Well after recommending that everyone lift their game and keep exercising through winter, it seems that we should practice what we preach! We missed the July Blog, and tend to blame short days, cold mornings, and repeat doses of the flu as an excuse! To make up this month we have a blog about Patellofemoral Syndrome- a very common cause of knee pain in exercisers that can be frustrating to manage. Rest assured that the experts at BSEMS will help you with diagnosis, investigations, and appropriate rehab. Until Spring- happy exercising!

Patellofemoral Syndrome (PFS)

Definition:

This syndrome describes pain in and around the patella (knee cap). It was formerly known as ‘chondromalcia patellae’, but this has fallen out of vogue. It is thought to be secondary to patellar malalignment to the femoral trochlea, resulting in abnormalities within the articular cartilage. It is also thought to be due to a ‘supra physiological mechanical loading and chemical irritation of the nerve endings denoting loss of tissue homeostatsis’- causing an inflammatory cascade and consequent peripatellar synovitis.

Mechanics: At full extension the patella sits lateral to the trochlea. During flexion it moves medially and comes to lie within the intercondylar notch at 10-20°, until 130° when it starts to move laterally again. With increasing flexion, more of the patella articular surface comes into contact with the femur, offsetting the increased load associated with flexion.

Contributing factors:

• Femoral anteversion (congenitally ‘internally rotated femur’)

• Limited hip external rotation: secondary to soft tissue restriction eg tight anterior hip joint capsule, short adductors, tensor fascia lata, iliopsoas or rectus femoris.

• Tightened ITB: results in overactivity of TFL and decreased activity of posterior fibres of gluteus medius.

• Tightened lateral structures: Superficial structures: vastus lateralis and ITB which restrict medial glide. Deep structures: lateral retinaculum which restricts medial tilt.

• Tightened posterior structures: hamstring and gastrocnemius, cause lateral tracking of the patella by increasing the dynamic Q angle.

• Altered foot biomechanics

The VMO (inside quadriceps muscle) in PFS pain sufferers may need to fire earlier to overcome abnormal tracking forces.

The patella is the centrepiece of all the stabilizing forces that act around the knee. It increases effective extension force by as much as 50%. A patellofemoral joint reactive force (PFJRF) is created by compression of the patella against the femur and this force is transmitted to subchondral bone.

The PFJRF increases with increased knee flexion: 15º = 1 times body weight; 20º = 2 times; 45º = 3 times; and 75º = 6 times.

• Normal walking creates a PFJRF of half body weight

• Ascending stairs 3.3 times body weight

• Squatting 6-7 times body weight.

Limitation of knee extension necessitates increased tension within the quadriceps and increased PFJRF. A large PFJRF distributed over a large area yields a lesser degree of articular stress, if this area is decreased then stresses are increased.

History:

A medial site to the femoral pain is indicative of PFS. The onset of PFS pain is often insidious but may present after an acute traumatic episode. Patients often have a diffuse ache, which may be exacerbated by prolonged sitting (‘movie-goer’s knee’) or activity. It can occur during running and gradually worsens. There may be recurrent clicking or crepitus.

Treatment:

In an open kinetic chain, the hamstrings are predominant in flexion and quadriceps in extension. These exercises (e.g. straight leg raises and knee extensions while wearing ankle weights) place a greater load on the patellofemoral joint and should be avoided early in rehab. In closed kinetic chain exercises (e.g. leg presses or partial squats) there is co-activation of both hamstrings and quadriceps. These exercises strengthen agonist and antagonist muscles simultaneously, result in decreased PFJRF, and are far more physiologic for lower extremity sporting activities.

• Reduction of pain and inflammation: RICE, NSAIDs, and electrotherapeutic modalities.

• Taping: Should reduce symptoms by 50% and result in earlier activation of VMO. Acute cases may need taping for 24 hours per day until pain settles, then gradually reduce.

• Muscle training: Training of VMO and gluteus medius. Isolate VMO by palpating when it is contracting (biofeedback better). Start with closed chain exercises (i.e. foot on the ground) and progress to weight bearing and functional exercises.

• Stretching: Stretch tight lateral structures- side lying position with knee flexed. Glide patella medially using the heel of the hand. Also work on quads, hamstrings, calf and ITB.

• Massage: Work on tight areas, particularly ITB.

• Braces: Not as good as tape.

• Orthotics: may correct excessive subtalar pronation.

• Correction of other precipitating factors: eg training, shoes, surfaces.

• Surgery: only if failure conservative management. May need chondroplasty and rarely lateral release.

Happy New Year to all of our BSEMS patients, staff and friends.

We hope that 2011 proves successful in maintaining health and fitness. If you are struggling than feel very welcome to come and see one of our specialists- at BSEMS there is someone who can help get you back on track.

Welcome to Dr Thomas Gan

In mid January Dr Tom Gan will be commencing sessions at BSEMS. Tom is a senior registrar, meaning he is nearing completion of his Sport and Exercise Medicine specialty training. Tom has worked as a team physician for various elite sporting teams and has also been medical director for world class sporting events such as the Brisbane International Tennis tournament.

He has many professional interests including lower limb stress fractures, tennis injuries, cricket injuries, and trigger-point acupuncture.  He is available to provide consultations for a variety of paediatric and adult sports medicine conditions.

Tom will be working Tuesday mornings between 8am-12pm in the BSEMS rooms.

This year we are aiming to include a fact sheet from one of our practitioners to each blog. The fact sheets will be catalogued in our “Patient Info” webpage, under appropriately enough “Factsheets”.

For January we have provided an information sheet for patients and referrers regarding the appropriate preparation needed before a compartment pressure test is performed. This can help ensure that the test is performed correctly the first time and to reduce the chance of a false negative investigation.

Compartment Pressure Testing

Pre-test Preparation

Chronic exertional compartment syndrome is a cause for leg pain with exercise. The usual pattern is a gradual increase in pain during continuous exercise to a point when the athlete has to stop. Pain then takes between minutes to hours to go. Patients describe a feeling of hardness or fullness in their legs, and occasionally will notice lumps in the muscles. The condition is diagnosed by performing a compartment pressure test (CPT).

During a CPT the patient must be able to reproduce their leg pain as bad as they can get it. This means that in the days to weeks before the test is done, the patient should perform moderate level exercise (and not rest) so that they can reliably reproduce their symptoms on the day of the test. The patient will also guide the Sport and Exercise Medicine (SEM) Physician as to which compartments need testing, and they must pay attention to where they develop their pain (i.e. front of the leg, side, behind the shin bone, or more than one area).

The CPT involves injecting a small amount of local anaesthetic into the skin at the sites where the pressures will be tested. The patient will then jog/run/whatever needs to be done to bring on their symptoms, usually for 10-15 minutes. They then return to the room, and the SEM Physician performs the test, which involves inserting pressure manometer needles into the relevant muscles. One special needle has a catheter inside it, and this remains in the leg while the patient does specific exercises, whilst the pressure in the leg is monitored.

The test is very safe, but complications can occur- listed below. The test takes one hour. Typically the patient can drive or fly after the test is completed.

The SEM Physician always prefers to see the patient before arranging a time for the test, to ensure the test is done correctly right the first time, reducing the risk of getting a false negative result. If the diagnosis is confirmed, then the only real treatment is surgery (a procedure called fasciotomy, performed by an orthopaedic surgeon).

Complications

Compartment pressure testing is a relatively safe procedure, but is an invasive intervention, and some complications may result including (but not limited to):

Infection

Bleeding and bruising at the puncture sights

Possible (permanent) damage to underlying blood vessels

Possible (permanent) damage to underlying nerves, resulting in sensory or motor disturbance

Failure of the procedure

Risk of development of acute compartment syndrome requiring and urgent operation

Risk of development of a complex regional pain syndrome

Please feel free to discuss any questions or concerns you may have with the BSEMS staff and specialists.

Welcome to the first blog from BSEMS.  We hope to make this a regular occurrence, and a chance to pass on information on what is happening behind the scenes at BSEMS, as well as to provide information on topics provided by our specialists.

Since opening on the 7th April 2010, we have seen hundreds of patients from southeast Queensland with Sports and Exercise medicine issues. The first 5 months have been great, and we look forward to growing and providing a one-stop-shop for Sports Medicine. We have a multidisciplinary team waiting to help wherever we can. Every 1-2 months, we will endeavour to provide a topic of interest on the blog from one of our specialists.

Team coverage

Dr Matt Hislop is joint team physician for the Brisbane Broncos, and looks after the Reds Rugby Academy. The past few months have been a busy time with team cover.

Rugby League:

Dr Hislop was also happy to help with the screening and coverage of the two Queensland teams that played the curtain raisers for State of Origin game 2 held at Suncorp. Of course the real achievement of the night was when Queensland won the series for an historic fifth time.

The last few months have been interesting with the Broncos unfortunately falling short and out of finals contention for the first time in 17 years. Darren Lockyer's rib injury was quite significant, and it is a testament to him that he came close to returning to play. The timing of his injury was incredibly bad for the Broncos, but that is the nature of any sport. The Broncos no doubt are looking forward to some time off, before starting up again for the preseason.

Rugby Union:

The club rugby finals are on at the moment. It has been good to see many past Reds Rugby Academy members progressing to play Super 14 for the Reds- Poutasi Luafutu, Quade Cooper, Scott Higginbotham, Luke Morahan, and Ben Lucas to name a few. Dr Hislop is proud to be part of the team that helps young and upcoming rugby players in the best Academy programme in the country. His Academy role helps with screening, injury prevention, and management of injuries when they do occur.

Soccer:

Dr Hislop was privileged to be invited to help with medical cover for Everton FC when they completed their successful tour of Down Under in July. Thankfully the game was completed injury free, as the team had to board a flight back to the UK later that evening!

Dr Daelyn Vivers

BSEMS have been happy to welcome Dr Daelyn Vivers who has arrived from Perth recently.

She is settling in well and developing a dedicated patient following.

Dr Vivers is the newly appointed QAS Swimming doctor, and also looks after Water Polo.

She was involved in the coverage of National Short Course Championships at the Sleeman Centre, Chandler in July. Many of the well known Queensland swimmers have gone on to do well at the Pan Pacs Championship recently held in the USA, including Jessica Schipper, Sophie Eddington and Emily Seebohm.

Dr Vivers has recently undertaken a thorough review of exercise induced asthma and its management and is happy to manage any musculoskeletal problem.

Feedback

At BSEMS we are proud of our world class new rooms, great website, and our multidisciplinary team of specialists. We want to make life easy for our patients, by offering a one-stop shop for Sports and Exercise Medicine. (We do not have physiotherapy on site, but work closely with many of the excellent sports physiotherapists in our area.) Please peruse our website for more information on what each practitioner does. We welcome and value your feedback, both positive and negative.

Best regards until next blog!

Dr Matt Hislop

Practice Principal