1. Patella Femoral Pain Syndrome Patient Presentation No: 3 Dr G Coetzer 1999061854

2. PATIENT DETAILS Girl 13 years old S.A Swimmer Recently started playing hockey

3. COMPLAINT Pain in right knee Aggravated by: »Running »Climbing stairs »Squatting

4. FURTHER HISTORY No history of injury/trauma No medical history No previous problems with exercise –What changed? –Started playing hockey

5. CLINICAL EXAMINATION Ligaments »Intact Cartilage »Negative grind test

6. CLINICAL EXAMINATION (Continued) Extrinsic Factors »Increased repetition »Astro Turf »Hockey shoes

7. CLINICAL EXAMINATION (Continued) Intrinsic Factors »Increased sub-talor pronation »Reduced muscle bulk of Vasti »Lateral patella tilt

8. BIOMECHANICAL Q angle not increased Increased Sub-talor pronation Patella lateral tilt

9. 3 STAGE SUMMARY

10. CLINICAL 13 year old girl with patella femoral pain of right knee

11. PERSONAL Worried about performance with swimming as well as popularity with pupils who play hockey

12. CONTEXTUAL 13 year old girl with pain of the right knee with the diagnosis of patella femoral pain syndrome

13. PROBLEM LIST Active »To maintain fitness relatively pain free Passive »To correct bad biomechanical and Vasti weakness

14. PLAN Reduce Inflammation »Taping »NSAIDS Addressing the Extrinsic Factors »Better shoes »Arch support Addressing Intrinsic Factors »Strengthening of the Vasti, especially Vastus Medialus »Soft tissue therapy/stretching to decrease lateral tightness

15. DISCUSSION Umbrella term used to describe pain around the patella Very common specially in female runners Usually starts in adolescence

17. FACTORS THAT CONTRIBUTE TO PATELLA FEMORAL PAIN Extrinsic Factors Intrinsic Factors

18. EXTRINSIC FACTORS Body Mass Speed at gait Contact with the ground Foot wear Also with an increase in knee flexion

19. INTRINSIC FACTORS Factors that influence the load on the patella femoral joint –Remote Factors –Local Factors

20. INTRINSIC FACTORS (Continued) Remote Factors »Increased femoral internal rotation »Increased knee valgus »Increased tibial rotation »Increased Subtalar pronation »Inadequate flexibility

21. INTRINSIC FACTORS (Continued) Local Factors »Patella position »Soft tissue contributions »Neuromuscular control of the vasti

22. TREATMENT OF PATELLA FEMORAL PAIN SYNDROME Requires an integrated approach

23. AIMS OF TREATMENT Reduction of pain and inflammation »NSAIDS »Taping »Bracing Addressing Extrinsic Factors Addressing Intrinsic Factors »Strengthening of the vasti and hip abductors »Stretching »Mobilisation of the patella

24. LESSON Patella Femoral Pain Syndrome has multiple aetiology Good history and clinical examination is essential in diagnosing patella femoral pain syndrome Treatment is a team approach involving the physio, trainer, doctor, patient, and sometimes orthopaedic specialist

25. REFERENCES Clinical Sports Medicine, Third Edition –Peter Brukner and Karim Khan Anatomy of Huma Movement Structure and Funciton, Fifth Edition –Nigel Palastanga, Derek Field, Roger Soames The American Journal of Sports Medicine –AMJ Sports Med 2010 38: 1626 originally published online May 26 2010 BMJ Research –Cite this as: BMJ 2009;339;b4074 doi:10.1136/bmj.b4074