For this edition of In Touch, dedicated to patellofemoral pain (PFP), I am delighted to present some ways of interpreting the really interesting applied research in a fast maturing eld. By interpreting, I mean using clinical assessment with an individual patient to direct speci c treatment. I am therefore taking this opportunity to share some suggestions that may be a little different from the norm, and clinical tips which may or may not be familiar, in order to provoke thought and further innovation and, additionally, extend the ndings of a large body of work on patellofemoral pain to people with osteoarthritis of the joint.
- Understand the depth of evidence available in a fast moving eld.
- Consider how assessment can be modi ed and link, via treatment, to better outcome.
- Consider the links between treating patellofemoral pain associated with, or without, arthritis.
There seems little point in presenting a complete, de nitive guide to PFP assessment as that has been done many times before. Instead, this article puts forward some ideas that have been percolating for some time, underpin my clinical practice and will, hopefully, offer some fresh food for thought.
Let’s ip our approach for a moment; as well as collecting the evidence in the usual order and then deciding on a management plan, testing a series of structures and determining nocioceptive mechanisms, ruling out masqueraders, judging the psychosocial as well as the bio “-genics”, exploring the context of the individual patient’s presentation, and quantifying objective measures of symptom severity and irritability, let’s work backwards.
The strength of the evidence we now have allows us to think anew about what we are looking for. So the ip is to look for evidence within the individual presentation that we know we can treat. Why not look for aspects that lead us to evidence-based treatment?
Systematic review (SR) and consensus based evidence is now strong enough that we have a review of high quality reviews to work from, informed by clinical reasoning analysed from interviews with the world’s experts (Barton et al 2015). I may be biased, but I regard this paper as clinical gold, and a must-read for any clinician treating people with PFP. For example, we know that PFP in young women can usually be helped by addressing lower limb biomechanics from the hip down with a focus on improving coronal and horizontal plane lower limb control during weight-bearing tasks. So does the patient present with that?
If so, can we alter their movement and so alter symptoms? Equally, are there strength de cits at the hip or knee that we know should bene t from strengthening (Lack et al 2015)? If so, how can we reliably identify these, and address them? Further, if the pain is associated with running or cycling, what can we determine from our assessment that would lead us to interventions such as those described in the articles by Brad Neal (page 28) and Michael Callaghan (page 24) respectively?
In this edition of In Touch, Brad Neal, Christian Barton and I have also attempted to produce a summary of where we are in terms of SR evidence that may be useful to guide your assessment. The diagram in gure 1 is meaty in terms of the evidence contained and in its strength. Level 1 evidence, from systematic reviews, is exactly that – the top of the pyramid – robust, accessible and immediately applicable.This diagram is the tool to use to apply it. Factors leading to PFP development are summarised to the left and those which alter symptoms or biomechanics to the right. Areas which need more work, such as the direct links between biomechanical changes and symptom improvement, are indicated with a question mark. Dotted lines are high levels of evidence and solid lines are level 1. So, when next assessing, my challenge to you is to go looking for some of the aspects mentioned in the diagram and target your treatment accordingly.
I suspect you are already picking up a theme. This article is based on sound principles. The real value of a diagnostic test, or assessment procedures, should be best judged by the resultant outcome for the patient in the longer term, via the treatment that is then applied. In other words, the assessment should ideally lead further than just to diagnosis, but on – via treatment – to outcome. Is there any real value in a testing procedure if there is no ultimate gain for the patient? Arguably, not a strong one. In the case of MRI for low back pain for instance, if the results will not change treatment, why request one?
We know that tailored “McConnell” taping works for some people (Barton et al 2014) and that weight-bearing lower limb alignment can also be successfully addressed, but how do we prove this to ourselves and to the patient? How about taking a symptomatic manoeuvre, such as a painful weight bearing lunge, with your next patient and with expert handling and clear communication skills determine how to focus your treatment? If you can immediately alter symptoms using a patellar glide, or lower limb realignment, or muscle facilitation manoeuvre, then you will gain strong evidence to guide treatment.
This example can be easily applied in many presentations as long as they are non-irritable. Further, patient compliance may well be enhanced by this proof of effect, as the power of a tangible reduction in symptoms is a potent indicator to the patient of likely outcome.Then the hard work begins to make the changes long term and within the patient’s control.
To switch track a little, let’s give ourselves permission to think multimodal in the presence of mild-moderate patellofemoral osteoarthritis (PFOA). High quality trials of multimodal treatment, including taping, education and exercise, have been successfully employed both for PFP (Barton et al 2015) and for PFOA (Crossley et al 2015).We do not yet fully understand the continuum between PFP and PFOA, if indeed there is one, but from some perspectives it may not matter. PFP is perceived pain from the patellofemoral joint, whether or not there is radiological evidence of degenerative change. Any nocioceptive input to the central nervous system will go through the same, or similar, psychological and physiological pain “lenses” before being interpreted as pain. Further, there is emerging evidence that an essentially similar treatment approach may have similar positive results (Crossley et al 2015) so we can – with caution – take what we know about non- degenerative PFP and use this with our patients with osteoarthritic disease. Given the aging population, and the need to keep people as active as possible throughout life in the interest of adding “life to years”, this is knowledge we must use and explore to the full.
Where might future innovation and guidance come from? At the 2015 International PFP research retreat, hosted in Manchester by James Selfe and Michael Callaghan, the progress of the targeted interventions for patellofemoral pain syndrome (TIPPS) work on the classi cation of clinical subgroups was shared, revealing sub- grouping that may move us toward choosing the most appropriate treatment for our patients. One of the conundrums we face is that men with PFP present, and respond, very differently to women. Equally there are people who have high function and are strong, and people who are weak with low function.There may be men and women in each category and it is reasonable to hypothesise that different treatments may be more bene cial to some sub-groups.
You will also be able to get future evidence synthesis from the consensus statements being produced after the retreat. Some sterling work was carried out by a faculty of 50 led by some key players; Chris Powers, Kay Crossley and Bill Vicenzino among them, which will extend the interpretation of the existing evidence still further and give more therapeutic targets to aim at, using the approach described above.
It’s 25 years since, inspired by the work of Jenny McConnell, a rising star of physiotherapy, I did my rst research on PFP and I found very little, although it was my research skills that were the issue, not the hypothesis I was testing.Times have changed.To be able to contribute to, bene t from and share the work done by a dynamic research community, and produce high quality reviews, has been extremely rewarding and I hope you nd the description of a few of them here, together with the clinical tips offered, useful.
The Private Physiotherapy Education Foundation (PPEF)
A last word about the support received from the PPEF. It is through this funding that we have been able to kick-start some future projects, about which more will be announced soon.
About the author
Dylan Morrissey aims to combine the best of educational, clinical and research practice in order to develop and deliver high-quality, evidence based physiotherapy for patients with musculoskeletal disorders. Dr Morrissey is part funded by the National Institute
for Health Research (NIHR)/HEE Senior Clinical Lecturer Scheme. He is a Consultant Physiotherapist in Sports and Musculoskeletal Physiotherapy and combines this with a Clinical Readership in Sports and Exercise Medicine (SEM). He recently started a ve-year NIHR/HEE fellowship with clinical trials as a primary focus. His key research theme is the link between movement and pathology, whether that link serves as a diagnostic tool, treatment modality or outcome measure.The views expressed in this article are those of the author and not necessarily of the NHS, NIHR or the Department of Health.
Barton CJ, Balachandar V, Lack S, Morrissey D. Patellar taping for patellofemoral pain: a systematic review and meta-analysis to evaluate clinical outcomes and biomechanical mechanisms. British Journal of Sports Medicine 2014;48:417-24
Barton CJ,Lack S,Hemmings S,Tufail S,Morrissey D.The“best practice” guide to conservative management of patellofemoral pain: incorporating level 1 evidence with expert clinical reasoning. British Journal of Sports Medicine 2015;49:923-24
Crossley KM, Vicenzino B, Lentzos J, Schache AG, Pandy MG, Ozturk H, Hinman RS. Exercise, education, manual therapy and taping compared to education for patellofemoral osteoarthritis: a blinded, randomised clinical trial. Osteoarthritis Cartilege 2015;23:1457-64
Lack S, Barton CJ, Sohan O, Crossley K, Morrissey D. Proximal muscle rehabilitation is effective for patellofemoral pain: a systematic review with meta-analysis. British Journal of Sports Medicine 2015;e-pub; doi:10.1136/bjsports-2015-094723
Neal BS, Barton CJ, Gallie R, O’Halloran P, Morrissey D. Runners with patellofemoral pain have altered biomechanics which targeted interventions can modify: a systematic review and meta-analysis. 2016:in press
Selfe J, Janssen J, Callaghan M, Witvrouwe E, Sutton C, Richards J, Stokes M, Martin D, Dixon J, Hogarth R, Baltzopoulos V, Ritchie E, Arden N, Dey P. Are there three main subgroups within the patellofemoral pain population? A detailed characterisation study of 127 patients to help develop targeted intervention (TIPPs). British Journal of Sports Medicine 2016:e-pub; doi:10.1136/bjsports-2015-094792
Also of interest
- 05 July 2016
- 01 July 2016
- 23 June 2016