THE BOX AND NOT ONLY FOCUS ON BIOMECHANICS AND STRENGTH FACTORS


SOMETIMES WE MAY NEED TO THINK OUTSIDE


may be a very important factor as PFP is probably the result of excessive loading of the patellofemoral joint caused by physical activity or structural mal-alignment of the patellofemoral joint (8,12). The clinical implication of this is that more emphasis should be placed on helping the adolescents to modify their physical activity level (Fig. 4). If we simply add exercise therapy on top of a high physical activity level we will not remove the factor that is the likely cause of their knee pain.


WHEN SHOULD WE INTERVENE? On average the adolescents reported knee pain for more than 3 years. This was quite surprising. Previous studies show that a long symptom duration is associated with worse outcome and only 5% of the adolescents reported a symptom duration below 6 months (22,23). This is a much longer symptom duration compared to previous trials on adults (17,24). The primary implication of this is that we need to treat adolescents sooner, rather than later, and to educate health personnel involved in the treatment of PFP of this. One of our previous studies showed that 50% of adolescents with knee pain seek treatment (5). Among those who choose to contact their GP only few are referred to physiotherapy. This means that 50% of adolescents don’t seek medical care even though they have significant knee pain. This highlights that we need to educate both adolescents and their parents to seek medical care and not wait too long to see if their knee pain will disappear by itself.


ADHERENCE AND PLACE OF TREATMENT Adherence may be one of the biggest challenges towards using exercise therapy as a treatment of adolescent


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PFP. From clinical experience we know that only few of the adolescents will regularly show up at the clinic and only few will do their home-exercises. So the question is where the optimal place of exercise therapy should be? The high prevalence of PFP in upper secondary schools (6–7%) show that in a normal sized school of 500–800 adolescents there would be 30–50 adolescents with PFP. Because of the high prevalence it might be worth considering if treatment of adolescent PFP using exercise therapy should be done at school premises. This would have the advantage of easier access to treatment as the adolescents are already at school five days per week. The exercise therapy can be done with minimal additional equipment besides rubber mats and therefore could be performed in any classroom.


CONCLUSION AND CLINICAL MESSAGE Most physiotherapists treating adolescents are likely to have used some sort of exercise therapy in the treatment of adolescent PFP. Our research highlights that we should continue to do so and now we can comfortably state that we have evidence for the effect of exercise therapy among adolescents. The exercise therapy should aim at increasing strength as well as improving neuromuscular knee control, as both seem to be affected. This is a heterogeneous patient group and in some adolescents it may be more relevant to target strength deficits whereas others are in need of exercises to help increase control of their knee. We need to talk to the adolescents and ask how much sport they are doing and help them to modify their activity to an appropriate level that does not overload or provoke their knee pain. From a health perspective it is important that we don’t encourage them to stop participating in sport – only to modify the level and intensity as needed. Additionally there may be some adolescents with both peripheral and central sensitisation where exercise therapy may not be the first step of their treatment but rather consider general exercises not involving the knee and focus on self-


management and education. Adherence may be the biggest obstacle towards the use of exercise therapy. Exercises are unlikely to work if they are not performed. Therefore, discuss with the adolescents and the parents how exercises may be implemented in their everyday life and how it fits best with their schedule.


References 1. Perquin CW, Hazebroek-Kampschreur AA, et al. Pain in children and adolescents: a common experience. Pain 2000;87:51–58 2. King S, Chambers CT, et al. The epidemiology of chronic pain in children and adolescents revisited: a systematic review. Pain 2011;152:2729–2738 3. Rathleff MS, Roos EM, et al. High prevalence of daily and multi-site pain--a cross-sectional population-based study among 3000 Danish adolescents. BMC pediatrics 2013;13:191 4. Molgaard C, Rathleff MS, Simonsen O. Patellofemoral pain syndrome and its association with hip, ankle, and foot function in 16- to 18-year-old high school students: a single-blind case-control study. Journal of the American Podiatric Medical Association 2011;101:215–222 5. Rathleff MS, Skuldbol SK, et al. Care- seeking behaviour of adolescents with knee pain: a population-based study among 504 adolescents. BMC musculoskeletal disorders 2013;14:225 6. Haim A, Yaniv M, et al. Patellofemoral pain syndrome: validity of clinical and radiological features. Clinical Orthopaedics and Related Research 2006;451:223–228 7. Witvrouw E, Werner S, et al. Clinical classification of patellofemoral pain syndrome: guidelines for non-operative treatment. Knee Surgery, Sports Traumatology, Arthroscopy 2005;13:122– 130


8. Powers CM, Bolgla LA, et al. Patellofemoral pain: proximal, distal, and local factors, 2nd International Research Retreat. Journal of Orthopaedic & Sports Physical Therapy 2012;42:A1–54 9. Rathleff MS, Roos EM, et al. Lower mechanical pressure pain thresholds in female adolescents with patellofemoral pain syndrome. Journal of Orthopaedic & Sports Physical Therapy 2013;43:414–421 10. Rathleff CR, Olesen JL, et al. Half of 12-15-year-olds with knee pain still have pain after one year. Danish Medical Journal 2013;60:A4725 11. El-Metwally A, Salminen JJ, et al. Lower limb pain in a preadolescent population: prognosis and risk factors for chronicity--a prospective 1- and 4-year follow-up study. Pediatrics 2005;116:673–681 12. Powers CM, Bolgla LA, et al. Patellofemoral pain: proximal, distal, and local factors, 2nd International Research Retreat. Journal of Orthopaedic & Sports Physical Therapy 2012;42:A1–54


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