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November 2016
Special Issue: The Patellofemoral Joint

Biomechanics and Pathomechanics of the Patellofemoral Joint

Authors: Loudon JK
The patellofemoral joint is a joint that can be an area of concern for athletes of various sports and ages. The joint is somewhat complex with multiple contact points and numerous tissues that attach to the patella. Joint forces are variable and depend on the degree of knee flexion and whether the foot is in contact with the ground. The sports medicine specialist must have a good working knowledge of the anatomy and biomechanics of the patellofemoral joint in order to treat it effectively.
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Examination of the Patellofemoral Joint
Authors: Manske RC, Davies GJ
Patellofemoral pain is one of the leading causes of knee pain in athletes. The many causes of patellofemoral pain make diagnosis unpredictable and examination and treatment difficult. This clinical commentary discusses a detailed physical examination routine for the clinician who treats patients with patellofemoral pain. Critically listening and obtaining a detailed medical history followed by a clearly structured physical examination will allow the physical therapist to diagnose most forms of patellofemoral pain. This clinical commentary goes one step further by suggesting an examination scheme and order in which it should be performed during the examination process.  This step-by-step guide will be helpful for the student or novice therapist and serve as review for those that are already well versed in patellofemoral examination.
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Current Concepts in the Treatment of Patellar Tendinopathy
Authors: Reinking MF
Patellar tendon pain is a significant problem in athletes who participate in jumping and running sports and can interfere with athletic participation. This clinical commentary reviews patellar tendon anatomy and histopathology, the language used to describe patellar tendon pathology, risk factors for patellar tendinopathy and common interventions used to address patellar tendon pain.  Evidence is presented to guide clinicians in their decision-making regarding the treatment of athletes with patellar tendon pain.
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Current Concepts in the Treatment of Gross Patellofemoral Instability
Author: Buchanan G, Torres A, Czarkowski B, Giangarra CE
Patellofemoral instability is a painful and commonly recurring condition, which often must be managed surgically. Diagnosis can be aided by the use of a variety of physical exam signs, such as the Q angle, Beighton hypermobility score, glide test, J sign, patellar tilt test, and apprehension test. Imaging modalities including x-ray, CT, and MRI guide both diagnosis and management by revealing trochlear dysplasia, bony malalignment, and ligamentous injury that contribute to instability. Following an initial patellar dislocation, nonoperative management with bracing and physical therapy is an acceptable option, because limited evidence exists that operative management may improve functional outcome and reduce recurrent dislocations.  For recurrent dislocations, operative management is indicated, and the appropriate procedure depends on the patient’s anatomy and the cause of instability. Reconstruction of the MPFL restores the primary soft tissue restraint to lateral patellar dislocations, and can be performed using a variety of techniques. In patients whose instability is related to bony malalignment, a tibial tubercle osteotomy is commonly performed to realign the extensor mechanism and establish proper patellar tracking. In patients with trochlear dysplasia, a trochleoplasty may be performed to create a sufficient groove for the patella to traverse. Often these procedures must be combined to address all causes of instability. The reported outcomes following all three of these procedures are generally very good, with the majority of patients experiencing functional improvements and a low rate of recurrent instability, although more large randomized controlled trials are needed to determine which techniques are most effective.  The purpose of this clinical commentary is to provide an overview of the current methods employed by orthopedic surgeons to diagnose and manage patellar instability.
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Current Concepts in Biomechanical Interventions for Patellofemoral Pain
Authors: Willy RW, Meira EP
Patellofemoral pain (PFP) has historically been viewed a complex and enigmatic issue. Many of the factors thought to relate to PFP remain after patients’ symptoms have resolved making their clinical importance difficult to determine. The tissue homeostasis model proposed by Dye in 2005 can assist with understanding and implementing biomechanical interventions for PFP. Under this model, the goal of interventions for PFP should be to re-establish patellofemoral joint (PFJ) homeostasis through a temporary alteration of load to the offended tissue, followed by incrementally restoring the envelope of function to the baseline level or higher. High levels of patellofemoral joint (PFJ) loads, particularly in the presence of an altered PFJ environment, are thought to be a factor in the development of PFP. Clinical interventions often aim to alter the biomechanical patterns that are thought to result in elevated PFJ loads while concurrently increasing the load tolerance capabilities of the tissue through therapeutic exercise. Biomechanics may play a role in PFJ load modification not only when addressing proximal and distal components, but also when considering the involvement of more local factors such as the quadriceps musculature.  Biomechanical considerations should consider the entire kinetic chain including the hip and the foot/ankle complex, however the beneficial effects of these interventions may not be the result of long-term biomechanical changes. Biomechanical alterations may be achieved through movement retraining, but the interventions likely need to be task-specific to alter movement patterns. The purpose of this commentary is to describe biomechanical interventions for the athlete with PFP to encourage a safe and complete return to sport.
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Current Concepts and Treatment of Patellofemoral Compressive Issues
Authors: Mullaney MJ, Fukunaga T
Patellofemoral disorders, commonly encountered in sports and orthopedic rehabilitation settings, may result from dysfunction in patellofemoral joint compression. Osseous and soft tissue factors, as well as the mechanical interaction of the two, contribute to increased patellofemoral compression and pain. Treatment of patellofemoral compressive issues is based on identification of contributory impairments. Use of reliable tests and measures is essential in detecting impairments in hip flexor, quadriceps, iliotibial band, hamstrings, and gastrocnemius flexibility, as well as in joint mobility, myofascial restrictions, and proximal muscle weakness. Once relevant impairments are identified, a combination of manual techniques, instrument-assisted methods, and therapeutic exercises are used to address the impairments and promote functional improvements. The purpose of this clinical commentary is to describe the clinical presentation, contributory considerations, and interventions to address patellofemoral joint compressive issues.
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Current Concepts in Treatment of Patellofemoral Osteochondritis Dissecans
Authors: Juneau C, Paine R, Chicas E, Gardner E, Bailey L, McDermott J
Identification, protection, and management of patellofemoral (PF) articular cartilage lesions continue to remain on the forefront of sports medicine rehabilitation. Due to high-level compression forces that are applied through the PF joint, managing articular cartilage lesions is challenging for sports medicine specialists. Articular cartilage damage may exist in a wide spectrum of injuries ranging from small, single areas of focal damage to wide spread osteoarthritis involving large chondral regions. Management of these conditions has evolved over the last two centuries, most recently using biogenetic materials and cartilage replacement modalities. The purpose of this clinical commentary is to discuss PF articular cartilage injuries, etiological variables, and investigate the evolution in management of articular cartilage lesions.  Rehabilitation of these lesions will also be discussed with a focus on current trends and return to function criteria.
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Pain, Function, and Strength Outcomes for Males and Females with Patellofemoral Pain who Participate in Either a Hip/Core- or Knee-Based Rehabilitation Program
Authors:  Bolga LA, Earl-Boehm J, Emery C, Hamstra-Wright K, Ferber R
Hip exercise has been recommended for females with patellofemoral pain (PFP). It is unknown if males with PFP will benefit from a similar treatment strategy. The purpose of this study was to compare improvements in pain, function, and strength between males and females with PFP who participated in either a hip/core or knee rehabilitation program. The directional hypothesis was that females would respond more favorably to the hip/core rehabilitation program and males to the knee program.  Patients were randomly assigned to a six-week hip/core or knee rehabilitation program. Visual analog scale (VAS), Anterior Knee Pain Scale (AKPS), and hip and knee isometric strength were collected before and after subjects completed the rehabilitation program. Data were analyzed using an intention-to-treat basis. Separate mixed-model analyses of variance (ANOVA) with repeated measures were used to determine changes in VAS and AKPS and strength changes for subjects classified as treatment responders (successful outcome) and non-responders (unsuccessful outcome).  Regardless of sex or rehabilitation group, VAS (F1,181 = 206.5; p < 0.0001) and AKPS (F1,181 = 160.4; p < 0.0001) scores improved.  All treatment responders demonstrated improved hip abductor (F1,122 = 6.6; p = 0.007), hip extensor (F1,122 = 19.3; p < 0.0001), and knee extensor (F1,122 = 16.0; p < 0.0001) strength. A trend (F1,122 = 3.6; p = 0.06) existed for an effect of sex on hip external rotator strength change. Males demonstrated a 15.4% increase compared to a 5.0% increase for females. All treatment non-responders had minimal and non-significant (p > 0.05) strength changes.  On average, males and females with PFP benefitted from either a hip/core or knee rehabilitation program.  Subjects with successful outcomes likely had hip and knee weakness that responded well to the intervention. These males and females had similar and meaningful improvements in hip extensor and knee extensor strength. Only males had relevant changes in hip external rotator strength. Clinicians should consider a subgroup of males who may benefit from hip extensor and external rotator exercise and females who may benefit from hip extensor exercise.
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The Nine Test Screening Battery - Normative Values on a Group of Recreational Athletes
Authors:  Flodstrom F, Heijne A, Batt ME, Frohm A
A variety of risk factors predispose athletes to injury, such as impaired neuromuscular control, insufficient core stability, and muscular imbalances. The goal of assessing functional movement patterns is to detect imbalances and correct them with prevention strategies and thereby decrease injuries, and improve performance and quality of life. The purpose of this study was to generate normative values for the ‘Nine Test Screening Battery'  (9TSB) in a group of recreational athletes. A secondary aim was to study gender differences and differences between subjects with (more than six weeks before test occasion) and without previous injury (regardless of injury location). A third aim was to investigate the psychometric properties of the 9TSB. Eighty healthy recreational athletes, (40 men and 40 women) aged 22-58, were included. The subjects were tested according to strict criteria during nine functional movement exercises that comprise the 9TSB; each graded using a ordinal scale of 0-3, at one occasion. The maximum possible score is 27 points. The median score for the whole group was 18 (Range 12 - 24). A normal distribution of the test scores, with no floor-ceiling effects was found. There was no significant gender difference (p = 0.16) or difference between the group that reported previous injuries (regardless of injury location) and the group that did not (p = 0.65). The internal consistency was 0.41 with Cronbach's alpha. A normal distribution of test results with no floor-ceiling effect was found. History of previous injury (more than six weeks before testing) or gender did not affect the results. In order to determine and cut scores for what is considered optimal or dysfunctional movement patterns, further cohort studies are required.
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Functional Hop Tests and Tuck Jump Assessment Scores Between Female Division I Collegiate Athletes Participating in High versus Low ACL Injury Prone Sports: A Cross Sectional Analysis
Authors: Hoog P, Warren M, Smith CA, Chimera NJ
Although functional tests including the single leg hop (SLH), triple hop (TH), cross over hop (COH) for distance, and the tuck jump assessment (TJA) are used for return to play (RTP) criteria for post anterior cruciate ligament (ACL) injury, sport-specific baseline measurements are limited. The purpose of this study was to examine differences in SLH, TH, and COH distance and LSI, as well as total scores, number of jumps, and individual flaws of the TJA in 97 injury-free Division I collegiate female student athletes participating in ACL injury prone vs. non ACL injury prone sports. The hypothesis was that significant mean differences and asymmetries (LSI) would exist between the two groups in SLH, TH, COH and TJA. Due to research suggesting inherent ACL injury risk associated with specific sport involvement, participants were grouped into high (HR, n=57) and low (LR, n=40) ACL injury risk based on participating in a sport with high or low ACL injury rates. The HR group was composed of athletes participating in soccer, basketball, and volleyball, while the LR group athletes participated in diving, cross country, and track and field. Participants performed all SFT and side-to-side differences for each participant as well as between group differences were assessed for the hop tests. The Limb Symmetry Index (LSI), a ratio frequently used to gauge athletes’ readiness for RTP post injury, was also assessed for between group differences. The TJA was compared between the groups on individual flaws, overall scores, and number of jumps performed.  No between group differences for hop distances were found, with medium to large effect sizes for SLH, TH, and COH. The HR group had a higher TJA score, number of jumps, and higher proportion of the flaw of ‘foot placement not shoulder width apart.  Although most SFT’s showed no significant differences between athlete groups, some differences were seen in the TJA;  the HR group showed an increase in ‘foot placement not shoulder width apart’ flaw, higher overall flaw scores, and overall jumped more times compared to the LR group. These results may warrant caution in relying solely on SFT for RTP decisions, due to potential asymmetries seen in an uninjured population with baseline testing.
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Pre-season Jump and Hop Measures in Male Collegiate Basketball Players: An Epidemiologic Report
Authors:  Brumitt J, Engilis A, Isaak D, Briggs A, Mattocks A
Injuries are inherent in basketball with lower extremity (LE) injury rates reported as high as 11.6 per 1000 athletic exposures (AEs); many of these injuries result in time loss from sport participation.  A recent trend in sports medicine research has been the attempt to identify athletes who may be at risk for injury based on measures of preseason fitness. The primary purpose of this prospective cohort study was to determine if the standing long jump (SLJ) and/or the single-leg hop (SLH) for distance functional performance tests (FPT) are associated with non-contact time loss lower quadrant (LQ, defined as lower extremities or low back) injury in collegiate male basketball players. It was hypothesized that basketball players with shorter SLJ or SLH measures would be at an increased risk for LQ injury. Seventy-one male collegiate basketball players from five teams completed a demographic questionnaire and performed three SLJ and six SLH (three per lower extremity) tests. Team athletic trainers tracked non-contact LQ time loss injuries during the season. Mean SLJ distance (normalized to height) was 0.99 (± 0.11) and mean SLH distances for the right and left were 0.85 ± 0.11 and 0.87 ± 0.10, respectively. A total of 29 (18 initial, 11 subsequent) non-contact time loss LQ injuries occurred during the study. At risk athletes (e.g., those with shorter SLJ and/or SLH) were no more likely to experience a non-contact time loss injury than their counterparts [OR associated with each FPT below cut scores = 0.9 (95% CI: 0.2, 4.9)]. The results from this study indicate that preseason performance of the SLJ and the SLH were not associated with future risk of LQ injury in this population. Pre-season SLJ and SLH measures were not associated with non-contact time loss injuries in male collegiate basketball players. However, the descriptive data presented in this study can help sports medicine professionals evaluate athletic readiness prior to discharging an athlete back to sport after a LQ injury.
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Functional Outcomes After Distal Biceps Brachii Repair: A Case Series
Authors:  Redmond CL, Morris T, Otto C, Zerella T, Semmler JG, Human T, Phadnis J, Bain GI
While relatively uncommon, rupture of the distal biceps tendon can result in significant strength deficits, for which surgical repair is recommended. The purpose of this study was to assess patient reported functional outcomes and muscle performance following surgery.  A sample of 23 participants (22 males, 1 female), who had previously undergone surgical repair of the distal biceps tendon, were re-examined at a minimum of one year after surgery. Biodex isokinetic elbow flexion and supination testing was performed to assess strength (as measured by peak torque) and endurance (as measured by total work and work fatigue). The Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH) and Mayo Elbow Performance Scale (MEPS) were used to assess participants’ subjectively reported functional recovery.  At a mean of 7.6 years after surgical repair, there were no differences between the repaired and uninvolved elbows in peak torque (p=0.47) or total work (p=0.60) for flexion or supination. There was also no difference in elbow flexion work fatigue (p=0.22). However, there was significantly less work fatigue in supination, which was likely influenced by arm dominance, as most repairs were to the dominant arm (F(1,22)=5.67, p= 0.03).  The long-term strength of the repaired elbow was similar to the uninvolved elbow after surgery to the distal biceps tendon. Endurance of the repaired elbow was similar in flexion but greater in supination, probably influenced by arm dominance.
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A Clinical Guide to the Assessment and Treatment of Breathing Pattern Disorders in the Physically Active: Part 2, A Case Series
Authors: Hansen-Honeycutt J, Chapman EB, Nasypany A, Baker RT, May J
Breathing pattern disorders (BPDs) are characterized by persistent, suboptimal breathing strategies that may result in additional musculoskeletal pain and/or dysfunction. The purpose of this case series was to examine the effects of Primal Reflex Release Technique (PRRT) and breathing exercise interventions in physically active individuals that presented with a primary complaint of musculoskeletal pain, a BPD, and startle reflexes. The assessment techniques described in Part 1 of this series were used to identify three student athletes (aged 16-22) who presented with musculoskeletal pain of the low back, mid back, and knee, who also had BPDs, and startle reflexes. The subjects were unable to identify an apparent source of their pain. The clinician’s classification of the subject’s breathing patterns guided intervention(s). Each subject was treated once with PRRT and/or a breathing reflex triggering exercise. Each of the three subjects demonstrated clinically important improvements on the numerical pain rating scale specific to their tender areas and/or with their primary musculoskeletal complaint. These findings suggest that it may be useful to assess for a BPD and startle reflexes along with a standard orthopedic evaluation in the physically active athlete.  Treatment of BPD’s may positively impact musculoskeletal pain and/or dysfunction. 
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Cervical Contribution to Functional Shoulder Impingement: Two Case Reports
Authors: Pheasant SD
Subacromial impingement is a common condition among overhead athletes. The cause of subacromial impingement can be multifactorial and often involves impaired rotator cuff function. The following cases outline the presentation, examination and intervention of two overhead athletes, a high school football quarterback and a collegiate swimmer, each presenting with signs and symptoms of subacromial impingement.  The unique feature in each case was the manifestation of the cervical spine as the apparent source of rotator cuff weakness, which contributed to functional subacromial impingement although other overt signs of cervical or associated nerve root involvement were absent. Subsequent to this finding, the athletes demonstrated a rapid recovery of rotator cuff strength and resolution of impingement symptoms in response to cervical retraction and retraction with extension range of motion exercises along with posture correction. They both returned to unrestricted sporting activities within a week, with maintenance of strength and without reoccurrence of symptoms. The signs of functional subacromial impingement often include weakness of the supraspinatus and infraspinatus. The cause of the weakness in the two cases appeared to be the result of stresses associated with forward head posture contributing to a possible intermittent C5 nerve root compression. The findings in the two cases would suggest the cervical spine should be considered as a potential cause of rotator cuff weakness in individuals presenting with subacromial impingement.
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Midfoot and Forefoot Involvement in Lateral Ankle Sprains and Chronic Ankle Instability. Part 1: Anatomy and Biomechanics
Authors: Fraser JJ, Feger MA, Hertel J
The modern human foot is the culmination of more than five million years of evolution. The ankle-foot complex absorbs forces during loading, accommodates uneven surfaces, and acts as a lever for efficient propulsion. The ankle-foot complex has six independent functional segments that should be understood for proper assessment and treatment of foot and ankle injuries: the shank, rearfoot, midfoot, lateral forefoot, and the medial forefoot. The compliance of the individual segments of the foot is dependent on velocity, task, and active and passive coupling mechanisms within each of the foot segments. It is also important to understand the passive, active, and neural subsystems that are functionally intertwined to provide structure and control to the multi-segmented foot. The purpose of the first part of this clinical commentary and current concepts review was to examine foot and ankle anatomy, detail the roles of the intrinsic and extrinsic foot and ankle musculature from a multi-segmented foot perspective, and discuss the biomechanics of the ankle-foot complex during function. The interplay of segmental joint mobility, afferent and efferent sensorimotor function, and movement and stabilization provided by the extrinsic and intrinsic musculature is required to coordinate and execute the complex kinematic movements in the ankle-foot complex during propulsion.
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