PATELLOFEMORAL PAIN REHABILITATION

Figure 2: Ober’s test for iliotibial band length

Figure 3: Modified Thomas test for iliotibial band length

Stretching shortened soft tissues Decreased length of the hamstrings, rectus femoris, gastrocne- muis/soleus complex or iliotibial band (ITB) may all contribute to PFPS. Numerous variations on hamstring and rectus femoris stretches exist and can be used to lengthen these tissues. Care must be taken when instructing and monitoring the patient’s per- formance of these exercises, it is important that they maintain a neutral lumbar spine/pelvic tilt position to avoid over-straining the lumber spine or sacro-iliac joint.

While carrying out weight bearing gastrocnemuis (ankle dorsi- flexion with an extended knee) and soleus (dorsi-flexion with knee flexed) stretches care must be taken that the patient main- tains a sub-talar joint neutral position during the stretch. Pronating the foot decreases the efficacy of the stretch and also encourages a faulty movement pattern.

The length of the ITB can be assessed using the Ober’s test (Fig.2) or the modified Thomas test (Fig.3). The Ober’s test is carried out with the pelvic position fixed and the leg lowered towards the bed in neutral or slight hip extension. A normal range for males is to touch the plinth and in females to be within 5cm of the plinth. In the case of the modified Thomas test the test involves drawing both knees to the chest to flatten the back, which rotates the pelvis posteriorly. While the individual holds one to the chest the other leg is lowered towards the table, maintaining a degree of hip adduction. The thigh should reach the table without any ante- rior rotation of the pelvis or hip abduction.

Both of these test positions can be used as a stretch for the ITB, along with the wall ITB stretch (Fig.4) and the posterior pelvic tilt ITB wall stretch (Fig.5). To perform the wall ITB stretch stand with affected leg closest to the wall, cross it behind the other and lean the hips towards the wall. To perform the posterior pelvic tilt, flex the knees posteriorly, tilt the pelvis to flatten the back against the wall, straighten the legs sliding up the wall to the point where posterior tilt is beginning to be lost and hold.

Quadriceps strengthening In terms of retraining the dynamic control of the PFJ, ie. increas- ing the activity of vastus medialis oblique (VMO) and the quadri- ceps, the available research recommends the exercise protocol outlined in the Practitioner Prompt on the next page (3,4). Initially, strengthening of the quadriceps should take place using closed kinetic chain exercises within the range of 20-50 degrees knee flexion. Contracting the quadriceps in a flexed position has been shown to reduce inhibition and weightbearing facilitates

Above: Figure 4: Wall iliotibial band stretch Right: Figure 5: Posterior pelvic tilt iliotibial band wall stretch

VMO activity. Within this range of knee flexion loading per unit area on the PFJ has been shown to be reduced and the closed kinetic chain position increases the overall activity of the quadri- ceps and improves PFJ congruency.

In the above position, the patient would initially carry out iso- metric contractions in order to facilitate the tonic holding func- tion of the patella stabilisers. They would then progress to dynam- ic eccentric and then concentric contractions still using closed kinetic chain exercises in the above range progressing to a full range of motion. Finally, ballistic and functionally specific exer- cises as appropriate, including open kinetic chain exercises if nec- essary, are incorporated into the programme. While carrying out closed kinetic chain exercises the correct positioning of the foot and hip is essential for maximal facilitation of the quadriceps and so VMO and good postural alignment should be emphasised to the patient at all times.

Control of lower limb rotation Dynamic control of lower limb rotation is essential to reduce the stresses on the PFJ. Correct alignment of the lower limb during activity minimises the Q angle (see Fig 3a on page 28), while incorrect alignment considerably increases the Q angle (See Fig 3b on page 29) and the tendency for mal-tracking of the patella. Central to control of limb rotation is activation of gluteus medius because of its function in stabilising pelvic position in unilateral stance. Correct limb alignment needs to be emphasised to the patient, encouraging coactivation of the gluteus medius at all times to stabilise the pelvis during all closed kinetic chain activ- ities. Initially exercises may have to be carried out in front of a mirror for visual feedback of position, then gradually greater and greater proprioceptive

challenges are incorporated with the use

of trampets and wobble boards. Orthotic devices may have to be used as a temporary (or even permanent) aid to the control of foot pronation.

References 1. McConnell J. The management of chondromalacia patellae: a long term solution. Australian Journal of Physiotherapy 1986;32(4):215-222 2. Maitland G. Peripheral Mobilisation 3rd edition. Butterworth- Heinemann, Oxford, 1991 3. Herrington L. The role of vastus medialis obliques in patellofemoral pain. Critical Reviews in Physical and Rehabilitation Medicine 1998;10(3):257-263 4. Powers C. Rehabilitation of patellofemoral joint disorders: a critical review. Journal of Orthopaedic and Sports Physical Therapy 1998;28(5):345-354

SportEX 31