMRI
study." Knee Surgery Sports Traumatology Arthroscopy 18 (8):1145-9.
Vieira, E.P.L. 2011. "Anatomic study of the portions long and oblique of the
vastus lateralis and vastus medialis muscles: review article." J Morphol
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Ward, S. R., and Powers, C. M. 2004. "The influence of patella alta on
patellofemoral joint stress during normal and fast walking." Clinical
Biomechanics 19 (10):1040-7.
Chapter 6
CLINICAL TESTS OF
PATELLOFEMORAL PAIN
Michael Callaghan1 and Jessie Janssen2

1
Department of Health Professions, Manchester Metropolitan University,
Manchester, UK
2
Allied Health Research unit, University of Central Lancashire,
Preston, UK
INTRODUCTION
For many years we have struggled to devise a gold standard test for
patellofemoral pain (PFP); that is, a test to tell us that the patient is highly
likely to have PFP rather than any other knee problem. This is a different
scenario from other knee conditions such as the anterior cruciate ligament
rupture for which there are good clinical tests to help rule the diagnosis in or
rule it out. This chapter concentrates on those tests purported to help
‘diagnose’ PFP. It excludes the other common tests which are part of the
standard knee examination such as range of movement, signs for joint
effusion, and special tests for meniscus and ligament deficiency.
Keywords: reliability, sensitivity, specificity, diagnosis of exclusion, gold

standard test, subgroup tests
62 Michael Callaghan and Jessie Janssen
WHICH PHYSICAL EXAMINATION TESTS ARE

RECOMMENDED FOR THE PATELLOFEMORAL JOINT?
There have been many tests over the years purported to ‘diagnose’ PFP
mainly by reproducing the patient’s pain.
Patella Compression Test (Clarke’s Test)
One of the most commonly used tests is the patella compression test, also
known as Clarke’s test, the shrug test or patella grind test. For this test, the
patient lies supine with the knee relaxed and fully extended on the examination
coach. The clinician compresses the superior border of the patella directly into
the trochlea and asks the patient to contract their quadriceps. This movement
forces the patella into the trochlea. If the patient’s patellar pain is reproduced,
the test is said to be positive. This test should not be used as a diagnostic test
of PFP, as it causes significant pain and has too many false positive results to
be worthwhile (i.e., people without PFP or any kind of knee symptoms may
have a positive Clarke’s test); the reasons for this conundrum are unknown.
Variations of this test include Zohler’s test (Magee 1997).
Critical Test
This was originally described by Jenny McConnell (1986) and in one text
is called the McConnell test for chondromalacia patellae (Magee 1997). This
test is performed with the patient sitting over a treatment couch and involves
10 second isometric quadriceps contractions at 120°, 90°, 60°, 30° and 0°,
knee flexion angles with the femur externally rotated. If pain is reproduced
during any of the isometric contractions, the patient's knee is returned to full
extension. A manual patella glide can be performed using both thumbs
flattened against the lateral border of the patella. This glide is maintained
while the patient performs another isometric contraction at the knee angle
which was previously painful. A significant reduction in pain confirms that the
pain was patellofemoral in origin and predicted a favourable outcome for the
patient. Once again, the usefulness of this test is doubtful because it is likely
that many people without PFP can have a positive test. A similar test in which
the patella is percussed at various knee angles to reproduce PFP is termed
Clinical Tests of Patellofemoral Pain 63
Frund’s test (Magee 1997). A more functional variation of the critical test /
McConnell test and Frund’s test is Waldron’s test (Waldron, 1983) in which,
the various knee angles are assessed whilst performing a deep squat. We do
not know if these tests are more useful than the critical test.
Patella Apprehension Test
The patella apprehension test (also known as the Fairbank apprehension

test) is used when PFP is a result of patellar dislocation. With the patient in
supine lying and the knee in full extension, the clinician glides the patella
laterally whilst passively initiating knee flexion. Here the sign of interest is the
patient displaying apprehension as the test is performed because they feel their
patella might sublux or dislocate again due to the passive lateral movement of
the patella. They often contract their quadriceps to prevent further knee
flexion.
Soft Tissue Tests
There are other tests in which the peripatellar soft tissues are palpated to
reproduce pain. These include the tendinous insertions of the quadriceps and
the medial and lateral retinacula (Fulkerson 2004). Palpating medial and
lateral patella facets is also done on the basis that this will detect any
‘soreness’ of the articular surfaces of the patella, but distinguishing the facet
from the overlying retinacula has been described as ‘anatomically dubious’
(Fulkerson 2004).
Because the infrapatellar (Hoffa’s) fat pad is a source of anterior knee
pain, a clinical test has been devised to test this structure. The ‘Hoffa sign’ can
be found when pressure is exerted along the lateral side of the patellar tendon
over the fat pad while the patient extends the knee from 900 flexion. If the
patient feels extreme pain in last 100 of extension sign is positive.
It is interesting that Jenny McConnell’s chapter in ‘The Patella: a team
approach’ (Grelsamer and McConnell 1998) does not have a specific patella
test. Components of her physical examination are concerned with the patency
of the soft tissue structures around the knee and patellofemoral joint rather
than the physical tests mentioned above.
Patella Mobility Tests
There are other tests in which the patella is palpated and moved to assess
patella mobility and joint play (Magee 1997, Fulkerson 2004). These
manoeuvres assess if the patella is hyper or hypomobile in either medial or
lateral directions and to a lesser extent in the caudal and cranial directions.
They are also referred to as medio-lateral tilt tests. They differ from the other
tests because they do not specifically seek to reproduce pain. They may not be
diagnostically useful but they are helpful in sub-grouping for PFP (see below).
The ‘J sign’ is seen when there is lateral subluxation of the patella each time
the knee joint moves into terminal extension. This is an obvious and dramatic
sign, usually due to trochlea dysplasia. It should not be used as a diagnostic
test for PFP.
Crepitus Tests
It seems clear that testing for painless crepitus or clicks or ‘sounds’ from
the knee in PFP does not help our diagnosis even though Waldron’s test
(Waldron, 1983) is described as positive when crepitus and pain are produced
during a particular part of the knee range of motion. The diagnostic knee tests
for cracking or crepitus are often not reproducible and do not have high
sensitivity and specificity which means there will be too many false positive
and false negative results for them to be useful. In other words, if you have
PFP the test for crepitus can be normal (negative) and if you do not have PFP
the test can be abnormal (positive). This should not be confused with the
crepitus from patellofemoral arthritis. Crepitus from arthritis is often described
as a grinding noise with a clearly palpable vibration, which could indicate
cartilage damage in the patellofemoral joint. It is one of the signs for diagnosis
of both tibiofemoral joint and patellofemoral joint osteoarthritis especially
useful in primary care and is a sign of MRI detected articular cartilage lesions
in the patellofemoral joint rather than in the tibiofemoral joint (Schiphof et al.
2014).
HOW WELL DO THE PATELLA TESTS HELP

DIAGNOSE PFP?
Cleland (2005) has a chapter in his book about the diagnostic usefulness
of several knee tests. In order to find out if a patella test is useful in diagnosing
PFP a gold standard diagnostic test is needed using either open surgery,
arthroscopy, or (increasingly) MR imaging. This works well for cruciate
ligament, meniscal injury and other conditions with clearly defined and
diagnosed findings which are directly related to the pathologies. As PFP
cannot be diagnosed solely by any invasive orthopaedic procedure or imaging
technique, testing the validity of the tests with sensitivity, specificity and
likelihood ratios cannot be achieved. Cleland therefore can only recommend
intra-tester and inter-tester reliability of a few clinical tests for the
patellofemoral joint. Many of the studies cited by Cleland are compromised by
having either entirely asymptomatic subjects, or a mixture of symptomatic and
asymptomatic subjects. The best intra-examiner agreement for examining
medio-lateral tilt in 66 patients with PFP is a kappa value of 0.28, which is
classed as ‘fair’ agreement. The inter examiner reliability is lower at 0.21
which is close to ‘poor’ agreement. As well as poor reliability, confirmation of
the poor validity of tests for diagnosing PFP has come from Nijs et al. (2006)
for the patellar apprehension test, Waldron’s test, Clarke’s test.
WHAT CAN WE USE INSTEAD OF PHYSICAL TESTS?

As it is highly unlikely that there is a single clinical test to diagnose
accurately PFP, what are the alternatives? We might take a lead from PFP
researchers who have stopped using a single clinical test to include and
exclude subjects with PFP in their studies. Instead they have decided to ask
patients about PFP during certain provoking activities which are considered to
characterise PFP (Cowan et al. 2002, Crossley et al. 2004, Callaghan and
Oldham 2004). Pain should be present in at least two provoking activities in
order for patients to be included in any research study on PFP study (Syme et
al. 2009, Cook et al. 2010, Selfe et al. 2013). These ‘hands off’ patellofemoral
joint loading activities still do not provide diagnostic certainty as people with
meniscal and/or knee ligament injury may have as much pain with going up
and down stairs as a similar aged matched group of patients who have PFP
(Callaghan, Selfe, and Dey 2009). Running and prolonged sitting are better
questions to ask patients but even these activities, which are known to provoke
PFP, do not fully discriminate between those with PFP and those with other
knee soft tissue problems. The eccentric step test represents a more functional
approach to reproducing a patient’s PFP and helping you decide if a diagnosis
of PFP is more likely than other knee conditions (Selfe et al. 2001). Nijs et al.
(2006) calculated that the likelihood of this test confirming that a patient had
PFP was 2.3 (95% CI: 1.9–2.9). With likelihood ratios, the closer the ratio is to
1 the less likely you are able to differentiate between PFP and non-PFP. In this
case, it means that if the patient has pain on an eccentric step test (a positive
test) they are 2.3 times more likely to have PFP than not. In addition to the
above, at least two of the three following clinical examination findings should
be present: pain during resisted isometric quadriceps contraction; pain with
palpation of the medial & lateral facets of the patella; pain during squatting
(Cook et al. 2010). Ultimately, a combination of tests is likely to be the best
way of getting close to a diagnosis of PFP. This is a reasonable approach and
is also recommended for meniscal tears (Callaghan and Pugh, 2008). Cook et
al. (2010) found that a combination of ‘hands on’ and ‘hands off’ tests which
provoked PFP were an isometric quadriceps contraction, during squatting,
and/or pain during palpation of the postero-medial or postero-lateral patella
border. They calculated that 89% of positive combination of tests will be
accurate (i.e., the subject has PFP) and 50% of negative tests will be accurate
(i.e., subject does not have PFP)
SO WHAT IS LEFT?
A special, single physical test to diagnose PFP does not exist. This mirrors
the lack of highly sensitive and specific tests for many other knee conditions.
As with other knee problems, the diagnosis of PFP may be achieved by a
combination of an accurate and detailed subjective examination, signs and the
reproduction of the patient’s symptoms in clinic using functional tests or, as
shown by Cook et al., a combination of clinical (hands on) and functional
(hands off) tests (Cook et al. 2010). Once this has been done, other
assessments can be used in order to attempt a sub-classification or
subgrouping of your patient. In the next part of this chapter we will describe
the tests that we have used to identify subgroups (Selfe et al. 2013).
SUBGROUP ASSESSMENT TESTS

Three probable subgroups have been identified within the patellofemoral
population (Selfe et al. 2016). It must be noted that patients were included
only when they reported pain in two of the following six activities (prolonged
sitting, ascending or descending stairs, squatting, running, kneeling, and
hopping/jumping) and perceived pain on two of the following three clinical
diagnostic tests:
 pain during resisted isometric quadriceps contraction;

 pain with palpation of the medial & lateral facets of the patella;
 pain during squatting.
In addition patients were excluded with a history of subluxation of the

patella. A full list of inclusion and exclusion criteria can be found in the
introduction chapter and Selfe et al. (2013). As described above this is not
necessarily the best way to initially diagnose people with PFP, but used as a
recruitment technique for in a study of PFP from different NHS trusts across
the UK. If a clinician can subgroup a patient with a diagnosis of PFP by
finding the predominant cause of the PFP this will provide a focus for
treatment. The three subgroups were identified by six assessment tests and
these are described below.
Local Patellar Factors
Clinical test: Total manual medial and lateral displacement of the patella
(Witvrouw et al. 2005).
Equipment required: Tape measure and pen.
Starting position: Supine lying with the quadriceps relaxed and the knees
in extension.
Procedure: The physiotherapist applies a medially directed force to the
lateral border of the patella and the maximum displacement of the pole of the
patella marked on the skin with a pen. This is followed by a laterally directed
force to the medial border of the patella and the maximum displacement of the
pole of the patella marked on the skin with a pen.
Measurement: The distance between medial displacement skin mark and

the lateral displacement skin mark is recorded in mm to give the total
displacement of the pole of the patella in the coronal plane (see Figure 6.1).
Figure 6.1. Measurement of total patella displacement.
Lower Limb Biarticular Muscle Tightness
Rectus Femoris Length Test

Clinical test: Prone Knee bend method (Witvrouw et al. 2000) (see Figure
6.2).
Starting position: The patient lies prone and the foot on the non-involved
side is placed on the floor in a 90 degree hip flexion position. The tested leg is
positioned with the knee at 90 degrees of knee flexion. Instruct the patient to
verbalise when he/she is experiencing pain or discomfort at the front of the leg
or in the knee.
Procedure: The knee is passively maximally flexed by the therapist. End
position is reached when the patient is feeling pain or discomfort at the front of
the leg or in the knee. When recorded repeat on non-involved or less involved
side.
Figure 6.2. Measurement of Rectus Femoris length.

Gastrocnemius Length Test

Clinical test: Standing method (Witvrouw et al. 2000).
Equipment required: Tape measure and goniometer.
Starting position: The patient leans on a solid support 60 cm away with
the tested leg parallel with and posterior to the non-involved leg, so that the
toes of the tested painful leg are level with the heel of the non-involved leg
(see Figure 6.3). Instruct the patient to verbalise when they experience pain or
discomfort at the back of the leg or in the knee.
Procedure: Keeping the knee of the painful tested leg extended the patient
is instructed to maximally flex their tested ankle while keeping their heel on
the floor. To ensure the heel does not lift a piece of paper can be placed under
the heel which the therapist should not be able to remove (see Figure 6.3). The
end position is reached when the patient reports feeling pain or discomfort at
the back of the leg or in the knee or when the patient lifts their heel. When
recorded repeat on non-involved or less involved side.
Figure 6.3. Measurement of gastrocnemius length.
Lower Limb Muscle Weakness Tests

Quadriceps (see Figure 5.2a).
Starting position: Patients are seated on the side of a treatment couch with
the knee flexed at 90 degrees.
Procedure: The patient is instructed to apply a maximum force against the
dynamometer. Subjects can hold the sides of the plinth for their stability when
extending the knee. When recorded repeat on non-involved or less involved
side.
Hip abductors (see Figure 5.2b).

Starting position: Patients are positioned in side lying with their legs in the
neutral anatomical position with the top leg supported on a pillow to ensure a
neutral hip starting position.
Procedure: The patient is instructed to ensure their toes are pointing
horizontally during the contraction and then they will be asked to abduct their
leg sideways towards the ceiling to apply a maximum force against the
dynamometer. When recorded repeat on non-involved or less involved side.
Distal (Foot) Factors
Problem: Foot Pronation.

Clinical test: Foot Posture Index (FPI) (Redmond 1998). Online there are
multiple videos of how to conduct the FPI. We would encourage you to have a
look at these and do some practice assessments before commencing this as it
needs practice before becoming competent even for experienced clinicians.
Individual test items:
1. Talar head position

2. Supra and infra lateral malleolar curvature
3. Calcaneal frontal plane position
4. Prominence in the region of the talonavicular joint
5. Congruence of the medial longitudinal arch
6. Abduction/adduction of the forefoot on the rearfoot
Equipment required: Ruler.

Starting position: Relaxed standing in double limb support. When
recorded repeat on non-involved or less involved side.
Calculation: Each foot should be scored independently. Each of the
component tests or observations are graded 0 for neutral, with a score of -2 for
clear signs of supination, and +2 for positive signs of pronation. Unless the
criteria outlined for each of the features are clearly met then the more
conservative score should be awarded. When the scores are combined, the
aggregate value gives an estimate of the overall foot posture. High positive
aggregate values indicate a pronated foot posture, significantly negative
aggregate values indicate a supinated overall foot posture, while for a neutral
foot the final FPI aggregate score should lie somewhere around zero.
SUMMARY
A gold standard clinical test to diagnose PFP does not exist. You will have
to use a combination of tests to help establish the diagnosis. There are some
clinical tests which will help differentiate sub-groups of patients with PFP and
which may help direct the correct treatment.
REFERENCES
Callaghan, M.J. and Pugh, S. 2008. Which is the best clinical test for
diagnosing a knee meniscal injury? Emergency Medicine Journal
25(2):105-107 Available: http://bestbets.org/bets/bet.php?id =1514.
Callaghan, M., Selfe, J., and Dey, P. 2009. "Activity-associated pain in
patellofemoral pain syndrome: how does it inform research and practice?"
Callaghan, MJ., and Oldham, JA. 2004. "Electric muscle stimulation of the
quadriceps in the treatment of patellofemoral pain." Archives of Physical
Medicine and Rehabilitation 85 (6):956-962.
Cleland, J. 2005. Orthopaedic Clinical Examination: an evidence based
approach for Physical Therapists. New Jersey: Icon Kearning Systems.
Cook, C., Hegedus, E., Hawkins, R., Scovell, F., and Wyland, D. 2010.
"Diagnostic accuracy and association to disability of clinical test findings
associated with patellofemoral pain syndrome." Physiotherapy Canada
62 (1):17-24.
Cowan, SM., Bennell, KL., Crossley, KM., Hodges, PW., and McConnell, J.
2002. "Physical therapy alters recruitment of the vasti in patellofemoral
pain syndrome." Medicine & Science in Sport & Exercise 34 (12):1879-
1885.
Crossley, K.M., Cowan, S.M., Bennell, K.L., and McConnell, J. 2004. "Knee
flexion during stair ambulation is altered in individuals with
patellofemoral pain." Journal of Orthopaedic Research 22 (2):267-274.
Fulkerson, J. P. 2004. Disorders of the patellofemoral joint. Vol. 4th edn.
Baltimore: Williams & Wilkins.
Grelsamer, R. P., and McConnell, J. 1998. The patella. A team approach. Vol.
1. Gaithersburg: Aspen Publishers Inc.
Magee, D.J. 1997. Orthopedic Physical Assessment Pennsylvania: Saunders.
McConnell, J. 1986. "The management of chondromalacia patellae: a long

term solution." Australian Journal of Physiotherapy 32 (4):215-223.
Nijs, Jo, Van Geel, Catherine, Van der auwera, Cindy, and Van de Velde,
Bart. 2006. "Diagnostic value of five clinical tests in patellofemoral pain
syndrome." Manual Therapy 11 (1):69-77
Redmond, A. 1998. "Foot Posture Index User Guide and Manual." accessed
17/6. http://www.leeds.ac.uk/medicine/FASTER/fpi.htm.
Schiphof, D., van, Middelkoop M., de Klerk, B. M., Oei, E. H., Hofman, A.,
Koes, B. W., Weinans, H., and Bierma-Zeinstra, S. M. 2014. "Crepitus is
a first indication of patellofemoral osteoarthritis (and not of tibiofemoral
osteoarthritis)." Osteoarthritis Cartilage 22 (5):631-638
Selfe, J., Callaghan, M., Witvrouw, E., Richards, J., Dey, M. P., Sutton, C.,
Dixon, J., Martin, D., Stokes, M., Janssen, J., Ritchie, E., and Turner, D.
2013. "Targeted interventions for patellofemoral pain syndrome (TIPPS):
classification of clinical subgroups." British Medical Journal Open 3
(9):e003795
Selfe, J., Harper, l, Pedersen, I., Breen-Turner, J., and Waring, J. 2001. "Four
outcome measures for patellofemoral joint problems. Part 2. Reliability
and clinical sensitivity." Physiotherapy 87 (10):516-522
Journal of Sports Medicine 50 (14):873-80
Syme, G., Rowe, P., Martin, D., and Daly, G. 2009. "Disability in patients
with chronic patellofemoral pain syndrome: a randomised controlled trial
of VMO selective training versus general quadriceps strengthening."
Waldron VD. 1983. A test for chondromalacia patellae. Orthopedic Reviews
12:103
Witvrouw, E., Lysens, R., Bellemans, J., Cambier, D., and Vanderstraeten, G.
2000. "Intrinsic risk factors for the development of anterior knee pain in
an athletic population. A two-year prospective study." American Journal
of Sports Medicine 28 (4):480-9
Witvrouw, E., Werner, S., Mikkelsen, C., Van Tiggelen, D., Vanden Berghe,
L., and Cerulli, G. 2005. "Clinical classification of patellofemoral pain
syndrome: guidelines for non-operative treatment." Knee Surgery Sports
Traumatology Arthroscopy 13 (2):122-30.
SECTION 2: INTERVENTION
Introduction to Section 2
TREATMENT ADHERENCE
Michael Callaghan
Manchester, UK
INTRODUCTION
A key aspect of any physiotherapist’s treatment for patellofemoral pain
(PFP) is a patient’s self-management strategy which can only really work if
the patient follows it. Those who do not follow the programme you set are
likely to exercise at less than a therapeutic dose (Hay-Smith et al. 2016) and
might lead you to believe that there are technical problems with the exercise
programme, whereas the real problem is the dosage.
It is likely that 50–70% of patients are either non-adherent or only
partially adherent to the home programmes you give them. There are many
reasons for this (McLean et al. 2010) and there is no easy fix. Within
physiotherapy it is still not clear which factors act as barriers to adherence.
Other interventions such as braces have an adherence rate which varies
from 45% to 100% (Moyer et al. 2015). Narrative reviews of brace use from
experienced clinicians (Hunter 2015, Segal et al. 2015) have noted the
formidable challenge of attaining high adherence. Conversely, in one trial on
braces (in scoliosis) just telling patients that brace use would be monitored
electronically increased usage from 56% to 86% even though the monitoring
never occurred (Miller et al. 2012).
76 Michael Callaghan
So how can we improve this? Education, effective communication,

patient–therapist rapport, social support and encouragement, goal setting,
treatment efficacy and tailoring have all been shown to have an impact on
patient adherence rates in the short term, but there is less impact on long term
adherence.
WHY IS THIS IMPORTANT?

Because there is some tentative evidence that greater adherence leads to
greater efficacy, this can be linked to a dosage level. In PFOA for every hour a
brace was worn, there was an improvement in pain of 1mm on a 0-100mm
visual analogue score (Callaghan et al. 2015). In other words, dosage is
important in conservative non-medical treatment and should be given the same
emphasis and priority as medication dosage.
REFERENCES
Callaghan, M. J., Parkes, M. J., Hutchinson, C. E., Gait, A. D., Forsythe, L.
M., Marjanovic, E. J., Lunt, M., and Felson, D. T. 2015. "A randomised
trial of a brace for patellofemoral osteoarthritis targeting knee pain and
bone marrow lesions." Annals of the Rheumatic Diseases 74 (6):1164-
1170.
Hay-Smith, E. J., McClurg, D., Frawley, H., and Dean, S. G. 2016. "Exercise
adherence: integrating theory, evidence and behaviour change
techniques." Physiotherapy 102 (1):7-9.
Hunter, D. J. 2015. "Bracing for knee osteoarthritis: translating evidence into
practice." Arthritis Care & Research (Hoboken) 67 (4):455-6.
McLean, S. M., Burton, M., Bradley, L., and Littlewood, C. 2010.
"Interventions for enhancing adherence with physiotherapy: a systematic
review." Manual Therapy 15 (6):514-21.
Miller, D. J., Franzone, J. M., Matsumoto, H., Gomez, J. A., Avendano, J.,
Hyman, J. E., Roye, D. P., Jr., and Vitale, M. G. 2012. "Electronic
monitoring improves brace-wearing compliance in patients with
adolescent idiopathic scoliosis: a randomized clinical trial." Spine (Phila
Pa 1976) 37 (9):717-21.
Treatment Adherence 77
Moyer, R. F., Birmingham, T. B., Bryant, D. M., Giffin, J. R., Marriott, K. A.,
and Leitch, K. M. 2015. "Valgus bracing for knee osteoarthritis: a meta-
analysis of randomized trials." Arthritis Care & Research (Hoboken) 67
(4):493-501.
Segal, N. A., Stockman, T. J., Findlay, C. M., Kern, A. M., Ohashi, K., and
Anderson, D. D. 2015. "Effect of a Realigning Brace on Tibiofemoral
Contact Stress." Arthritis Care & Research (Hoboken) 67 (8):1112-8.
Chapter 7
EXERCISES: STRETCHING, STRENGTHENING

AND PROPRIOCEPTION
Michael Callaghan1 and Jessie Janssen2

1
Manchester Metropolitan University,
Manchester, UK
2
Allied Health Research Unit,
University of Central Lancashire, Preston, UK
INTRODUCTION
The prescription of exercises plays a central role in the modern day
approach to the treatment of patients with patellofemoral pain (PFP) (Crossley,
Callaghan, and van Linschoten 2015). As mentioned in Chapter 1, patients
with PFP are often treated with a multimodal approach. This approach offers
several treatment options and the physiotherapist chooses the combinations of
ones that they feel are suitable for the patient. Generally this will consist of
advice and education on symptom management and pain, stretching,
strengthening and proprioception exercises. Physiotherapists may also offer
patellar taping, foot orthoses or other modalities. Despite the central role
exercise plays, the evidence for its effectiveness in providing a clinically
important improvement in patients’ pain and function is of very low quality
(van der Heijden et al. 2015). This chapter will mainly focus on the exercise
element rather than the advice, however we have briefly listed below some of
the important aspects concerning advice and education. Once again we would
like to emphasise the importance of patient ‘buy in’ to whatever treatment
approach is offered from the first appointment as described in Chapter 2.
Keywords: Self-management, Advice, Exercises, Exercise prescription
EXERCISE: PAIN FREE OR CONTROLLED

PAINFUL LOADING?
The general consensus in clinical practice is that people with PFP should
be rehabilitated within their pain free zone (see Chapter 2). In other words, the
exercises prescribed are not supposed to be painful when patients execute
them (McConnell 1986, Dye et al. 1999). However this notion is currently
being challenged by some (Osteras et al. 2013, Osteras, Osteras, and
Torsensen 2013). Osteras et al. (2013) asked 21 people with PFP to perform
pain free exercises for 20 minutes (current practice) and 21 other people with
PFP to perform high loading repetitive exercises within their pain limit for a
one hour session per day. They found that the people who were exercising
within their pain for longer had less PFP and were better functioning after 12
weeks than the people who were treated with the current ‘exercise without
pain’ practice. This pattern of improvement was still measurable after one year
(Osteras, Osteras, and Torsensen 2013). This provides an evidence base for
exercising patients within their pain instead of exercising without any pain at
all. Because this evidence base is very limited (van der Heijden et al. 2015) we
need to be cautious about this new approach and we need more research to
confirm this is a useful way forward in what some would describe as a
controversial area.
OFFERING ADVICE AND EDUCATION ON SYMPTOM

MANAGEMENT AND PAIN
When offering general advice and education some patients might benefit
from the following:
 Try non-weight bearing exercises such as cycling or an exercise bike.

The height of the saddle is important as a saddle that is set too low can
Exercises 81
cause PF pain (Callaghan 2005). The most functional way to measure

your patient’s correct saddle height is to have the knee at 300 flexion
(i.e., not full extension) when the pedal is at the bottom of its
revolution.
 Try to cut down slightly on sports that put a lot of pressure on your
knees e.g., Football, rugby, tennis
 Try to limit walking up and down hills
 Try to wear appropriate footwear (i.e., limit wearing high heels)
 Try to cut down on kneeling and squatting, and standing for long
periods of time
 Do consider weight control strategies such as healthy eating. We
know that every 1 pound weight loss reduces force through the knee
four fold (Messier et al. 2005).
 Do remind the patients that they need to ask any questions they might
have concerning their knees or patellae.
When patients are not expressing their concerns, their fear might lead to
pain avoidance.
Some patients may ask if they can take analgesics or anti-inflammatories
to reduce pain during their exercise. This is can be point of concern when
people need to exercise within their pain free range. However physiotherapists
should remember to work within their scope of practice and any doubts should
be referred back to their primary care physician or general practitioner.
STRETCHING, STRENGTHENING AND

PROPRIOCEPTION EXERCISES
Below we will focus on stretching, strengthening and proprioceptive
training. These three forms of exercises have been chosen for specific reasons.
First of all it appears that there are different subgroups within the
patellofemoral population (Selfe et al. 2016). Some people appear to have
weak gluteii and quadriceps which may also be tight whereas others appear to
have normal values for muscle strength. There are also those with PFP who
have either good or poor proprioception (Callaghan et al. 2008). From this we
can select who needs strengthening exercises and stretching exercises, whereas
others might not need strengthening but may require proprioceptive training.
DOSAGE: HOW MANY EXERCISES SHOULD I PRESCRIBE?

When clinicians prescribe exercises for patients with PFP, the patient will
usually ask: how many do I need to do? and for how long? Unfortunately,
there is no simple answer to this simple question. In chapter 2 Jenny
McConnell states clearly that to gain maximum adherence exercises should
“….be easy for the patients to do, requiring minimal or no equipment”. In the
healthy limb in which muscle strengthening is the goal, the system of
progressive overload is advocated.
In people with PFP who need muscle strengthening, this system is likely
to reproduce pain, which will usually be your guide as to how many repetitions
should be done.
The likelihood of large variations of pain response between patients with
the same PFP diagnosis makes prescriptive exercise regimes and dosage
difficult to advise. Stretching exercises to improve flexibility suffer from the
same problems. For example, one recommendation for time spent passive
stretching states that the ‘minimal prolonged stretch duration is usually about
15-20 minutes’ (Houglum 2005). There is no consensus about the optimum
exercise regime and dosage, but in line with and informed by
recommendations from the American College of Sports Medicine and
American Heart Association (Haskell et al. 2007, American College of Sports
2009) the strengthening exercises should be performed pain-free at an
exertional level that participants would describe as hard. Participants will
perform 10 repetitions within 3 sets as recommended for strength training.
Participants will be advised to ensure the time under tension is 8s (3s
concentric, 2s isometric hold and 3s eccentric contraction). So, no clear
evidence exists with regards to optimal exercise dosage for patients with PFP.
In this chapter we have set a baseline of exercises of twice a day, and have
cited the recommendations from the American College of Sports Medicine,
but these can be expanded on or diminished as required to maintain a pain free
schedule of exercises.
In the following sections we give some patient focussed guides to selected
exercises that we find useful with progression being achieved by increasing
resistance and therefore the exertion required by the patient through using
elasticated bands.
Exercises 83
STRETCHING
Hamstring Stretching
Position yourself as shown in Figure 7.1. Bend your painful leg. Grip your
thigh with your hands to keep the thigh steady. Straighten your left leg in the
air until you feel a stretch in the back of your thigh. Hold for 20 seconds and
then relax. Do the exercise slowly, 10 times.
Figure 7.1. Stretching of hamstrings.
Gastrocnemius Stretching
Position yourself as shown in Figure 7.2 against a chair or wall. Keep your
painful leg at the back with your heel on the floor.
Figure 7.2. Stretching of gastrocnemius.

Bend your front knee and lean towards the wall. Keeping your painful leg
straight you should feel a stretch in the back of your calf. Hold for 20 seconds
and then relax. Do the exercise slowly, 10 times.
Rectus Femoris Stretching
Holding onto a chair or wall for support, bend your painful knee and grip
your ankle as shown in Figure 7.3. Hold for 20 seconds, then relax. Do the
exercise 10 times.
Figure 7.3. Stretching of rectus femoris.
STRENGTHENING
Hip Abduction Strengthening
Keeping your back nice and straight with the painful leg on top, bend the
underneath supporting leg (Figure 7.4). Raise your painful leg slowly, hold for
2 seconds and then slowly lower your leg back down. Do the exercise 10
times.
Exercises 85
Figure 7.4. Strengthening of hip abductors.
Functional Strengthening
Mini squat: Tighten your quadriceps then slowly and smoothly bend your
knees to approximately 20-30o, hold for 2 seconds and then slowly and
smoothly straighten them again (Figure 7.5). Do the exercise 10 times.
Figure 7.5. The mini squat.

Progression to Lunge
Lunge: Stand as shown with your painful leg in front, and both feet facing
forward. Keeping your back leg as straight as you can, slowly transfer your
weight over to your front foot (Figure 7.6). Hold for 2 seconds and then slowly
transfer your weight back again. Do the exercise 10 times.
Figure 7.6. The lunge.
Progression to Single Leg Dip
Single leg dip: Whilst standing, raise your least painful leg off the floor.
Bend your painful leg slowly to 20-30° hold for 2 seconds and then slowly
straighten again (Figure 7.7). Do the exercise 10 times.
Figure 7.7. The single leg dip.

Exercises 87
PROPRIOCEPTION TRAINING
Supine Position
Position yourself as shown, lying on your back with a ball under your foot
against the wall (Figure 7.8). Move the ball slowly up and down from your
heel to your toes, from side to side and around and round for 30 seconds.
Repeat 5 times.
Figure 7.8. Proprioceptive training in supine position.
Progression to balance on One Leg
Standing on 1 leg try to stay still for 30 seconds (Figure 7.9). Do not lock
your knee, but keep it slightly bent and mobile. Repeat 5 times.
Figure 7.9. Balance on one leg.

Progression to Balance on one Leg with Eyes Closed
Standing on 1 leg try to stay still for 30 seconds, but this time with your
eyes closed. Again, do not lock your knee, but keep it slightly bent and mobile.
Repeat 5 times.
Progression to Balance on One Leg while Bouncing a Ball
Whilst balancing on 1 leg, throw and catch a ball against the wall (Figure
7.10). To make this more difficult throw the ball to different places on the
wall. Keep your knee slightly bent and mobile. Do this for 30 seconds. Repeat
5 times.
Figure 7.10. Balance on one leg while bouncing a ball.
Progression to Balance on One Leg while Standing on a Cushion

and Bouncing a Ball
Whilst standing on a cushion, or other unstable soft surface such as a

trampoline balance on 1 leg, and throw and catch a ball against the wall
(Figure 7.11). To make this more difficult throw the ball to different places on
the wall. Keep your knee slightly bent and mobile. Do this for 30 seconds.
Repeat 5 times.
Exercises 89
Figure 7.11. Balance on one leg while standing on a cushion and bouncing a ball.
SUMMARY
There is consensus and an evidence base to support the use of exercise as
a central component to any rehabilitation approach for PFP. Traditionally,
those with PFP are instructed to perform them pain free, but the exact dosage
required to perform therapeutic results is unknown.
REFERENCES
American College of Sports, Medicine. 2009. "American College of Sports
Medicine position stand. Progression models in resistance training for
healthy adults." Medicine & Science in Sports & Exercise 41 (3):687-708.
Callaghan, Michael J. 2005. "Lower body problems and injury in cycling."
Journal of Bodywork and Movement Therapies 9 (3):226-236.
Crossley, K. M., Callaghan, M. J., and van Linschoten, R. 2015.
"Patellofemoral pain." British Medical Journal 351:h3939.
Dye, S. F., Staubli, H. U., Bierdert, R. M., and Vaupel, G. L. 1999. "The
mosaic of pathophysiology causing patellofemoral pain: therapeutic
implications." Operative Techniques in Sports Medicine 7 (2):46-54.
Haskell, W. L., Lee, I. M., Pate, R. R., Powell, K. E., Blair, S. N., Franklin, B.
A., Macera, C. A., Heath, G. W., Thompson, P. D., and Bauman, A. 2007.
"Physical activity and public health: updated recommendation for adults
from the American College of Sports Medicine and the American Heart
Association." Medicine & Science in Sports & Exercise 39 (8):1423-34.
Houglum, P.A. 2005. Therapeutic Exercise for Musculoskeletal Injuries. 2nd
Edition ed. Champaign Il: Human Kinetics.
McConnell, J. 1986. "The management of chondromalacia patellae: a long
term solution." Australian Journal of Physiotherapy 32 (4):215-223.
Messier, S. P., Gutekunst, D. J., Davis, C., and DeVita, P. 2005. "Weight loss
reduces knee-joint loads in overweight and obese older adults with knee
osteoarthritis." Arthritis & Rheumatology 52 (7):2026-2032.
Osteras, B., Osteras, H., and Torsensen, T. A. 2013. "Long-term effects of
medical exercise therapy in patients with patellofemoral pain syndrome:
Results from a single-blinded randomized controlled trial with 12 months
follow-up." Physiotherapy 99 (4):311-316.
Osteras, Berit, Osteras, Havard, Torstensen, Tom Arild, and Vasseljen, Ottar.
2013. "Dose-response effects of medical exercise therapy in patients with
patellofemoral pain syndrome: a randomised controlled clinical trial."
van der Heijden, R. A., Lankhorst, N. E., van, Linschoten R., Bierma-Zeinstra,
S. M., and van, Middelkoop M. 2015. "Exercise for treating
patellofemoral pain syndrome." Cochrane Database of Systematic
Reviews 1:CD010387.
Chapter 8
PATELLOFEMORAL TAPING
Jenny McConnell
McConnell Institute, Mosman, New South Wales, Australia
INTRODUCTION
The prime reason for using patellofemoral taping is to relieve a patient’s
symptoms. In my experience, if the symptoms are not relieved by at least 50%,
it is a waste of time, money, effort and skin putting the tape on. Taping is
therefore a means to an end, and as such, is an adjunct to treatment. If the
patient’s symptoms are significantly diminished, then adherence with
treatment is almost always assured (for about a month anyway). The following
chapter has descriptions of various taping techniques.
Keywords: taping, pain relief, proprioception
THE EVIDENCE BASE FOR TAPING

The evidence in the literature about the effectiveness of tape is mixed,
whether you are using rigid or elasticised tape (Parreira et al. 2014, Callaghan
and Selfe 2012, Callaghan et al. 2008, Callaghan et al. 2002, Leibbrandt and
Louw 2015, Chang et al. 2015, Oliveira et al. 2016). The most important
92 Jenny McConnell
consideration for you, as a clinician, is improving the patient’s symptoms with

tape. If this does not happen you should consider whether:
1) the tape positioning was correct – it could be too low on the patella,
causing an irritation of the fat pad.
2) the tape application was incorrect - too much tension, resulting in skin
breakdown or not enough tension, resulting in taping that is
ineffective and may as well not be there.
3) the tape was applied in too much knee flexion – if the knee is flexed
over 30o then the patella is already lodged in the trochlea.
4) tape was not appropriate for that patient – you should not put tape on
the knee of anyone you suspect has complex regional pain syndrome,
as it will make them worse. Tape is inappropriate for someone whose
symptoms are only mild, say less than 2cm on a numeric pain rating
scale for present pain and therefore aren’t in severe enough pain
enough to warrant taping.
Additionally, tape can be used to facilitate and inhibit muscle activity,

either of which can also expedite symptom improvement. To understand what
we are trying to do with tape, we need to understand the effect of creep and
adaptive shortening.
WHAT IS CREEP AND ADAPTIVE SHORTENING?

Creep
Creep is the tendency of a viscoelastic material to elongate during

sustained low load. If the tissue is elongated past its elastic limit or elongated
for too long a period of time, it will not return to its pre-stretched resting
length. Creep, particularly of non-contractile tissue such as ligaments and
retinacular tissue, may be responsible for changes in patellar positioning and
excessive loading on tissue. Twenty minutes of sustained static or cyclic
loading of lumbar viscoelastic tissues in felines has been shown to cause
micro-damage in the collagen structure resulting in a release of pro-
inflammatory cytokines and neutrophils, lasting up to eight hours, which is
indicative of sub-clinical tissue damage (Whittingham, Palmer, and Macmillan
2004, Derasari et al. 2010, Solomonow 2004).
Patellofemoral Taping 93
Adaptive Shortening
When non-contractile tissue is shortened for a prolonged period (adaptive

shortening), the collagen fibre distance decreases, whereas with contractile
tissue, the actin and myosin fibres overlap, decreasing the number of
sarcomeres, so the muscle belly becomes shorter and stiffer, causing the length
tension curve to alter (Solomonow 2012). So, in some cases, physiotherapists
may have to decrease stress on abnormally strained tissue around the
patellofemoral joint, whereas in other cases they may need to increase the
length of adaptively shortened tissue. In my opinion both of which can be
accomplished by the judicious use of tape.
PRINCIPLES OF TAPING
Painful, inflamed tissue does not respond well to stretch, so the principle
of unloading painful tissue is to shorten the tissue (Solomonow et al. 2003,
Williams et al. 1988), so there is an opportunity for the inflammation to
decrease, promoting optimal repair. In this situation, the most appropriate tape
is a rigid non-stretch tape, as it provides support to the tissue, but still allows
knee joint movement. If you want to increase muscle activity you tape in the
direction of the muscle fibres (McConnell 2000). In this case you can use a
more elastic tape, as it stimulates the muscle during contraction and stretches
with muscle lengthening. If you want to decrease muscle activity for an
overactive antagonist muscle you can tape firmly across the muscle belly,
particularly at the musculotendinous junction (Tobin and Robinson 2000; Hug
et al. 2014). Again, a more rigid rather than elastic tape may help you achieve
this end.
WHAT ARE WE TRYING TO DO WITH TAPE?

The type of taping you use in your treatment depends on your assessment
of the patient’s patellofemoral joint. The primary effect of tape is to reduce
pain (Callaghan and Selfe 2012). A secondary effect is to reduce
patellofemoral joint reaction forces (Mostamand, Bader, and Hudson 2010).
The third effect is to improve proprioception (Callaghan et al. 2002, Callaghan
et al. 2008). You must always reassess the patient’s symptoms after each
94 Jenny McConnell
application of tape. The patient only requires the amount of tape necessary to
reduce their symptoms by at least 50%. The patella tape should always be
applied with the knee extended and relaxed, whether in supine when the
clinician is applying the tape, or sitting on the edge of a chair with the leg out
straight when the patient is self-applying.
Pain
Unload the Fat Pad

One of the most pain sensitive structures in the knee is the infrapatellar
(Hoffa’s) fat pad (Macgregor et al. 2005), and it is often the source of the
symptoms in patellofemoral pain (PFP) Dye, Vaupel, and Dye (1998). It is
essential to identify an inflamed fat pad, as failure to do so may mean that tape
is placed too low on the patella, further aggravating the fat pad and increasing
the patient’s symptoms. You can quickly reproduce symptoms of an inflamed
fat pad by a quadriceps contraction or an extension overpressure in supine. If
this does not reproduce the symptoms, then you can determine whether the fat
pad is inflamed, by palpating the fat pad just below the patella, from the most
medial to the most lateral side, and comparing this assessment with one from
the patient’s other knee. The symptomatic fat pad will be greater in diameter
and feel more ‘boggy’ than the less symptomatic side. When the fat pad is
inflamed, the inferior pole of the patella is tilted posteriorly into the fat pad
often leading to the appearance of a ‘dimple’ in the skin overlying the area.
Some patients are very self-conscious about this. To correct a posterior tilt of
the inferior pole of the patella, every piece of tape must be commenced on the
superior half of the patella to tilt the pole of the patella out of the fat pad. The
posterior tilt component is corrected in combination with lateral tilt and glide
(see techniques 2 and 3 below).
If you have not adequately decreased the patient’s symptoms by tilting the
inferior pole of the patella anteriorly, you will need to unload the fat pad, by
shortening the fat pad. You can unload the fat pad by taping from the tibial
tubercle to the medial and lateral joint lines, forming a wide ‘V’. As the tape is
pulled towards the joint line, you lift the soft tissue towards the patella, thus
shortening the fat pad and creating a ‘muffin top’ appearance. The final piece
of tape needed to unload a recalcitrant fat pad problem commences in the
centre of the calf posteriorly, just below the popliteal fossa, and you pull the
tibia forward firmly.
Correct Lateral Tilt – Decreasing Adaptive Shortening

If the patient has a laterally tilted patella, because the deep lateral
retinacular structures are tight, increasing the loading of the lateral facet of the
patella, you need to tilt the patella medially, which will provide a constant low
load to the adaptively shortened retinacular tissues. To decrease a lateral tilt of
the patella, you position the tape in the middle of the patella, pulling the tape
to the medial side of the knee, lifting the skin towards the patella, easing the
tension off as you tape around the back of the knee, anchoring just past the
medial hamstrings.
Improve Lateral Displacement – Decreasing Creep

If the patella is laterally displaced, resulting in elongation of the medial
soft tissues (medial retinaculum, medial patellofemoral ligament and medial
quadriceps) due to creep, then you start the tape just past the lateral border of
the patella and pull the patella medially, again just past the medial hamstrings.
This will shorten the elongated tissue and improve the firing of the medial
quadriceps (Dye, Vaupel, and Dye 1998, Bennell et al. 2004). If the patient has
a combination of lateral tilt and glide, you correct the lateral tilt first as this
will provide a more effective correction of the glide component.
Change Rotation – Decreasing Creep

If you find after correcting the tilt and glide components, the patient still
has medial pain, you may need to shorten the medial retinacular tissue further
by internally rotating the inferior pole of the patella. You do this by placing
the tape in the middle of the patella at a 45o angle, turn the superior pole of the
patella externally with one hand, while the other hand uses the tape to turn the
inferior pole internally. The end result looks like a ‘Nike’ tick or reverse ‘Nike’
tick, depending on which knee you are taping.
Facilitate Quadriceps Contraction

If you want to facilitate quadriceps muscle contraction, you apply the tape
along the muscle belly to improve muscle activation. At present there is little
scientific evidence that taping directly facilitates a muscle contraction but
don’t forget you are reassessing for clinical improvement.
Inhibit Lateral Structures

Inhibiting the lateral structures can be done by applying tape firmly across
the outer third of the anterior aspect of thigh, just above the patella and
repeating this process two or three more times up the thigh. This type of taping
96 Jenny McConnell
has only been investigated in one study on 15 asymptomatic individuals, but

was shown to be effective in causing some inhibition of the vastus lateralis
(Tobin and Robinson 2000).
Femoral Considerations
Altering femoral position and facilitating gluteal muscle contraction. As
many patients with PFP have internally rotated femurs, which contribute to the
dynamic knee valgus positioning seen in these patients, you may want to
improve femoral positioning with tape (Gilleard, McConnell, and Parsons
1998). To increase external rotation and limit internal rotation of the femur,
you can tape from the middle of the anterior aspect of the femur, bringing the
tape behind the greater trochanter and anchoring on the sacrum. While you are
applying this tape you ask the patient to keep their feet facing the front while
they turn their body away from you, creating an external rotation of the femur.
This tape is helpful in minimising dynamic valgus knee collapse.
Additionally many patients with PFP have suboptimal gluteal activation,
adding to the poor control of the femur during dynamic activities. To facilitate
gluteal contraction, you can tape under the gluteals to lift the muscle belly up.
This tape is also applied in weight bearing.
Patellofemoral Joint Reaction Forces

Taping has been shown to reduce the patellofemoral joint reaction force
during a single leg squat in those with PFP (Mostamand, Bader, and Hudson
2010). Taping can help by reducing knee flexion range of motion in PFP
subjects both coronal and transverse plains on a slow step descent (Selfe et al.
2011).
Proprioception
The results of several studies using a variety of proprioception tests
suggests that taping can have a non-mechanical effect on the knee by affecting
the areas of the brain concerned with co-ordination, decision making and
motor control (Callaghan et al. 2010). The accuracy of tests to assess joint
position reproduction, which is associated with symptom changes and
proprioception can be improved with taping and not necessarily due to
biomechanical reasons.
K Tape
The invention of Kinesio tape (Kase, Wallis, and Kase 2003) has
introduced a new product for taping of the patella. This is very popular and
widely used, especially in sport. Cyclists find this product useful as it

accommodates the repetitive high knee flexion angles required in this sport.
Nevertheless, it is uncertain whether or not the tape itself has any more benefit
over other types of tape in terms of influencing muscle activation,
patellofemoral joint forces or proprioception.
SKIN PROBLEMS
There are 2 major skin problems you will see when applying tape:
Friction Rub
If you are unloading tissues, there can often be considerable tension on the
overlying soft tissue, as the patella generally wants to move laterally and you
want the patella to stay medial. Thus, the commonest form of skin irritation is
a friction rub on the medial side of the knee, which often presents as a blister.
The friction rub is caused by:
1) vigorous application of tape, trying to pull the patella too far and not
easing the tension off as you place the tape around the medial side of
the knee.
2) uneven tape tension.
3) rapidly removing the tape.
Solutions are to:
1) Use other hand to ease tension off skin when removing tape
2) Peel tape off slowly
3) Use eucalyptus oil or tea tree oil over tape before removing tape.
4) Use skin protection on medial aspect of the knee – comfeel, calamine
lotion, cutifilm, opsite
Allergic Reaction
An allergic reaction is uncommon, occurring in about 5-10% of

individuals. It is due to a reaction to the adhesive either on the zinc oxide or
98 Jenny McConnell
the latex in the elasticised tape. The skin will be raised, red and itchy. There
can be a 3 week delay before irritation begins, as the patient may not have
been exposed to that allergen before. The patient often has an allergic history –
asthma, eczema, hay fever, and this should be checked prior to any tape
application.
CONCLUSION
Patellofemoral tape should always:
1) relieve pain immediately

2) be used in conjunction with an appropriate muscle training
programme.
3) be taught to the patient so they can self-manage.
REFERENCES
Bennell, K., Hodges, P., Mellor, R., Bexander, C., and Souvlis, T. 2004. "The
nature of anterior knee pain following injection of hypertonic saline into
the infrapatellar fat pad." Journal of Orthopaedic Research 22 (1):116-21.
4:CD006717.
Callaghan, M. J., Selfe, J., Bagley, P. J., and Oldham, J. A. 2002. "The Effects
of Patellar Taping on Knee Joint Proprioception." Journal of Athletic
Training 37 (1):19-24.
Callaghan, M.J., McKie, S., Richardson, P., Oldham, J.A,. “Effects of patellar
taping on brain activity during knee joint proprioception tests 7.1using
functional magnetic resonance imaging.” Physical Therapy 92 (2): 821-30.
Chang, W. D., Chen, F. C., Lee, C. L., Lin, H. Y., and Lai, P. T. 2015. "Effects
of Kinesio Taping versus McConnell Taping for Patellofemoral Pain
Syndrome: A Systematic Review and Meta-Analysis." Evidence-Based
Complementary and Alternative Medicine 2015:471208.
Derasari, A., Brindle, T. J., Alter, K. E., and Sheehan, F. T. 2010. "McConnell
taping shifts the patella inferiorly in patients with patellofemoral pain: a
dynamic magnetic resonance imaging study." Physical Therapy 90
(3):411-9.
Dye, S. F., Vaupel, G. L., and Dye, C. C. 1998. "Conscious neurosensory
mapping of the internal structures of the human knee without intraarticular
anesthesia." American Journal of Sports Medicine 26 (6):773-7.
Gilleard, W., McConnell, J., and Parsons, D. 1998. "The effect of patellar
taping on the onset of vastus medialis obliquus and vastus lateralis muscle
activity in persons with patellofemoral pain." Physical Therapy 78 (1):25-
32.
Hug, F., Ouellette, A., Vicenzino, B., Hodges, P. W., and Tucker, K. 2014.
"Deloading tape reduces muscle stress at rest and during contraction."
Medicine & Science in Sports & Exercise46 (12):2317-25.
Kase, K., Wallis, J., and Kase, T. 2003. Clinical Therapeutic Applications of
the Kinesio Taping Method. 2nd ed. ASIN B00PKJNGPW: Kinesio.
Leibbrandt, D. C., and Louw, Q. A. 2015. "The use of McConnell taping to
correct abnormal biomechanics and muscle activation patterns in subjects
with anterior knee pain: a systematic review." Journal of Physical
Therapy Science 27 (7):2395-404.
Macgregor, K., Gerlach, S., Mellor, R., and Hodges, P. W. 2005. "Cutaneous
stimulation from patella tape causes a differential increase in vasti muscle
activity in people with patellofemoral pain." Journal of Orthopaedic
Research 23 (2):351-8..
McConnell, J. 2000. "A novel approach to pain relief pre-therapeutic
exercise." Journal of Science and Medicine in Sport 3 (3):325-34.
Mostamand, Javid, Bader, Dan L., and Hudson, Zoe. 2010. "The effect of
patellar taping on joint reaction forces during squatting in subjects with
Patellofemoral Pain Syndrome (PFPS)." Journal of Bodywork and
Movement Therapies 14 (4):375-381.
Oliveira, A. K., Borges, D. T., Lins, C. A., Cavalcanti, R. L., Macedo, L. B.,
and Brasileiro, J. S. 2016. "Immediate effects of Kinesio Taping((R)) on
neuromuscular performance of quadriceps and balance in individuals
submitted to anterior cruciate ligament reconstruction: A randomized
clinical trial." Journal of Science and Medicine in Sport 19 (1):2-6.
Parreira, C., Costa, C., Hespanhol, L. C., Jr., Lopes, A. D., and Costa, L. O.
2014. "Current evidence does not support the use of Kinesio Taping in
clinical practice: a systematic review." Journal of Physiotherapy 60
(1):31-9.
100 Jenny McConnell
Selfe, J., Thewlis, D., Hill, S., Whitaker, J., Sutton, C., and Richards, J. 2011.
"A clinical study of the biomechanics of step descent using different
treatment modalities for patellofemoral pain." Gait & Posture 34 (1):
92-6.
Solomonow, M. 2004. "Ligaments: a source of work-related musculoskeletal
disorders." Journal of Electromyography and Kinesiology 14 (1):49-60.
Solomonow, M. 2012. "Neuromuscular manifestations of viscoelastic tissue
degradation following high and low risk repetitive lumbar flexion."
Journal of Electromyography and Kinesiology 22 (2):155-75.
Solomonow, M., Baratta, R. V., Zhou, B. H., Burger, E., Zieske, A., and
Gedalia, A. 2003. "Muscular dysfunction elicited by creep of lumbar
viscoelastic tissue." Journal of Electromyography and Kinesiology 13
(4):381-96.
Tobin, S., and Robinson, G. 2000. "The Effect of McConnell's Vastus
Lateralis Inhibition Taping Technique on Vastus Lateralis and Vastus
Medialis Obliquus Activity." Physiotherapy 86 (4):173–183.
Whittingham, M., Palmer, S., and Macmillan, F. 2004. "Effects of taping on
pain and function in patellofemoral pain syndrome: a randomized
controlled trial." Journal of Orthopaedic & Sports Physical Therapy 34
(9):504-10.
Williams, P. E., Catanese, T., Lucey, E. G., and Goldspink, G. 1988. "The
importance of stretch and contractile activity in the prevention of
connective tissue accumulation in muscle." Journal of Anatomy 158:
109-14.
Chapter 9
KNEE BRACES
Michael Callaghan
Manchester, UK
INTRODUCTION
Knee braces are commercially available for a variety of knee conditions,
including patellofemoral pain (PFP). Braces for PFP are usually a flexible
sleeve type. Some have a soft padding or support attached on the lateral side of
the brace close to the patella which the manufacturers state improves patellar
mal-alignment. It is only recently that we have been able to investigate if these
claims are true.
Keywords: bracing, pain, biomechanics
WHICH TYPE OF KNEE BRACE?

Although there are many knee braces commercially available there are
few which have been studied in PFP.
The Stabilization through External Rotation of the Femur (SERF®) brace
is designed to alter alignment of the patellofemoral joint. This is done not by
enveloping the knee joint but by externally rotating the femur by a long band
which wraps around the thigh and waist (Figure 9.1). This brace has not yet
been evaluated in a clinical trial and certainly not over any long term treatment
programme, but some studies have tried to assess its biomechanical effects in
PFP including its inventor Dr. Chris Powers. Other effects from the SERF®
brace are seen on the step down test. Powers, Souza, and Selkowitz (2007)
showed that the SERF® brace could significantly reduce the internal hip
rotation in five subjects with PFP. Lee, Souza, and Powers (2012) measured
medio-lateral centre of pressure excursion of the patella during a step down
task and found a significant difference of 8mm displacement between the
SERF® brace and no-brace conditions due to the hip being controlled by the
SERF® brace. Finally, significant reductions were found in knee valgus angle
in the coronal plane during a step down task with the SERF® brace
(Herrington 2013). The effect on pain of the SERF® brace was confirmed by
Powers, Souza, and Selkowitz (2007) and Herrington (2013) but only as a
within subjects analysis during the step down task. As yet, the SERF® brace
has never been subjected to a clinical trial. All of these studies examined small
sample sizes of patients with PFP and recorded an immediate decrease in
Visual Analogue Scale (VAS) pain scores just as patellar taping has been
found to cause an immediate decrease in pain (Callaghan and Selfe 2012).
This brace has been slightly redesigned, is now marketed as the Powers Strap
but to date has only been investigated on healthy subjects (Greuel, Jones, and
Herrington 2016, Greuel et al. 2016).
Another brace designed for treatment of patellofemoral problems is the
Bioskin® Q brace (Figure 9.2). This is a sleeve brace made of Lycra® and has
a Velcro® attachable ‘C’ shaped soft support which fits around patella. The
purpose of the support is to contain the movement of the patella. There have
been two randomised trials on this brace both on patients with patellofemoral
osteoarthritis (Hunter et al. 2011, Callaghan et al. 2015). Both showed
improved symptoms after 6 weeks and 12 weeks of treatment. In both trials the
recommended minimum time for wearing the brace was 3 hours daily. In the
Callaghan et al. trial, patients wore the brace on average for approximately 7
hours daily. There was a drop in VAS of 1.5mm for each extra hour the brace
was worn. Extrapolating these results to those with non-arthritic PFP should be
done cautiously. Evidence of patellar maltracking or malalignment was not
assessed or evident in those with patellofemoral osteoarthritis. But the
symptoms are very similar and it is possible that a successful brace treatment
in one PFP condition might be replicated in another. Similarly, it is possible
that other sleeve type braces might have the same effect as the Bioskin Q
brace.
Knee Braces 103
Figure 9.1. SERF® brace.
Figure 9.2. Bioskin® Q brace.

Figure 9.3. Donjoy® Reaction brace.
A third knee brace is the Donjoy® Reaction knee brace (Figure 9.3). This
is marketed as being suitable for those with anterior knee pain emanating from
a variety of conditions such as chondromalacia patellae, Osgood-Schlatter’s
disease, quadriceps and patella tendonitis/tendinosis, mild osteoarthritis (OA)
or patellofemoral tracking issues. Richards et al. (2015) studied this brace on
those with PFP and found that it gave a sense of improved knee stability
during functional tasks. As yet, there have been no clinical trials and no formal
assessment of pain relief in PFP for this brace.
HOW DO THESE BRACES WORK?

It is remarkable that PFP can be relieved during a stressful and difficult
task such as step down by applying a simple sleeve brace or by a brace which
does not even touch the patella. The success of either type of brace suggests
that there are biomechanical and non-biomechanical mechanisms to explain
their efficacy.
For the biomechanical mechanism, the SERF® brace is purported to work
by controlling hip and femoral rotation, changing mechanical stress at the
patellofemoral joint and ultimately decreasing pain. A useful analogy to give
to patients is if they think of the patella as a ‘train’ and the femur as a ‘rail
track’, then we are improving the movement of the patella by changing the
position of the ‘rail track’ (unlike all other braces which try and change the
Knee Braces 105
‘train’). Control of the hip and femur is now an integral part of patellofemoral
joint rehabilitation due to the growing consensus that proximal (i.e., hip)
mechanics are altered in women with PFP (often observed as excessive hip
adduction and/or internal rotation and referred to as ‘valgus collapse’)
although these altered mechanics have not been reported as consistently in
men (Witvrouw et al. 2014). Key to this explanation is validating the concept
that the SERF® brace is capable of causing external rotation of the femur.
There is now data using standing MRIs showing that the SERF® brace changes
patellofemoral joint alignment and position by externally rotating the femur
(Callaghan et al. 2016).
A sleeve brace such as the Bioskin® Q brace might work by increasing
the contact area between the patellar and femoral surfaces. Decreasing joint
stress by increasing contact area is a theory to explain the success of some
interventions in non-arthritic PFP. Two studies using standing MRIs have
shown a subtle biomechanical effect of two types of brace for PFP which is
more obvious in those with a lateralised patella (Callaghan, Guney, et al. 2016,
Callaghan, Reeves, et al. 2016).
The Donjoy® reaction brace most likely works as a consequence of
altered lower limb biomechanics due to an improvement in varus and valgus
movement control at the knee. Thus, there is no direct effect on the patella but
by a small movement of the femoral trochlea.
From the non-biomechanical perspective, there is a sensory stimulation
and proprioception explanation (Van Tiggelen, Coorevits, and Witvrouw
2008). Here the brace has the ability to improve joint position sense used as a
measure of proprioception. These findings are not unexpected because several
studies had already found that simple and inexpensive elasticated bandages
such as Tubigrip™ (Perlau, Frank, and Fick 1995) and a single strip of self-
adhesive tape across the patella (Callaghan et al. 2002, Callaghan et al. 2008)
improves active and passive joint position sense.
A further explanation of the non-biomechanical effects of bracing can be
found by looking at response in the brain after the application of the sleeve
type brace on subjects with healthy knees. These results are not directly
applicable to knee problems such as PFP as these were done on asymptomatic
subjects, but they provide us with clues of the mechanisms for braces. Thijs et
al. (2010) found that both a tight elasticated knee brace and a less tight knee
sleeve increased brain activity in the sensory motor cortex in contrast to a no
brace condition. This suggests that even a light compression of the knee
creates a sensory stimulus to the sensory motor cortex when the knee is
moving. The fMRI detected effects of the brace on the brain are supported by
similar findings for patellar taping (Callaghan et al. 2012).
One final thing about brace wearing is that clinicians often warn patients
that wearing a knee brace will ’make your muscles weak’. This is not true. We
now have evidence in patellofemoral OA that after 12 weeks, a knee brace
does not make the knee extensors weaker as traditionally thought. In fact there
is a slight improvement in strength and a reduction in quadriceps inhibition
(Callaghan, Parkes, and Felson 2016). This is likely due to the patient feeling
more stability, security and confidence in their knee when the brace is on
which in turn means greater use of the leg in less painful circumstances.
CONCLUSION
There is good evidence in those with PFP resulting from underlying
pathology of osteoarthritis that knee braces are effective in relieving pain and
improving function. The symptoms are similar to non-arthritic PFP. It is likely
that the brace has a biomechanical effect and a proprioceptive effect. It also
has a powerful placebo effect, which should be embraced rather than rejected
in terms of the clinical management of this difficult condition.
REFERENCES
Callaghan, M. J., Guney, H., Reeves, N. D., Bailey, D., Doslikova, K.,
Maganaris, C. N., Hodgson, R., and Felson, D. T. 2016. "A knee brace
alters patella position in patellofemoral osteoarthritis: a study using weight
bearing magnetic resonance imaging." Osteoarthritis Cartilage
24(12):2055-2060
Callaghan, M. J., Parkes, M. J., and Felson, D. T. 2016. "The Effect of Knee
Braces on Quadriceps Strength and Inhibition in Subjects With
Patellofemoral Osteoarthritis." Journal of Orthopaedic and Sports
Physical Therapy 46 (1):19-25.
Callaghan, M. J., Parkes, M. J., Hutchinson, C. E., Gait, A. D., Forsythe, L.
M., Marjanovic, E. J., Lunt, M., and Felson, D. T. 2015. "A randomised
trial of a brace for patellofemoral osteoarthritis targeting knee pain and
bone marrow lesions." Annals of the Rheumatic Diseases 74 (6):1164-
1170.
Knee Braces 107
Callaghan, M. J., Reeves, N. D., Cootes, T. F., Hodgson, R., and Felson, D. T.
2016. "Two Different Knee Braces Alter Patella Position: A Moving
Image Analysis Using Weight Bearing Magnetic Resonance Imaging."
Osteoarthritis and Cartilage 24:S492-S494.
4:CD006717.
Callaghan, M. J., Selfe, J., Bagley, P., and Oldham, J. A. 2002. "The effect of
patellar taping on knee joint proprioception." Journal of Athletic Training
37 (1):19-24.
Callaghan, M. J., McKie, S., Richardson, P., and Oldham, J.A. 2012. "Effects
of Patellar Taping on Brain Activity During Knee Joint Proprioception
Tests Using Functional Magnetic Resonance Imaging." Physical Therapy
92 (6):821-830.
Greuel, H, Jones, R., and Herrington, L. 2016. "The Powers™ strap modifies
the hip internal rotation during the stance phase of running." Gait &
Posture 49, Supplement 2:84-85.
Greuel, H, Jones, RK, Herrington, L, and Anmin, L. 2016. "The powers strap
modifies hip and knee movement during the single leg squat and the single
leg step down task." British Journal of Sports Medicine 50 (22):e4-e4.
Herrington, L. 2013. "Effect of a SERF strap on pain and knee-valgus angle
during unilateral squat and step landing in patellofemoral patients."
Journal of Sport Rehabilitation 22 (1):27-32.
Hunter, D. J., Harvey, W., Gross, K. D., Felson, D., McCree, P., Li, L., Hirko,
K., Zhang, B., and Bennell, K. 2011. "A randomized trial of
patellofemoral bracing for treatment of patellofemoral osteoarthritis."
Osteoarthritis and Cartilage 19 (7):792-800.
Lee, S. P., Souza, R. B., and Powers, C. M. 2012. "The influence of hip
abductor muscle performance on dynamic postural stability in females
with patellofemoral pain." Gait & Posture 36 (3):425-429.
Perlau, R., Frank, C., and Fick, G. 1995. "The effect of elastic bandages on
human knee proprioception on the uninjured population." American
Powers, C.M., Souza, R.B., and Selkowitz, D. M. 2007. "The effect of femoral
strapping on pain response, hip rotation and gluteus maximus activation in
persons with patellofemoral pain." Physiotherapy 93 (S1):S198.
Richards, J., Chohan, A., Janssen, J., and Selfe, J. 2015. "Taping and bracing
of the knee joint: a ladder of conservative intervention for patellofemoral
pain." Physiotherapy 101, Supplement 1:e1280-e1281.
Thijs, Y., Vingerhoets, G., Pattyn, E., Rombaut, L., and Witvrouw, E.. 2010.
"Does bracing influence brain activity during knee movement: an fMRI
study." Knee Surgery, Sports Traumatology, Arthroscopy 18 (8):1145-
1149.
Van Tiggelen, D., Coorevits, P., and Witvrouw, E. 2008. "The use of a
neoprene knee sleeve to compensate the deficit in knee joint position
sense caused by muscle fatigue." Scandinavian Journal of Medicine &
Science in Sports 18 (1):62-66.
Witvrouw, E., Callaghan, M. J., Stefanik, J. J., Noehren, B., Bazett-Jones, D.
M., Willson, J. D., Earl-Boehm, J. E., Davis, I. S., Powers, C. M.,
McConnell, J., and Crossley, K. M. 2014. "Patellofemoral pain: consensus
statement from the 3rd International Patellofemoral Pain Research Retreat
held in Vancouver, September 2013." British Journal of Sports Medicine
48 (6):411-414.
Chapter 10
THE USE OF FOOT ORTHOSES IN

THE MANAGEMENT
OF PATELLOFEMORAL PAIN
Sarah A. Curran
Cardiff School of Health Sciences, Cardiff Metropolitan University,
Cardiff, UK
INTRODUCTION
For over 35 years, a steady stream of research papers have attempted to
establish a link between abnormal foot pronation and patellofemoral pain
(PFP), but the scientific explanation of this complex relationship is still poorly
understood. Foot orthoses are typically used to manage PFP and a number of
clinical studies have shown that they reduce pain levels, improve function and
satisfaction rates. The specific ‘mechanism of action’ of foot orthoses remains
unclear with much of the literature focussed on modifying kinematic
behaviour of the lower limb during weight bearing activities. This chapter
provides a review on the theoretical and clinical status of the proposed
relationship between abnormal foot function, foot orthoses and PFP. The
chapter also provides an overview of clinical assessment and considerations
for prescribing foot orthoses.
Keywords: foot orthoses, kinetics, kinematics, clinical assessment

110 Sarah A. Curran
FOOT FUNCTION AND THE LOWER LIMB:

BIOMECHANICAL OVERVIEW
The foot is described as an intricate multi-articular structure which
supports the lower limb and acts as the interface between the ground and the
lower limb kinetic chain (Donatelli 1996). Rose (1962) published a seminal
paper illustrating the effect of this functional anatomical relationship using a
rod imbedded into the tibia (in-vivo) to demonstrate how movements of the
subtalar joint, pronation and supination are associated with internal and
external tibial rotation (Figure 10.1). The mechanism shows how there is a
functional anatomical link between the tibia and how it can be associated with
proximal pathology. In terms of the influence on the patella, rotation of tibia
produces rotation of the patella due to it being fixed to the tibia via the patellar
tendon. Various studies have shown that external rotation of the tibia (15
degrees) can increase the contact pressures on the facets of the patella, whilst
internal rotation (15 degrees) can increase the contact pressures on the medial
facet of the patella, and occurs as the knee is slightly flexed (Lee et al., 2001,
Csintalan et al., 2002, Salsich and Perman 2007, Ward, Terk, and Powers
2007, Post, Teitge, and Amis 2002, Hautamaa et al., 1998) (Figure 10.2).
These observations provide evidence of the patellofemoral joint’s
predisposition to instability and pain in this position, and is further supported
by Barton et al., (2012) who used three-dimensional motion analysis during
walking. They noted an association between increased rearfoot eversion and
an increase in peak internal rotation of the tibia whilst walking in 26
individuals with PFP compared to 20 individuals in a control group.
In comparison to tibial rotation, femoral rotation with the patella is
perceived to be more complex undergoing a translational motion due to the
combination of forces from the trochlear groove and ligamentous structures.
Evidence also suggests that femoral rotations of 20 to 30 degrees can increase
pressures on the lateral facet of the patella with internal rotation and the
medial facet of the patella with external rotation. (Powers et al., 2002, Reischl
et al., 1999) (Figure 10.3). It is also important to remember that as the patella
is a sesamoid bone, embedded within the quadriceps tendon (continuation of
rectus femoris) it does not always follow the rotations of the femur in the same
way as those of tibial rotation.
The Use of Foot Orthoses … 111
Figure 10.1. Three photos recreate Rose’s (1962) tibial rotation and subtalar joint
motion method using an external tibial pointer (rather than inserting a rod into the
tibia). Photo A shows a supinated position, photo B a relaxed position and photo C a
pronated position.
In considering the above points, by its positional virtue of providing a

platform, the foot can be considered to orchestrate (and compensate) lower
limb rotations. In addition, the knee is designed to absorb rotatory forces
through transverse plane rotation (Bellchamber and van den Bogert 2000).
However, the complexity and extent of this rotation is dependent on the ability
of the muscles, ligaments and tendons of each individual which may absorb
this motion, and is known as the ‘lag concept’ (Nester 2000).
EVIDENCE FOR THE USE OF FOOT ORTHOSES AND PFP

Foot orthoses are frequently used as part of the conservative management
approach for PFP (Barton et al., 2015). The basic biomechanical principle for
this form of intervention is based on minimising abnormal foot pronation and
associated lower limb rotations. Historically, James (1979) was one of the first
to recognise the link between abnormal pronation and PFP and coined the term
‘miserable malalignment’, however it is Tiberio (1987) who has been
consistently quoted in the literature for proposing a theoretical model that
abnormal pronation would increase internal tibial rotation, delaying external
rotation of the tibia and knee extension during the latter part of stance phase.
In response, an increase of internal femoral rotation would be required, which
in turn increases hip adduction.
112 Sarah A. Curran
Figure 10.2. Tibial rotation and its effect on the patella. A) Internal rotation causes the
patella to move medially which results in an increase in contact of the medial patella
facet and femoral condyle, and increase the inferior loading on the medial patella facet.
(B). A) Neutral rotation of the tibia produces equal contact and pressure distribution on
patella facets and femoral condyles (B). A) External rotation results in lateral rotation
of the patella increasing the contact of the lateral patella facet and femoral condyle.
This results in higher loading of the lateral patella facet (B).
Figure 10.3. Femoral rotation and its effect on the patella. A) Internal rotation causes
the patella to move in a lateral direction which increases the contact and pressure on
the lateral patella facet and femoral condyle (B). A) Neutral rotation of the femur
produces equal contact and pressure distribution on patella facets and femoral condyles
(B). A) External rotation causes the patella to move medially which increases the
contact of the medial patella facet and femoral condyle resulting in higher loading of
the lateral patella facet (B).
Whilst evidence exists to suggest that foot orthoses can successfully treat
PFP with studies reporting a general reduction of pain ratings and improved
satisfaction, there are some inconsistencies (Saxena and Haddad 2003, Amell,
Stothart, and Kumar 2000, Gross, Davlin, and Evanski 1991, Blake and
Denton 1985). These discrepancies relate to the retrospective nature of the data
collected in the earlier studies, insufficient information concerning foot type
and lower limb characteristics, details of foot orthosis fabrication, and the
effects the foot orthoses on functional performance (pain and symptoms)
(Barton et al., 2010).
In a systematic review, Barton et al. (2010) identified only one
randomised controlled trial by Collins et al., (2008) which showed
improvements in PFP at 6 weeks in the group who received pre-fabricated foot
orthoses compared to the group who received flat inserts, multi-modal
physiotherapy, and a combination of foot orthoses and physiotherapy. Whilst
this supports the theoretical assumption that foot orthoses control abnormal
foot function; the rationale for successful improvements may not always be
dominated by changes in kinematic behaviour. The very nature of wearing a
foot orthosis that is contoured to support the arch (and control calcaneal
eversion) can increase surface area and dissipate ground reaction forces and
alter muscle activity of the limb. In particular, it could be assumed that pre-
fabricated orthoses can discreetly alter function of the lower limb. This is
supported by the preferred movement pathway paradigm introduced by Nigg
(2001) which suggests that foot orthoses rather than realigning the bony
skeleton can filter impact forces placed upon the foot and adjust muscular
response. Empirical research by Hertel, Sloss, and Earl (2005) showed that,
regardless of foot type and rearfoot posting (medial or lateral) an increase in
gluteus medius and vastus medialis muscle activity was noted with a pre-
fabricated foot orthosis during a lateral step down and single leg squat task. A
further study by Lack et al., (2014) showed that during a step-up task, 20
individuals with PFP had a combined immediate reduction of peak amplitude
of the gluteus medius, earlier vastus medialis oblique onset and reduced
kinematic changes of hip adduction and knee internal rotation with foot
orthoses. In contrast, Boldt et al., (2013) showed that the use of 6 degree
medially wedged foot orthoses had a minimal effect on hip and knee motion in
20 female runners with PFP. The calcaneal angle was also unchanged with the
use of these orthoses. However, the medial wedge was full length which does
not correlate with clinical intervention for foot orthosis prescription.
Moreover, the addition of the wedge under the first metatarsal head can reduce
114 Sarah A. Curran
the function and stability of the foot (i.e., Hicks windlass mechanism) and
therefore reduces the clinical and functional appeal.
Functional activities are a predominant factor in exacerbating and causing
PFP. Assessing functional performance therefore is an important parameter. In
a study of 52 individuals with PFP, Barton, Menz, and Crossley (2011)
determined the immediate effect of pre-fabricated foot orthoses whilst
performing various tasks of single leg squat, pain free step downs and single
leg rise to determine the immediate effect of pre-fabricated foot orthoses.
Significant improvements were noted with the pre-fabricated foot orthoses
when each of the tasks were performed. These improvements were also linked
to individuals who had a more pronated foot posture and footwear which
lacked motion control, highlighting the need to assess patient suitability prior
to considering foot orthoses intervention. The influence of foot orthoses on
functional performance at 6, 12 and 52 weeks should be explored to determine
short to long term success.
CLINICAL ASSESSMENT AND PRESCRIBING FOOT

ORTHOSES – YOUR APPROACH
Whilst every clinician’s approach to patient assessment will differ to
accommodate time, cost, and other factors, it is important that your approach
should be standardised with a view of providing the evidence to support and
rationalise your management strategies. Although not really discussed
previously in this chapter, the role of foot and ankle characteristics should be
considered and recorded to provide baseline information. In particular, clinical
measures for foot posture such as the Foot Posture Index (version 7)
(Redmond, Crosbie, and Ouvrier 2006) and the navicular drop demonstrate
reliability and a relationship with PFP. In particular, they provide a baseline
and reference point to define foot posture. There are several tutorials online
which explain how to perform the Foot Posture Index or the navicular drop
test. The Foot Posture Index in particular is a useful and popular tool since,
unlike the navicular drop which measures one aspect (one plane) of foot
posture, it is a multi-dimensional, multiplanar tool which scores a range of foot
characteristics, combining it into one result (Redmond, Crosbie, and Ouvrier
2006). Normal values presented are of a slightly pronated foot posture (FPI
raw score of +5). Obtaining these measures with the patient in their own
relaxed standing posture is important since a contrived stance position may not
provide a true representation of anatomical /functional alignment. This can

often distort and bias clinical measures of the lower limb. However, many
traditional clinical measures are static in nature, and are consistently criticised
by their inability to predict dynamic significance. With this in mind, the
addition of functional performance tasks such those previously mentioned
(single leg squat, pain free step downs and single leg rise) combined with a
five-point Likert scale (more painful, somewhat painful, no change, less
painful, no pain) can add further information to predicting foot orthosis
interventions (Barton, Menz, and Crossley 2011).
Prescribing Foot Orthoses
Foot orthoses come in various forms, and range from simple (flatbed)
devices, minimally contoured insoles, pre-fabricated devices (that can be
customised) and a full custom made device that can be produced from casts,
CAD/CAM or three dimensional printing. Within the most recent evidence, it
appears that pre-fabricated foot orthoses offer a reduction of pain and improve
function in patients with patellofemoral joint. These observations are also
linked to other musculoskeletal conditions of the lower limb (Richter, Austin,
and Reinking 2011). Of critical consideration prior to proceeding to
prescribing foot orthoses is the recognition of whether footwear will
accommodate them. The performance of foot orthosis can be enhanced by the
correct, accommodating and supportive footwear and compromised when it is
incorrect. This guidance for clinicians is further supported by the work of
Barton, Menz, and Crossley (2011) who employed the motion control
properties from the Footwear Assessment Tool (Barton et al., 2009) and are
shown in table 10.1. Their study of 60 individuals with PFP showed that a
combined combination of clinical predictors which included poor motion
control of footwear, a reduction of pain during a single leg squat and limited
ankle joint dorsiflexion had an increased 25% to 78% probability improvement
with pre-fabricated foot orthoses. In comparison, the Footwear Comfort Scale
can also be incorporated into the assessment and used with foot orthoses
intervention. This particular scale has been used by a number of authors and
consists of eight questions which rates perceived comfort on a 15mm visual
analogue scale (15mm: 0 points = not comfortable; 15 points = most
comfortable) (table 10.2) (Curran, Holliday, and Watkeys 2010, Eslami et al.,
2009, Yung-Hui and Wei-Hsien 2005, Mundermann et al., 2002). Whilst no
studies have incorporated the Footwear Comfort Scale for patients with PFP, it
116 Sarah A. Curran
does offer an alternative, particularly as comfort perception may influence

function (preferred motion of pathway paradigm – Nigg (2001)).
Table 10.1. Footwear motion characteristics from the Footwear

Assessment Tool
Section Response
Fixation method Laces, other none
Dual density soles Present or non-present
Heel counter stiffness Absent, minimal, moderate, rigid
Midfoot sagittal and torsional stiffness Minimal, moderate or rigid
Table 10.2. Footwear Comfort Scale
1. Overall comfort
2. Heel cushioning
3. Forefoot cushioning
4. Medio-lateral control
5. Arch height
6. Heel cup
7. Heel width
8. Shoe length
SUMMARY
This chapter reviewed the theoretical and clinical relationship of lower
limb function and the foot. Abnormal foot pronation continues to be linked
with PFP and whilst the kinematic behaviour of the lower limb should be
acknowledged, the notion that foot orthoses directly influence this should be
viewed with caution. Alternative paradigms and reasoning potentially serve as
evidence to rationalise foot orthosis prescription for patients with PFP, which
is based on comfort and changes in muscle activity. However, the therapeutic
effect requires further research. Each patient should be managed on an
individual basis that incorporates functional significance and comfort for fit
for foot orthoses, along with assessment of footwear.
REFERENCES
Amell, TK, Stothart, JP, and Kumar, S. 2000. "The effectiveness of functional
foot orthoses as a treatment for patellofemoral stress syndrome: the client's
perspective." Journal of Physiotherapy Canada 52:153 - 157.
Barton, C. J., Lack, S., Hemmings, S., Tufail, S., and Morrissey, D. 2015.
"The 'Best Practice Guide to Conservative Management of Patellofemoral
Pain': incorporating level 1 evidence with expert clinical reasoning." In
British Journal of Sports Medicine 49(14):923-34.Barton, C. J., Levinger,
P., Crossley, K. M., Webster, K. E., and Menz, H. B. 2012. "The
relationship between rearfoot, tibial and hip kinematics in individuals with
patellofemoral pain syndrome." Clinical Biomechanics 27 (7):702-5.
Barton, C. J., Levinger, P., Menz, H. B., and Webster, K. E. 2009. "Kinematic
gait characteristics associated with patellofemoral pain syndrome: a
systematic review." Gait & Posture 30 (4):405-16.
Barton, C. J., Menz, H. B., and Crossley, K. M. 2011. "Clinical predictors of
foot orthoses efficacy in individuals with patellofemoral pain." Medicine
& Science in Sports & Exercise 43 (9):1603-10.
Barton, C. J., Munteanu, S. E., Menz, H. B., and Crossley, K. M. 2010. "The
efficacy of foot orthoses in the treatment of individuals with
patellofemoral pain syndrome: a systematic review." Sports Medicine 40
(5):377-95.
Bellchamber, TL, and van den Bogert, AJ. 2000. "Contributions of proximal
and distal moments to axial tibial rotation during walking and running."
Journal of Biomechanics 33 (11 (November)):1397 - 1403.
Blake, RL, and Denton, JA. 1985. "Functional foot orthoses for athletic
injuries. A retrospective study." Journal of American Podiatric Medical
Association 75:359 - 362.
Boldt, A. R., Willson, J. D., Barrios, J. A., and Kernozek, T. W. 2013. "Effects
of medially wedged foot orthoses on knee and hip joint running mechanics
in females with and without patellofemoral pain syndrome." Journal of
Applied Biomechanics 29 (1):68-77.
Collins, N., Crossley, K., Beller, E., Darnell, R., McPoil, T., and Vicenzino, B.
2008. "Foot orthoses and physiotherapy in the treatment of patellofemoral
pain syndrome: randomised clinical trial." British Medical Journal
337:a1735.
Csintalan, R. P., Schulz, M. M., Woo, J., McMahon, P. J., and Lee, T. Q.
2002. "Gender differences in patellofemoral joint biomechanics." Clinical
Orthopaedics and Related Research (402):260-9.
118 Sarah A. Curran
Curran, SA., Holliday, JL., and Watkeys, L. 2010. "Influence of High Heeled
Footwear and Pre-fabricated Foot Orthoses on Energy Efficiency in
Ambulation." Foot and Ankle Online Journal 3 (3).
Donatelli, DA. 1996. "Normal anatomy and biomechanics." In The
biomechanics of the foot and ankle, edited by DA. Donatelli, 3-33.
Philadelphia: FA Davis Company.
Eslami, M., Tanaka, C., Hinse, S., Anbarian, M., and Allard, P. 2009. "Acute
effect of orthoses on foot orientation and perceived comfort in individuals
with pes cavus during standing." Foot (Edinb) 19 (1):1-6.
Gross, ML, Davlin, LB, and Evanski, PM. 1991. "Effectiveness of orthotic
shoe inserts in the long-distance runner." American Journal of Sports
Medicine 19 (4 Jul-Aug):409 - 12.
Hautamaa, PV, Fithian, DC, Kaufman, KR, Daniel, DM, and Pohlmeyer, AM.
1998. "Medial soft tissue restraints in lateral patellar instability and
repair." Clinical Orthopaedics and Related Research 349 (4):174 - 182.
Hertel, J., Sloss, B. R., and Earl, J. E. 2005. "Effect of foot orthotics on
quadriceps and gluteus medius electromyographic activity during selected
exercises." Archives of Physical Medicine and Rehabilitation 86 (1):26-
30.
James, SJ. 1979. "Chondromalacia of the patella in the patella." In The Injured
Adolescent Knee, edited by JC Kennedy. Baltimore: Williams and
Wilkins.
Lack, S., Barton, C., Woledge, R., Laupheimer, M., and Morrissey, D. 2014.
"The immediate effects of foot orthoses on hip and knee kinematics and
muscle activity during a functional step-up task in individuals with
patellofemoral pain." Clinical Biomechanics 29 (9):1056-62.
Lee, T. Q., Yang, B. Y., Sandusky, M. D., and McMahon, P. J. 2001. "The
effects of tibial rotation on the patellofemoral joint: assessment of the
changes in in situ strain in the peripatellar retinaculum and the
patellofemoral contact pressures and areas." Journal of Rehabilitation
Research & Development 38 (5):463-9.
Mundermann, A., Nigg, B. M., Stefanyshyn, D. J., and Humble, R. N. 2002.
"Development of a reliable method to assess footwear comfort during
running." Gait & Posture 16 (1):38-45.
Nester, C. 2000. "The relationship between transverse plane leg rotation and
transverse plane motion at the knee and hip during normal walking." Gait
& Posture 12 (3):251-6.
Nigg, B. M. 2001. "The role of impact forces and foot pronation: a new
paradigm." Clinical Journal of Sport Medicine 11 (1):2-9.
Post, WR, Teitge, R, and Amis, AA. 2002. "Patellofemoral joint alignment:
Looking beyond the viewbox." Clinics in Sports Medicine 21:521 - 546.
Powers, CM, Chen, PY, Reischl, SF, and Perry, J. 2002. "Comparison of foot
pronation and lower extremity rotation in persons with and without
patellofemoral pain." Foot and Ankle International 23 (7 Jul):634-40.
Redmond, A. C., Crosbie, J., and Ouvrier, R. A. 2006. "Development and
validation of a novel rating system for scoring standing foot posture: the
Foot Posture Index." Clinical Biomechanics 21 (1):89-98.
Reischl, SF, Powers, CM, Rao, S, and Perry, JE. 1999. "Relationship between
foot pronation and rotation of the tibia and femur during walking." Foot
and Ankle International 20 (8 Aug):513 - 20.
Richter, R. R., Austin, T. M., and Reinking, M. F. 2011. "Foot orthoses in
lower limb overuse conditions: a systematic review and meta-analysis--
critical appraisal and commentary." Journal of Athletic Training 46
(1):103-6.
Rose, G. K. 1962. "Correction of the pronated foot." The Journal of bone and
joint surgery. British volume 44-b:642-7.
Salsich, GB, and Perman, WH. 2007. "Patellofemoral joint contact area is
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patellofemoral joint pain." Journal of Orthopaedic and Sports Physical
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Saxena, A., and Haddad, J. 2003. "The effect of foot orthoses on
patellofemoral pain syndrome." Journal of American Podiatric Medical
Association 93 (4 Jul -Aug):264-271.
Tiberio, D. 1987. "The effect of excessive subtalar joint pronation on
patellofemoral mechanics: a theoretical model." Journal of Orthopaedic
& Sports Physical Therapy 9 (4):160-5.
Ward, SR, Terk, MR, and Powers, CM. 2007. "Patella alta: Association with
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Yung-Hui, L., and Wei-Hsien, H. 2005. "Effects of shoe inserts and heel
height on foot pressure, impact force, and perceived comfort during
walking." Applied Ergonomics 36 (3):355-62.
Chapter 11
RADIOLOGY OF THE
PATELLOFEMORAL JOINT
Zeid Al-Ani, Gulraiz Ahmad and Waqar Bhatti

Department of Radiology, University Hospital South Manchester NHS
Trust, Manchester, UK
INTRODUCTION
Patients with patellofemoral pain (PFP) are often referred for imaging
when their symptoms have not responded to conservative interventions. In this
chapter, we will discuss the modalities used to assess the patellofemoral joint,
their advantages and limitations. This will be followed by case examples with
further discussion on the role of radiology in diagnosis and management of
patellofemoral joint disease. The Royal College of Radiologists have issued
guidelines for radiological investigations the iRefer Guidelines
(www.irefer.org.uk). The suggested modified guidelines for PFP are
summarised in table 11.1 below.
Keywords: radiology, MRI, ultrasound, x-ray

122 Zeid Al-Ani, Gulraiz Ahmad and Waqar Bhatti
Table 11.1. Modified iRefer guidelines
Condition Investigation Dose of Recommendation

Radiation
PFP due to PF OA X-ray Ionising Only specific circumstances
PFP due to patella Ultrasound None Anterior knee pain
tendinopathy, bursitis, fat
pad impingement
PFP due to persistent MRI None Often first line investigation
undiagnosed pain
X-RAY IMAGING
Plain radiographs provide valuable information about the patellofemoral
joint and often are the first imaging modality in acute trauma settings. Two
knee projections, an anteroposterior and lateral radiograph are routinely
performed. The positions for taking plain radiographs are in Figure 11.1. The
normal bony anatomy of the knee joint is in Figure 11.2. Knee radiographs are
assessed by the ‘ABCS’ method. A = alignment, B = Bones outline and
density, C = cartilage (joint spaces) and S = soft tissues. The latter can often
provide a lot of information on conditions such as effusion, prepatellar
bursitis, other soft tissue swelling and even tendinopathy.
Figure 11.1. The common positions used for radiographic assessment of patellofemoral
joint. A- Anteroposterior radiograph, B- Lateral flexion radiograph, C- Lateral cross
table radiograph, D- Skyline projection radiograph.
Radiology of the Patellofemoral Joint 123
Figure 11.2. Normal anatomy of the patellofemoral joint on (A) AP and (B) lateral
cross table radiographs.
In acute trauma, the lateral radiograph is usually performed with the knee
in full extension with the tibia parallel to the table top (cross table projection
Figure 11.1c) to demonstrate any significant knee joint effusion (Figure 11.3)
bursitis (Figure 11.4) or lipohaemoarthrosis (Figure 11.5). The latter indicates
a fracture line extending to the joint surface with resultant release of a mixture
of fat and blood into the joint with resultant classic fat - blood level. Acute
fractures (Figure 11.6) mimicking bipartite/multipartite patella (Figure 11.7)
can also be demonstrated. In acute trauma settings and in the absence of a
fracture, knee joint effusion usually indicates ligamentous injury that may
require further imaging.
Figure 11.3. Joint effusion. (A) Small and (B) Large joint effusions in the suprapatellar
pouch.
Figure 11.4. Prepatellar bursitis. Lateral knee radiograph showing significant soft
tissue swelling anterior to the patella in keeping with prepatellar bursitis.
Figure 11.5. Lipohaemoarthrosis. (A) Lateral (sagittal plain) knee radiograph and (B)
MRI sagittal T1 weighted image showing lipohaemoarthrosis secondary to a PCL
avulsion and intra articular fracture leading to layering of fat and blood within the knee
joint.
Figure 11.6. Patella fracture. (A) AP and (B) Lateral knee radiograph demonstrating a
transverse displaced patellar fracture. The fracture is comminuted with further non-
displaced fracture lines seen through the inferior patellar pole.
Figure 11.7. Bipartite patella. AP knee radiograph demonstrating a bipartite (two-part)

patella. The superolateral position of the accessory ossification centre is the
commonest.
For assessment of patellofemoral joint degenerative changes, a non-weight

bearing, lateral flexed knee radiograph is used (Brower and Flemming 1997).
In some hospitals, a skyline (axial) projection can also be performed for this
purpose. Plain radiography is also employed for the assessment of
patellofemoral joint osteoarthritis and an axial (skyline) view can be added
(Figure 11.8).
Figure 11.8. Patellofemoral joint degenerative changes. (A) AP, (B) Lateral and (C)
Skyline radiographs demonstrating Patellofemoral joint degenerative changes as
evident by the reduction in medial facet joint space and marginal osteophyte formation.
ULTRASOUND
Ultrasound has several advantages over plain radiography. It is a dynamic
assessment particularly useful in the assessment of dynamic fat pad
impingement and clicking knees, has high spatial resolution (Figure 11.9),
allows sonographic palpation to elicit tender areas and its Doppler capabilities
allow for assessment of neovascularity. This is particularly useful in the
evaluation and grading of patella tendinopathies and inflammatory

arthropathies. Ultrasound can readily assess superficial swellings around the
patellofemoral joint and guide interventional procedures such as high volume
saline or steroid injections (Figures 11.10 and 11.11), aspiration and biopsies.
Figure 11.9. Normal patellar tendon on ultrasound assessment with a uniform linear
organised fibrillar pattern.
Figure 11.10. Longitudinal plane image. Ultrasound guided injection of steroid into the
supralateral Hoffa’s fat pad for the treatment of fat pad impingement.
Figure 11.11. Transverse plane image. Patellar tendon paratenon injection.
MAGNETIC RESONANCE IMAGING (MRI)

MRI, in the opinion of many clinicians, is the imaging test of choice for
PFP. It is a non-ionising modality and allows for a complete global assessment
of all the anterior knee structures including the patella tendon, infrapatellar fat
pads, the patella itself, the patellofemoral joint articular cartilage and the
various ligaments including the medial patellofemoral ligament (MPFL) and
tendons around the knee. It is very sensitive for detecting bone marrow
oedema changes and oedematous/inflammatory changes within the soft tissues
around the patellofemoral joint. Examples of this will be included later in the
chapter.
COMPUTERISED TOMOGRAPHY
Computerised Tomography (CT) referrals for assessment of the
patellofemoral joint are not common in many hospitals. Indications include
assessment of patellofemoral joint when MRI is contraindicated where
typically CT with intra-articular contrast injection into the joint can assess the
patellofemoral joint cartilage for thinning, fissuring (Figure 11.12),
osteochondral injuries and loose bodies (Outerbridge 1961).
Figure 11.12. CT arthrogram in the transverse plane showing grade 3 chondral

fissuring through the patella articular surface.
A modified grading system as described by Outerbridge (1961) is used to

describe the spectrum of changes encountered within the patella articular
cartilage from softening, fraying, fibrillation or full thickness defects in the
articular cartilage.
 Grade 1 – Focal softening or blistering of the articular cartilage, with

swelling and loss of the normal laminar appearance to the articular
cartilage
 Grade 2 – focal chondral surface fraying building typically less than
50% of the articular cartilage thickness.
 Grade 3 – focal chondral fibrillation extending through greater than
50% but not full thickness.
 Grade 4 – focal full thickness chondral loss, with exposed bone plus
or minus subchondral marrow oedema.
Most detailed MRI reports describe the extent of these changes to both the
femoral and patellar articular surfaces, but not all changes described may
account for the patient’s symptoms.
CASE 1
A 25-year-old man who was tackled while playing rugby and injured his
knee. Plain film showed joint effusion but no definite fracture.
Figure 11.13. MRI Coronal PD fat suppressed (left) and Axial PD fat suppressed
(right) images.
Diagnosis: Traumatic patellar dislocation with background trochlear

dysplasia.
Discussion: The case demonstrates characteristic findings indicating
recent patellar dislocation. The patella almost always dislocates laterally. The
common mechanism of injury is valgus force to a flexed and internally rotated
knee Kramer et al., (2009). Trauma on its own is not usually sufficient to
cause patellar dislocation and most patients would have an underlying
predisposing factor. Plain radiographs are often the first imaging performed.
This will show the position of the patella and assess for any acute bony
injuries. The lateral knee radiograph can evaluate the trochlea by assessing its
normal relations to the femoral condyles. On a true lateral knee radiograph, the
floor of the femoral trochlea should not cross the ventral outlines of the
femoral condyles. In trochlear dysplasia, the floor of the trochlea maybe seen
crossing the femoral condyles. This is referred to as the ‘crossing sign’ (Figure
11.14) (Pfirrmann et al., 2000).
Figure 11.14. Plain radiograph assessment of trochlear dysplasia. (A) Normal relation
of the trochlea to the femoral condyles on a lateral radiograph, the trochlear floor
(dashed line) is dorsal to the femoral condyles (dotted line). (B) Abnormal relation of
the trochlea to the femoral condyles in a patient with trochlear dysplasia. The lateral
radiograph demonstrates the “crossing sign” Where the trochlear floor (dashed line)
crosses the femoral condyles outline (dotted line) indicating that the trochlea is
dysplastic at that site.
In addition to helping establish the diagnosis of dislocation, MRI can

assess the severity of the injury and the presence of any predisposing factors
Dieredrichs et al., (2010). These are summarised in Table 11.2 along with the
methods used for measurement on MRI (Pfirrmann et al., 2000 and
Dieredrichs et al., 2010) and allows for the assessment of femoral trochlear
dysplasia. Trochlear dysplasia is one of the main factors, predisposing to
patellofemroal maltracking. Dejour et al., (1990) have classified this into 4
subtypes (Table 11.3) based on the morphological appearance of the trochlea.
The type of dysplasia has direct implication on the surgical corrective
technique. Other factors that reduce the dynamic stability of the patellofemoral
joint are high patella position (patella alta) and lateralisation of the tibial
tuberosity. It is worth mentioning that patella alta is considered a normal
anatomic variant and can be seen in asymptomatic people. However, this is
important to assess in the settings of patellar dislocation and patellofemoral
joint instability (Pfirrmann et al., 2000 and Dejour et al., 1990).
Table 11.2. Various measurements for patellofemoral joint instability that

we usually perform on MRI images
Factor Assessment Description Value Illustration

method
Trochlear Lateral The most Normal ≥ 11o
dysplasia trochlear superior image
inclination from the axial Abnormal < 11o
angle slices
demonstrating
trochlear
cartilage is used.
The angle is
formed by a line
along the
subchondral
bone of the
lateral trochlea,
and a line
tangent to the
femoral
condyles.

method
Trochlear facet The ratio of Normal ≤ 40%
asymmetry medial/lateral
trochlear facets Abnormal > 40%
length as a
percentage
measured 3 cm
proximal to the
tibiofemoral
joint.
Trochlear Same level as Normal > 3 mm
depth above. A
reference line is Abnormal ≤ 3 mm
drawn along the
posterior femoral
condyles. From
this Two
perpendicular
lines are drawn
to the highest
point of the
medial and
lateral trochlear
facets (A and C)
and a third line
(B) to the
deepest part of
the trochlea.
Trochlear depth=
(A+C)/2-B.
High Patella Alta The ratio of the Normal < 1.2
position patellar tendon
of the length/patella Abnormal ≥ 1.2
patella superoinferior
length.
Table 11.2. (Continued)

method
Lateralisa Tibial Distance from Normal < 15 mm
tion of the Tuberosity- the deepest point
tibial Trochlear in the trochlear Abnormal > 20
tuberosity Groove groove to the mm
(TTTG) mid tibial
distance tuberosity. The
lines used should
be perpendicular
to a reference
line paralleling
the femoral
condyles.
Note for
calculation
purpose, the two
slices showing
the tibial
tuberosity and
femoral condyles
are
superimposed.
Red line
represents TTTG
distance.
Table 11.3. Dejour classification of patellar dysplasia
Classification Description
Type A Normal trochlear shape but shallow trochlear groove.
Classification Description
Type B Flattened or convex trochlea
Type C Asymmetrical trochlear facets with high lateral facet and

hypoplastic medial facet.
Type D Same as C with a cliff between the facets
Patellar dislocation is not suspected clinically in up to 50% of cases prior

to the MRI examination (Lisa et al., 2013). A specific injury pattern that can
be seen on MRI is bone marrow oedema within the inferomedial patella and
the anterior aspect of the lateral femoral condyle indicating impact injury. The
other typical finding is injury to the medial patellar stabilising ligaments
(mainly the medial patellofemoral ligament and medial retinaculum)
(Pfirrmann et al., 2000). The presence of both of the above on MRI is
diagnostic for prior patellar dislocation (Figure 11.15). Partial injuries of the
medial patellofemoral ligament will appear as thinning or attenuation of the
ligament usually with surrounding soft tissue oedema. Full thickness tears will
be depicted as loss of ligament continuity or complete disruption of the
ligament fibres. MRI can also assess the exact site of medial patellofemoral
ligament injury, which will have implications for surgical management
(Pfirrmann et al., 2000 and Dejour et al., 1990). Injury at the patellar
attachment of the ligament is the most common pattern (Pfirrmann et al., 2000
and Lance et al., 1993). MRI is very sensitive in detecting associated chondral
injuries and assessing their stability since more than 60% of patients will have
medial patellar osteochondral injury (Pfirrmann et al., 2000).
Figure 11.15. Illustration of the mechanism of patellar dislocation. (A) Before

dislocation. (B) At time of transient dislocation, the patella dislocates laterally
resulting into impaction of the medial patella and the anterior aspect of the lateral
femoral condyle (star). There will be also injury to the medial patellar stabilising
ligaments, mainly the medial patellofemoral ligament and medial retinaculum (arrow).
(C) At time of imaging, the patella has relocated but the characteristic bone contusions
and the injury to the medial patellar stabilising ligaments are diagnostic.
CASE 2
A 34 year old female cyclist with lateral knee pain.
Figure 11.16. MRI Coronal PD fat suppressed image (left).Axial PD fat suppressed
image.
Diagnosis: Hoffa’s fat pad impingement.

Discussion: Fat pad impingement syndrome or oedema within the fat pad
around the knee is being increasingly recognised and described on MRI
examination and included on MRI reports (Figure 11.16). Fat pad oedema is
typically seen within the most superior and lateral portion of the Hoffa's fat
pad, oedema can also be seen within the quadriceps fat pad and within the pre-
femoral fat pad. The presence of oedema within the fat pads is not always
symptomatic and correlation with clinical findings should be sought. Grading
of fat pad impingement can be described according to the appearances on
MRI.
SUMMARY
Radiological assessment by a variety of modalities can confirm clinical
diagnoses and help direct your management and guide therapeutic injections if
these are needed. Use the iRefer guidelines when requesting imaging but if in
doubt contact your local radiologist for advice. Fat pad impingement
syndromes are better evaluated dynamically by assessment of repeated knee
movement from flexion and movement can guide treatment to the affected
region.
REFERENCES
Brower A, Flemming D. 1997. Arthritis in black and white. Philadelphia:
W.B. Saunders.
Dejour H, Walch G, Neyret P, Adeleine P. 1990. Dysplasia of the femoral
trochlea. Revue de chirurgie orthopédique et réparatrice de l'appareil
moteur 76(1):45–54.
Diederichs G, Issever A, Scheffler S. 2010. MR Imaging of Patellar
Instability: Injury Patterns and Assessment of Risk Factors 1.
RadioGraphics. 30(4):961-981.
Kramer J, White LM, Recht MP. 2009. MR imaging of the extensor
mechanism. Seminars in Musculoskeletal Radiology 13(4):384–401.
Lance E, Deutsch AL, Mink JH. 1993. Prior lateral patellar dislocation: MR
imaging findings. Radiology. 189(3):905–907.
Lisa O, Ballehr D O. 2013. Transient Lateral Patellar Dislocation. MRI Web

Clinic. Available from: http://radsource.us/transient-lateral-patellar-
dislocation
Outerbridge RE. 1961. Further studies in the etiology of chondromalacia
patellae. The Journal of bone and joint surgery. British volume 49(2):
179-190
Pfirrmann CW, Zanetti M, Romero J, Hodler J. 2000. Femoral trochlear
dysplasia: MR findings. Radiology. 216(3):858–64.
Chapter 12
RECALCITRANT PATELLOFEMORAL PAIN
Jenny McConnell
McConnell Institute, Mosman, New South Wales, Australia
INTRODUCTION
When thinking about recalcitrant patellofemoral pain (PFP), we have to
ask what does recalcitrant mean? In this context recalcitrant means intractable,
which signifies that both you and the patient have given up and feel that the
pain will never improve. The one piece of advice I have for you is, never give
up - be like a dog with a bone and just keep at it (McConnell 2013). I will put
into context what may make someone’s symptoms recalcitrant. First, the
patient may have had the symptoms for a long period of time (this is quite
common in PFP), which means their quadriceps muscle is atrophied, resulting
in adaptive co-contraction of the hamstrings and gastrocnemius around their
knee and thus inappropriate loading through the joint (Besier et al. 2009,
Hopkins et al. 2001). Pain-associated muscle disuse causes selective atrophy
of type 2 muscle fibres in the vastus medialis (Fink et al. 2007). Second, the
knee pain may not have been diminished sufficiently, to allow the patient to
actually increase muscle strength (Henriksen et al. 2011). Third, the patient
may not have been adequately informed about why they have knee pain and
what they can do about it (see Chapter 2 on motivation for coming to the
physiotherapist). Fourth, treatment may not have adequately addressed the
factors that were causing the symptoms. Fifth, the rehabilitation has been too
demanding for the patient’s knee and/or progressed too quickly. Sixth, the
142 Jenny McConnell
patient may have complex regional pain syndrome, which has not been
recognised and therefore not addressed (see Chapter 2 on motivation for
coming to the physiotherapist and Chapter 4 on Red Flags) or may have a
different Red Flag pathology that no one has yet been able to identify, so
double check Chapter 4 just in case someone has overlooked something.
Keywords: persevere, daily activity training, feedback, maintenance checks
DECREASING THE PAIN

When working through a rehabilitation programme with a patient with
PFP, it is imperative that you reduce the pain as much as you can, because, if
the patient continues to have pain, the quadriceps will continue to atrophy and
their subconscious fear of pain will continue unabated. Pain can cause
quadriceps muscle inhibition and reduced function. Unless this process is
explained to the patient, in my experience the patient cannot understand why
their quadriceps strength does not improve and sometimes worsens, even
though they are working out at the gym, so their enthusiasm towards
rehabilitation turns negative. You need to ascertain the types of exercises the
patient is doing. A leg extension machine, rapid extension of the knee on a leg
press machine or in freestyle swimming, straight leg raises or even a ‘quads
set’ can aggravate the symptoms, particularly when the fat pad is inflamed. A
stationary bike can be a good alternate exercise, as there is only 1.0-1.5 times
body weight going through the knee with this activity (D’Lima et al. 2008).
But in many instances you may find that the soft tissues around the knee have
not been adequately unloaded. The first structure you should examine is the fat
pad to determine if it needs further unloading. Fat pad unloading is described
in Chapter 8, but the final piece of tape needed to unload a recalcitrant fat pad
problem commences in the centre of the calf posteriorly, just below the
popliteal fossa, and you pull the tibia foreword firmly (Dragoo, Johnson, and
McConnell 2012).
Recalcitrant Patellofemoral Pain 143
IMPROVING FEMORAL POSITION

AND GLUTEAL ACTIVATION
As the proximal part of the patellofemoral joint is the femur, controlling

femoral position is an important part of rehabilitation. Physiotherapists are
aware of dynamic valgus knee collapse, so, many treatments are geared
towards gluteal strengthening, using elasticised bands, as well as side-lying
exercises. However, sometimes it is difficult for a patient to maintain a neutral
femoral alignment, so you can tape the femur externally, or use a brace, while
the patient is training their gluteals. You can also tape the gluteals to improve
the muscle contraction (Kilbreath et al. 2006), improving the proximal stability
(see Chapter 8). The gluteal training should be performed in weight bearing,
simulating walking (McConnell 2013, 2016), as muscle training is very
specific to limb position, joint angle, type and force of contraction (Sale and
MacDougall 1981, Jensen, Marstrand, and Nielsen 2005). You need to
emphasise to the patient that you are giving them brain training to improve the
limb loading for daily activities. The training must be symptom-free, repeated
frequently during the day, requiring minimal or no equipment, as this will
ensure adherence and decrease the possibility of increasing the symptoms
(Perry 1992). If the patient has femoral anteversion, the anterior hip structures
will be adaptively shortened, which will make it difficult for the patient to
keep the knee aligned over the foot, so you may need to increase anterior hip
joint flexibility. Initially firmly pressing on the adductor longus tendon will
allow you to more effectively elongate the anterior hip structures in prone. The
‘prone Figure 4’ stretch should be given to the patient as part of their home
programme (Figure 12.1).
Figure 12.1. Example of a prone Figure 4 position.

144 Jenny McConnell
DECREASING DYNAMIC VALGUS KNEE COLLAPSE

Dynamic valgus knee collapse is not only due to femoral anteversion, or
poor control of the gluteal muscles, particularly the gluteus medius during stair
descent, but it can also be due to limited dorsiflexion range. If the patient has
limited range of motion in their talocrural joint, then the only way they can
descend stairs is to pronate their foot, which is manifested as a dynamic valgus
knee collapse. You can ask the patient to do every hip stabilising exercise ever
suggested, but until their ankle dorsiflexion range is increased, the valgus knee
collapse will not improve. Ten degrees of dorsiflexion is required in normal
walking (Jack et al. 2010), but more range is required on stairs, particularly if
the step is steep. To improve dorsiflexion range you can mobilise the
talocrural joint. Mobilisation of the talocrural joint can commence with the
patient supine, knee bent and the foot on the plinth with the toes raised on a
block, to simulate the stance phase of gait. The talocrural mobilisation should
be progressed quickly to weight bearing, where the patient stands on a box,
holds onto a firm object in front of them e.g., a treadmill, while the distal end
of the tibia is mobilised with a seat belt.
Controlling mid foot collapse will also improve dynamic knee valgus. In
my experience this can be done by prescribing orthoses (see chapter 10). As
well as training the tibialis posterior muscle, to control the position of the base
of the first metatarsal, which allows the peroneus longus to more effectively
stabilise the first ray for push off, decreasing the loading on the knee. Advice
about footwear using the Footwear Assessment Tool (Barton et al. 2009) and
the Footwear Comfort Scale (Curran, Holliday, and Watkeys 2010) described
in Chapter 10 is also essential. Patients who are wearing orthoses need to
ensure that their shoes are supportive and laced up (this is hard for teenagers as
the fashion often dictates a sloppy shoe fit, but the orthotic is almost rendered
useless with this type of footwear). Also, for females, you need to reinforce
that not only will high heeled shoes prolong symptoms, but, in many cases, so
will the ballet flat, as the patient is tipped slightly backwards, leading to knee
locking thus aggravating the fat pad.
CONTROL OF THE KNEE IN WEIGHT BEARING

Many patients with recalcitrant PFP have quadriceps atrophy, so they have
poor inner range quadriceps control, with no subtle small range flexion
nuances, which is required in walking, particularly over uneven surfaces.

Thus, when they walk their knees will hyperextend or ‘lock back,’ potentially
aggravating the infrapatellar fat pad. Training the quadriceps in walk stance,
where the patient commences the training with the knee off lock, slightly
flexes to 30, then, slowly extends the knee back to just off lock, will improve
the knee flexion required for shock absorption in the stance phase of gait. With
this exercise, the patient needs to ensure they maintain neutral limb alignment
by keeping the knee positioned over the middle of the foot and the arch of the
foot lifted. This exercise can be progressed with the patient stepping through
with the back foot, as well as, standing on a pillow or other unstable surface
and repeating the small range flexion and extension activity in order to
improve proprioception of the knee. The patient, standing in front of a mirror,
can also practise slowly lowering their less symptomatic leg down from a
small step to toe-touch the floor then back up again, maintaining a level pelvis,
neutral alignment of the leg on the step, keeping soft knees. As the patient
improves, the number of repetitions is increased before the depth of the step or
the amount of load is altered. Load can be added by putting books in a
backpack.
DAILY STRATEGIES
Patients with recalcitrant patellofemoral symptoms need to know how to
cope with every day activities, in a pain-free manner. So, you need to
empower the patient to manage their symptoms, emphasising the need to
reinforce appropriate limb alignment with daily practice, requiring a small
amount of time, just like they would keep their teeth in good health by regular
brushing. To ensure the success of the daily strategies and to keep symptoms
under control, the patient needs to visit you every six months or twelve months
for a ‘body maintenance check,’ similar to a car service, but for the body,
because chronic PFP is not cured, but managed, so this is a way you can
ensure long term adherence, with a self-management programme.
Daily activity training should incorporate showing the patient how to:
1) Stand for prolonged periods, adopting a modified ballet 3rd position,

involving slight femoral external rotation and the legs touching with
soft, not locked knees.
2) Get in and out of a chair without using their hands. The patient feels
the back of the chair with their legs, flexes their hips (sticking their
146 Jenny McConnell
bottom out) and slowly lowers themselves down onto the chair,
keeping their knees over their feet. To stand from the chair, they rock
themselves forwards, keeping their spine straight and their knees over
their feet.
3) Go up and down stairs. The patient needs to flex their hips to decrease
the lever arm of the quadriceps muscle and optimise the muscle
control.
These strategies should become automatic with repeated practice, so the

load through the knee becomes more balanced.
OTHER OPTIONS TO EXPLORE WHEN ADDRESSING

RECALCITRANT PFP
Some investigators have advocated the use of acupuncture to the
patellofemoral joint (twice weekly for 4 weeks) as well as intramuscular
injection of botulinum toxin type A to reduce relative overactivity of the
vastus lateralis muscle. This was done in conjunction with 12 weeks of
customised home programme of re-training of vastus medialis muscle as an
adjunct to rehabilitation for chronic anterior knee pain (Jensen et al. 1999,
Singer et al. 2006). Other investigators have suggested that using interventions
that facilitate muscle activation (e.g., neuromuscular electrical stimulation) or
improve awareness of the muscle contraction (e.g., biofeedback) may counter
deficits in quadriceps strength and hence decrease PFP (Callaghan, Oldham,
and Winstanley 2001, Mizner et al. 2005).
CONCLUSION
There are many ways which you can help and guide your patients with
recalcitrant PFP. It can be a long road, but your options are improving femoral
position and gluteal activation, decreasing dynamic valgus collapse or control
of the knee in weight bearing. I finish this chapter where I started emphasising
never give up because if you do the patient will go onto surgery which can
often have catastrophic consequences.
REFERENCES
Besier, T. F., Fredericson, M., Gold, G. E., Beaupre, G. S., and Delp, S. L.
2009. "Knee muscle forces during walking and running in patellofemoral
pain patients and pain-free controls." Journal of Biomechanics 42
(7):898-905.
Callaghan, M. J., Oldham, J. A., and Winstanley, J. 2001. "A comparison of
two types of electrical stimulation of the quadriceps in the treatment of
patellofemoral pain syndrome. A pilot study." Clinical Rehabilitation 15
(6):637-46.
Curran, SA., Holliday, JL., and Watkeys, L. 2010. "Influence of High Heeled
Footwear and Pre-fabricated Foot Orthoses on Energy Efficiency in
Ambulation." Foot and Ankle Online Journal 3 (3).1
D'Lima, D. D., Steklov, N., Fregly, B. J., Banks, S. A., and Colwell, C. W., Jr.
2008. "In vivo contact stresses during activities of daily living after knee
arthroplasty." Journal of Orthopaedic Research 26 (12):1549-55.
Dragoo, J. L., Johnson, C., and McConnell, J. 2012. "Evaluation and treatment
of disorders of the infrapatellar fat pad." Sports Medicine 42 (1):51-67.
Fink, B., Egl, M., Singer, J., Fuerst, M., Bubenheim, M., and Neuen-Jacob, E.
2007. "Morphologic changes in the vastus medialis muscle in patients
with osteoarthritis of the knee." Arthritis & Rheumatology 56 (11):3626-
33.
Henriksen, M., Rosager, S., Aaboe, J., Graven-Nielsen, T., and Bliddal, H.
2011. "Experimental knee pain reduces muscle strength." The Journal of
Pain 12 (4):460-7.
Hopkins, J. T., Ingersoll, C. D., Krause, B. A., Edwards, J. E., and Cordova,
M. L. 2001. "Effect of knee joint effusion on quadriceps and soleus
motoneuron pool excitability." Medicine & Science in Sports & Exercise
33 (1):123-6.
Jack, K., McLean, S. M., Moffett, J. K., and Gardiner, E. 2010. "Barriers to
treatment adherence in physiotherapy outpatient clinics: a systematic
review." Manual Therapy 15 (3):220-8.
Jensen, J. L., Marstrand, P. C., and Nielsen, J. B. 2005. "Motor skill training
and strength training are associated with different plastic changes in the
central nervous system." Journal of Applied Physiology 99 (4):1558-68.
Jensen, R., Gothesen, O., Liseth, K., and Baerheim, A. 1999. "Acupuncture
treatment of patellofemoral pain syndrome." The Journal of Alternative
and Complementary Medicine 5 (6):521-7.
148 Jenny McConnell
Kilbreath, S. L., Perkins, S., Crosbie, J., and McConnell, J. 2006. "Gluteal
taping improves hip extension during stance phase of walking following
stroke." Australian Journal of Physiotherapy 52 (1):53-6.
McConnell, J. 2013. "Management of a difficult knee problem." Manual
Therapy 18 (3):258-63.
McConnell, J. 2016. "Running Injuries: The Infrapatellar Fat Pad and Plica
Injuries." Physical Medicine & Rehabilitation Clinics of North America
27 (1):79-89.
Mizner, R. L., Petterson, S. C., Stevens, J. E., Vandenborne, K., and Snyder-
Mackler, L. 2005. "Early quadriceps strength loss after total knee
arthroplasty. The contributions of muscle atrophy and failure of voluntary
muscle activation." The Journal of bone and joint surgery. American
volume 87 (5):1047-53.
Perry, J. 1992. Gait Analysis. Edited by McGraw-Hill New York.
Sale, D., and MacDougall, D. 1981. "Specificity in strength training: a review
for the coach and athlete." Canadian Journal of Applied Sport Sciences 6
(2):87-92.
Singer, B. J., Silbert, P. L., Dunne, J. W., Song, S., and Singer, K. P. 2006.
"An open label pilot investigation of the efficacy of Botulinum toxin type
A [Dysport] injection in the rehabilitation of chronic anterior knee pain."
Disability and Rehabilitation 28 (11):707-13.
ABOUT THE EDITORS
James Selfe
Professor of Physiotherapy
Department of Health Professions
Manchester Metropolitan University
Manchester, UK
Email: [email protected]
James is Professor of Physiotherapy in the Department of Health

Professions at Manchester Metropolitan University and has been visiting
academic Physiotherapist at Satakunta Applied University, Pori, Finland since
1995. James graduated with a distinction in his Diploma of Physiotherapy
from Salford in 1984, was awarded a Masters Degree in Health Research from
Lancaster University in 1995 and gained his PhD in 2000 from the University
of Bradford for a thesis titled “Outcome measures for patellofemoral
dysfunction (an investigation of the validity, reliability and clinical sensitivity
of four outcome measures for the patellofemoral joint)”. In 2008 James was
honoured by the Chartered Society of Physiotherapy by being awarded a
fellowship for his outstanding contribution to musculoskeletal physiotherapy,
particularly in the field of patellofemoral pain dysfunction. James’ research in
this field has enlightened physiotherapy knowledge and more importantly has
changed the clinical practice of many physiotherapists internationally. In 2015,
James was awarded a Doctor of Science (DSc) from the University of Central
Lancashire for a thesis titled "Research in Musculoskeletal Physiotherapy:
Providing Evidence for Practice"; this was the first ever award of a DSc to a
Physiotherapist in Europe and only the second in the world.
150 About the Editors
Jessie Janssen
Research Fellow (Physiotherapy)
Allied Health Research unit, University of Central Lancashire,
Preston, UK
Email: [email protected]
Jessie Janssen is a Research Fellow with the Allied Health Research unit
at the University of Central Lancashire, UK. She received her Master of
Science in Biomedical Health Sciences from the Radboud University in
Nijmegen (the Netherlands) in 2002, and her Bachelor in Physiotherapy from
the University of Applied Sciences in Utrecht (the Netherlands) in 2005. She
discovered that her passion lay in combining these two areas and has worked
in applied physiotherapy research ever since. She gained experience in
musculoskeletal and neuromuscular research in the Netherlands, Australia,
Argentina, New Zealand and England. In 2012 she was awarded a PhD for her
thesis: ‘Building research capacity in a clinical setting’ from the University of
Otago, Dunedin, New Zealand. In recent years Jessie has coordinated a UK
wide clinical research project looking at Targeted Interventions for
Patellofemoral Pain.
Michael J. Callaghan
Professor of Clinical Physiotherapy
Clinical Specialist Physiotherapist
Manchester Metropolitan University
Hospital Affiliation: Manchester Royal Infirmary
Michael Callaghan is Professor of Clinical Physiotherapy at Manchester

Metropolitan University. He is a Clinical Specialist Physiotherapist at
Manchester Royal Infirmary. He is Head of Physical Therapies at Manchester
United FC. He has honorary posts as a senior lecturer at the University of
Manchester and the University of Salford. He has been to five Olympic Games
and five Commonwealth Games in a variety of sports medical roles. He
qualified as a physiotherapist at the Salford School of Physiotherapy. He
worked at Wrightington Hospital and the Royal Liverpool Hospital in junior
and senior posts. Whilst at Liverpool he was awarded his first research degree
of MPhil studying gait analysis in patellofemoral pain. He then moved to
Manchester where he was awarded his PhD for studying the effects of
electrical muscle stimulation in those with patellofemoral pain. His area of
About the Editors 151
clinical work and research has been the assessment and rehabilitation of
musculoskeletal problems the lower limb. He continues to be at the forefront
of research into patellofemoral joint dysfunction.
INDEX
Bioskin® Q brace, 102, 103, 105

A bipartite patella, 127
bone, 4, 5, 32, 34, 36, 37, 44, 45, 46, 110,
adduction, 9, 54, 70, 105, 111, 113
122, 130, 131, 134, 137, 138, 141
adductor longus, 143
bone marrow, 5, 37, 130, 137
adherence, v, x, 15, 18, 75, 76, 82, 91, 143,
bracing, 55, 56, 101, 105
145
brain, 17, 55, 96, 105, 106, 143
adipose tissue, 6, 50
brain activity, 55, 105
aetiology, vii, 34
bursitis, x, 45, 122, 124, 125
American Heart Association, 82
anatomy, 49, 50, 122, 123
anterior cruciate, 61 C
anti-inflammatories, 81
anti-inflammatory drugs, 44 CAD, 115
arthritis, 23, 32, 33, 43, 44, 64 CAM, 115
arthrogram, 131 cancer, 31, 32, 44, 45
arthroplasty, ix cartilage, 4, 5, 25, 34, 50, 64, 122, 130, 131,
arthroscopy, 24, 42, 65 134
articular cartilage, 34, 50, 64, 130, 131 chondromalacia patella, ix, 4, 62, 104
assessment, vii, 25, 27, 36, 37, 39, 44, 49, Clarke's test, 62, 65
53, 54, 57, 58, 66, 67, 70, 93, 94, 104, clinical concepts, 4, 8, 10
109, 114, 115, 116, 122, 127, 128, 129, clinical diagnosis, 21
130, 133, 134, 135, 136, 139, 144, 151 clinical examination, 24, 66
asymptomatic, 45, 65, 96, 105, 134 clinical tests, 62, 65, 71
atrophy, 141, 142, 144 clinical trials, 104
clinical vigilance, 33
combination of tests, 66, 71
B complex regional pain syndrome (CRPS),
17, 37, 38, 39, 92, 142
biofeedback, 56, 57, 146
compression, 27, 36, 40, 62, 105
biomechanics, 6, 49, 50, 101, 105
computrized tomography, 130
biopsychosocial approach, 28
154 Index
corticosteroids, 32, 44
crepitus, 25, 42, 64
F
Crepitus Test, 64
Fairbank apprehension test, 63
critical test, 63
false negative, 64
cryotherapy, 43
false positive, 62, 64
CT, 130, 131
fat, 4, 5, 6, 24, 50, 63, 92, 94, 122, 124, 125,
cure, 27, 44
128, 129, 130, 132, 138, 139, 142, 144,
cycling, 80
145
cyst, 46
feedback, 56, 57, 142
cytokines, 92
femur, 4, 6, 15, 18, 44, 50, 51, 52, 62, 96,
101, 104, 105, 110, 112, 143
D fever, 31, 44, 98
foot posture index (FPI), 70, 114
daily activity training, 142, 145 footwear, 16, 81, 114, 115, 116, 144
daily living, 49, 55 force(s), 4, 5, 26, 49, 50, 51, 52, 53, 54, 56,
Dejour classification, 136 62, 67, 69, 70, 81, 93, 96, 97, 110, 111,
desensitisation techniques, 39, 41 113, 132, 143
desensitising, 17 Frund's test, 63
Donjoy® Reaction knee brace, 104 functional approach, 66
dosage, 75, 76, 82, 89 functional strengthening, 85
dynamic valgus knee collapse, 96, 143, 144
dysplasia, 64, 132, 133, 134, 136
G
E gait, 37, 144, 145, 150

gastrocnemius, 69, 83, 141
eccentric step test, 66 gastrocnemius length test, 69
edema, 138 gastrocnemius stretching, 83
effusion, x, 25, 36, 45, 61, 122, 124, 132 genetic predisposition, 34
emotional problems, 26, 27 growth, 7, 36
endocrine disorders, 34 growth factor, 7
envelope of function, 7, 16
evidence, viii, ix, 3, 18, 55, 56, 76, 79, 80,
82, 89, 91, 95, 106, 110, 113, 114, 115,
H
116
hamstring stretching, 83
exclusion, 21, 46, 61, 67
healing, 36
exercise program, 18, 39, 56, 75
health, 18, 28, 145
exercise(s), vi, xi, 8, 16, 17, 18, 26, 36, 38,
height, 57, 80, 81, 116
39, 40, 55, 56, 75, 79, 80, 81, 82, 83, 84,
hip abduction strengthening, 84
85, 86, 89, 142, 143, 144, 145
hip and femoral rotation, 104
stretching, strengthening and
hip joint, 4, 143
proprioception, 79
history, x, 9, 21, 25, 26, 31, 32, 33, 38, 44,
exertion, 82
67, 98
extensor, ix, 51, 53, 54, 106
Hoffa sign’, 63
homeostasis, 4, 7
Index 155
hyperesthesia, 37, 38
hypersensitivity, 17
L
legs, 9, 70, 145

I lesions, 5, 24, 34, 44, 64
ligament(s), x, 50, 61, 65, 92, 95, 100, 111,
ice pack, 27 130, 137, 138
implants, 36 Likert scale, 115
improvements, 55, 56, 113, 114 lipohaemoarthrosis, 124, 125
index of suspicion, 31, 44 load on joints, 16
individuals, 16, 55, 96, 97, 110, 113, 114, lower limb muscle weakness, 69
115 lumbar spine, 23
infection, 32, 37, 43
inflammation, 6, 7, 43, 93
inflammatory bowel disease, 33
M
infrapatellar (Hoffa's) fat pad, 4, 5, 6, 23,
magnetic resonance imaging (MRI), 34, 35,
24, 50, 63, 94, 130, 139, 145
37, 38, 42, 46, 64, 121, 122, 125, 130,
inhibition, 24, 96, 106, 142
132, 134, 137, 138, 139
injections, 129, 139
maintenance checks, 142
injuries, 130, 132, 137
malignancy, 31
injury, 6, 22, 26, 33, 41, 52, 57, 65, 124,
marrow, 5, 37, 38, 130, 131, 137
132, 134, 137, 138
mass, 44, 45
intervention(s), x, xi, 27, 40, 55, 56, 58, 75,
McConnell test, 62, 63
105, 111, 113, 114, 115, 121, 146, 150
measurement, 53, 54, 57, 68, 69, 134
intramuscular injection, 146
mechanical stress, 104
iRefer guidelines, 121, 122, 139
medial and lateral displacement of the
iritis, 33, 44
patella, 67
ischemia, 4, 9, 34, 40
medial meniscus, 41
metatarsal, 113, 144
J modifiable and non-modifiable factors, 22
modifiable factors, 25
J sign, 64 motion control, 114, 115
joint pain, 23, 43, 45 motivation, 15, 22, 141, 142
joint position sense, 105 motor control, 96
joints, 16, 33, 43, 50, 56, 57 MRI, 34, 35, 37, 38, 42, 46, 64, 121, 122,
125, 130, 132, 134, 137, 138, 139
multimodal, viii, 4, 8, 18, 79
K multimodal exercise, 18
muscle contraction, 95, 96, 143, 146
knee braces, 101, 106 muscle strength, 49, 53, 56, 81, 82, 141
knee valgus angle, 102 muscles, 9, 50, 56, 106, 111, 144
knees, 4, 9, 22, 23, 26, 38, 39, 40, 41, 43, musculoskeletal, vii, x, 16, 18, 23, 28, 115,
67, 81, 85, 105, 128, 145, 146 149, 150, 151
myosin, 93
156 Index
physical examination tests, 62

N poor control, 55, 96, 144
prepatellar bursitis, 122, 125
nervous system, 17
prescriptive exercise regimes, 82
neuroma, 4, 6, 7
prevention, 18
NHS, 31, 43, 44, 67, 121
pro-inflammatory, 92
non-modifiable factor, 25
proprioception, vi, 36, 49, 55, 56, 79, 81,
non-steroidal anti-inflammatory drugs, 44
87, 91, 93, 96, 97, 105, 145
non-weight bearing exercises, 80
proprioception training, 87
psychosocial, 4, 9, 10, 18
O
Q
oedema, 6, 130, 131, 137, 138, 139
orthoses, vi, xi, 8, 52, 53, 79, 109, 111, 113,
quadriceps, 9, 17, 24, 25, 51, 52, 62, 63, 66,
114, 115, 116, 144
67, 81, 85, 94, 95, 104, 106, 110, 139,
osteoarthritis, viii, x, 36, 64, 102, 104, 106,
141, 142, 144, 146
127
quadriceps inhibition, 106
osteoporosis, 39
outcome, x, 9, 10, 18, 22, 62, 149
overweight, 26 R
radiography, 127, 128

P rating scale, x, 22, 92
reactive arthritis, 23, 43, 44, 47
pain free zone, 80
rectus femoris, 25, 84, 110
pain relief, 91, 104
rectus femoris length test, 68
palpation, 33, 39, 66, 67, 128
rectus femoris stretching, 84
paradigm shift, 18
red flags, 22, 31, 32, 33, 44, 142
patella, vii, x, 3, 4, 5, 6, 7, 17, 18, 23, 34,
rehabilitation, 18, 22, 25, 26, 89, 105, 141,
39, 40, 42, 50, 51, 52, 54, 55, 56, 62, 63,
142, 143, 146, 151
64, 65, 66, 67, 68, 92, 94, 95, 96, 97,
rehabilitation program, 18, 142
101, 102, 104, 105, 110, 112, 122, 124,
relief, 18, 31, 41, 91, 104
125, 127, 129, 130, 131, 132, 134, 135,
repair, 93
137, 138
reproduction, 66, 96
patella apprehension test, 63
researchers, viii, 3, 65
patella compression test, 62
resistance, 6, 40, 82
patella fracture, 126
response, 22, 27, 36, 38, 42, 55, 82, 105,
patella grind test, 62
111, 113, 116
patella mobility tests, 64
rheumatoid arthritis, 32, 33
patellar dislocation, 63, 132, 134, 137, 138
risk (factors), 7, 32, 52, 55
patellar tendon, 63, 110, 129, 130, 135
pathology, 26, 28, 31, 32, 33, 38, 44, 46,
106, 110, 142 S
patient's motivation, 22
persevere, 142 self-management, 15, 16, 75, 80, 145
physical activity, 10 sensation(s), 15, 24, 25, 42, 44
Index 157
sensitivity, 31, 61, 64, 65, 149

septic arthritis, 32
T
(SERF®) brace, 100, 101, 102, 103, 104,
tape, 67, 69, 91, 92, 93, 94, 95, 96, 97, 98,
105,
105, 142, 143
serious pathology, 26, 28, 31, 33, 38, 44, 46
taping, vi, 8, 18, 42, 55, 56, 79, 91, 92, 93,
shrug test, 62
94, 95, 96, 102, 106
signs, 17, 27, 31, 36, 42, 45, 46, 61, 64, 66,
temperature, 17, 26, 40
70
tendon(s), 51, 52, 63, 110, 111, 129, 130,
skin, 9, 17, 37, 38, 39, 67, 68, 91, 92, 94,
135, 143
95, 97, 98
tension, 82, 92, 93, 95, 97
sleeve type braces, 102
therapeutic relationship, 28
social participation, viii
therapist(s), 23, 27, 28, 39, 56, 68, 69, 76
spine, 23, 146
tibia, 6, 44, 50, 94, 110, 111, 112, 124, 142,
stability, 49, 53, 55, 56, 57, 69, 104, 106,
144
114, 134, 138, 143
tissue, 5, 6, 7, 32, 42, 44, 50, 52, 63, 66, 92,
step down task, 52, 55, 102
93, 94, 95, 97, 122, 125, 138
stimulation, 37, 105, 146, 150
torsion, 9, 40
stimulus, 105
training, 16, 18, 36, 56, 57, 81, 82, 87, 98,
strength training, 82
142, 143, 144, 145, 146
strengthening, vi, 8, 17, 36, 56, 79, 81, 82,
trauma, 9, 24, 32, 37, 38, 41, 44, 122, 124,
84, 85, 143
132
stress, 15, 40, 41, 51, 93, 104, 105
treatment, viii, 4, 6, 8, 9, 10, 15, 17, 18, 22,
stretching, vi, 8, 36, 79, 81, 82, 83, 84
24, 27, 36, 38, 39, 40, 43, 44, 49, 50, 55,
structural changes, 3, 7
56, 58, 62, 67, 69, 71, 75, 76, 79, 80, 91,
structural concepts, 3, 4, 5, 10
93, 102, 129, 139, 141, 143
structure(s), 3, 4, 6, 7, 23, 36, 43, 63, 92, 94,
treatment adherence, 17
95, 110, 130, 142, 143
trochanter, 96
subgroups, 4, 8, 9, 54, 58, 66, 67, 81
trochlear dysplasia, 132, 133, 134
subgroup assessment tests, 67
Tubigrip™, 17, 40, 105
subjective examination, 16, 22, 23, 28, 41,
tumours, 32, 44
43, 66
subluxation, x, 64, 67
swelling, 7, 15, 24, 25, 27, 32, 33, 43, 44, U
45, 122, 125, 131
symptoms, 5, 7, 10, 15, 16, 17, 18, 21, 22, ultrasound, 121, 122, 128, 129
26, 31, 36, 42, 43, 44, 46, 62, 66, 91, 92, urine, 43, 44
93, 94, 102, 106, 113, 121, 132, 141,
142, 143, 144, 145
syndrome, ix, x, 17, 33, 37, 41, 43, 92, 139, V
142
synovial membrane, 41, 50 valgus, 54, 55, 56, 57, 96, 102, 105, 132,
synovial tissue, 42 143, 144, 146
synovitis, 33 varus, 55, 56, 57, 105
vastus lateralis, 25, 50, 96, 146
vastus medialis, 25, 50, 113, 141, 146
158 Index
W X
Waldron's test, 63, 64, 65 x-ray, 38, 43, 121, 122

walking, 16, 24, 27, 39, 40, 81, 110, 143,
144, 145
weakness, 54, 69 Z
weight control, 26, 36, 81
zinc oxide, 97
weight loss, 26, 31, 32, 44, 81
Zohler's test, 62
World Health Organization (WHO), viii,
xiii, 7, 28, 29

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PAIN AND ITS ORIGINS, DIAGNOSIS AND TREATMENTS

Additional books in this series can be found on Nova’s website

Additional e-books in this series can be found on Nova’s website

NOTICE TO THE READER

Library of Congress Cataloging-in-Publication Data

ISBN:  H%RRN

Library of Congress Control Number: 2017937256

Published by Nova Science Publishers, Inc. † New York

Introduction What is patellofemoral pain? vii

Chapter 7 Exercises: Stretching, Strengthening

WHAT IS PATELLOFEMORAL PAIN?

DURATION AND SEQUELAE OF PFP

patellofemoral arthroplasty to remember if they had PFP when they were

WHAT DO WE MEAN BY PFP IN THIS BOOK?

Table 1. Common terms for PFP

Anterior knee pain

PFP is normally diagnosed by excluding other pathologies that fall outside

IMPORTANCE OF RESEARCH INTO PFP

knee kinematics in adolescents with patellofemoral pain." Medicine &

CONCEPTS OF PATELLOFEMORAL PAIN

Keywords: structural concepts, clinical concepts

 Subchondral bone deformation

STRUCTURAL CONCEPTS: DUE TO OVERLOADING

Subchondral Bone Deformation

In 1976 Goodfellow et al. hypothesised that people with PFP developed

Intramedullary Pressure Changes

Intramedullary pressure is the internal pressure within the bone marrow.

to measure and therefore the concept has encountered some resistance

Lateral Retinacular Neuroma

The lateral retinaculum is a passive support structure located on the lateral

Infrapatellar Fat Pad

The concept of tissue homeostasis encompasses much more than just

NGF in this area (Sanchis-Alfonso, Rosello-Sastre, and Revert 2001) than

Targeted Treatment Based on Subgroups

An alternative to the multimodal approach is to use a targeted approach in

Studies on low back pain have demonstrated that psychosocial factors

measures predicted pain and functional outcome. Fear avoidance towards

Collins, N. J., Bisset, L. M., Crossley, K. M., and Vicenzino, B. 2012.

rehabilitation of patients with patellofemoral pain syndrome." The Knee

PATIENTS’ EMOTIONAL STATES

Keywords: self-management, adherence, desensitisation, communication

patient and the contribution of these factors must be understood if

EXPLANATION TO THE PATIENT ABOUT THE REASONS

MINIMISING OCCURRENCE OF COMPLEX REGIONAL

RELIEVING THE PAIN

In fact these activities have almost become accepted as pathognomic for

The subjective examination has a number of functions to;

 Rule out Red Flags (Chapter 4)

Keywords: subjective examination, modifiable and non-modifiable factors,

WHEN AND HOW DID PAIN START?

‘What is your current pain right now’

The best method of recording the patient’s responses to these questions is

WHERE IS THE PAIN?

LOCKING AND GIVING WAY

SITTING PAIN, NIGHT PAIN, STIFFNESS

ALTERED PATELLA TEMPERATURE

 Do you get night pain

 Do you wear extra tights/long johns in winter

ATTITUDE, EXPECTATIONS AND EMOTIONS

ISBN: H%RRN