Patellofemoral Joint Syndromme (PFJS)<xml:namespace prefix = o ns = "urn:schemas-microsoft-com:office:office" />
PFJS is a common knee problem which accounts for 25% of all knee problems treated in sports clinics (Fredrickson et al, 2006). People with PFJS, experience pain around or behind the patella (knee cap). Common signs of PFJS are pain after sitting for a period and when descending the stairs. It often presents in runners and cyclists
How does it occur
The patella normally moves or tracks within a grove on the femur (thigh bone). Several forces act on the patella to provide stability and keep it tracking properly (Figure 1). An imbalance of forces on the patella can cause it to mal-track resulting in pain.
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Figure 1: Forces acting on the patellafemoral joint
What causes the patella to mal-track
The following can cause the patella femoral joint to mal-track:
1) An imbalance of muscular forces around the knee. In order for the patella to track problem there needs to be a balance between the strength of the muscles on the medial side of the knee (medial quadriceps) and the lateral side of the knee (Illiotibial band). An imbalance of these forces can cause the patella to track laterally.
2) Poor biomechanics. Flat feet can cause the femur to rotate inwards disturbing the patellofemoral mechanism.
3) Proximal weakness. The hip abductors play a strong role in control of the lower limb, Weakness in theses muscles can result in a loss of control and patellafemoral pain.
The role of the physiotherapist:
In order to treat PFJS properly, the therapist has to identify the root cause of the problem> A thorough assessment is therefore very important. Physiotherapists often treat PFJS with soft tissue release, patella taping, postural and biomechanical correction and strengthening exercises. Often orthotics are given.
Anterior Crutiate Ligament (ACL) Injuries
The knee joint consists of an articulation between the femur and the tibia and is an inherently shallow joint. Ligaments around the knee therefore play a vital role in knee stability. There are 4 main ligaments that surround the knee joint. The ACL, PCL (posterior crutiate ligament) MCL (medial collateral ligament) and LCL (Lateral Collateral Ligament).The ACL (Figure 1) is a very important ligament in the knee and prevents forward movement of the tibia on the femur. The ACL is most commonly torn in a twisting injury when the foot is planted firmly on the ground or when the knee is forced to make sharp changes in movement.
Figure 1: ACL Ligament
Common signs of ACL tears
Often a popping sound can be heard when the ACL is torn. The ACL is a very vascular ligament and therefore immediate swelling straight after injury is a common sign. Pain, feelings of instability and locking of the knee can occur in people after an ACL injury. Restricted movement especially with an inability to straighten the knee is common.
People can live without their ACL ligament, however in people who are more active, the ACL often needs to be repaired. The decision to operate depends on a number of factors including age, lifestyle, sporting involvement and degree of instability.
What is the role of the physiotherapist
Physiotherapist treat ACL injuries both pre and post operatively. Preoperatively the physiotherapist works with the patient to try and gain full range of movement, reduce swelling and build up quadriceps and hamstring strength. This enables the patient to be in the best possible condition before his operation. Post operative rehabilitation often includes management for pain and swelling, (soft tissue massage, mobilisations), strengthening exercises (especially of the hamstrings) and functional sports specific exercises. Physiotherapists aim to get patients back to playing sport within about 9 months.
Sciatica:
Sciatica is a common problem that is caused by irritation and or compression of the sciatic nerve. Sciatica is a set of symptoms rather than a diagnosis for what is irritating the nerve and causing the pain. It is the role of the physiotherapist to figure of the origin of the pain and treat the cause.
What is the Sciatic Nerve?
The sciatic nerve is made up of 2 lumbar and 3 sacral nerve roots (Figure One). These nerve roots join together to form the sciatic nerve which runs through the buttocks and down the lower leg. The Sciatic nerve supplies the whole of the skin of the thigh, the muscles of the back of the thigh and those of the lower leg and foot. Problems with the sciatic nerve can therefore cause changes in sensation and weakness
Figure One: Sciatic Nerve Roots
What can cause Sciatica?
A ‘slipped’ or herniated discs are a common cause of sciatica. A disc can either compress one of the nerve roots or cause inflammation around it resulting in pain and altered sensation. Wear and tear of the joints related to the vertebra (facet joints) can also result in sciatica. The piriformis muscle in your buttock is also closely related to the sciatic nerve and can compress the nerve. This syndrome is known as piriformis syndrome.
What are the signs and symptoms of sciatica?
Sciatic symptoms can range from very mild symptoms to excruciating pain. Pins and Needles and numbness can also occur. Sometimes a patient can experience weakness in one or more of the muscle groups in the lower leg.
How can physiotherapy help?
Physiotherapists first need to identify the cause of the sciatica and then treat accordingly. Soft tissue techniques and mobilisations can be used and acupuncture can be a good treatment for pain reduction.
Acupuncture:
Acupuncture is an Ancient Chinese method of treatment which is more recently being accepted in Western medicine. Acupuncture treats patients by insertion and manipulation of needles in the body. Acupuncture points are based around Meridians which are paths through which life energy or ‘Qi’ is meant to flow. Physiotherapist often use acupuncture to treat pain and swelling and to enhance the body’s own healing mechanisms to help aid recovery. In patients who are experiencing alot of pain, acupuncture can be useful to reduce pain before the physiotherapist starts their hands on treatment
How does Acupuncture work?
Acupuncture stimulates the brain to release the body’s natural chemicals including endorphins (which helps with pain relief), melatonin (to help sleep) and serotonin (to promote general wellbeing). Research has shown that alot of people gain pain relief from acupuncture. Acupuncture can work straight away however, patients treated will generally require 3 treatments before the physio can be certain if it is working or not.
Is Acupuncture painful?
Acupuncture is not painful, but often a patient can feel the sensation of the needles known as DEQI. This is described as a numbness, fullness, warm or deep aching feeling.
Are there any side effects from acupuncture?
There are some side effects but they generally tend to be very mild. Occasionally one may get a small bruise from the needle. One can feel tired after acupuncture. Very rarely one may feel faint as acupuncture can have an effect on ones blood pressure. The physiotherapist should ask a set of general health questions before administering acupuncture
Planter Fasciitis
The planter fascia (figure 1) is a thick band of connective tissue which starts from the heel bone and extends along the foot to the 5 toes. The planter fascia has a number of roles, the most important of which is to support the arch of the foot. Planter Fasciitis was once thought to be an inflammation of the planter fascia, however now it is thought to be more of a degenerative process of the collagen structure which makes up the fascia.
Risk Factors
Planter Fasciitis can often occur in people who have worked a long distance in an unsupportive shoe or barefoot. One of the risk factors for planter fasciitis are people who overpronate or who have flat feet. In young people there are some fascial connections between the Achilles tendon and the planter fascia, therefore a tight calf muscle can also be a risk factor for the development of Planter Fasciitis
Figure 1: Planter Fascia
Signs and Symptoms of Planter Fasciitis
Pain is the main symptom of planter fasciitis and can be felt anywhere along the line of the planter fascia. The most common place tends to be the in the heel. Planter fasciitis sufferers tend to feel the worst pain first thing in the morning as they put their foot down after a nights rest. Pain is also felt after standing when sitting for a long period of time. Palpation of the planter fascia can be very painful.
How can physiotherapy help?
Physiotherapy can help cure Planter Fasciitis. Soft tissue massage, stretching exercises, ultrasound and acupuncture are some techniques physiotherapists use to treat Planter Fasciitis. As soon as the condition in identified, it is very important for the patient wear good supportive shoes and to avoid walking around in slippers or barefoot. Often orthotics are given to patients to help correct their overpronation
Are you Hypermobile and is it a problem?
What is hypermobility?
Hypermobility implies a range of joint movement that exceeds what is considered to be normal for that joint taking into consideration the individual’s age, gender and ethnic background. Joint hypermobility is very common, 10-20% of the population have it. Hypermobility does not necessarily lead to symptoms and most hypermobile people are not even aware they are hypermobile.
What is Joint Hypermobility Syndrome (JHS)?
Joint hypermobility only becomes a syndrome when it is deemed responsible for pain and instability. JHS is often missed. Doctors may be unaware of the prevalence of the condition, its affect on life and its multisystem nature.
How is JHS diagnosed?
Diagnosis of JHS requires the Brighton score. You either have to have 2 major criteria, one major and 2 minor criteria or 4 minor criteria to be classified as having JHS. One major criteria of the Brighton score is a score of 4 or more in the Beighton score. This is a list of 4 manoeuvres where a maximum score of nine is possible. The manoeuvres include certain positions with the hands, elbows and knees (See figure one below). Other criteria of the Brighton score include pain in joints, history of dislocations, skin abnormalities etc. People with JHS may also have an increase in pain perception, experience a lack of efficiency of local anaesthetics and have gastrointestinal problems.
Figure One: The 9 point Beighton Scale
How can Physiotherapy help?
The role of the physiotherapist in treating JHS is multifactoral. Firstly it is important for the physio to use mobilising techniques to restore natural hypermobility to joints or spinal segments that have been lost as a result of deconditioning. Core stability, joint stabilising and proprioception enhancing exercises are very important in patients with JHS. General fitness training will help to offset the tendency to lose condition.
