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Management of Patellofemoral Pain : NATA Guideline

Management of Patellofemoral Pain : NATA Guideline

The National Athletic Trainers’ Association released guidelines for athletic trainers and other health care providers regarding the identification of risk factors for and management of individuals with patellofemoral pain (PFP). The position statement was published in the Journal of Athletic Training.

Patellofemoral pain is one of the most common knee diagnoses and challenging to manage. Early identification of risk factors may allow clinicians to develop and implement programs aimed at reducing the incidence of this condition.

The key recommendations included are:

Risk Factors 

1. Hip adduction and internal rotation during dynamic tasks such as running and landing from a jump are risk factors for the development of PFP.
2. Increased knee-abduction impulses and moments during running and drop landings are risk factors for the development of PFP.
3. Novice runners who developed PFP generated greater vertical peak force to the lateral heel and second and third metatarsals. Military recruits who developed PFP walked with greater lateral foot pressure.
4. Reduced isometric hip-abductor, external-rotator, and hip-extensor strength are not likely to risk factors for the development of PFP.
5. Quadriceps weakness is a risk factor for the development of PFP.
6. Delayed activation of the vastus medialis obliquus (VMO) relative to the vastus lateralis (VL), as identified with a patellar tendon tap or voluntary tasks (eg, rocking back on the heels), can contribute to the onset of PFP.
7. Static measures, such as the quadriceps angle (Q-angle), foot posture index, lower leg-heel alignment, and heel-to-forefoot alignment, are not predictors of PFP development.
8. Individuals with quadriceps tightness and decreased vertical-jump performance have developed PFP.

Pain and Functional Outcome Measures

9. Clinicians should use a 10-cm visual analog scale (VAS) to assess changes in pain during rehabilitation. A 2-cm or greater change in VAS score for usual or worst knee pain in the past week represents a clinically meaningful difference.
10. Clinicians should use patient-reported outcome measures, such as the Anterior Knee Pain Scale (AKPS) or the Lower Extremity Functional Scale (LEFS), to assess function in individuals with PFP. For the AKPS, a 10-point or greater change represents the minimal clinically important difference. For the LEFS, an 8-point or greater change represents the minimal detectable change.

Nonsurgical Treatment

11. Due to the complexity of managing PFP, clinicians should develop and implement a multimodal plan of care. The plan of care should include gluteal- and quadriceps-strengthening exercises, patient education (ie, contributing factors, the importance of exercise, rehabilitation expectations), and activity modification. Individuals with PFP who complete an 8-week gluteal-strengthening program reported greater improvements in pain and health status 6 months after completing rehabilitation compared with those who completed an 8-week quadriceps-strengthening program.
12. For individuals with PFP, clinicians should prescribe an initial 3-week program of isolated gluteal-strengthening exercises before a program of quadriceps-strengthening exercises.
13. Clinicians should prescribe interventions that address trunk-muscle (eg, abdominal oblique, rectus abdominis, transversus abdominis, erector spinae, and multifidi) control and capacity in individuals with PFP.
14. To minimize patellofemoral joint stress, patients should perform nonweight-bearing quadriceps exercises between 45° and 90° of knee flexion and weight-bearing quadriceps exercises between 0° and 45° of knee flexion.
15. Patellar taping appears to be beneficial if it enables patients with PFP to exercise in a pain-free manner.
16. Movement-retraining programs that incorporate either real-time visual or auditory feedback can benefit individuals with altered lower extremity gait mechanics such as excessive hip adduction or hip internal rotation or increased knee valgus (or a combination of these).
17. Movement retraining that emphasizes keeping the pelvis level and the knees facing forward during dynamic activities has been beneficial for females with PFP. Providing visual and verbal feedback to the patient about keeping the pelvis level and knees facing forward appears to be an important component of this training.
18. Foot orthoses as an adjunct intervention in combination with other treatment strategies provide some benefit to patients with PFP.
19. Forms of electrotherapy including therapeutic ultrasound and low-level laser therapy have shown limited effectiveness in the management of PFP.

Surgical Treatment

20.  Referral for surgical intervention should be considered only if an individual with PFP presents with either evident lateral patellar compression or patellar instability and has failed to improve despite exhaustive rehabilitation attempts.
21.  Lateral retinacular release or lengthening can benefit individuals with PFP who present with excessive lateral patellar tilting but no patellar instability or grade III-IV articular cartilage changes.

Although PFP is one of the most common lower extremity diagnoses experienced by active individuals, it continues to be among the most challenging to manage. A multifactorial problem, PFP has numerous causes resulting from irritation of innervated patellofemoral joint structures. However, a common theme is that excessive patellofemoral joint loading not only leads to PFP but must be minimized during rehabilitation.

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Source: With inputs from Journal of Athletic Training

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