Patellofemoral Pain Syndrome (PFPS)



Patellofemoral Pain Syndrome (PFPS)Maurice WellsPhoenix Institute of Herbal Medicine and AcupunctureEvidence Based Clinical ResearchRES 630Gail Rekers PhDFebruary 11, 2020AbstractPatellofemoral Pain Syndrome (PFPS) is a descriptive diagnosis of long term anterior knee pain that is not constant and varies in intensity with activity. PFPS is the most diagnosed condition and is the most common presentation of knee pain. However, it must be noted that "Medical literature shows no clear consensus in the definition, etiology or diagnosis of PFPS.” (Jensen, 2009) In this paper PFPS will be discussed from the Western Medicine and Traditional Chinese Medicine (TCM) perspectives to include diagnosis, treatment modalities, and perspective outcomes. Concluding with suggested acupuncture treatment protocol. Patellofemoral Pain Syndrome (PFPS)Patellofemoral Pain Syndrome (PFPS) which falls in the general category of musculoskeletal pain can be seen in two ways. Anatomically the (Western) model and constitutionally the (Chinese) model. (Maclean & Lyttleton, 1998) Each has its positives and negatives in the treatment of PFPS. The (Western) anatomical models positives are its ability to be precise in its identification and treatment of pain from structural and biomechanical issues. The negative is the inability to recognize the interrelationship of the body’s constitution and physical structures. The (Chinese) constitutional model is more concerned with the interrelationship of the “pathogenic invasion, organ system function and local pathology of joints and soft tissue and understand how the interior and exterior and distant parts of the body are linked.” (Maclean & Lyttleton, 1998, p. 633) The constitutional model is more concerned with interrelationship at the expense of local precision.Anatomical Model (Western Medicine)PFPS (a.k.a runner's knee) is characterized by a localized dull aching pain in the patella and around the anterior portion of one or both knees, which worsens with walking up or downhill, climbing or descending stairs, kneeling, squatting or prolonged sitting with knees flexed. There also may be swelling around the knee and a sensation of grinding or grating when extending or flexing the knee and limited range of motion. It is most common in people who participate in sports that require running and jumping but can also develop in those that do not participate in sports. PFPS can develop in both children and adults. “PFPS can be defined as anterior knee pain involving the patella and retinaculum that excludes other intraarticular and peripatellar pathology.” (Dixit, Difiori, Burton, & Mines, 2007, p. 194)Constitutional Model (Chinese Medicine)PFPS in Traditional Chinese Medicine is diagnosed as Painful Obstruction Syndrome or Bi Syndrome (Bi Zheng). “Bi Syndrome refers to the syndrome characterized by the obstruction of qi and blood in the meridians due to the invasion of external pathogenic wind, cold and dampness, manifested as soreness, pain, numbness, heavy sensation, swelling of joints and limbs, limitation of movements.” (Zhang, 2010, p. 145) “Bi syndrome can be caused by either external factors or internal factors.” (Zhang, 2010, p. 145) This is characterized by acute or chronic pain and stiffness in the musculoskeletal system due to the obstruction of qi and blood in the meridians from the invasion of external pathogenic wind, cold and dampness. Or a general weakness of the body as well as a weakness of defensive qi (Wei Qi). There is always a deficiency of qi, blood or body fluids involved in bi syndrome.Anatomy and BiomechanicsAt this point to understand what is happening with PFPS we’ll need to review the structure and functioning of the knee. The knee joint is a large and complex structure, one of the most complex joints in the body. “The patellofemoral joint comprises the patella and the femoral trochlea. The patella acts as a lever and also increases the moment arm of the patellofemoral joint, the quadriceps and patellar tendons. Contact of the patella with the femur is initiated at 20 degrees of flexion and increases with further knee flexion, reaching a maximum at 90 degrees.” (Dixit, Difiori, Burton, & Mines, 2007, p. 194)“Articular cartilage covers the ends of the femur, trochlear groove, and the underside of the patella. Articular cartilage helps your bones glide smoothly against each other as you move your leg. Also aiding in movement is the synovium—a thin lining of tissue that covers the surface of the joint. The synovium produces a small amount of fluid that lubricates the cartilage. Also, just below the patella is a small pad of fat that cushions the kneecap and acts as a shock absorber.” (Hettrich & Liechti, 2015)“The combination of the quadriceps tendon, lateral retinaculum, medial retinaculum, and the patella tendon help stabilize the patella. Because the patella is not completely engaged in the patellar groove during the first 0–30 degrees of flexion, instability and the potential for subluxation/dislocation injury increases if patellar stabilizers are weak or malaligned.” (Waryasz & McDermott, 2008, p. 3) See figure 1 below for knee structures indicated previously. Figure 1. Schematic of the right knee, anterior view. Dynamic stability of the patellofemoral joint is provided by the quadriceps tendon, patellartendon, vastus medialis obliquus (VMO), vastus lateralis, and iliotibial band. The VMO is the only muscle that provides a medial force and is therefore of particular importance in stabilizing the patella. Static stability is provided via the articular capsule, the femoral trochlea, the medial and lateral retinacula, and the patellofemoral ligaments. Palpation of the bony and soft tissue structures should be performed in an attempt to identify the anatomic site of the pain. (Dixit, Difiori, Burton, & Mines, 2007, p. 195) Causes and Risk Factors of PFPS, Western MedicineOne of the difficulties of PFPS is that there is no consensus of the pathophysiology for PFPS. PFPS may be attributed to more than one cause in western medicine but will present similarly in patients. “Despite being commonly diagnosed, its exact pathophysiology is unknown, but it is believed to be related to a combination of anatomical, biomechanical, behavioral, and psychological factors.” (Sisk & Fredricson, 2019, p. 534) The most updated factors found in Sisk & Fredricson, (2019) that seem to attribute to PFPS are: 1. Quadriceps Weakness; Quadriceps weakness has been long believed to be associated with PFP especially the discrepancy in strength between the vastus medialis (VMO) and the vastus lateralis (VL). (p. 535)2. VMO Delayed Activation; In addition to muscle size, delayed activation of VMO in comparison with the vastus lateralis has been shown to be associated with the presence of PFP in multiple studies. The exact relationship of delayed muscle activation to PFP remains a focus of research. (p. 535)3. Foot Overpronation; During the gait cycle, normal pronation of the subtalar joint takes place during the first portion of the gait cycle in response to lateral movement of the calcaneus creating space for the talus to move medially. As a result of inward rotation of the talus, the tibia internally rotates. Pronation of the subtalar joint is a normal part of the gait cycle. It becomes abnormal when it occurs during the wrong phase of the gait cycle or does not resupinate. This leads to excessive internal rotation of the tibia which can result in downstream compensatory internal rotation of the femur in order for the knee to reach full extension. An internally rotated femur would theoretically move the patella medially and thereby increase the Q angle and lateral forces on the patella. (p. 535)4. Hip Weakness; Patients with PFP were found to have decreased hip strength in extension, abduction, and external rotation. However, this has been found retrospectively; studies looking prospectively have not found a causal relationship between hip weakness and development of PFP. It is possible that hip weakness is a result rather than a cause of PFP. (p. 535-536)5. Flexibility/Inflexibility; Soft tissue structures surrounding the knee and their flexibility play their own role in patellofemoral pain especially the lateral retinaculum. It is comprised of transverse fibers from the iliotibial band and quadriceps aponeurosis extending to the lateral aspect of the patella, forming a dense sturdy piece of tissue. These fibers act on the patella as a lateral restraint preventing medial translation on the patella during movement and varus forces. However, if the lateral retinaculum is too taut, theoretically lateral forces overcome medial forces leading to patellar maltracking. (p. 536)6. Training Errors and Overuse; External factors to patients may play a role in patellofemoral pain. As Dye explains, the pathophysiology of patellofemoral syndrome is one of loss of homeostasis. It is argued that pain results when underlying bone and synovial tissues are overloaded. Dye suggests the source of pain can even be seen in changes to the bony architecture highlighted by positive patellar bone scans and often disappear after resolution of symptoms. This can be from external factors that increase stress on the patellofemoral joint (PFJ). External pressures can be anything from overuse, poor running technique, weight gain, or improper footwear. (p.536)Causes and Risk Factors of PFPS, Traditional Chinese MedicineAlthough the above western causes need to be taken into account, TCM has additional factors. In the Zhang (2010) lecture on bi syndrome listed those factors: 1. External factors – the invasion of the muscles, joints and meridians by pathogenic wind, cold and dampness:In Chapter 43 the Bi Syndrome of Su Wen (Plain Questions), a part of The Yellow Emperor’s Canon of Internal Medicine (BC475-221), said that ‘if pathogenic wind, cold and dampness invade the body together, it will lead to obstruction in the meridians and Bi syndrome may take place’. Clinically, we can also see that Bi syndrome is more common in the areas where the weather is cold, wet and windy.2. Internal factors - general weakness of the body as well as the defensive qi:This condition may cause the weakened resistance to pathogens, marked by dysfunction of skin and pores as well as defensive qi. As a result pathogenic wind, cold and dampness can easily invade the body causing Bi syndrome, this was described in the book -prescriptions for Succouring the Sickness / Ji Sheng Fang, by Dr YAN Hong-he, in 1253, which stated that ‘it is because of weakness of the body with poor function of defensive qi that invasion of pathogenic wind, cold and dampness can result in Bi syndrome’.Now we can see that the basic pathology of Bi syndrome is the obstruction of qi and blood in the meridians, due to the invasion of pathogenic wind, cold and dampness.Western Diagnosis and TreatmentDiagnosis of PFPS is a diagnosis of exclusion. After all other knee pathologies have been excluded PFPS will be the diagnosis.“Medical treatment for patellofemoral pain syndrome is designed to relieve pain and restore range of motion and strength. In most cases, patellofemoral pain can be treated nonsurgically.” (Hettrich & Liechti, 2015) Treatment for PFPS typically begins with rest, ice and avoidance or modification of aggravating activity. The use of over the counter pain relievers such as acetaminophen and anti-inflammatory medications. Treatment may include physical therapy such as stretches, braces, patella taping and massage. As a final possible treatment is surgery to remove damaged cartilage and in severe cases of patellofemoral syndrome may involve an operation on the knee to change the direction that the patella passes over and rubs against the femur.TCM Diagnosis and TreatmentDiagnosis of bi-syndrome can be complex due to the four main type of bi-syndrome:Wind Bi, Cold Bi, Damp Bi and Heat Bi. More often than not these forms of bi-syndrome are seen in combination.1. Wind Bi (wandering arthralgia) syndrome: Wandering arthralgia without fixed location, accompanied with aversion to wind, tongue white or greasy fur and floating pulse.2. Cold Bi (painful arthralgia) syndrome:Severe stabbing arthralgia with fixed location as well as local cold sensation, alleviated by warmth, aggravated by cold, tongue white fur and tight pulse.3. Dampness Bi (fixed arthralgia) syndrome: Soreness and fixed pain in the joints with local swelling and numbness, aggravated on cloudy and rainy days, tongue white and greasy fur, soft and slow pulse.4. Heat Bi (heat arthralgia) syndrome:Arthralgia with local redness, swelling and burning sensation, accompanied with fever, sweating and thirst, tongue yellow and greasy fur, slippery and rapid pulse.“According to TCM theory, if the meridians are open and the qi and blood are circulating smoothly and normally, there will be no pain; but if the meridians are obstructed and the flow of qi and blood are blocked, pain will arise.” (Zhang, 2010, p. 145)Acupuncture Treatment PlanGiven the information presented and the presentation of PFPS the diagnosis would be a combination of Wind, Cold, and Damp Bi-Syndrome. The following is the proposed treatment principle and protocol for PFPS. Treatment will vary depending on the type of bi syndrome wind, cold and dampness or internal weakness. But the primary treatment principle will be to expel the pathogen (wind, cold or dampness), restore circulation of qi and blood and correct any imbalance or deficiency. Treatment may include acupuncture, exercise, tui na and herbal medicine. For our purposes acupuncture will be the modality that will be utilized.Local Acupoints:Lateral knee pain; influences the lateral collateral ligamentXiyan – Dispels wind damp, reduces swelling and pain – Interior knee painST36 – Courses wind and transforms damp, tonifies qi and nourishes blood and yin GB34 – Removes obstruction from the channel (wind, damp and stagnation), benefits sinew and joints ST34 – Clears the channel (clears heat and dampness), alleviates pain GB33 – Dispels wind and cold; relaxes the sinew and invigorates the channels; Sedates knee pain Medial and posteromedial pain; influences the medial collateral ligament SP9 – Local point for knee disorders, especially when accompanied by swelling SP10 – Invigorates the blood and dispels stasis KD10 – Dispels damp, pain in knee and popliteal fossa. LV8 – Knee disorders with coldness, swelling and painDistal Acupoints:Medial Pain and Reduce Swelling SP5 – Benefits the sinew and bones (Damp Bi-Syndrome)SP6 – Promotes and invigorates circulation KD3 – Strengthens the lower back and kneesLateral Pain and Reduce SwellingST41 – Activates the channel and alleviates painGB40 – Opens the Dai Mai and balances the upper and lower bodyThe above treatment plan and point prescription should be effective in treating PFPS. With the edition of e-stim (electro-stimulation) and moxa depending on the internal deficiency would be a possible addition to the treatment.Conclusion“There is no documented treatment of choice for this pain syndrome in western medicine. Most experts agree that strengthening the extensor muscles in the leg is beneficial to both reduction in pain and improved function.” (Jensen & Baerheim, 2000, p. 15) “Although 1 study points to the effectiveness of acupuncture, this was in comparison to no treatment, highlighting the need for a placebo/sham-controlled trial. Additionally, acupuncture has not been evaluated in comparison to, or in combination with, exercise therapy.” (Willy et al., 2019, p. 40) Although patellofemoral pain syndrome (PFPS) is a diagnosis of exclusion and there is not a consensus of treatment either western or eastern. Being a musculoskeletal condition that benefits from an integrative method of treatment would be a greater effective treatment than eastern or western medicine. Acupuncturist InterviewThis short interview with a licensed acupuncturist was designed to discuss some techniques used and outcomes associated with Bi Syndrome – PFPS that have been utilized in practice.For this interview I contacted Robert (Kirby) Woods L.Ac at Love Light and Healing Centers in Gilbert, AZ. Kirby Woods has practiced acupuncture for over 10 years. During the course of our interview we discussed how chronic bi-syndrome presents. We also discussed addition treatment modalities such as tui na and herbs.Mr. Woods went on to say that about 70% of patients come in for acute pain and about 30% present with chronic pain and that typically he has good outcomes by using the acu-point prescriptions in the Chinese Acupuncture and Moxibustion (CAM) book. He recalled a patient that had come in with cold bi-syndrome and was able to relieve the pain of the patient in the first treatment and continued to have success for over two years that the patient now only has occasional flare ups. Kirby also went on to remind us that when presented with bi-syndrome it may present as heat bi but began as cold bi and it’s important to track the progress of treatment.Mr. Woods continued by stating that “it’s important to use all tool available to an acupuncturist” to treat this condition. The use of herbal medicine and not just formulas that are drank but the use of poultices and plasters. Depending on the presentation of the patient tui na or massage will be utilized.Lastly we discussed outcomes are tailored to the individual. One thing that he said is “Nothing overcomes life style”. Meaning that no matter what treatment you provide if a person is marathon runner and is presenting with bi-syndrome, the only way for them to get better is to stop running or reduce running for a period of time.ReferencesDixit, S., Difiori, J. P., Burton, M., & Mines, B. (2007, January 15). Management of patellofemoral pain syndrome. American Family Physician, 75(2), 194-202. Retrieved from , C. M., & Liechti, D. (2015). Patellofemoral pain syndrome. Retrieved from , R. (2009). Patellofemoral pain syndrome. Studies on a treatment modality, somatosensory function, pain and psychological parameters (Master????????s thesis, University of Bergen). Retrieved from , R., & Baerheim, A. (2000, October). Bi syndrome of the knee treated with acupuncture with patellofemoral pain syndrome as a case. The Journal of Chinese Medicine, 64, 13-16. Retrieved from , H. (2002). How to differentiate and treat bi-syndrome with acupuncture and moxibustion? The Journal of Traditional Chinese Medicine, 22(1), 73-77. Retrieved from , W., & Lyttleton, J. (1998). Clinical handbook of internal medicine: Treatment of disease with traditional chinese medicine. New South Wales, Australia: University of Western Sydney.Sisk, D., & Fredricson, M. (2019, December). Update of risk factors, diagnosis, and management of patellofemoral pain. Current Reviews in Musculoskeletal Medicine, 12(4), 534-541. , G. R., & McDermott, A. Y. (2008, June 26). Patellofemoral pain syndrome (PFPS): A systematic review of anatomy and potential risk factors. Dynamic Medicine, 7. , R. W., Hoglund, L. T., Barton, C. J., Bolgla, L. A., Scalzitti, D. A., Logerstedt, D. S., ... McDonough, C. M. (2019). Patellofemoral PainClinical Practice Guidelines Linked to the International Classification of Functioning, Disability and Health From the Academy of Orthopaedic Physical Therapy of the American Physical Therapy Association. Journal of Orthopaedic & Sports Physical Therapy, 49(9), 1-96. , E. (2010, June). Bi syndrome (Arthralgia syndrome). Journal of Traditional Chinese Medicine, 30(2), 145-152. (10)60032-5 ................
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