Definition & Background Information
Patella syndrome, also known as patellofemoral pain syndrome (PFS), has been defined in the literature as “retropatellar or peripatellar pain resulting from physical and biochemical changes in the patellofemoral joint” (Mark & Juhn 2012).
Patella syndrome qualifies as the commonest cause of chronic knee pain, with current research studies demonstrating that it is triggered by a deformity in how the kneecap (patella) glides over the lower end of the femur or the thigh bone (Witvrouw et al 123).
Although there has been intense debate about the causes of patella syndrome, with some researchers suggesting that one of the likely causes is the maltracking of the patella on the femur as a direct consequence of a discrepancy in the activity of the vastus medialis oblique relative to the vastus medialis (Fagan & Delahunt 790), consensus is still lacking about the actual causes of the syndrome (Mark & Juhn 2012).
The patella is undoubtedly “the largest sesamoid bone of the skeleton that is formed and located within the tendon of the quadriceps femoris muscle” (Bongers et al 302).
Owing to certain physical and biochemical shifts in the patellofemoral joint, including weight overload and overuse (Mark & Juhn 2015), the quadriceps (thigh) muscle is unable to pull the patella up over the end of the femur in a straight line, hence allowing the underside of the patella to grate along the femur to cause chronic inflammation and pain which worsens when patients engage in an activity such as descending steps or hills (Vicenzino et al 1-2).
The pain and inflammation can also be caused by prolonged sitting.
Signs or Symptoms
Most studies in the medical, sports and physical therapy literature describe symptoms of subtle commencement, such as vague discomfort of the inner knee area which may affect one or both knees and is worsened by extreme physical activity, running, jogging, descending a stairway, bending, stooping, or by prolonged sitting with knees in a somewhat bent position.
Congenital knee dislocation due to sustained loss of quadriceps strength (Percin 705-706), as well as knee swellings (Moyano et al 411), are also possible symptoms of patella syndrome.
Many patients of patella syndrome also present with strength deficit of the quadriceps (decreased knee extensor strength), which is normally exhibited in terms of hypotrophy of the quadriceps muscle, selective hypotrophy of the vastus medialis obliquus (VMO), neuromuscular timing dysfunction as well as low muscular flexibility along the kneecap area (Witvrouw et al 126-128).
Contradictions
One common contradiction regarding patella syndrome, according to available literature, is that the patella (knee cap) can only move in an up-and-down direction, implying that it cannot tilt sideways or even rotate.
However, the correct position is that the patella “also tilts and rotates, so there are various points of contact between the undersurface of the patella and the femur” (Mark & Juhn 2016).
Owing to this capability of the Patella to tilt and rotate, researchers in the fields of medicine, sports and physical therapy are of the opinion that the repetitive contact between the underside of the kneecap and the thigh bone, as well as the maltracking of the kneecap that is often not noticeable by the naked eye, are the most probable triggering mechanisms for patella syndrome among physically active people (Dolak et al 562).
The result of these dynamics is the classic presentation of retropatellar and peripatellar pain, which is often confused with pain that occurs directly on the patellar tendon, also known as patellar tendonitis (Mark & Juhn 2016).
The two conditions come from different backgrounds and are triggered by diverse musculoskeletal dynamics, hence the contradiction.
The last contradiction is that patella syndrome is often confused with chondromalacia; however, this is a wrong perception since patella syndrome describes a condition where an individual experiences retropatellar or peripatellar pain resulting from physical and biochemical shifts in the patellofemoral joint, whereas chondromalacia describes the tangible fraying and damage to the underlying patellar cartilage (Moyano et al 410).
Prevention
Extant literature demonstrates that athletes and other sports personalities can prevent patella syndrome by having at their disposal knowledge about the contributing factors, which include overuse and overload of the patellofemoral joint, biomechanical issues and muscular dysfunction (Moyano et al 410-411).
Emerging literature also suggests that it is possible to prevent the occurrence of patella syndrome by
- undertaking a proper warm up before vigorous physical exercises,
- varying the types of activities that athletes participate in to keep fit (e.g., alternating running and swimming rather than running everyday),
- taking care of injuries immediately,
- icing of kneecaps for ten to twenty minutes after physical activity (Dolak et al 561-562; Mark & Juhn 2014-2017).
Rehabilitation
It is indicated in the medical and physical therapy literature that under the strict guidance from a qualified trainer or medical doctor, patients can use one or multiple rehabilitation methodologies available, such as knee sleeves, braces, tapes, low-intensity physical exercises, arch supports, custom orthotics and surgery (Mark & Juhn 2014-2017).
Although the use of knee sleeves and braces to rehabilitate patients with patella syndrome is shrouded in controversy, the tools are to a large extent beneficial as they hold the patella into position and keep it from deviating too laterally.
In rehabilitating patients, however, the common practice is that knee sleeves and braces should not outpace or substitute therapeutic exercises.
Rehabilitation can also be effected by taping the patella (kneecap) in a particular position not only to reduce friction between the underside of the patella and the lower end of the femur, but also to offer short-term pain relief (Mark & Juhn 2014).
Low intensity physical exercises such as stretching and stationary bicycling act to rehabilitate patients suffering from patella syndrome by strengthening the quadriceps and hamstring muscle to more comfortably be able to hold the patella in place.
Indeed, extant literature demonstrates that “quad sets” act as the foundation for a rehabilitation program, where patients with this syndrome are encouraged to contract their thigh muscles with their legs in a straight orientation and to hold the contraction for a count of ten (Moyano et al 410).
Athletes should experience a speedy recovery and return to full functionality in sports if they optimise these exercises by doing a minimum of ten contractions between fifteen and twenty times per day (Mark & Juhn 2016).
Moving on, it is evident that arch supports and custom orthotics can be helpful not only in reducing the chronic pain associated with patella syndrome, but also in enhancing lower extremity biomechanics by thwarting overpronotion in pes planus and by availing a wider base of support for the normal or pes cavus foot (Mark & Juhn 2016; Vicenzino et al 2).
However, these authors further note that although custom orthotics are relatively expensive compared to over-the-counter arch supports, it is yet to be established whether they provide greater and superior efficacy when used to rehabilitate athletes with patella syndrome.
Footwear should not be left behind in any attempt to rehabilitate an athlete from the devastating effects of patella syndrome. Within the sports domain, physical therapists and trainers are in agreement that the quality and age of footwear are more fundamental than the manufacturer or the brand name (Mark & Juhn 2017).
It would benefit the physician to have patients use quality running shoes from reputable footwear stores as they the go about their healing process to reduce unnecessary pressure in the knee area. Reconstructive surgery can also be done on the affected knee, but this should be considered a last resort (Vicenzino et al 11).
Appropriate Exercises
The physician or physical therapist should work closely with the patient to develop an all inclusive training regimen that not only focus on strengthening the quadriceps muscles, but also stretching the hip, hamstring, calf and iliotibial band (Mark & Juhn 2017).
Quadriceps strengthening can be achieved through low-resistance stationary bicycling, pool running or flutter-kick swimming, whereas correct kneecap positioning can be achieved using EMG biofeedback machines as well as exercises in water using a Buoyancy Aid.
In addition, the physical therapist should evaluate the possibility of introducing the patient to closed-chain exercises (where the sole of the patient’s foot is in sublime contact with an even surface) such as the squat and leg-press exercises, with the view stabilizing the thigh muscle and other ligaments that holds the kneecap into position hence successfully dealing with the problem of loose quadriceps (Vicenzino et al 6).
These exercises, though appropriate, must only be undertaken in a secure, pain-free range of motion and under the direct regulation of a qualified physical therapist or any other qualified personnel (Moyano et al 413; Dolak et al 561). Lastly, patients should be encouraged to reduce knee activity by undertaking relative rest.
Exercises to Avoid
People with patella syndrome must at all times avoid traditional knee extension exercises that only serve to worsen the situation by directing excessive force/weight into the patellofemoral joint.
Exercises such as intense running and jogging should also be avoided as they tend to increase friction between the patella and the lower end of the femur (Vicenzino et al 6).
Works Cited
Bongers, E.M.H.F., van Kampen, A., van Bokhoven, H. and Knoers, N.V.A.M. (2005). Human Syndromes with Congenital Patellar Anomalies and Underlying Gene Defects. 302-319. Netherlands.
Dolak, Kimberly L, Silkman Carrie, McKeon Medina Jennifer, Hosey Robert G., Lattermann Christian and Uhl Timothy L. (2011). Hip Strengthening Prior to Functional Exercises Reduces Pain Sooner than Quadriceps Strengthening in Females with Patellofemoral Pain Syndrome: A Randomized Clinical Trial. 560-570. United States of America.
Fagan, V. and Delahunt, E. (2008). Patellofemoral Pain Syndrome: A Review on the Associated Neuromuscular Deficits and Current Treatment Options. 789-795. Ireland.
Mark, S. and Juhn D.O. (1999). Patellofemoral pain syndrome: A review of guidelines for treatment. 2012-2018. United Kingdom.
Moyano, F. Revelles, Valenza M.C., Martin L. Martin, Cabellero Y. Castellote, Gonzalez-Jimenez E. and Demet G. Valenza. Effectiveness of Different Exercises and Streching Physiotherapy on Pain and Movement in Patellofemoral Pain Syndrome: A Randomised Controlled Trial. 409-417. Spain.
Percin, Ferda E., Bulut Sema, Kunt Tanfer, Percin Sitki, Bulut Okay and Sungu Selma. (1999). Waardenburg Syndrome Type 1 and Small Patella Syndrome in the Same Patient. 704-706. Turkey.
Vicenzino, Bill, Collins Natalie, Crossley Kay, Beller Elaine, Darnell Ross and McPoil Thomas. (2008). Foot Orthoses and Physiotherapy in the Treatment of Patellofemoral Pain Syndrome. A Randomised Clinical Trial. 1-12. Australia.
Witvrouw. Eric, Werner S., Mikkelsen, C., van Tiggelen, D.V., Berghe, Vanden L., and Cerulli G. (2005). Clinical classification of patellofemoral pain syndrome: Guidelines for non-operative treatment. 122-130. Italy.