Journal of Orthopaedic & Sports Physical Therapy

2OOO;3O (3):138-1 42

Diagnosis of Patellofemoral Pain After

Arthroscopic Meniscectomy
Karen Muller, MPT1
Lynn Snyder-Mackler, ScD, P7; SCS2

BACKGROUND ture, meniscal tear, neuroma, tumor, and iliotibial

band syndrome).5"J4
Anterior knee pain is a common complaint, occur- When examining subjects with PFPS, clinicians
ring in approximately 1 of 4 people; individuals in- have observed all the following symptoms: quadri-
volved in athletics report an even higher incidence.' ceps weakness, excessive forefoot pronation, limb
The condition is more common in women than men length discrepancy, increased Q angle, patella alta, il-
and most often affects younger persons, with a peak iotibial band, vastus lateralis and lateral retinacular
incidence between the ages of 10 and 35 years. tightness, excessive genu recurvaturn, and patellar in-
Symptoms include the following: pain in the knee stability. These factors are hypothesized to affect the
when ascending and descending stairs, when squat- alignment of the patellofemoral joint. Dysplasia of
ting, or with prolonged sitting; swelling; a popping the oblique fibers of the vastus medialis has been im-
or grinding sensation; and incidences of the knee plicated in the development of aberrant direction of
buckling or giving ~ a y . " ~Often J ~ termed patellofernOT- the effective quadriceps pull on the at el la:^ Lateral
a1 pain syndrome (PFPS), the spectrum of symptoms tracking of the patella can result in excessive com-
varies greatly from one individual to another (eg, pression between the patellar facets and the femoral
achy pain after a long run or severe pain when rising g r ~ o v e . ~ J This malalignment may provoke irrita-
from a chair). Many patients with anterior knee pain tion or inflammation of the soft tissue structures
are eventually referred to rehabilitation. Although about the joint. Identifying the origin of the irrita-
PFPS is one of the most common clinical conditions tion or inflammation may be critical for developing a
treated by orthopaedic and sports physical therapists, treatment that will result in prompt resolution of
a consensus as to how these patients should be man- symptoms. Wilk et a1 proposed a classification system,
aged does not exist. Subtle variations in symptoms based on an individual's signs and symptoms, that
(and the attribution of symptoms to a variety of dif- can be used as a foundation for treatment strategies
ferent causes) deem it unlikely that a generic proto- and interventions for the nonoperative management
col for treatment or exercise prescription can be de- of patients with PFPS. This system divides patellofe-
veloped for the entire scope of individuals experienc- moral disorders into 8 groups as outlined in table 1
ing PFPS. Differential diagnosis must consider a of the article by Wilk et al.14
range of inflammatory conditions, mechanical prob- Trauma to the knee, including surgery, can also
lems, and other conditions (eg, tendinitis and bursi- cause inflammation and mechanical problems associ-
tis, patellar hypermobility, subluxation and disloca- ated with PFPS. Postoperatively, patients may develop
tion, posterior cruciate ligament tear, plica, loose symptoms consistent with PFPS even after knee liga-
bodies, reflex sympathetic dystrophy, osteochondritis ment or meniscal surgery. Failure of voluntary activa-
dissecans, systemic arthritis, muscle strain, stress frac- tion of the quadriceps can occur as a result of an
acute effusion and have a deleterious effect on the
Spom physical therapy resident, Department of Physical Therapy, Uni- extensor mechanism. This will also result in irritation
versity of Delaware, Newark, Del. or inflammation around the patellofemoraljoint. Cli-
Associate professor, Department of Physical Therapy, University of Dela- nicians must recognize the patient's complaints as
ware, Newark, Del.
Send correspondence to Lynn Snyder-Mackler, Department of Physical PFPS rather than simply attributing the pain to sur-
Therapy, 053 McKinly Lab, University of Delaware, Newark, DE 19716. gery itself. Patellofemoral pain can be the primary
E-mail: smack@udel.edu diagnosis for patients after knee surgery.
 A variety of techniques have been advocated for injury or surgery. Weakness of the extensor mecha-
treatment of PFPS. Some of these techniques include nism could be the cause of the irritation about the
nonsteroidal anti-inflammatory drugs, ice, quadriceps patella. His symptoms focused our evaluation on the
strengthening, stretching, patella taping or bracing, patellofemoral region.
and orthotics-%'J1J4;however, if we simply treat the
inflammatory process without treating the underlying PHYSICAL EXAMINATION
cause, the condition will ultimately become chronic
or recurrent. Conversely, if we attempt to treat the General observation revealed visible atrophy to the
malalignment without addressing the inflammatory left quadriceps with vastus medialis dysplasia, 1+
process first, a chronic complaint of pain may result. joint effusion (swelling can be milked out and does
Any exercise or technique that recreates pain might not return until it is swept back down), and well-
perpetuate inflammation. A technique that works in healed portal scars. Patellar mobility was decreased
one instance may not work in another. The chronici- medially, laterally, and superiorly compared with the
ty of the disorder, level of pain and inflammation, ac- opposite side. A verbal pain scale of 0-10 was used
tivity level, and lower extremity alignment should all during palpation, with 0 representing absence of
be considered when developing a management strat- pain and 10 representing the worst pain imaginable.
egy. Treatment and exercise programs must be based Palpation of the peripatellar region on the right did
on specific signs and symptoms of each individu- not produce pain. Pain was produced on palpation
a1.5.hJ1J4The purpose of this report, therefore, is to of the left patellar tendon (3-4/10), lateral patellofe-
illustrate the diagnostic process in the development moral ligament (1-2/ lo), and quadriceps tendon
of a treatment plan for a patient with anterior knee (3-WlO). Both lower extremities demonstrated gen-
pain after meniscal surgery. eralized decreased flexibility.
Range of motion was measured using a universal
HISTORY goniometer. Active and passive knee extension was
measured in long sitting with the heel propped on a
The patient is a 52-yeardd state police officer who wedge (-2" with active quad set and 0" statically for
was referred to physical therapy 2 months after ar- the left side and 0" with active quad set and 2" stati-
throscopic debridement of his left knee with knee cally for the right side). Active knee flexion was mea-
pain. Operatively, he had meniscal degeneration, sured in prone (135" left and 131" right). Hamstring
some fibrillation of the articular cartilage on the me- tightness was assessed in supine with a passive
dial side, and medial osteoarthritis. The patient's ma- straight leg raise (65" left and 58" right). Gastrocne-
jor symptom before surgery was medial knee pain, mius flexibility was also tested in long sitting with
which resolved after surgery. passive dorsiflexion of the ankle (5" left and 8"
After surgery, he developed symptoms of anterior right). Rectus femoris tightness was assessed in a
knee pain while ascending and descending stairs, modified Thomas test position? with the thigh dan-
walking on the beach, jogging, and squatting. The gling off the end of the table, and the angle of pas-
patient continued working, because he had a desk as- sive knee flexion was measured (45" left and 60"
signment. The anterior knee pain now prevented right). Iliotibial band tightness was assessed using an
him from golfing and jogging. The patient had re- Ober test? the results of which were positive bilater-
ceived an injection of lidocaine and dexamethasone ally.
to his left knee 9 days before his physical therapy Manual muscle testing grades were 4 of 5 for the
evaluation, decreasing his pain enough to allow him quadriceps and hamstrings on the left and 5 of 5 for
to return to playing golf. He was also taking an oral the quadriceps and hamstrings on the right. Because,
nonsteroidal anti-inflammatory drug. His goal was to with a stronger individual, it is difficult to determine
return to jogging without pain. how large a deficit a grade of 4 of 5 on the manual
muscle test is, we decided that testing with an instru-
ment was needed. Further strength testing was per-
Differential Diagnosis Based on History and formed using an electromechanical dynamometer to
Symptom Behavior test maximal volitional isometric contraction of the
quadriceps at 60" of knee flexion. The left quadri-
The patient had significant relief of his symptoms ceps maximal volitional isometric contraction was
from the steroid injection, suggesting that an inflam- 20% less than the right quadriceps.
matory process was involved. His pain and symptoms Provocative testing was performed using a stepup
were different from those he had before surgery. His test. Pain grades and the angle of the knee when
symptoms of anterior knee pain when ascending pain occurred were recorded. Patellar taping (medial
stairs, descending stairs, and squatting were consis- glide then superomedial glide) was used serially to
tent with those of PFPS. It is possible that the patient assess effect of medial glide on the results of the step
experienced quadriceps weakness from his previous test (Figure 1A and B). The patient reported pain

J Orthop Sports Php Ther-Volume 30. Number 3. March 2000

 1
FIGURE 1. Step test (A) with the patella taped (B).
levels of 7 of 10 at 52" of knee flexion, stepping onto
a 10-in step. Medial taping decreased his symptoms
to 5 of 10, and the pain did not begin until 70" of
knee flexion. Addition of superomedial taping fur-
ther decreased his symptoms to 0-1 of 10 at 70".
-
Differential Diagnosis Based on Results of
Physical Examination
The flexibility of the rectus femoris, hamstring, ili-
otibial band, and gastrocnemius was not dramatically
different from one side to the other. This suggests
that flexibility was not a significant factor causing
pain symptoms. The evaluation also indicated deficits
in strength of the left quadriceps and vastus medialis
dysplasia and decreased patellar mobility. Weakness
and patellar hypomobility may have increased stress
on the patellofemoral joint, causing pain and inflam-
mation. The step-up test produced the most pain
and provided a maneuver for evaluating treatment
effectiveness. Patellar taping dramatically decreased
the pain during step-up, suggesting that addressing
the weakness and patellar mobility should improve
the patient's symptoms and function.
TREATMENT
Treatment addressed each of the impairments
found during the evaluation. High-intensity electrical
stimulation, burst-modulated alternating current, and
ice were used for reduction of pain.12 The burst-mod-
ulated alternating current consisted of a 2500-Hz
sine wave at a 50% duty cycle. Fifty bursts per second
(2-second ramp) for 12 seconds (includes ramp) fol-
lowed by 8 seconds of rest were applied for 10 min-
utes. The stimulation was applied by preparing the
area directly over the painful sites of the quadriceps
and patellar tendons with alcohol, after which each
site was bounded by small electrodes (approximately
1 X 2 cm) (Figure 2). The intensity of the current
was slowly increased as high as was tolerable for the
patient.12 The quadriceps tendon was treated for 2
sessions and the patella tendon for only the first ses-
sion, after which the pain to palpation had resolved.
Bilateral stretching exercises for the quadriceps,
hamstrings, gastrocnemius, and iliotibial band were
incorporated into a home exercise program. Patella
hypomobility was treated both actively and passively.
Superior patella glides were achieved actively by per-
forming quadriceps sets and other active quadriceps
J Orthop Sports Phys Ther-Volume 30. Number 39 March 2000

FIGURE 2. Set-up for high-intensity electrical stimulation.
exercises. Medial patella mobility was treated using
passive medial gliding of the patella to stretch the
lateral soft tissue structures. The therapist performed
grades I11 and IV glides,1 and the patient was taught
to perform the glides as part of his home exercise
program. Patellar taping was used during perfor-
mance of strengthening exercises. After 2 sessions,
the tape was no longer needed for pain control, and
his strengthening exercises progressed: repetitions
were increased from 2 X 10 to 2 X 12, step height
was increased from 4 to 6 in, and treadmill jogging
was initiated. The patient began jogging 1 week after
his initial treatment and returned to the clinic for 2
more visits to monitor his response to the progres-
sion of jogging activities and exercise program. The
patient was discharged after a total of 6 visits with no
complaints of pain during the performance of activi-
ties of daily living. He had the ability to jog for 10
minutes without symptoms. He was instructed to con-
tinue his stretching and strengthening program inde-
pendently at home.
DISCUSSION
This patient's symptoms were quickly and easily re-
lieved by directing treatment at specific impairments
and pain identified by palpation of soft tissue struc-
tures and provocative stepup testing. Although our
initial hypothesis strongly emphasized the effect of
quadriceps weakness on the patellofemoraljoint, in
retrospect, the pain control treatment had an imme-
diate effect on quadriceps muscle performance. Con-
sequently, the measured weakness was most likely
caused by local inflammation, resulting in pain pro-
voked during a c ~ n t r a c t i o n . ~ . ~
The inflammation and pain were addressed by us-
ing high-intensity electrical stimulation. This is an
uncomfortable modality for the patient, but there a p
pears to be a positive dose-response relationship.12
There should be immediate and long-lasting sympto-
matic relief, which gives the patient motivation to
J Orthop Sports Phys There Volume SO. Number 3. March 2000
withstand the procedure. Preliminary research on
this modality indicates that the reduction in pain lev-
els can be linked to immediate improvement in
quadriceps muscle performance. Not only is this sig-
nificant in the treatment of patellofemoral pain, for
which quadriceps function is a critical component to
recovery, but to any other condition in which pain
and muscle function are linked.1.2.4J2 Increasing pa-
tellar mobility also decreased the patient's pain symp
toms. Again, improvement in symptoms (a reduction
of pain and weakness) was too rapid to be the result
of improved medial patellar mobility; however, im-
proved active superior mobility can occur rapidly and
would theoretically increase measured quadriceps
strength by allowing optimal tracking of the knee ex-
tensor mechanism. In this patient's case, there was
complete relief of pain symptoms after 2 treatments
that resulted in marked improvement in quadriceps
function as exhibited by swift progression of
strengthening exercises.
In conjunction with the noxious stimulation and
increased patella mobility, patellar taping also al-
lowed the patient to begin performing strengthening
exercises without pain and irritation. Once the pa-
tient's pain and quadriceps inhibition were resolved,
he no longer needed taping intervention and was
able to progress his strengthening exercises to
achieve his goal of jogging pain free.
Quadriceps strengthening was performed using
exercises that are completely pain free to avoid ex-
acerbating the patient's symptoms. In this specific
case, the weakness recorded during evaluation was
most likely secondary to quadriceps inhibition from
pain rather than substantial weakness of the muscle
itself. The patient was able to rapidly progress his
exercise program once this pain and inhibition cy-
cle was broken. In situations where true weakness
exists, the strengthening progression will take place
in a more gradual, stepwise fashion. Patients' exer-
cise programs, therefore, must be individually tai-
lored to their present abilities and their long-term
goals.3.6,11.14
Clearly, not all patients with anterior knee pain
will present with the same symptoms. The approach
to treatment should address identified impairments
and relate them to function. Similar treatment prin-
ciples can be applied to patients with anterior knee
pain that results from overuse or structural proh
lems, traumatic injuries, and surgical interventions.
Patients who have knee surgery will have muscle
weakness, inhibition, or both and lack of joint mobil-
ity that can result in patellofemoral pain syndrome as
previously described. Their complaints should not be
dismissed as related to the preoperative condition. It
is important to systematically evaluate and reevaluate
patients, following up with a treatment that is specifi-
cally directed by findings. This process might shorten
episodes o f care and increase patient satisfaction with
physical therapy.
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J Orthop Sports Phys Ther .Volume 50. Number 3. March 2000