THE EFFECTIVENESS OF PHYSIOTHERAPY AND FOOT ORTHOSES IN THE TREATMENT OF PATELLOFEMORAL PAIN SYNDROME: A RANDOMISED CONTROLLED TRIAL

Transkript

1 THE EFFECTIVENESS OF PHYSIOTHERAPY AND FOOT ORTHOSES IN THE TREATMENT OF PATELLOFEMORAL PAIN SYNDROME: A RANDOMISED CONTROLLED TRIAL Carsten M. Mølgaard Jane Andreasen Marianne Christensen Søren Lundbye-Christensen Ole Simonsen Michael Voigt Søren Kaalund

2 AIM To access the clinical efficiency of foot exercise and foot orthoses as a supplement to a physiotherapy intervention in the management of patellofemoral pain syndrome and excessive foot pronation.

3 METHODS

4 METHODS

5 INSOLES: CUSTOM MADE EVA FOAM

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7 RESULTS (1)

8 RESULTS (2) Mea n Control Intervention Between groups Mean Difference Mean Mean Difference Mean Difference^ (95% CI) (95% CI) (95% CI) Assessment (mth.) Pain (0-100) Symptom (0-100) ADL (0-100) Sport (0-100) QoL (0-100) Kujala (0-105) (-12:10) (-15:6) (-10:12) (-21:19) (-16:9) (-17:7) -5.6 (-16:5) -5.2 (-16:5) -2.4 (-13:8) -5.0 (-25:15) -3.8 (-17:9) -5.4 (-17:7) * (-24:-5) * (-19:-2) (-15:2) (-29:2) (-20:3) (-18:0.1) -14.7* (-24:-5) -10.9* (-20:-2) -8.8* (-17:-1) (-30:1) -12.1* (-24:-0.3) (-19:-1) -13,7* (-21:-6) -5,8 (-12:,4) -7,5* (-15:-,1) -12,3* (-22:-2) -5,4 (-14:3) -4,0 (-10,5:2,5) -10,1* (-19,2:-1,0) -5,7 (-13:2) -6,4 (-15:2) -9,8 (-23:4) -10,4* (-20:-1) -3,4 (-11,8:5,0)

9 CONCLUSION Specific foot exercise combined with foot orthoses can significantly reduce pain in patients with PFPS and excessive foot pronation at short and long term follow up. The primary effect is seen after the first four months of treatment but is still present at twelve months follow-up. Foot training and orthoses may have important implications for disease treatment in patients with PFPS as part of the treatment strategy.

10 DISCUSSION Is it possible to differentiate between foot training and knee/hip training? Both distal and proximal components in PFPS Training is not the only answer to the PFPS problem

11 Spørgsmål? Carsten Mølgaard

12 PATELLOFEMORAL PAIN SYNDROME A syndrome characterized by retropatellar or peripatellar pain resulting from physical and biochemical changes in the patellofemoral joint. The pain is most prominent when ascending or descending stairs, squatting, or sitting with flexed knees. MeSH heading There is a lack of consensus on the etiology and treatment. The syndrome is often confused with or accompanied by chondromalacia patella, the latter describing a pathological condition of the cartilage and not a syndrome.

13 RISK FACTORS FOR PATELLOFEMORAL PAIN SYNDROME: A SYSTEMATIC REVIEW LANKHORST, BIERMA-ZEINSTRA, VAN MIDDELKOOP 2011 Conclusion: Being female and having a lower knee extension strength expressed by peak torque appears to be a risk factor for PFPS based on metaanalyses of pooled results from multiple studies. evidence level 1b

14 ÆTIOLOGI OG PATOGENESE Overbelastning af patellofemoralledet En almindelig årsagsmekanisme er svækkelse af m. vastus medialis, hvilket sker meget hurtigt efter en knæskade med hydartron Skade af brusken i patellofemoralleddet Kan være sequela efter direkte traumer mod patella

15 DISPONERENDE FAKTORER Ændringer i patellar tracking, øgede patellofemorale ledkræfter eller kombinationer af disse biomekaniske faktorer Medfødte skævheder og anomalier : F.eks. øget Q-vinkel, platfod eller subtalar pronation eller patellar hypermobilitet Quadricepsaktivitet Knæskade med hydartron Direkte traumer mod patella Habituel patellaluksation Øget Q-vinkel Øget anteversion i collum femoris Øget pronation i foden Højtstående patella Stramme laterale strukturer Svækket vastus medialis Traumer mod ledbrusken

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17 ÆNDRING I KONTAKTFLADE Ved at øge trækket i Quadriceps fra 500N til 2500N ændres kontaktfladen fra 1 cm 2 til 4cm 2, altså en firedobling Klingman et al 1997 Det mest afgørende for belastningen af ledbrusken er aktiviteten i quadriceps, men dette kan selvfølgelig ændres, hvis der er skader på brusken.

18 ICD 10: DISORDERS OF PATELLA M22.0Recurrent dislocation of patella M22.1Recurrent subluxation of patella M22.2Patellofemoral disorders M22.3Other derangements of patella M22.4Chondromalacia patellae M22.8Other disorders of patella M22.9Disorder of patella, unspecified

19 LÆGEHÅNDBOGEN Kaldes også "forreste knæsmerter" og "løberknæ" Smerter lokaliseret til forsiden af knæet uden patologiske forandringer eller skade af brusken i patellofemoralleddet (chondromalaciforandringer) Tidligere kaldte man tilstanden chondromalacia patellae 90% af alle personer over 50 år har chondromalaciforandringer ved obduktion uden nødvendigvis at have haft knæsymptomer

20 PATELLOFEMORAL PAIN SYNDROME AND ITS ASSOCIATION WITH HIP, ANKLE, AND FOOT FUNCTION IN 16- TO 18-YEAR-OLD HIGH SCHOOL STUDENTS Carsten Mølgaard, Michael Rathleff og Ole Simonsen

21 AIM 1. to investigate the prevalence of PFPS in high school students 2. to compare passive internal and external hip rotation, passive dorsiflexion, navicular drop and drift, and activity levels between healthy high school students and students with PFPS

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24 NAVICULAR DROP

25 NAVICULAR DRIFT

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27 LIMITATIONS Static measurements show only a moderate correlation with dynamic assessments Not sufficient power to conclude that hip rotation and activity level are irrelevant to adolescents with PFPS. Case-control design: it is not possible to reject or confirm the causative factors in the development of PFPS.

28 CONCLUSION A prevalence of PFPS of 6% in high school students. Individuals with PFPS have increased navicular drop and drift. A static clinical evaluation of navicular drop and drift may be useful in routine examination of patients with PFPS.

29 EX. OF TREATMENT Exercises (strength and stretch) Rest Ice and medication Taping and braces Arch support