PT Classroom - Review of the Outcomes of Surgical Intervention vs. Conservative Intervention in the Treatment of Anterior Knee Pain (AKA: Patellofemoral Pain) ׀ by Krista Formanek, DPT

 

Krista Formanek, DPT, received her doctor of physical therapy degree from the University of Wisconsin - LaCrosse. Her special area of interests include orthopedics and sports medicine. She is trained in video gait analysis and is also a personal trainer/group fitness instructor. In her free time she enjoys running, biking, Pilates and yoga.



 Review of the Outcomes of Surgical Intervention vs. Conservative Intervention in the Treatment of Anterior Knee Pain

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In the articles reviewed regarding conservative versus surgical management of patellofemoral pain, all of the articles suggested conservative management should be the first attempt. This statement is based on the fact that the cause of patellofemoral pain syndrome is uncertain and can be caused by an array of possible dusfunctions. Calpur et al (2002) reported that surgical intervention should be performed as the last option after conservative management has failed. Physical therapists can treat conservatively until improvements are no longer apparent, then referral for diagnostic imaging may be necessary to identify another possible cause. Physical therapy may not be able to correct anatomical misalignments; therefore, patients with these types of dysfunctions would be candidates for surgical interventions. According to Bruce and Stevens (2004), patient’s reported full satisfaction with the rotational osteotomies of the femur and tibia, however, the outcome measures used in this study were not valid, reliable or functionally related. Based on the poor research design of the two surgical articles, the benefits of surgical outcomes remain questionable.

Patellofemoral pain would be best treated with conservative interventions. A treatment program including both open kinetic chain (OKC) and closed kinetic chain (CKC) exercises focusing on hip flexion strength has shown to decrease pain (Tyler et al, 2006). The study also noted that improvements in flexibility of iliotibial band (ITB) and iliopsoas muscles contributed to decreased patellofemoral pain. However, it remains to be determined whether a treatment protocol that exclusively focuses on hip flexion strengthening and ITB and iliopsoas stretching would prove more effective in the treatment of patellofemoral pain than the comprehensive protocol used in this study. Witvrouw et al (2000) reported no significant differences in improvements between OKC compared to CKC exercises with both types of exercise improving pain, function, strength and muscle length.

If patients are willing to participate in an exercise program, patellar taping as performed in the study by Whittingham (2004), would be an effective adjunctive therapy to aid in improving acute patellofemoral pain. If tape is applied correctly, patellar taping is a safe addition to an exercise program consisting of strengthening and stretching and can be beneficial for physical therapists to try with their patients. However, physical therapists need to reinforce to their patients that taping is not a cure and adherence to their home exercise program is essential. Another possible adjunct to the exercise program is foot orthoses. Physical therapists may be able to use the following three predictions in their decision to recommend an off-the-shelf foot orthotic: forefoot valgus alignment of greater than equal to 2
, passive great toe extension of less than or equal to 78, and navicular drop of less than or equal to 3 mm (Sutlive et al, 2004). Seventy-two percent of the 45 subjects reported at least a 50% decrease in pain with orthotic use and activity modification. However, the navicular drop and forefoot to rearfoot alignment measurements have low interrater reliability, in addition to the lack of a control group in the study. Therefore, activity modification may have given a false sense of improvement when using the orthotic. With this in mind, an educational approach similar to that of patellar taping is needed. Orthotics should not cause any serious negative effects in patients and for that reason can be used as an adjunct to physical therapy. Again, patients need to understand that orthotic or tape use alone will not decrease their pain or dysfunction completely.
 

Last revised: June 1, 2009
by Krista Formanek, DPT


References:
1. Calpur O, Tan L, et al. Arthroscopic mediopatellar plicaectomy and lateral retinacular release in mechanical patellofemoral disorders. Knee Surg Sports Traumatol Arthrosc. 2002; 10:177-183.
2. Bruce WD, Stevens PM. Surgical Correction of Miserable Malalignment Syndrome. J Pediatr Orthop. 2004; 24(4):392-396.
3. Tyler TF, Nicholas SJ, et al. The Role of Hip Muscle Function in the treatment of patellofemoral pain syndrome. Am J Sports Med. 2006; 34:630-636.
4. Sutlive TG, Mitchell SD, et al. Identification of individuals with patellofemoral pain whose symptoms improved after a combined program of foot orthosis use and modified activity: A preliminary investigation. Phys Ther. 2004; 84: 49-61.
5. Witvrouw E, Lysens, et al. Open versus closed kinetic chain exercises for patellofemoral pain. Am J Sports Med. 2000; 28(5):687-694.
6. Whittingham M, Palmer S, et al. Effects of aping on pain and function in patellofemoral pain syndrome: A randomized controlled trial. J Orthop Sports Phys Ther. 2004; 34:504-510.

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