The Nonsurgical Treatment of Patellofemoral Disorders
Abstract & Commentary
Synopsis: This is an overview of the elements of a nonsurgical treatment program for patellofemoral pain. The athlete’s active participation in this process is essential.
Source: Grelsamer R. The nonsurgical treatment of patellofemoral disorders. Op Techniques Sports Med 1999; 7:65-68.
This article, one in a series devoted to patellofemoral problems in athletes, is an excellent overview of the elements of a nonsurgical treatment program for patellofemoral pain. Grelsamer emphasizes the need to initially perform a thorough evaluation of the athlete since treatment for this entity, as for most, depends on an accurate diagnosis. Lyme disease, inflammatory arthritis, neuromas, and referred pain from the hip or spine need to be excluded.
Treatment mainstays include physical therapy, bracing and taping, orthotics, and medications. Grelsamer’s preferred exercise regimen is for closed chain exercises (e.g., feet pressed against floor or other structure) as he feels open chain exercises (feet freely dangling) do not parallel most real-life situations (with the exception of kicking) and are also probably associated with nonphysiologic stresses to the patella as the knee nears extension. Stretching is a key component of physical therapy programs for patellofemoral pain. Also emphasized is the need to have therapeutic exercises parallel those activities performed most frequently by the athlete. The use of surface electromyography (SEMG), the recording of muscle action potentials with skin surface electrodes, enables monitoring of the amplitude and timing of muscle contractions, thus giving feedback to the therapist and patient to ensure that the performed exercises are indeed strengthening the desired muscles in the proper firing sequence.
Suggestions for bracing and taping are also presented. Taping is highly adaptable since there are numerous variations; however, skin sensitivity is the main drawback. Slip-on braces can be active (with a medially directed force) or passive. Infrapatellar straps may be better tolerated by some athletes, especially in warm weather conditions, and seem to be more beneficial in some patients. Arch supports or custom-made orthotic devices may also be used to alter patellar tracking and are particularly effective in patients with abnormal foot mechanics. Although medications (primarily NSAIDs) have been found to be useful in some athletes, Grelsamer reminds us to monitor laboratory studies if NSAIDs are used longer than several months.
Comment by Letha Y. Griffin, MD
The ideal treatment for patellofemoral problems still eludes us, but, as emphasized by this review, nonsurgical care is the treatment mainstay for the majority of athletes with patellar pain. The physician must emphasize to the athlete that no one therapeutic regimen is applicable to all athletes and initial rehabilitation efforts are typically directed at trying various exercises, modalities, braces, taping techniques, orthotics, and/or medications to discover an effective, customized program for each athlete. The physician and therapist should emphasize to the athlete that their active participation in this process is essential, as is the need for patience since improvements typically come slowly over time.
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