Patella Femoral Mal-Tracking – The cause & effect debate

Much has been written on the pathophysiology of patella femoral pain and hence the multitude of treatment strategies to rehabilitate it.

Of course patella femoral pain is not a single clinical entity but in fact constitutes a spectrum of pathology encompassing the entire extensor mechanism and involving structures such as the quadriceps insertion, the iliotibial band, the retropatellar articular surface, the patella tendon, the infra-patella fat pad and the medial joint line/retaniculum.  Each of these distinct anatomical structures show their own inflammatory characteristics and healing response times.  The challenge from a therapeutic perspective is to identify:

1)                  The structures reproducing symptoms.

2)                  The mechanism underlying the tissue irritation.

3)                  Rational protocols for effective rehabilitation.

The pioneering work of Jenny McConnell in the 1980’s on this area precipitated an explosion of research evaluating local muscle imbalance around the patella.  More specifically the ratio of muscle activity between VMO (Vastus Medialis Obliquus) and the VL (Vastus Lateratus).  This conceptual model of patella maltracking suggests as an impairment of dynamic restraint around the patella and has fostered much heated debate and clinical research since originally proposed.

However, the alignment of the patella within the patellar grove is profoundly influenced by lower limb alignment and consequently evaluation of these components must be an integral part of any examination process for extensor mechanism dysfunction.

Both extremes of foot malalignment – namely excessive pronation and excessive supination – by virtue of the torque converter mechanism through the tibia, induce tibial rotation, which essentially changes the patella tendon insertion strain and distorts the relative position of the tibia relative to the femur.  Likewise femoral malalignment with respect to the tibia, most notably excessive internal rotation has the effect of lateralising the patella with respect to the vertical and potentially precipitating a sequence of effects along the lateral joint line from lateral retinaculum tightness, fibular head restriction, peroneal nerve vulnerability, medial retinaculum and tibio-femoral joint line overload.

It is therefore incumbent upon treating clinicians to quantify the limb alignment  status as accurately as is possible. In my opinion assessment of the tibial and femoral components of lower limb alignment are a clinical priority over the alignment of the patella within the patellar grove.  The rational of utilising vastus medialis obliquus contractions (VMO) to realign a lateralised patella when the under lying mechanical dysfunction is a distortion of tibia femoral alignment, is obviously irrational as well as anatomically impossible!.  Therefore attempts to quantify patella tilt, prominence or angulation is an exercise in searching for effect rather than cause.  US physiotherapist Gary Gray refers to this phenomena as the train on the track.  Preoccupation with regard to detail of the patella position (train) without adequate attention to tibiofemoral alignment (track) results in an uncomfortable ride with neither patient nor therapist likely to reach their destination!.

Do you have the tools to adequately assess limb alignment mechanics and the appropriate treatment arsenal to influence recovery?

How do you  prioritise your treatment strategy in patello-femoral dysfunction?

Share your thoughts and comments with other therapists.

Rise to the clinical challenge.
David

Technorati Tags: chondromalacia patella, extensor mechanism pain, knee pain, knee rehabilitation, patella

Psychosocial Flags

As one on the frontlines for 20 years the concept of “flags” was useful to provide a strategy for integrating multiple elements into patient management strategies. Unfortunately , much like pain management programs recognition has driven a hands off strategy of patient management on the basis that “manual therapy” is either ineffective or creates dependance in this patient group.

The converse view is that manual therapy and functionally specific rehabilitation can be used directly as a cognitive-behavioural strategy to address specific patient complaints / functional impairments. As physiotherapists we need to recognise that any interactions we have with patients have cognitive / emotive connotations and there is no practical reason why physical means cannot be used to facilitate this approach as an adjunct or an alternative to psychotherapy techniques

Those who attended the “Decade of the Flags” conference in Keel university at the end of 2007 will know that primary care clinicians can now no longer hide behind professional boundaries as an excuse not to challenge patients distorted beliefs or facilitate rehabilitation programs which are tailored to their needs.

This obviously poses clinical challenges but the facts won’t go away by passing the buck.

What do you find the most challenging aspects of of this situation?

Technorati Tags: low back pain, physhosocial, physiotherapy, psychosocial flags, rehabilitation

ACL Rehabilitation

The topic of ACL rehabilitation has revieved great attention particularly in regard to accellerated programs.

What is an accellerated program?

Do you know how to structure one?

For details see here…..