CLASSIFICATION OF PFPS tional information for the clinician.

One important question that the clinician should be able to answer after the PF alignment evaluation is whether the malalignment of the PF joint (if present) is caused by muscular structures, or by static structures (retinaculum, bony con- firmations, ligaments). Examining the PF alignment with and without quadriceps contraction is a good way to determine this. As shown by studies and confirmed by clinical experience, about 50% of the PFPS patients show an abnormal PF align- ment only after quadriceps contraction. In these patients the quadriceps can be iden- tified as an important structure contribut- ing to the malalignment problem. Consequently, the treatment should be focused on retraining the quadriceps mus- cle. In order to obtain this appropriate treatment programme, the clinician must perform a musculature assessment as described above.

If PF joint malalignment is present with the quadriceps relaxed, it seems evident that this malalignment is caused by non- muscular structures (bone or retinacu- lum). A radiograph is essential to recog- nise the presence of any bony abnormali- ty (dysplasia). If a bony abnormality is identified (by radiological examination), non-operative treatment is not likely to be successful.

The condition of the non-muscular soft tissue structures around the PF joint can be examined by a medio-lateral patellar displacement test and gentle palpation of the retinaculum and anterior aspect of the knee while observing the patient’s reac- tion and a possible sign of apprehension. In case of any hypersensitivity of these structures ice, gentle friction techniques and the use of transcutaneous electrical nerve stimulation can be applied to treat those patients. In case of a tight retinac- ulum, stretching of this structure should be performed. This stretching can be done manually by the clinician.

REGISTER YOUR INTEREST If you would be interested in attending a course on the classification and diag- nosis of PFPS as discussed in this article, please email hollie@sportex.net mak- ing sure to include the words ‘PFPS course’ in the email subject heading.

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In addition, the use of a brace or tape may be beneficial to continuously give a gentle stretch to the tight retinaculum. In case of a hypermobile patella (evaluat- ed by the the medio-lateral patellar mobility test) the application of a brace or tape seems crucial in addition to a CKC exercise programme.

CONCLUSION Current studies have showed that alterations observed in some PFPS patients are not found in other PFPS patients. These findings emphasise the existence of several different entities of PFPS, which may respond to dif- ferent treatment protocols. Thus, a general PFPS patient does not exist, and as a result a general treatment programme for PFPS can not be given. Consequently, a thorough examination of every PFPS patient is imper- ative before starting a rehabilitation pro- gramme. The aim of this article is to offer a classification system that provides the clin- ician with guidelines to classify and treat PFPS patients.

If a malalignment is observed, treatment should be based on the unique presenta- tion of the patient and therefore the reha- bilitation protocol should be tailored for each patient. Furthermore, the assessment shows that PFPS patients frequently show alterations in quite a few parameters. Since it is the objective of each pro- gramme to treat all observed alterations, the programme should include the treat- ment of these different alterations. Next, it is often seen that a specific dysfunction disappears during rehabilitation, and as a result the rehabilitation program needs to emphasise on treating another altered parameter. Hence, we recommend a week- ly patient evaluation to modify the treat- ment programme to the up to date condi- tion of the patient.

Finally, it is important to note that not every PFPS patient must have an identi- fied malalignment. PFPS can simply be the consequence of excessive loading on the PF joint. This supraphysiologic loading can be a result of a single event or repet- itive loading. In this case, the programme should contain anti-inflammatory therapy and an exercise program that most likely results in pain reduction. Once the pain has diminished, the patient may gradually increase patellofemoral loading.

THE AUTHOR Dr Erik Witvrouw PT, PhD is assistant profes- sor at the department of Rehabilitation Sciences and Physiotherapy at the Ghent University, Belgium. He is head of the sports physiotherapy department of the Sports Rehabilitation Centre, Ghent University Hospital. His main research area is sports medicine and more specifically rehabilita- tion of knee injuries. He has presented nationally and internationally on the sub- ject of patellofemoral pain syndrome.

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