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Man holding knee in pain, close up of knee, hands holding knee

Claire Robertson – Patellofemoral Update – Injury Rehab Network

The November Injury Rehab Network event with BASRaT featured a presentation from Claire Robertson AKA Claire Patella. The online event took place on the evening of Thursday 7th November with 260 sports rehabilitation practitioners in attendance.

Claire discussed the rehabilitation of patients with Patellofemoral pain (PFP). The recording is available to watch here.

A woman with shoulder length blonde hair, wearing a white blouse, looking directly at the camera against a graduated grey backdropClaire Robertson @clairepatella, Consultant Physiotherapist

Claire Robertson qualified in 1994 with a BSc(Hons) in Physiotherapy. She has since obtained her MSc in Physiotherapy in 2003 and PGCE in 2006. Claire has worked in the NHS, academia, and private practice and currently runs a specialist patellofemoral clinic at Fortius Clinic, spending an hour per patient and liaising closely with their treating clinician. Claire is also the physiotherapist for the Warren Smith Ski Academy.

Claire has lectured internationally and published many research papers and editorials in peer-reviewed journals. She is also a reviewer for Physiotherapy Research International, Physical Therapy in Sport, Clinical Anatomy, and Physiotherapy. Claire runs her own postgraduate course on patellofemoral problems for physiotherapists.

Claire sits on the British Patellofemoral Society committee and is on the subcommittee of BASK (British Association for Surgery of the Knee) that develops best practice guidelines for patella instability.

Claire has always enjoyed sports and played tennis to GB standard as a junior. She has a love of all outdoor sports, particularly skiing and hiking. She has two children and understands the difficulties of combining rehabilitation with a busy life!

Patellofemoral Update

Man holding knee in pain, close up of knee, hands holding knee

Claire shared her experience and research on rehabilitating patients with patellofemoral pain (PFP). She discussed how to integrate strength, flexibility, and movement retraining and offered tips on managing kinesiophobia and fear avoidance. She also considered challenges around exercising with pain and explored strategies for keeping runners running!

Introduction & Objectives

Claire discussed the objective for her presentation, which was to increase understanding of the differences between adolescent and adult PFP, provide tips for subjective examination, explain the latest understanding of the relevance of the VMO and quadriceps in PFP, and consider when and how to tape and brace.

Key areas of emerging literature

Claire considered emerging literature on adolescent PFP, crepitus, VMO (vastus medialis oblique)/ quads, and taping/ bracing for the management of PFP.

Subjective Examination – top tips

Claire provided tips for practitioner to support subjective examination of PFP. Claire noted there is currently minimal literature and to remember PFP is an umbrella term so a subjective examination can be used to signpost objective examination. Claire recommends the examination is completed through a process of clinical reasoning for pattern recognition in relation to injury symptoms.

Cinema sign

Cinema Sign Reference production clap board director clap board

Claire described the use of a cinema sign style examination method to ensure there are no issues around:

  • Muscle firing
  • Muscle strength
  • Shock attenuation
  • Foot biomechanics

Claire advises practitioners to consider muscle length (especially quads), sitting posture, and if the Fat Pad is stopping caudad glide of the patella.

Other factors to consider in examination

Other areas that Claire recommends are considered include:

  • Is there pain when walking uphill? Consider calf length and gluteal strength.
  • Does pain alter with different footwear? Consider that high heels increase PFJ load, flip-flops provide no hind foot support, and some shoes offer better shock attenuation.
  • Stairs: If pain worsens when ascending stairs, consider gluteal control and terminal extension control. If pain is worse when descending stairs consider joint surfaces, muscle length, and eccentric quads function.
  • Do skinny jeans/ tight fabrics cause pain or compression in flexion? Consider dislike of compression.
  • Are there patterns of pain? If pain only during activity, consider mechanics. If pain only after, especially later, or next day, consider inflammation. If pain improves with exercise, consider tendinopathy/ muscle length. Does pain cause sleep disturbance?

BMI

Claire considered weight change and the effects of increased BMI (Body Mass Index) on PFP. Research by Landsmeer et al. (2018) investigated the effects of weight change on the progression of knee osteoarthritis (OA). In individuals who gained weight, the odds of PFJ cartilage defects increased by 62%, synovitis increased by 2.5 times, and changes to cartilage in the PFJ were greater.

Crepitus

Claire discussed Crepitus with advice for practitioners to assess belief systems and knock on behavioural change. Qualitative research has demonstrated fear-avoidant and catastrophic beliefs (Robertson et al. 2017). Claire described how many individuals think that Crepitus means their knee is wearing away, they have arthritis, or it’s their bodies way of telling them to slow down.

Claire considered recent literature on Crepitus. Research by de Oliveira Sila et al. (2018) concluded that there is no relationship between the presence of crepitus and self-reported function, physical activity level, and pain climbing stairs. Research by Pazzinatto et al. (2018) showed that crepitus does not affect knee function.

Crepitus – what to do

Claire provided advice for practitioners about the management of Crepitus. The key point was to educate that Crepitus is a normal phenomenon, it does not correlate with the severity of pathology, and pain is abnormal, but crepitus may remain post-treatment.

Shopping bag of risk factors

Claire used the analogy of a shopping bag or basket of risk factors associated with PFP, with a series of factors coming together to create risk. One or two factors may be possible without pain, but more factors can lead to more pain and functional restriction. If overloaded, it may be necessary to consider what to get rid of.

Adolescent PFP

Claire’s advice for adolescents with PFP is to think load. Research by Rathleff et al. (2015) identified that two-thirds of adolescents with PFP are doing sports five times per week, and one-third do no sport. PFP is, therefore, present in those who do a lot or no sport.

Claire recommends that practitioners consider rest days, other activities, footwear, consistent use of orthotics, favourite activities, where pressure is from (coach/ parent/ themselves), and if there is fear of weight gain.

Research by Rathleff et al. (2019) incorporated a 12-week rehab programme/ intervention with load reduced for weeks 0-4, home-based exercises for weeks 5-8, and a return to sport during weeks 9-12. Eighty-six percent reported a successful outcome, with 68% back playing sport after 3 months, 79% at 6 months and 81% at 12 months.

Claire considered whether strength is an issue for adolescents, with changes centered more around poor motor control, especially at times of growth when strength may be insufficient for sporting activities, e.g., landing from a jump.

Kinesiophobia

Claire considered kinesiophobia and recent studies into the fear of physical activity. Claire’s advice for practitioners is to firstly measure/ assess (e.g. Tampa scale), identify movements that elicit fear avoidance, educate, and provided graded exposure to movement. Claire discussed how video education is successful in addressing kinesiophobia and can help individuals to control and manage their thoughts and behaviours around movement.

VMO/ Quads

Claire considered the VMO (vastus medialis oblique) and quads and described how recent studies now make a strong case for the fact that VMO is anatomically separate. Claire discussed factors that may affect VMO inhibition including:

  • Pain induced by fat pad injections may cause delayed VMO firing (Hodges et al. 2009).
  • Direct correlation between amount of pain and size of change.

Swelling

Claire discussed swelling of the VM (vastus medialis) with research showing that icing prior to exercise may be effective. Claire encourages practitioners to consider why there may be an effusion.

VMO Conclusions

Claire summarised the points discussed with conclusions about the VMO:

  • The field is still inconclusive.
  • Anatomy and biomechanics do not support hypothesis for ‘weak’ VMO.
  • Physiological mechanisms to support pain and swelling are driving VMO related PFP.
  • Delayed firing may be relevant but does exist in healthy population.
  • Research suggests fibre angle insertion ratio, not force generation may be key.

How can I strengthen a very painful knee?

Claire provided advice including exercise on alternate days, aim for light fatigue, consider time of day, consider pre-exercise icing, use static positions, and think about angles.

Claire described how patellofemoral join stress at different angles is a key consideration and advised to avoid deep squats and lunges, avoid a high volume of movement, avoid pain, and avoid increasing effusion.

Taping

Claire discussed sports taping for PFP pain with evidence showing that taping decreases pain (Miller et al 2000) and improves kinematics (Selfe et al 2009). Claire considered the proprioceptive aspects of taping with evidence showing functional brain activity (Callaghan et al 2009).

Claire described how there is a poor evidence base for kinesiology tape, but it is popular with patients.

Bracing

Claire considered the Q Brace with research by Callaghan et al (2015) showing a reduction in pain and bone marrow lesion.

What should be considered for every exercise?

Claire discussed research by Ford et al (2015) where the guidance for rehabilitation is to focus on:

  • Initiate = strength and activation.
  • Integrate = neuromuscular control.
  • Optimise = biomechanics for activities and sports.

Conclusions

Claire concluded here presentation with some advice for practitioners:

  • Be sharper at questioning to guide your physical exam.
  • Consider differences between adolescent and adult PFP.
  • Factor in pain, swelling and knee angle to quads work to create a more architecturally favourable VMO.
  • Utilise tape and bracing as adjuncts and be realistic about what you are doing.

Follow Claire Robertson

Q&A

Claire kindly answered questions put forward by practitioners who attended the session. Please see the presentation recording for the insights from Claire to the questions.

Presentation Recording

The recording of Claire’s presentation is available to watch here.

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