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[Physio Discussed] Patellofemoral pain explained with Claire Robertson and Dr Lisa Hoglund

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In this episode, we discuss patellofemoral pain (PFP). We explore: 

  • What is happening structurally in PFP? 
  • Differential diagnosis around the knee
  • Role of effusion and crepitus in PFP
  • Assessment of patients with suspected PFP
  • Role of squatting in objective assessments and treatment
  • What factors may lead to chronicity
  • Evidence based management of PFP
  • Role of blood flow restriction within PFP

Want to learn more about patellofemoral pain? Claire Robertson has done a brilliant Masterclass with us called “Patellofemoral Pain” where she goes into further depth on this topic. 

👉🏻 You can watch her class now with our 7-day free trial:
https://physio.network/masterclass-robertson

Claire Robertson qualified in 1994 with a BSc(hons) Physiotherapy. She has since obtained her MSc Physiotherapy, in 2003, and PGCE in 2006. Claire has worked in the NHS, academia and private practice, and currently runs a specialist patellofemoral clinic at Fortius, London spending an hour per patient and liaising closely with their treating clinician. Claire has lectured internationally and has many research papers and editorials published in internationally peer-reviewed journals.  

Dr Lisa Hoglund, PT, PhD, OCS, Cert. MDT is a professor, board-certified orthopedic specialty physiotherapist, and researcher. She has more than 30 years’ experience as a clinician helping people with musculoskeletal conditions of all ages achieve their goals of returning to work, sport, or increased activity. Dr. Hoglund teaches courses in musculoskeletal physical therapy and differential diagnosis at Thomas Jefferson University. 

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Our host is @James_Armstrong_Physio

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SPEAKER_02:

On today's episode of Physiodisgust, we dive into the world of patelephemoral pain with two outstanding guests, Claire Robertson and Professor Lisa Hogland. Claire is a consultant physiotherapist and internationally recognised knee specialist, often referred to as the patellophemoral queen. With decades of clinical experience, she's helped countless patients and clinicians better understand and manage patellaphemoral pain. Lisa is a professor at Thomas Jefferson University in Philadelphia, Pennsylvania, USA, and a leading researcher and physiotherapist whose work focuses on knee pain, biomechanics, and rehabilitation strategies. Her research has shaped how we view risk factors, prevalence, and management approaches across diverse populations, from athletes to military recruits. Together, we unpack what telephemoral pain is, how it presents, and what clinicians should look out for. We discuss risk factors, differential diagnoses, and management strategies while also exploring the latest research, adjunct, and future direction in treatment. This is a must-listen for clinicians wanting to sharpen their approach to one of the most common and often tricky presentations in practice. I'm James Armstrong and this is Physiodisgust. Claire Lisa, it's great to have you on the Physio Disgust podcast today to talk all about patellophemoral pain. So tell us just a brief introduction of where you're both coming in from today.

SPEAKER_00:

Thanks for the welcome, James. I'm coming to you from Philadelphia, Pennsylvania, in the United States. And by way of background, I'm a physical therapist, a physiotherapist all around the world. And I am also in academia. I'm a researcher, and my primary area of research relates to patelephemoral pain and other iterations of that, including patelephemoral osteoarthritis. So happy to be here.

SPEAKER_02:

Brilliant. And great to have you on, Lisa. Claire.

SPEAKER_01:

Hi, James. Thanks and Lisa. Thanks for the invite also. So I'm in London in the UK, and I'm a clinician just seeing patients with patellifemoral pain. A little bit of ITB of fat pad thrown in, but patelephemoral pain at second opinion service. I'm also a researcher and teach all around, yeah, and anything to do with patelephemoral pain as well.

SPEAKER_02:

Wonderful. So we're going to get stuck in. We've already said before we we started the recording that this is a huge topic, a very specific area of pain, a presentation around the knee, but one that has an awful lot of meat around the bones, if you like. So there's lots we could talk about. But we're going to do our best to pull out some real clinical pearls for listeners today to be able to take away into their practice. The best thing to do, as always, is to start with a bit of definition and introduction into what we mean by patelephemoral pain. Claire, do you want to kickstart us with when we use this term? What are we talking about in overall terms?

SPEAKER_01:

Yeah, well, that in itself is an interesting point because I think we need to view it as a really big umbrella term, but in essence, we're talking about pain arising from the patelephemoral joint. That doesn't mean there needs to be the presence of any structural damage. And very often, particularly in our adolescence, there's a complete absence of structural damage. So we're looking at often a vague distribution of pain, maybe anterior, but not necessarily. We're looking at characterizations, particularly of what aggravates the patient. So it's often loaded flexion. So sit-to-stand, stares, returning, coming out from a crowd, they're very much the hallmarks. We might also view it as a diagnosis of exclusion when we know that we're excluding other pathologies that may create pain at the knee.

SPEAKER_02:

Lisa, anything to add to that from your point of view?

SPEAKER_00:

I completely agree with that. What Claire said really, she very nicely summarized what the Academy of Orthopedic Physical Therapy, our patelephemoral pain clinical practice guideline, we really focused on three factors. The first is that location of pain being peripatellar or retropatellar, and that it is something that is provoked by or aggravated by those loaded flexed knee activities. Squatting is a big one, rising from the squat, et cetera, descending stairs. And then the other third important point was to exclude any other condition that might be a cause of that patient's symptoms.

SPEAKER_02:

Both of you have alluded to there that that subjective history is giving you quite significant clues there when outside of the mechanism of injury, away from any trauma, those sorts of things that patients might present with, which we're going to talk about more later on. Are there any populations that we see that will are more likely to present with this condition?

SPEAKER_01:

Actually, you can see it across all different ages, but I think there are some sort of clusters, if you like. So we've got our adolescence, which is often, I'm sure we'll talk about it often around excess sporting and athletic load. We then have perhaps another cluster is where there's been a rapid change and a deloading, and then perhaps an attempt at reloading. So the clo the thing that comes to mind there would be a young, new mum who's trying to get back into a running. We've also got our sort of hypermobiles and perhaps our weaker patients who it's not to do with athletic load, it's to just to do with insufficient strength. And then obviously as we go through the advancing years, we might then be then looking more into on a spectrum with catella from osteoarthritis.

SPEAKER_02:

So is we're looking at a wide range of age groups? Is there any sort of statistics around this in terms of what we see in practice across, not just in the United Kingdom, but across the globe? Lisa, do you anything on that?

SPEAKER_00:

Yes, and I completely agree with what Claire is saying. The one one other group that I think she didn't mention that it is quite prevalent in is the military population, those individuals, young adults in their basic training, for example, it's quite common in those. So it's really, we think a lot about adolescence. The first one that you mentioned, Claire. The general population, actually, general population, the prevalence is about 23%. And with adolescence, 29%. That's from an article by Smith that was published a few years ago. And then it's individuals with high levels of physical activity. So that could be your runners, but it also could be those military recruits. So those are some of the populations that we see it in. And another group that I found was very interesting was cyclists. And if you think about the loads on those knees, they uh reported about 35% prevalence in both in some kind of amateur cyclists who were involved in a competition, but also in elite cyclists. So it really does hit a lot of people.

SPEAKER_02:

It was quite broad. And again, a common theme there you're talking about there essentially is varying types of overload. We're overloading that structure. And that brings about the question of what do we know what's going on? So actually anatomically, pathology-wise, what do we know about the actual structures that are involved and what's going on with those? Are we talking about cartilage? Are we talking about subchondrial structures? Do we even know? Claire, anything around those that we know at the moment?

SPEAKER_01:

I think if we look at our younger patients, they're particularly interesting because often you'll get an MRI and or they have an MRI and it's pristine structurally. So I think we can say that invariably it's not to do with structural damage. And I try and purposely move the patients away from the concept in their mind from structural damage degradation. And I absolutely hate the term conjugation patelli because it's banded around. Patients Google, and then the next thing you think, oh my goodness, my knee's falling apart. And they presume that they're on this slippery slope. And actually, it's really useful, I think, to say to the patients, look, the cartilage is they knew it doesn't have any nerve and it's not that blocked-up cartilage that's the cause of your pain. And you can see them sitting there, and it's almost like a ticker tape. Why does my knee hurt? And then I purposely use the word pressure, and I have my fatal knee model with me, glued to me at all times. I get very cross if anyone goes off with it. And I will use it to demonstrate that asymmetrical loading, that concept of pressure on the subcontrol bone. Just as much as anything to try and help them make sense of it and try and get buy-in from the patients.

SPEAKER_02:

And that's really important, isn't it? That I mean, know about patient understanding, coming away from that first appointment, having a really a good education around what's going on, because a lot of them I think are potentially around the knee as well. It it is that fear of the unknown as well, isn't it? Lisa, anything more to say around what we might know more around that's going on in that knee with our patelephemoral pain presentations?

SPEAKER_00:

I just think that it really does vary so much. And several years ago, I used to see more in the literature about exactly which tissue was the culprit, if you will, for causing patients' patelephemoral pain. And I, you know, I don't see that as much in the literature. Now, I do have to say I'm not specifically looking for it. But some other tissues, in addition to totally agree with what Claire said, that healthy articular cartilage is a neural. And there can be some overload of the bone, some subchondral bone. I have seen some studies mentioning that. And also some of the soft tissues around the knee. There have been some studies looking at that too. But I just think it varies so much. And at the end of the day, we really want to do what we can to remove those excessive loads, right? No matter which tissue it is.

SPEAKER_02:

And I suppose whilst removing those loads and adapting load, which we're going to talk about in short soon, is not then or removing the fear of load. And that's quite an important element to it when we're looking at rehab, isn't it, in terms of our understanding and reducing fear around the knee?

SPEAKER_01:

I think the fear thing is incredibly important. And thankfully, finally, there is some really nice literature around this sort of over the last sort of five years or so. And Ben Smith really kicked that off in 2018 when he did a sort of really rich qualitative analysis of people with patelephromal pain. And that's been followed up with quite a lot of work now looking at kinese poem and catastrophizing. And the one study really comes to mind, Salhorst's work, and I think it was 21, looking at basically adolescents with patelophermal pain. Being showed an eight-minute video then measuring fear avoidance, catastrophizing, and TRE pain school immediately after, but also two weeks after, and showing that eight-minute viewing of education matters can really bring down that fear factor. Because otherwise, we're sending people off to do exercises, and Ben Smith's work has shown that most patients with patelochromal pain believe exercise to be harmful, the cause of their pain, create damage potentially. So bringing down that fear factor is really incredibly important, I think.

SPEAKER_02:

Absolutely, yeah, definitely. Well, we're gonna talk about that, I think, the sort of a approach to these patients later when we talk about management, which is gonna be which can be really important. But I think we could move on now in terms of how patients present to us. So we're gonna see that this is a presentation that we're the clinicians watching this probably see an awful lot of. If you're working in an outpatient musculoskeletal department, sure many people are, whether that be private, NHS, or health insurance or whatever it might be, you're gonna see a lot of it. How might we see patients present? And I think we can split this maybe happily into subjective and objective assessments. We'll come on to how we might test this more objectively, but what would we see in subjectively? We've touched on this earlier. Lisa, what do we see in maybe in the literature or yourself clinically in our subjective assessment when someone comes in to see us?

SPEAKER_00:

So subjectively, of course, it's going to vary with the patient according to their lifestyle, if you will. You could have the patient who is an active runner, an active adolescent, involved in different sports. And in most of their life, they're doing fine. And it's only when they try to perform their sport that they're having their problems, etc. That could then subjectively lead to the pain that's more intermittent and those kinds of things, and their disability, if you will. But then you also could have somebody who's relatively sedentary, could be somebody with an office job. I'm thinking about a patient that I had a few years ago that was an office worker, because of being sedentary was relatively weak. And so some very basic activities of daily living were the things that he was having problems with, just ascending, descending, stairs, et cetera. And then, of course, you could have other people who are at the other spectrum of the, or maybe at the older age or group that are starting to have some osteoarthritic changes. And they also are having problems with some basic ADLs, et cetera. So but all of them having pain centered around that patellophemoral part of the body.

SPEAKER_02:

So it's again, yeah, that focal area, that point that we might see peripatello or retropatello, as we talked about before. And Claire, what might lead us to be more suspicious of that patellophemoral joint being involved? Lisa's talked about activities of daily living and uh and movements, other things that might tell us a little bit. Prick our ears to think that sounds much more patelephemoral than it does other areas of the knee.

SPEAKER_01:

Yeah, so it's in essence a mechanical pain. Apart from sitting with your knee flex, which is an important question to ask, because if they have pay sat still with a knee flex, that again is very common in telephonal pain suffers. But apart from that, it tends to be quite on off. I go upstairs or downstairs, oh, it's a bit sore. And I often say, what happens when you get to the bottom and you walk off? And they might say it lingers a little bit, but in essence, it's gone again. You can highlight the positions, the movements in loaded flexion is the real hallmark. For example, walking on the flat would be highly unlikely to be patelephral pain, but walking downhill where you're bringing extra load onto the patella, you'd be more suspicious of patelephromal pain. So really looking at which activities and also I guess the absence of trauma. We can have other pathologies that drive an effusion that the effusion drives patellofhromoral pain. And it's important we are on our guard for pathologies that'd be picked up. But in essence, we're looking at a knee that it's just an insidious onset, which also is why the patient struggled to make sense of it.

SPEAKER_00:

Yeah, and just to hop in on that, because it is that insidious onset of pain, and it is very mechanical, as you said, Claire, it's often quite a long time that the person has been experiencing this pain around the patella, by the time they get to see a physical therapist, we may or may not be that first provider that the person sees. So by the time we start to see them, I do completely agree that it's mechanical, that when they aren't sitting with their flexed knee, when they're resting, they're going to tend to feel better. But because it has become chronic pain, now it's going to start to have some of the changes within the central nervous system. And that nosoplastic kind of pain starts to develop. And that can almost be a spiral, if you will, leading to the kinesiophobia, to reduced physical activity and all of those kind of issues too. It's a really good point. I mean, the mean duration of Simpsons is long.

SPEAKER_02:

Yes. And that, I suppose, is it leads into more questions from a patient. I know from from experience, patients often struggle when something doesn't get better as quickly as a cut on the finger. It doesn't then make sense as to why does this not get up? What's going wrong? Is this something more serious when it's something that's going on for longer? And do we see that with patients?

SPEAKER_01:

I think so. And often their belief systems are really inaccurate. And that might be driven by things they've seen, they've heard, they might have had a mum that's had a knee replacement. Every patient's narrative is different, but often by the time they get to see you, there's a fair bit of unraveling to do around that inaccurate belief. And otherwise you're you're battling against that. And I think as I said before, Ben Smith's work just so beautifully encapsulated that. Really looking at what people thought it was about, what they thought would be the best interventions, rest, analgesia, and an ebrace was the consensus was going to be the best. So if you then waltzed in and say, right, let's do some exercises, and there's no education around that, you haven't helped the patient unravel that belief system and it's critical.

SPEAKER_00:

Yeah, I completely agree with that. And you mentioned education, Claire. I mean, that's part of education, right? Is educating the patient that, okay, we understand that you are experiencing pain when you do certain activities, but that pain does not necessarily mean damage. And those are the kinds of things that they're worried about, that they're worried that if they do those exercises that we know is so important for them to do, if it hurts, they need to stop because they could be damaging themselves. That's that false belief that many of them have. And so we really need to educate them or de-educate them, if you will. I think that's so important for our patient management here.

SPEAKER_01:

And I think perhaps in line with that, my Kreptis research, which was thematic analysis around semi-structured interviews. One of my questions was if you were doing your exercise your physio gave you, and whilst you were doing it, your knee made its noise, what would you do? Every single patient said, Oh, I wouldn't do it. And that was because they had the belief that the noise meant degradation and harm. So it's really important that we're on our toes. Otherwise, what we might be doing great assessment, got great exercises, and then the patient's gonna leave your room and not do it because that it's sore and they think that means damage, or it's crepitus, and they think that means damage. So it is very important.

SPEAKER_02:

I'm gonna hop in there on a question that I think is really key, because it is Claire, having looked to that work and on some of your courses, that it you talk about the crepitus and that ex explaining to the patient that's not something to be fearful on how you go about that. I'd be really interested to know from both of you how do you go about that conversation? How do you explain to a patient what that actually is? Because I think I know a lot of patients will wonder, what is it then? If I'm not going to worry about that creaking, cracking, clicking, crunching noise in my knee, can you tell me what it is? So, how do you go about that conversation, Claire?

SPEAKER_01:

The first thing, if they mention creptus, I often just say one question, and that is, what do you think it means? And if they say, Oh, I don't know, I don't think about it, fine. But if they say, Oh, look, my knee's falling apart or whatever, it opens the door to me thinking, okay, this is an inaccurate belief. So when I did my creptus research, yeah, it took me all over looking at noises. I ended up even looking at some of the engineering literature about noise or movement and what it meant. And in essence, I think the one that alarms patients the most is that sort of fine grating noise. And we can look at the engineering term slipstick, which basically means the noise that arises when fluid moves through an irregular surface. So, what I often say to patients is if I've got a nice thick pile carpet, and that's like your nice thick cartilage, so reinforcing that, but the top of the cart the top of the cartilage is just a bit fluffed up. If I pour water on that carpet and I do that, I'll get a sort of friction-y noise, and that's what's happening. It doesn't mean that the knee is falling apart, or you've got big holes in your cartilage, and we need to separate noise and pain because the noise may remain. Otherwise, you might get to get into good treatment and you think they're strong, their pain's gone, they leave your room and they still avoid the stairs because they still have the presence of crepitus.

SPEAKER_02:

Lisa, how how do you go about that question? What are your thoughts? So, if anything from research to clinical experience, the noisy knee question.

SPEAKER_00:

Well, the noisy knee, I mean that crepitus may or may not be present, but I completely agree with what Claire's saying. We can't necessarily base our interventions on that because that's kind of similar to maybe paresthesia in a lower extremity from a ridiculopathy. The person might experience centralization of their lower extremity pain, but the paresthesia stays for a while, right? So we can't just base our approach on that. And I love that description that you described, Claire, about the deep pile shag carpet, although I'm not looking forward to that coming back into popularity, that shag carpet, but that's such a great, uh great way to describe it. But honestly, I feel like patients have asked me more about the pain than the the crepitus. The older population that I've worked with who have some osteoarthritis of the knee involving the patal ephemeral compartment, they might ask me about it. And they come to me usually because I have a diagnosis of Neo A, and I can say that, you know, it might be having to do with that cartilage and that we won't worry about that so much. It'll be going more by their symptoms, any pain that they experience with different activities.

SPEAKER_02:

Brilliant, brilliant. I thought I had to touch on that. One other thing I wanted to just look at is would we expect any swelling? And if we do find that the knee has swelling as well, does that tell us anything else? Claire, I think I've heard you mention before about swelling around the knee and patelephemoral pain and whether we should or shouldn't see it. And if we do see it, what does it mean?

SPEAKER_01:

Well, I think there is different kinds of swelling, and I think that's the starting point here. Are we talking about a joint effusion? Are we talking about slightly puffy parapetella soft tissues, or are we talking about Hoffa's fat padema? So three quite distinct things that can indicate a different approach. So I think, particularly in a non-arthristic patella, if there's an effusion, I'm saying, why is there an effusion? And I would say, particularly if it's um an adolescent or a young adult, that should be treated as an as an urgent. Is there something more systemic going on? Is there a juvenile arthritis, a monomarthritis? Is there osteochondritis desiccins aggravating the synovium? Why is that effusion there? That's my starting point. If it's parapetella sort of puffiness, I think we often see that with the patients who perhaps are just subtly unstable. They're not dislocating, they might not even really be considered as a subluxa, but I think they've perhaps got a patella, maybe they've got a small patella sitting in a slightly shallow trochlea or a big tip of patella altar. And I think the patella just dings around and sort of pods the parapetella soft tissues. And I think you can see a little bit of puffiness, but it's not an effusion. And then obviously Hoffers is a whole different thing.

SPEAKER_02:

Absolutely, definitely. We're not going to go down that road today. We definitely haven't got time as much as we'd like to. Yeah, definitely. Lisa, anything on on sort of effusion and swelling that you want to add to what Claire's said there?

SPEAKER_00:

I think if we're thinking about just the typical patient with patellifemoral pain, there might be some on certain occasions because overuse is a big part of this. So if they have just had a long run the day before or something of that nature, they might have some mild effusion. And definitely if they have a problem with the patella impinging on the fat pad, that certainly could be swollen. But that would not be effusion, clearly. It might be present, but it might not.

SPEAKER_02:

Fair enough. Excellent. Wonderful. So it leads nicely on to our objective assessment. So the bit that people often think pziers will jump to, what can we test? How can I make sure I've got the right diagnosis? What are your approaches to your objective assessments? Lisa, clinically or from research, what do we know about how good our objective assessment is and what might it include when we're talking about patelephemoral pain?

SPEAKER_00:

So when I helped to work on the patelephemoral pain clinical practice guideline, we looked at some of the different diagnostic tests and, of course, their sensitivity and specificity. And so the test that we found for that had the best sensitivity for presence of patelephemoral pain was provocation of symptoms with squatting, which makes complete sense with the loading the knee in a flexed position. But as that could be painful for the person who has patellar tendinopathy, for knee osteoarthritis, for a lot of different conditions. So that's a great test to use early on. And if your patient does not have pain with squatting, patelli femoral pain becomes much less likely. Okay. And then the test that we found, and now this was a few years ago, and we're actually starting, we're preparing to do a revision of that clinical practice guideline. So stay tuned for a couple of years from now after we revise the literature. But the test at that time that had the highest specificity was the patellar tilt test. That is not a provocative test. That's a test to try to determine how tight essentially some of the lateral patellar retinacular structures are. And so that had the highest specificity, but it was not sensitive. So those were the tests and measures for whether or not the person might have patellophemoral pain. And of course, as we already mentioned, we need to be ruling out any other possible causes of their anterior knee pain, if you will.

SPEAKER_02:

Okay. Claire, objective assessment 101. What are we looking for?

SPEAKER_01:

I mean, I would be very much agreeing with what Lisa's saying then, but I perhaps the really mild patient that is perhaps saying, I've kind of got my pain out after a 12-mile mark of my run, for example, and they come in and then run for a week, you might need to do repeated single-leg squatting to just push that telephone or joint a bit hard. I mean, obviously, if you've got someone sort of coming in with a really irritable joint, we're not going to be doing that. But if you're thinking it does sound like sudden okay, but I can't quite produce it, that's where I would be going there, repeated single-leg squatting. And also, you know, I if somebody somebody is saying, look, it only comes and run a particularly it only comes on at five mile, ten mile point or whatever, I will get them to run to their appointment. And I know it might sound a bit extreme, but it's really interesting also from a risk factor point of view, assessing them at that point and assessing them fresh, it's often very different. And then it's easier to pick up whether it is definitely patelephemoral pain and also then look at, as I say, the sort of maybe the causative factors.

SPEAKER_02:

We talked about squatting there from clinical guidelines and from what we know about the loading. Can we be specific about that squat though? So if I got someone to do a quarter squat to 30 degrees, am I going to see pain with a patelephemoral pain, or would I be more like to see it if I was to get them to squat deeper, past that 50 degrees, for instance, down into 90 degrees and further? Would that be something where I would see more and more likely to provoke those symptoms? Do we know more about the ranges of movement and the pressures that are put through that joint?

SPEAKER_00:

I think we need to think about the biomechanics of the patelephemoral joint, James. So clearly, if people go back to their biomechanics education as an individual in the loaded condition, in a closed kinetic chain situation, as they go into a deeper squat, that is going to increase the loads on the patelephemoral compartment of the knee. Of course, some of that depends upon the position of the trunk, et cetera. But yes, I completely agree with what you're saying, Claire, with the patients who have the lower irritability, just a regular double leg squat is not going to necessarily provoke their symptoms. So we might want to progress to a single leg squat, maybe take it deeper, do more repetitions, et cetera. And yes, so biomechanically, the deeper squat more provocative. But then you're going to have your other patient who maybe is much more highly irritable, and just that a partial squat is going to provoke their symptoms.

SPEAKER_02:

Anything more on ranges, Claire at all?

SPEAKER_01:

I think just to sort of reiterate this point that the generally the deeper you're going into loaded flexion in a closed chain scenario, the bigger the loading pattern. It will be different in an open chain scenario. So we just need to make that distinction. But I think the patients will often be quite clever at just not even consciously, they'll be slightly offlating to the contralateral side, they'll stop just short of the tricky angles. So, you know, just be on your toes so that you don't think, oh, squat's okay. But actually, hang on, they're a bit asymmetrical. They've stopped at 60. What happens if we make that symmetrical and take it to 90? Oh, okay, now we can see it.

SPEAKER_02:

Wonderful. So it really it is very much a subjective assessment, ruling out other pathologies. And would you say that a lot of the objective testing would be more about ruling out other things?

SPEAKER_01:

Yes, but I wouldn't if there's absence of trauma, am I really going to spend a lot of time doing lots of ligament testing? We've only got so much time. I'd rather spend that time on looking at causation and muscle strength, muscle length, foot position, the things that we know may well be part or parcel of the driver. Yes, you can go to a tape box exercise. But if there's absolutely no history trauma, why am I testing their ACL? There's no clinical reasoning basis for that.

SPEAKER_00:

Yeah, part of that ruling out has a lot to do with the patient's history, their past medical history, other possible comorbidities, activities that they're involved in. And as Claire said, this is when we're thinking patellophemoral pain, we're thinking non traumatic, right? They haven't just had a fall or things of that nature. And some of the other ways to rule these other conditions out are somewhat simple tests, such as. Palpation, right? And location of symptoms, thinking about patellar tendinopathy. And we could potentially do more sophisticated tests. And that's, I think, one of the fun parts about this is it's like a mystery sometimes, right? Trying to make sure that it is just patelliphemoral pain and not something else, or something else in combination with patelephemoral pain.

SPEAKER_02:

Absolutely. Let us nicely really there into what sort of causes this. Why might this start? We talked about overload, but in your assessment, when you're looking at things like strength and range and things like that, what sort of things might we start to touch upon and see that we then might be able to forward into our plan and our management of these patients from our objective assessment? How might you prioritize those?

SPEAKER_00:

It's relatively straightforward to determine that the patient has patellophemoral pain. But patients are so different, not just the activities that they're involved in in their lifestyle. They're, you know, are they a military recruit? Are they an adolescent athlete? Are they a sedentary individual? There's those things. But even besides that, some patients have weakness. I mean, that is as far as risk factors for developing patellophemoral pain. That's one of the risk factors that we have the best evidence for, that presence of weakness of the quadriceps muscle. And that's mostly been shown in some military recruits, which many of us are not working with military recruits. Many of us are working with adolescents or the general population. So we don't really have great evidence about that. So we need to see, you know, examine them and see are these the patients that have a lot of weakness? And if so, that's an impairment that I might be looking to work on. Other patients may have fairly adequate strength, but their movement patterns might be, you know, what we would call faulty. And Claire, you kind of alluded to that when you said, well, okay, they're squatting down, but how are they squatting? Are they kind of avoiding certain positions or are they collapsing into genuus, things of that nature? Once again, not everyone will do that. And then there's kind of a third group that's, well, do they have problems with their mobility? Are they hypermobile? You know, the patella is moving around excessively and they have some hypermobility the rest of their body, et cetera. Are they hypomobile? Are they tight? Maybe they have that positive patellar tilt test that I described, where they have mobility issues at their feet, et cetera. And then the kind of fourth group that I think about is maybe the person doesn't have any of those issues, but they've just done too much too soon, that loading and not allowing their body sufficient chance to recover from that. And one group that I think of in that situation are those young adults going into basic training in the military who might have had adequate strength, but not for the loads that are being applied to their bodies on a daily basis with all the marching and exercise and things of that nature and insufficient time to recover from those loads. Brilliant. Yeah. Claire, anything more on that?

SPEAKER_01:

I guess there's a couple of things that I would perhaps add to that. In line with sort of hypomobility, I'd also be interested in restriction above and below. So if they haven't got any hip extension in take that into terminal stance in gate, they're going to have more knee flexion. So they're going to spend a bigger proportion of their gait cycle in knee flexion, higher patellophermal pressures. And similarly, if they have poor volume of dorsiflexion, we're going to see the same thing. We're going to have an early heel rising gait, tipping them into knee flexion, or they will excessively pronate to get over the foot. And I guess that then brings me to the final group. I ask every patient, do you notice your pain changes in different shoes? And some will say, No, absolutely saying barefoot slippers, get plops, trainers are no different. Others will say, Yeah, actually, there's a bit of a yes, my pain is different. And then I want to dig, what is it about that footwear? It might be someone with subchondral bone edema and it's just getting into a more cushioned shoe is better. But it might be someone in a flip-flop with no hindfoot support, and perhaps they're hypermobile, that that they're getting rear football as compensatory tubulation. So the foot in some patients, I think, is something that, and I say I the footwear, I think, is probably the best clue as to whether it's something to spend much time on.

SPEAKER_02:

Okay. So a few things there, and we talked about risk factors in in in quadriceps. Lisa, just going back to that, does the research and tell us more any more about risk factors? Because obviously that does come into our assessment and what we might be looking for.

SPEAKER_00:

Yeah. So most of the risk factors that have been looked at to date have mostly been biomechanical and kind of structural, if you will, anthropometric. And we really haven't looked a lot at the risk factors related to some of the psychological aspects, the fear avoidance beliefs, pain catastrophizing, some of those coping skills and things of that nature. And when we first started talking, Claire was talking about how we're getting more evidence about that, but we really don't have some good evidence about those factors related to risk for development of patelephemoral pain. And that those are some areas I'm I'm involved in a group right now from the International Patelephemoral Research Network that we've just been looking at. What's the evidence about the risk factors and where do we have gaps? And some of the gaps that need to be looked at more closely are definitely those psychological factors, other behavioral factors, pain coping, and those kinds of things, as well as looking at specific subgroups. We really haven't looked much at the general population, even though that's a big area. As I already mentioned, 23% of people in that general population are at risk every year for development of pataliphemoral pain. And more of the studies on risk factors have been done in somewhat controlled populations, military populations, individuals who all are just starting basic military training. Those have been some of the studies. Some of the other studies have looked at people all enrolled in a couch to 5K program, if you will, a start-to-run program. And I think it's probably a little bit easier to control the factors in those populations. But, you know, if I take the evidence from that military population for risk factors, how does that really transfer to my adolescent population or my general relatively sedentary population? So we really have a lot more work that needs to be done, particularly in those psychosocial and behavioral kind of areas.

SPEAKER_02:

And what about risk factors to prolonged time to get better? Do we know more about what might push someone to be more chronic, someone who might take the longer to get better or not at all?

SPEAKER_00:

So for the prognosis, that's another group is looking closely at that. So you folks will have to keep stay tuned for that. Some of these articles are actually under review right now by a journal. But for the prognosis, we definitely know that people who have a longer duration of symptoms when they start their treatment program, they are at risk for a poor prognosis and also greater self-reported disability. That's from an article that was done by Ninka Langhorst several years ago. And I believe that group that's investigating prognosis has also found that those psychosocial areas are really understudied, if you will. And that's another big area for that.

SPEAKER_02:

Brilliant. Claire, any more on that from research or from experience?

SPEAKER_01:

Anecdotally from the clinic setting that we fits. Those patients with poor self-efficacy, no sense of controllability about it, maybe inaccurate beliefs. They just often have engaged well with their program. And you know, you can have the best treatment in the world. But if someone doesn't do it or doesn't do it to the intensity take strengthening, you know, we want to strengthen a muscle and we have to overload it. So a few very light and fluffy exercises here and there, you know, is actually very unlikely to build meaningful strength gains. So it's yeah, anecdotally, I think those patients that have fearful, inaccurate beliefs are absolutely the ones with the worst prognosis. And we need to investigate that.

SPEAKER_00:

Yeah.

SPEAKER_02:

Yeah, definitely. And it links back to what we said right at the beginning in terms of how education and understanding is so important and leads to a lovely segue in into what we're going to talk about next, which is management in this population. And and this is a big area because obviously the kind of the main point here is our management is going to be different for very different patient populations. So I suppose what would be really good to come out of this is your tips and things that you found that have worked well, that things that you would look to do with that previously you found work well with patients for both of you. And then around the research, what do we know as a consensus guideline on how we should be managing these patients? Claire, we'll we'll start with you in terms of management. And I know I'm throwing you a really hard task here.

SPEAKER_01:

Yeah, well, except how long these are streaming, but let's just chip off load. It's very easy to say yes, it's really relevant, but actually, how are we going to impact on that? And what I do is I get I have a grid that I've made that I have, I get the patients to fill it in, particularly with my adolescents, and it says before school, morning, lunchtime, PM, after school, weekend. And it's people often have the impression it's the elite kids, and it's not. It's often just the very sporty kids. So they might be playing school hockey, might be playing hockey for a local club, maybe do a tennis lesson on a Saturday, Sunday, a part run on the Saturday, and they do Kit Fit on lunchtime just because they like it. And then when you actually look at the accumulative load, it's massive. And in terms of management, I say often we'll say, look, we don't want this to get so sore that it forces your hand and you can't then do anything, any sport for a while. That would be a real shame. So let's look at can we get a rest day? Can we actually change your position on the netball court temporarily so that you still play, but you're not herring around the court quite so much? What are the ways in which we can manage that load? And just having it mapped out, I find, particularly as I say with the kids, with hopefully mum or dad, if you can get them on board as well, you know, that which is obviously another challenge, that can be just a really useful way of actually managing it. Because you can't just say, don't do as much sport. That's very unlikely to bring about meaningful change. So starting with a load, that would be my top tip.

SPEAKER_02:

And on that, I think, Clara, remember from the masterclass, I think it was you did with the physio network, was there's some quite interesting research that showed actually a really vast improvement in just load management. Am I right?

SPEAKER_01:

In essence, he deloaded to then incrementally reload. So that's what I'm talking about. I don't want to stop them exercising, but just bring it back a bit and then layer it back in incrementally, making sure that they're a bit more aware of not just rest days, but also with the kids. I think often what it goes wrong because they have the long holidays and some of them don't do anything, and then they go straight back into full loading as well. So trying to avoid that robust graph of load as well.

SPEAKER_02:

Change of school as well, I suppose, is it? You know, when you go in from primary school or and to secondary school, that sudden change in expectations of availability of school sports and school activities. And Lisa, around load management, a big part of this. Anything you can add on that in terms of what we've found researched clinically around load management?

SPEAKER_00:

So I think load management is the part with the intervention that we really need to have more evidence about because there is a lot of research saying that what we call knee-targeted interventions, where we're really talking about strengthening the quadriceps muscle, that has really been shown to be helpful for most people. But we don't really know a lot about the dosing of that. And of course, that could vary depending upon the person. The other area is many people require some hip-targeted strengthening exercises. Not everyone, but many people will. And I think for some of the people who maybe have some of that excessive irritability of the knee, trying to tolerate some of the knee-targeted exercise, they might benefit from let's kind of back off a little bit from that right now. And we're going to focus maybe on some impairments of hip muscle strength. And also, I find some of the patellar taping with the rigid tape, such as the McConnell type of method, to be very helpful for some of my patients to kind of unload some of the tissues. And then maybe they can tolerate some of that quadriceps strengthening if I use that.

SPEAKER_01:

Absolutely. And I know tape is controversial and the literature is a bit all over the place. But my view is if it changes the pain, if it decreases the pain, gives you a window in, absolutely use tape. Not for everyone at all, but for some patients it can be, and again, I would use the rigid tape too.

SPEAKER_00:

Yeah. Yeah. Because you want to get that patient buy-in, right? If I can do something with that patient and help them take away their pain or at least reduce it quite a bit, and now I can get them to be doing the exercises. And especially for the taping that, you know, according to the McConnell method, I can teach my patient to tape their own knee. And that way they can use it and start to kind of wean off from it and things of that nature. I agree with you, Claire. It is a little bit controversial, partly because there's so many different ways to tape it. So that makes it really challenging for exercise for research studies, right? Where we want to try to do things systematically and the same for everyone.

SPEAKER_01:

I think just adding in about this concept of buy-in, it's very interesting running a second opinion service. So everyone I see has had failed treatment. And there's two things that come up again and again. One is I say to them, what was the gist of the treatment? And they'll say, exercises. And then I say, What were you trying to achieve with the exercises? And I'm not expecting to say in a range of gluteus medius or whatever. I'm expecting just a bit stronger up here or a bit flexible down there, something like that. And very often they have no idea. They've just been passively doing these exercises. So no buy-in. And then the other thing I see repeatedly is I was told I need to get stronger, and I was given these lunges and squats, and it just made me really sore and I've stopped. Not only is it probably not going to be affected as a strength modality, but you well and surely are going to lose your patient's confidence if you give them a painful treatment that makes them worse.

SPEAKER_00:

Or if we give them too many exercises, we can't just hand them a paper with six exercises that you want them to do twice a day or three times. You know, they're just not going to do it.

SPEAKER_01:

They often get the exercise out. There's like a sort of scroll. And actually, again, if we're trying to be evidence-based, if we look at the literature on adherence, if you're going to go above three exercises, you've got to have a highly motivated patient on board to do that.

SPEAKER_00:

So we can't forget to tell patients to stop doing certain exercises if we progress them to another one.

SPEAKER_02:

You see that patient that comes in with, I'm doing these, oh, and I'm still doing the other ones I was set right at the beginning, right through. Yeah. So understanding why you are doing or getting the patient or asking the patient to do what they're doing and having their buy-in. I often say to patients, I'd like you at the end of this to have as good as an understanding as I do about what's going on and why we're doing what we're doing. Because I think that we owe it to the patients to have that understanding. I'm aware of time, but I really want to carry on with this a little bit. So, in terms of loading, some might say that's going to be really hard because if we want to strengthen quadriceps, we know that a lot of that work is going to be done with a loaded knee. What are your tips and tricks around how you can get over that or get around that pain element of patellifemoral pain when we want to load those quads? How can we go about that? Thinking about dosage for strength and how we need to make it challenging.

SPEAKER_01:

I think this goes back to our understanding of biomechanics and angles. So if, for example, we do want to target the quads, then we could say, okay, well, I might get you if they've got say gym access, I might say, well, we know that open chain is kind of on the telephone or joint 90 to 45. So I might get you working through that range open chain, and then I might get you working, say, zero to 50 closed chain. Now they might say oh it feels a bit easy, but I say, well, I would prefer you doing zero to 50 with some isometric hold and a barbell than zero to 90 body weight banging up and down and upsetting with weight. So angles, really, really critical. And tape, as we mentioned, often gives you a really nice weigh-in. And I guess my final thing is if I really am just banging my head against the brick wall, I think I know they need to get stronger, but I just am struggling here, I would use blood flow restriction training as well.

SPEAKER_00:

I'm so glad you mentioned that blood flow restriction. I was exactly thinking of that. I mean, I know that, you know, could be expensive, could be something that's not necessarily available to people, but I have seen some good results. I'm thinking of someone I used it with who actually was having trouble regaining strength after a knee replacement surgery, but you know, just not able to exercise to the intensity that they needed to achieve that gain in strength, if you will. So that can be very helpful. Yes, I mean, alternating positions to try to mechanically reduce the load on the patellothermal compartment. And then the other thing that I have done, some of my older patients with patellofharmal osteoarthritis is wait a little bit with the quad strengthening and start with the strengthening around the hip, the posterior lateral muscles of the hip and the core. Many of them have quite a bit of abdominal weakness, and I can get them starting to strengthen those areas, and that hopefully can improve their movement patterns and you know, get them used to doing exercises and knowing what that sensation is when you just load a muscle and maybe have some soreness from that, but it's not the pain that they have from their patelephemoral pain.

SPEAKER_02:

Brilliant. I've just looked at the time and we are massively over time, but to finish off, what I want you to think of now is the listeners listen to this, some of them may be students, new graduates, experienced clinicians who see patellifemoral pain on a regular basis. But to all of those people, what would be your takeaway that you'd like them to get from this? Things that you've seen that people you think could improve. Claire, you mentioned your second opinion work, Lisa, particularly around the research. What are some of the things, the key things you'd like people listening to this to really take away and utilize in their clinics and practice tomorrow morning?

SPEAKER_01:

I suppose for me it would be, you know, I think dizzy is like to do, don't we like to feel, like to move, but I think listen, listen to your patient's narrative, listen to the fact that they are running for their mental health, or listen to the fact that they've had pain on the other leg and it actually took a year to go. So that's their expectation for this, or whatever it may be. Listen, because in response to that, you can make your education really bespoke. And then it is meaningful, it lands with a patient, they know you've listened to them, and again, then you're more likely to move forward with that patient biome.

SPEAKER_00:

I would completely agree with that. You know, just to keep in mind that every person is unique. We've been talking about patelephemoral pain, but that's part of a person's body, right? Their knee. You're treating the patient, you're treating the person. So when you're listening to them, keep in mind that not everyone is a runner trying to run further. People have different lifestyles and those types of things. And also not everyone is necessarily weak in their quadriceps or some other factor. So there could be other things going on. So don't just fall into the trap of giving everyone quad-strengthening exercises, and maybe you're also doing gluten mead strengthening exercises. We really need to think holistically about that person, who they are, what they're trying to get back to doing.

SPEAKER_02:

Brilliant. What a wonderful way to finish. Treat the person, not the pathology. Yes. Not the presentation. Claire, Lisa, thank you so much for this. Um, it's really sad to have to stop. I think we could have carried on this for a vast amount of time longer. But I really appreciate both of you for the time you've given us and our listeners, I'm sure, would have taken an awful lot from this. We'll make sure we've got links of how people can find more about both of you and the work that you both do so very well for us clinicians, of which is very much appreciated by everyone listening and certainly for myself. But on behalf of Pizza Network and everyone listening, thank you both very much for your time.