Patellofemoral Pain Syndrome (PFPS)

The knee is the largest joint in the body and includes the tibia, femur and patella (knee cap). The patella is known as a sesamoid bone which means it is built into the tendon of a muscle. In the case of the patella it is imbedded into the quadriceps tendon. Patellofemoral syndrome is one of the most common conditions that effect the patella.

What is PFPS?

PFPS is a condition wear there is a malalignment or poor tracking of the patella as it glides between the groove on the femur when bending the knee. This malalignment or poor tracking is usually a result of weakness to the quadriceps muscle. The poor tracking of the patella results in uneven wear and tear underneath the patella resulting in pain around the knee cap.

What causes PFPS?

PFPS can be caused by repetitive motions such as squatting, kneeling and impact sports such as running.
Obesity can cause increased stress on the patellofemoral joint causing increased pain.
Improper footwear can also create imbalances on the joint

What are the symptoms?
Pain around or on one side of the knee cap
A feeling of the knee wanting to give way when walking
A feeling of the knee wanting to give way when DESCENDING stairs
Pain when sitting with the knee bent for too long

Treatment Options
Treatment for PFPS is almost always conservative and aims towards physical therapy intervention. Your physical therapist will perform a full evaluation to decide in what direction the patella is tracking. Depending on the direction of the tracking your therapist will decide which specific muscle groups to target to prevent patella tracking. During your treatment you should avoid repetitive bone on bone activities such as squatting, running, jumping and minimal use of stairs if possible. There are also several braces and taping techniques that can be used until the muscles around the knee cap become stronger. You can discuss these options with your therapist or MD.

In rare cases that physical therapy intervention is unsuccessful your MD may recommend surgery to loosen structures around the patella in order to help realign the patella in the femoral groove.

ACL Injury

An injury to the ACL is one of the more common injuries to the knee among athletes and those who participate in recreational sports. The knee is the largest joint in the body which is where the ACL is found. The ACL is attached from the femur (thigh bone) to the tibia (shin bone) and prevents excessive forward motion of the tibia. An injury or tear to this ligament can greatly affect the stability and function of the knee-joint as the ACL is an important stabilizer in the knee-joint.

There are two types of tears to the ACL: a complete tear or a partial tear. Again, any tear to the ACL can result in affecting the function of the knee. When the ACL is torn this results in an excessive rotational movement to the knee which can result in tearing of the meniscus or surrounding cartilage in the knee-joint. It is not unusual to have a cartilage tear along with an ACL tear especially if the injured is an athlete.

So what causes the ACL to tear?

• The ACL can tear due to excessive knee hyper-extension combined with rotation while the foot is still planted to the ground (usually as a result from a hit directly to the outside (lateral) part of the knee, think of being tackled in football)
• The ACL can tear due to sudden lateral movement, such as cutting, as performed in basketball or due to a sudden stop or twisting motion to the knee as can occur with fast paced sports such as soccer, tennis, basketball, skiing, or football.

What are the symptoms of a tear and what do I do if I think I tore my ACL?

• Symptoms: usually hear an audible pop at the time of a tear following by excessive swelling to the knee joint as well as instability with walking as well as a feeling of your knee wanting to “give way” under you when trying to stand or walk. You will also experience a loss of motion when trying to bend or straighten your leg.
• If you suspect a tear: RICE (Rest, Ice, Compression, Elevation): remember, make sure your leg is elevated above the level of the heart and NEVER place ice directly on the skin. You should try to keep the knee as immobile as possible until you are evaluated by your physician for a possible tear.

Possible treatment options? After undergoing an x-ray or MRI your physician may prescribe conservative care such as physical therapy or recommend surgery. However, it will not be unusual for your physician to recommend pre-operative physical therapy to gain some range of motion and reduce swelling before surgery. You can read more about pre-surgical physical therapy here: physical therapy before surgery

What kind of graft should I use? Since surgery is usually recommended your doctor will discuss different types of grafts you can use to repair the ACL. The reason for the graft is because the ACL will not heal on its own without surgery.

• Patellar Tendon: This graft usually has very good outcomes and is one of the most common approaches to ACL repair. However, the downside of this graft is that it can result in a more painful rehab as well as weaken the patellar tendon.
• Cadaver Ligament: As the name suggests this ligament is taken from a cadaver which will be used to reconstruct the ACL. There is less post-operative pain with rehab however you have a higher risk of developing an infection with this graft.
• Hamstring Tendon: A piece of your hamstring is taken in order to reconstruct the ACL. Again, less pain than the patellar tendon but has a longer healing time as this can weaken your hamstrings. As I stated earlier the ACL helps prevent forward translation of the tibia. If your hamstrings are strong this will also help stabilize the tibia from moving forward in combination with your ACL. This graft can cause weakening of the hamstrings and therefore is not a common approach.

Remember, this decision is YOURS and should be discussed with your surgeon as every individual is different.

How long is physical therapy? If you tear your ACL by a freak accident and you are not an athlete you can expect a 4-5 month physical therapy period. Most athletes, however, can average a 7-8 month period of physical therapy as there is a strict protocol to follow. It is a step by step process in physical therapy to be able to return to high level activities and sport. If you were to return to a sport too soon without the correct rehab there is a chance of re-tear. It will also not be unusual if your surgeon recommends a brace as you return to your sport or athletic activity to help keep the knee stabilized.

Physical Therapy BEFORE surgery?

Although this has become a common treatment plan for surgical patients many patients consistently ask me.. why? If you’re about to let someone cut into your body to repair something wouldn’t you want your joint to be functioning at its maximum capacity before someone grabs a scalpel?

1-2 months of physical therapy before surgery can mean full range of motion and improved strength before going under the knife. The stronger your are before surgery and the better your joints are moving before surgery means for a happy and less pain-free recovery later.

Here is a brief list of common surgeries that can benefit greatly from pre-operative physical therapy

• Torn rotator cuff/labral repair – improve shoulder motion and strength before surgery to return to daily activities with improved ease after surgery
• Total Knee/Hip Replacement – a stronger knee is a happier knee/hip after surgery, especially in populations over 50 where for some there can be significant weakness
• Lumbar Discectomy/Fusion – a strong core before surgery means more support for your back after surgery
• Cervical Discectomy/Fusion – improvement in posture and flexibility in the neck can reduce stress to the cervical spine
• Meniscus or ACL repair – depending on the severity of injury there can be a severe loss of motion/swelling before entering surgery. It pays to have good range of motion and to get swelling under control before surgery – both of which can be achieved with pre-operative physical therapy

So- before you let someone convince you to go under the knife immediately, think about the potential that pre-operative physical therapy can do for you in the long run.

Do you buy the right sneaker?

We all have probably heard of the kinetic chain in the body at some point. At times, many joint problems start with the foot. The way a person walks and the type of foot wear they choose to wear can be a factor to pain in the foot, knee, hip, or even the low back. Remember, the foot bone’s connected to the leg bone, the leg bone’s connected to the knee bone, etc etc

So how can we pick out the right type of sneaker to wear? Well, I’m sure this is not news to anyone but always make sure when you try on the sneaker there is a good arch support. Why arch support? Well arch support helps the foot perform with correct mechanics when walking or running to prevent abnormal stresses on other joints such as the knee, hip, and back. However, there is another simple test you can do the next time you go to buy sneakers to know you are buying one to further help match the correct mechanics of the foot.

Take a look at these pictures

Notice where the foot bends in these pictures. This is where the foot bends each time we walk and push-off with our foot. Now, take a look at this picture

Notice when I squeeze the sneaker it bends in the same position our foot should? Well, this is one way to know you are buying a good show that will match the mechanics of your foot when you are walking. At times you may pick up a sneaker that bends directly in the middle. (which would be under the S on the sneaker in this picture) If that happens, when you wear the actual sneaker it will not match the mechanics of the foot when walking which in turn can cause pain to other joints.

I hope this simple tip helps. Oh, and don’t worry.. I always look like the weird one in the sneaker store!