Reviewed by Tyler Tice, PT, DPT, OCS, ATC
Article:
Patellofemoral Pain Clinical Practice Guidelines Linked to the International Classification of Functioning, Disability and Health From the Academy of Orthopaedic Physical Therapy of the American Physical Therapy Association
Introduction:
The orthopaedic section of the American Physical Therapy Association (APTA) published these clinical practice guidelines in 2019 to give recommendations to clinicians in the differential diagnosis, assessment and treatment of patellofemoral pain.
These recommendations are designed to fit into the International Classification of Functioning, Disability, and Health (ICF model) that was introduced by the World Health Organization (WHO) to improve clinician’s ability to appropriately treat and communicate with patients by including pathoanatomical, psychosocial and societal factors when assessing a patient’s wants and needs.
Methods:
Content experts were appointed by the orthopedic section of the APTA to search the current literature for articles relating to the treatment, assessment and diagnosis of patellofemoral pain. Articles included were taken from MEDLINE, Scopus, CINHAL, SPORTDiscus, and the Cochrane Library with dates ranging from 1960 to 2018.
The chosen articles were then categorized based on level of evidence where I represented the highest quality evidence and V represented expert opinion. After the evidence was reviewed and ranked, the experts developed and ranked recommendations utilizing the information. A ranked recommendations were based on strong evidence while F ranked recommendations were based on expert opinion. These recommendations were further categorized into the following content areas; diagnosis, classification, examination, and interventions.
Results:
After reviewing the available literature, the authors made the following recommendations:
Clinicians should use the reproduction of pain behind or around the patella during squatting or other motions that load the patellofemoral joint in a flexed position to help diagnose patellofemoral pain.
The following factors can be used to diagnose patellofemoral pain: pain behind or around the patella, reproduction of pain when the patellofemoral joint is loaded in a flexed position, exclusion of all other conditions that can cause anterior knee pain including tibiofemoral pathologies.
Clinicians can use the patellar tilt test with the presence of hypomobility to support the diagnosis of patellofemoral pain.
Since there are no previously established classifications of patellofemoral pain, the authors propose the following 4 classifications: overuse/overload without other impairments, muscle performance deficits, movement coordination deficits, and mobility impairments.
Clinicians should use the following patient reported outcome measures when assessing patients with suspected patellofemoral pain: the Anterior Knee Pain Scale, the patellofemoral pain and osteoarthritis sub-scale of the Knee Injury and Osteoarthritis Outcome Score, the Visual Analog Scale, the Eng and Pierrynowski Questionnaire, the Numeric Pain Rating Scale.
Clinicians should use functional tests such as squats, or step downs that reproduce patellofemoral pain to assess a patient’s progress throughout an episode of care.
Clinicians may use body structure and function impairments such as joint hypomobility, muscle weakness and lack of muscle extensibility to assess progress throughout an episode of care.
Clinicians should employ an exercise approach that targets both hip and knee musculature. During the early stages of therapy, exercises targeting the posterolateral hip musculature is preferred but as the plan of care continues, targeting knee musculature as well is essential.
Clinicians may use patellar taping in the early stages of rehabilitation with the goal of reducing pain to enhance exercise performance. Evidence shows that this can be helpful early on but generally has no lasting impact on prognosis or symptoms. Clinicians should not prescribe knee orthoses such as knee sleeves or braces for the treatment of patellofemoral pain.
Clinicians may prescribe prefabricated foot orthoses for patients with greater than normal foot pronation during the early stages of rehabilitation in concert with an exercise program. There is limited evidence suggesting that custom foot orthoses are more effective than prefabricated foot orthoses.
Clinicians should not use electromyography-based biofeedback on medial vastii activity to augment quadriceps exercise therapy for the treatment of patellofemoral pain. Clinicians should also not use visual biofeedback on lower extremity alignment during hip and knee targeted exercise during the treatment of patients with patellofemoral pain.
Clinicians may use gait retraining during running for multiple sessions to adopt gait changes during running for patients with patellofemoral pain.
Clinicians may use blood flow restriction plus high-repetition knee exercises for those with limited or painful resisted knee extension.
Clinicians should not use dry needling for the treatment of patellofemoral pain, however acupuncture may be used to reduce pain. There is limited evidence that acupuncture is more effective than placebo so caution should be exercised with this recommendation.
Clinicians should not use joint mobilizations or manipulations as a stand-alone treatment for patellofemoral pain. Clinicians should not use biophysical agents including ultrasound, cryotherapy, phonophoresis, iontophoresis, electrical stimulation, or therapeutic laser therapy to treat patellofemoral pain.
Evidence suggests that patient education regarding plan of care, patellofemoral joint loading and Kinesio phobia helps to improve exercise program compliance to a rehabilitation exercise program. The evidence suggests that a multimodal approach is ideal in the treatment of patellofemoral pain but that exercise is the primary factor in successful treatment.
Discussion and clinical utility:
This CPG is helpful because it provides new classifications of patellofemoral pain to help clinicians guide their plans of care. It is also useful to see that exercise is the biggest factor in the effective treatment of patellofemoral pain. This helps clinicians empower patients to be active and help treat their own symptoms.
References:
Willy RW, Hoglund LT, Barton CJ, Bolgla LA, Scalzitti DA, Logerstedt DS, Lynch AD, Snyder-Mackler L, McDonough CM. Patellofemoral Pain. J Orthop Sports Phys Ther. 2019 Sep;49(9):CPG1-CPG95. doi: 10.2519/jospt.2019.0302. PMID: 31475628.