September 11, 2003

How do you evaluate/ utilize
 static patellar position?

•     Evaluation

–  Q angle

•   Watson et al JOSPT 1999

–  K= -.03 - .35

•   Fitzgerald and McClure Phys Ther 1995

–  K= .10- .36

•     Manual Treatment (Mobs)

–  No

•   Lieb and Perry              JBJS 1968, JBJS 1971

•   Basmajian                            Anat Rec 1971

•   Hallen et al                   Acta Orthop Scand 1967

•   Jackson/ Merrifeld                  Med Sci Sport Exe 1972

•   Reynolds et al               Am J Phys Med 1983

•   Salzman et al.               Clin Orthop 1993

Can you selectively train the VMO?

•    Quad exercises

–  No

•   Cerny                          Phys Therapy 1995

•   LaPrade                      JOSPT 1998

•   Vaatainen et al              Int J Sports Med 1995

•   Mirzabeigi et al              AJSM 1999

Can you selectively train the VMO?

•    Biofeedback

–  Yes

•   Cowan et al         Med Sci Sport Ex 2002

–  No

•   Dursun et al        Arch Phys Med Rehabil 2001

Can you selectively train the VMO?

•     Hip Adduction

–  Yes

•   Hanten and Schulthies                 Phys Ther 1990

•   Hodges and Richardson               Scand J Rehab                                                      Med 1993

–  No

•   Karst and Jewett                        Phys Ther 1993

•   Grabiner                                 Eur J Exp                                                    Musculoskel Res 1993

•   Cerny                                    Phys Ther 1995

•   Laprade                                 JOSPT 1998

Can you selectively train the VMO?

•    Internal Tibial Rotation

–  Yes

•   Laprade et al.               Phys Ther 1998

–  No

•   Hanten and Schulthies   Phys Ther 1990

•   Cerny                          Phys Ther 1995

Can you selectively train the VMO?

•    “….it would appear that isolated recruitment or strengthening of the VMO through selected exercises may not be a realistic goal and any emphasis on selective strengthening of the VMO would most likely translate into a general quadriceps strengthening program.”

»  Powers JOSPT 1998

Can you selectively train the VMO?

•    “…..there is moderate evidence that non-weight bearing, weight bearing, isometric, and eccentric exercises may be useful in the management of PSPS; however, no single approach has been demonstrated to be superior to another.”

»  Bizzini et. al. JOSPT 2003

Is taping/ bracing effective?

Is taping/ bracing effective?

•     To decrease pain?

–   Yes

•   McConnel                      Aust J Physiotherap 1986

•   Gerrard                        Clin Orthop 1989

•   Finestone (RCT)              Clin Orthop 1993

•   Moller and Krebs              Arch Orthop Trauma Surg 1986

•   Palumbo                        AJSM 1981

•   Bockrath et al                  Med Sci Sports Exerc 1993

•   Grace                          JOSPT 1997

•   Powers                         JOSPT 1997

•   Crossley et al                  Clin J Sport Med 2001

•   Greenwald et al                Clin Orthop 1996

•   Ng and Cheng                 Clinical Rehabilitation 2002

•   Cochrane 2003 (Taping)

•   Wilson et al. (!!)               JOSPT 2003

–   No

•   Miller (RCT)                  Am J Knee Surg 1997

•   Kowall (RCT)                  AJSM 1996

Is taping/ bracing effective?

•    For changing patellar position?

–  Yes

•   Shellock et al                J Mag Res Imag 1994

–  Yes, but not maintained after ex

•   Larsen                        AJSM 1995

–  Yes, but only at rest (vs. AROM)

•   Muhle et al                            AJSM 2000

–  NO

•   Bockrath                      Med Sci Sports Ex 1993

Is taping/ bracing effective?

•    On VM/ VL activation?

–  Yes

•   Gilleard              Phys Ther 1998

–  No

•   Cerny                 Phys Ther 1995

Is taping/ bracing effective?

•     Protonics

–  “It’s not a brace.  It’s a system!”.

–  “This limited research-based evidence showed that Protonics orthosis at 6 wk F/U was significantly more effective for decrease in pain, functional improvement, and change in PF congruence angle when compared to no treatment”.  Cochrane 2002

–  “..there appears to be some evidence that this resistive brace may reduce pain and improve function”.  Bizzini JOSPT 2003

–  Timm (RCT)- Funding

Any role for foot orthotics?

•    Decrease pain?

–  Yes

•   Eng (RCT)                    Phys Ther 1993

•    Medialize the patella?

–  Yes

•   Klingman et al              JOSPT 1997

Any role for modalities?

•     US

–  Yes

•     Laser

–  NO

•   Rogvi- Hansen et al (RCT)             Int Orthop 1991

•     Acupuncture

–  Yes

•   Jensen et al (RCT)                     J Altern Complem                                          Medicine 1999

Combined Treatments

•    The norm not the exception

•    Bizzini et al

–  Harrison et. al.            Physiotherapy 1999

–  Clark et. al.                Ann Rheum Dis 2000

–  Eburne                     Knee 1996

–  Roush et al.                      Clin J Sport Med                                            2000

Outcomes

•    Kannus et al. JBJS 1999

–  2/3 - ¾ of all pts. – “full recovery”

–  No changes: 6 mos< x < 7 years

Can you predict outcome?

–  Quad strength

–  Pain with patellar apprehension

–  Crepitus initially and at F/U

–  Presence of B sx.

–  Pt’s age and height

–  Neither radiographic nor MR findings were correlated with 7 yr. Outcome

•     Doucette and Goble                      AJSM 1992

•     “….treatments that seem effective in decreasing pain and improving function in pts. with PFPS are acupuncture, quadriceps strengthening, the use of a resistive brace, and the combination of exercise with patellar taping and biofeedback.  The use of soft foot orthotics in pt’s. with excessive foot pronation appears useful to decrease pain.  In addition, at a short term F/U, pts. who received exercise programs were more likely to be D/C’d earlier from PT. “