Patellofemoral dysfunction (formerly called chondromalacial) is a mechanical imbalance between the movement of the patella (kneecap) and the femur (thigh bone). The patella rests in a groove between the two boney condyles of the femur beneath it. The patella tracks along a subtle curve as the knee moves from full straightening to full bending. When there is an imbalance around the patellofemoral joint, the patella may track more to the outside (laterally tracking patella). A source of dysfunction that may cause a laterally tracking patella is weakness of the inside part of quad (called the VMO). This imbalance allows the outside, or lateral, part of the quad (called the VLO) to overpower the VMO. Chronic, abnormal tracking may cause a “grating” of the patella against the femur and precipitate early degenerative changes on the underside of the patella as well as chronic inflammation during activity. This may be palpated as grinding or clicking of the patella as you move your knee. Other sources of imbalance would be stiffness in the iliotibial band (the ITB), tilted patella (most commonly tilted down and to the outside), shallow groove between the femoral condyles (cause patellar subluxations or dislocations), stiffness in the quadriceps or hamstrings, and/or strength imbalances at the knee and hip. Active teenagers are commonly victims of patellofemoral syndrome due to the stress of excessive physical activity during growth spurts.
Principles of Treatment:
- Activity Modification (refer to P.R.I.C.E )
- Specialized Manual Therapy Techniques: It is very common to have adhesions or scar tissue between the lower ends of the VLO and ITB on the lateral side of the knee. These adhesions prevent normal motion of the patella. If you look at an anatomy picture of the patellofemoral joint, you will see that the patella is surrounded by connective tissue. Adhesions can form anywhere in this connective tissue matrix. During activity, there is a degree of micro-trauma that occurs. This micro-trauma can cause scar tissue. Scar tissue is considered dysfunctional if it binds onto adjacent healthy tissue and prevents normal movement of that healthy tissue. We use our palpation skills to identify lesions in all of the surrounding tissues such as the ITB, hams, VLO, and tensor fascia lata muscle. Techniques such as ART, Graston and Cupping Therapy are used to release these adhesions.
- Altered Biomechanical Forces: We can fabricate custom foot orthotics in order to dissipate the shock caused by a supinated foot or the excessive torque created by an overpronating foot. We utilize taping techniques to reposition the patella during activity or during functional retraining exercises.
- Functional Electrical Stimulation: We may use an electrical stimulation device to retrain and strengthen the VMO in combination with taping techniques and functional retraining exercises. Voluntary muscles contractions recruit only 70% of the available muscles fibers where as electrical stimulation achieves 100% activation of the treated area.
- Stretching: Stretching exercises are used to increase the length and elasticity of your tissues. Your quads must work harder to straighten the knee against the resistance of stiff hamstrings. Most people are “quadriceps dominant” and this means that your quads are working overtime. This leads to significant stiffness in this overactive muscle. We utilize passive and dynamic stretches as well as the neurological principles of reciprocal inhibition to hasten your recovery. The ITB, hamstrings, and quadriceps are commonly tight in patellofemoral syndrome. We utilize self-mobilization techniques on styrofoam rolls as part of a home exercise program to break adhesion in the ITB, VLO, and hamstrings.
- Strengthening: Initially, we may use Medical Exercise Therapy (M.E.T.) to encourage circulatory exchange and promote healing. M.E.T. is functional retraining of injured tissues and uses low weight and high reps. Repetition is the mother of skill when performing an M.E.T. program. We then progress to functional retraining exercises in combination with electrical stimulation and taping. It is very important to evaluate and address muscular imbalances at the hips and gluteals. Chronic patellofemoral syndrome may not improve without adequate strengthening of the hips. Weakness of the hips places greater demand upon the knee during weight bearing activities and sports. Muscular imbalances in the hips are common in both the active and sedentary patient.
- Home Exercise Program: The rest is up to you! Compliance with your home exercise program is paramount to a speedy recovery.