by Dr Matt Fontaine
PATELLOFEMORAL PAIN SYNDROME/ PATELLAR TENDONITIS
The injury is common among young athletes aged 10 – 20 years. It also affects runners of all ages, even sports such as basketball and soccer. Correct rehabilitation is essential for this injury along with taping. Do not ignore this injury because if it becomes chronic it is extremely difficult to treat.
Patellofemoral Pain Syndrome is the term used to describe pain in or around the kneecap (patella). It is also known as PFJ (patellofemoral joint) syndrome and anterior knee pain. Pain results from the abnormal movement of the patella on the femur (thigh bone) during bending of the knee joint. Chondromalacia is sometimes used to describe this injury. However this is a common misconception as chondromalacia refers specifically to the softening of the articular cartilage on the underside of the patella.
When the knee is bent from being outstretched, a number of muscles and ligaments that are attached to the patella function to move it medially (towards the inside surface of the knee) to sit in the intercondylar fossa of the femur (groove in the middle of the femur where the patella glides up and down as the knee bends).
In general, patellofemoral pain syndrome occurs when the patella does not move or ‘track’ in a correct fashion when the knee is being bent. This movement can lead to damage of the surrounding tissues, such as the cartilage on the underside of the patella itself, which can lead to pain in the region. This injury is quite common in people who do a lot of sport, in particular women of an adolescent age. Women are more prone to several sports injuries than men based simply on biomechanical differences. One such difference is a wider pelvis in women then men. Many sports medicine experts have linked a wider pelvis to a larger “Q angle” (Quadriceps angle)- the angle at which the femur (upper leg bone) meets the tibia (lower leg bone). It is measured by creating two intersecting lines: one from the center of the patella to the anterior-superior iliac spine of the pelvis; the other from the patellar to the tibial tubercle.
On average this angle is degrees greater in women than in men. It is thought that this increased angle places more stress on the knee joint, as well as leading to increased foot pronation in women. While there may be other factors that lead to increase risk of injury in women athletes (strength, skill, hormones, etc…), an increased Q-angle has been linked to increase risk of ACL tear, patellofemoral pain, Osgood Schlatter’s Disease, and patellar tendonitis.
Correct and immediate rehabilitation is vital for this injury as, if ignored it becomes very difficult to treat.
There are a number of causes that can lead to abnormal movement of the patella:
Overloading – Bending the knee increases the pressure between the patella and the femur. Thus running, and squatting where repeated weight-bearing occurs, may result in PFJ syndrome.
Pronating Feet – Pronating or ‘flat’ feet lead to an increased biomechanical stress on the knee joint. This may affect the alignment of the patella particularly during movement.
Muscle imbalance – The quadriceps muscle group are responsible for the movement of the patella itself. If the lateral (outer) fibers are stronger or tighter than the medial fibers, or if the iliotibial band (ITB) is very tight this can lead to problematic patella tracking.
Q-angle – Some people have a larger than normal femoral angle (known as the Q-angle)and may have ‘knock-kneed’ appearance (genu valgum). When the person straightens their leg, the patella will be forced to the outside of the knee. With repeated bending and loading, this motion may lead to damage of the underlying structures and cause pain.

It is important to note that IT band tightness is caused by tightness in the outer hip muscles which insert directly onto the ITband. Tight outer hip muscles result from repetitive overuse, usually secondary to muscle imbalance, weak core strength, pronated(flat arched/ hyperflexible foot) or supinated(high arched/ rigid foot) feet and poor biomechanics.
Many people with weak core stability have weak gluteal muscles. These muscles are necessary for keeping the entire lower leg in normal alignment. When they are weak, they allow the knee to drift inward, thus resulting in tracking problems in the knee. Combined with faulty foot mechanics(either too flexible or too rigid) and the knee suffers repetitive stress and ultimate injury.
Addressing these core issue is crucial to permanent correction and recovery from injury. RICE treatments are effective only at alleviating acute inflammation. Correction of faulty biomechanics is the only way to prevent the repetitive stress from reoccurring.

What are the symptoms of patellofemoral syndrome
Aching pain occurs in the knee joint, particularly at the front, around and under the patella.
Pain under the patella when bending and straightening the knee.
Tenderness along the inside border of the kneecap.
Usually swelling is present.
Is often worse when walking up or down hills or stairs.
A clicking or cracking sound may be present on bending the knee.
Sitting for long periods may be uncomfortable. This is known as the theatre sign.
What other signs may be present with patellofemoral syndrome?
Temporary loss of function.
Wasting (atrophy) of the quadriceps muscles.
A Q-angle greater than 18 to 20 degrees.
Tight muscles including calf muscles, hamstrings, quadriceps (especially vastus lateralis on the outside) and iliotibial band.
Who is most at risk from patellofemoral syndrome?
You are more prone to this if you have a small kneecap or one that sticks out
If your feet roll in or pronate.
If you have weak quadriceps muscles.
Athletes who do a lot of long distance running, hill running, or squatting.
Those who have had a previous knee dislocation
Those with weak core stability.
What can the athlete do to prevent patellofemoral syndrome:
Apply RICE (Rest, ice compression and elevation) to the injured knee. This will help reduce swelling.
Rest until there is no pain (this is very important).
Use a knee support or patellar tendon strap ( Use caution when using. Straps provide additional support to injured tendons. They may reduce pain and allow you to exercise more, but the overuse cycle continues and more serious injury may result.

See a sports injury professional who can advise on treatment and rehabilitation.

Soft tissue treatment such as Active Release Techniques or Graston technique is an essential part of treatment. It is simply the best way to break down scar tissue in the muscles and tendons that affect the leg and knee function, particularly the gluteals, quadriceps, hamstrings, groin, and deep compartment tibial muscles.
Perform foam roller self massage to all affected muscles, followed by stretching.
Cross friction massage to tendon directly to break down scar tissue and aid healing, followed by ice massage for 5-10 minutes.
A Sports Injury Specialist or Doctor could:
Prescribe anti-inflammatory medication e.g. ibuprofen. Use electrotherapy equipment such as ultrasound, laser and electrical stimulation.
Prescribe a comprehensive rehabilitation program in conjunction with taping techniques.
Investigate the possibility of a synovial plica.
Recommend surgery in severe cases.
Vastus Medialis Obliquus (VMO) strengthening exercises combined with iliotibial band (ITB) stretches.
Provide orthotic foot supports if applicable.

by Dr. Matt Fontaine

This is the first article in a series on how to talk to your doctor.

Dealing with the information age

Long gone are the days of just trusting your doctor and doing what they say.  No more  “Take two and call me in the morning”.  To ensure clear and effective communication it is important to recognize that there is often a disconnect between the patient and his or her physician.  Doctors have a lot of graduate and specialized training, knowledge and experience in the field of medicine and within their respective fields of specialty.  With the advent of the internet, patients today have access to vast amounts of medical information.  From Web MD, Wikipedia and the like, patients
have readily available sources to review should they choose to research their condition.  A typical patient might present to the doctor stating the following:

Patient: “I think I have sciatica”.  Or they may state they want blood work done to rule out diabetes and request an A1C blood test.

I believe it is good for humans to have an understanding of their own body.  But unless you went to medical school, or are an allied healthcare professional, the average person is out there without an owner’s manual.  In the past we have been forced to rely on the physician’s expertise.  Much like going to an auto mechanic, the average Joe is at their mercy due to a remedial understanding of auto mechanics.  Trust and credibility is important.  That being said, taking an interest in your body and its physiology is essential because unlike the ability to buy a new car, you only get one body to go around.  It is important to know if what is happening  within your body is the result of altered physiology or is actually a pathology.

A well versed, well read patient who has researched his or her condition ad nauseam on the internet, likely has the knowledge base on that condition similar to that of a second year medical student.   What they lack is the clinical experience gained from years of residency and clinical practice.  That being said, physicians must be able to empathize with their patients and communicate with them in a way the patient can understand what their condition is, what caused it, what the treatment options are, and the risks and benefits of those treatments.  With this information, the patient can make an educated and informed decision.  The role of the doctor must first be that of a teacher.  According to Merriam-Webster’s Dictionary, the definition of doctor is:

a  learned or authoritative teacher.

a person skilled or specializing in healing arts; especially: one (as a physician, dentist, or veterinarian) who holds an advanced degree and is licensed to practice.

A person who restores, repairs, or fine-tunes things.

A Note on Insurance and Managed Care

Remember, that in today’s hectic world of managed care, doctors are forced to see more patients, which often means less face to face time with the doctor.  Therefore, efficiency is vitally important to providing quality care.  And being able to verbalize quickly to the doctor what hurts, where it hurts and most importantly, what actions or activities cause pain will speed up the process of diagnosing the cause.  This will enable your doctor to implement an effective treatment.

First things first.

Your doctor must document your pain on what is known as a visual analogue scale (VAS) in which you rate the intensity of your pain from 0-10 (a 10 is pain that would have you in the emergency room for a knife wound, gun shot or an acute appendicitis).  But more importantly, he or she must
document  Activities of Daily Living (ADL’s) that you are or are NOT able to perform due to pain.  Unfortunately, the insurance company does not care how much pain you are having.  What they do care about are activities you can and cannot do because of your pain or functional limitation.  Therefore, it is important to convey that information to your doctor for proper documentation.  Insurance companies want to see a treatment plan from your physician.
This plan details what he or she is treating you for, the type of treatment, and the frequency of treatment.  Most importantly, they want to know what the goals of treatment are. By understanding what activities you cannot perform due to pain, you and your doctor can devise attainable and measurable treatment goals within an expected time frame.  An example may be for a runner having knee pain and cannot run more than 5 K due to pain, but is training for a marathon.  A great treatment goal for the first month of treatment would be to allow the patient to run distances of 5 K three times per week without knee pain.  Documenting goal setting like this in detail in the medical record helps medical offices fight claims denials from your insurance company on your coverage because it allows them to report on progress and show that the treatment is both medically necessary and effective.

Let’s Talk Pain

Pain is a primary perceptual experience.  That means only you can tell what type of pain you are having, where you feel it and what description of pain it is.  Therefore, be as specific and descriptive as possible when telling the doctor where you hurt.

When the doctor asks how bad is the pain from 0-10, he needs a number. This is mainly for insurance documentation. After a number is given, then you and your doctor can talk about the really important stuff, like exactly where it hurts, what movements or activities cause the pain. It is important to describe the pain, as different types of pain indicate different anatomical structures.  Sharp pain often indicates nerve pain or severe trauma, deep dull ache usually occurs with muscle tightness, chronic soft tissue injury, and some joint restriction.  Sharp pain with
movement can be due to joint inflammation, often due to  joint compression or misalignment.  Numbness or tingling indicates nerve
irritation or entrapment (the infamous pinched nerve).

When the doctor is palpating or moving you around to test what hurts, he may ask if a certain pressure or movement makes it better or worse.  It is important to answer quickly.  Pain that is worse will usually be evident immediately.  Answering quickly will result in the doctor ceasing the movement that is causing pain.  Remember that pain provocation is one way doctors use to locate what tissues are injured or involved.  The more specific you can be with reference to exact pain location and what activities aggravate it the better the doctor can determine the cause.
Remember, Pain is a primary perceptual experience.  Only you know where and exactly how you hurt.

First Thing First:  A Note on Dealing with Multiple Areas of Pain

Often times patients present to their doctor with more than one complaint.  While some complaints may be related, they may require additional evaluation or testing, involve more treatment or different treatment approach.  Therefore, it is critical to give your doctor a hierarchy of your problem list.  Determine what is causing you the most pain and disability.  What problem do you want to tackle first?  Often times after some treatment, the number one problem begins to respond and that will allow your doctor to focus on other problems on your list.
It is important to note that working simultaneously on two or more problems may decrease the efficiency and effectiveness of the treatment.  It’s like a surgeon trying to do two knee replacements at the same time, with only the allotted time reserved for one knee surgery.  What can happen is the treatment is rushed can and the results can be unsatisfactory.

Remember, first things first.  Chunk down your problem list.  It will pay off in the end.

By Dr Matt Fontaine, ART

A.  Summary of complete team approach

A comprehensive sports medicine approach should include  1.) A team coach for the sport   2.)  A strength coach and/or Athletic Trainer
3.) A medical doctor who specializes in sports medicine and    4.) A Chiropractor/ Physical Therapist who is a certified ART® provider.   5.)
Proper Nutrition Counseling.  Get the best care you can by incorporating all these people into your team of Human Performance specialists.

It is important to note that the human frame and human performance physiology is far too complex for any one healthcare professional to be able to thoroughly detect, address, and resolve all issues that need attention.

The Need for a Multi-Modal Approach

Dynamic Neuromuscular Stabilization/Postural Restoration

-The need for soft tissue work such as Active Release Techniques to release overactive muscles.

-The need for joint manipulation to reduce joint compression and correct misalignment to restore proper  joint mobility.

-The need for rehab to restore mobility and stability to the muscles and joints of the body in order to ensure optimal body movement patterns.

-The need for proper nutrition to ensure optimal physiology.

A Multi-Modal Approach

A. Manipulation and the Arthrokinetic Reflex

The most common question patients ask in clinic is “is my problem muscle related or joint related?”  Another common statement is “I think I have a pinched nerve”.  The simplest way to answer a very complex set of occurrences that surround muscle and joint pain syndromes is that most patients are dealing with a tri-factoral problem.   Barring acute trauma whereby fracture or dislocation is involved, it is important to give note that nerve involvement should take priority in a muscle and joint pain syndrome.  Let’s look at the nerve issue first.

Hilton’s Law states:

The principle that the nerve supplying a joint also supplies both the muscles that move the joint and the skin covering the articular insertion of those muscles.

Understanding the Arthrokinetic Reflex

Arthrokinetic reflex refers to the neurology of joints in which joint movement can  reflexively cause muscle activation or inhibition.^[1]

Arthrokinetic Reflex of the Knee

Leonard A. Cohen ¹ and Manfred L. Cohen ¹ From the Department of Physiology and Pharmacology, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania

The prefix “Arthro-” means joint and  ”kinetic” signifies motion, and a reflex in humans refers to an involuntary movement in response to a given stimulus. Thus, the arthrokinetic reflex refers to the involuntary response that happens when a joint is moved, namely that relevant muscles fire reflexively.

The joints have nerve receptors called mechanoreceptors.  These mechanoreceptors are responsible for  transmitting movement impulses from the joint to the brain for interpretation.  Depending on the stimulus or lack thereof, these  Type I and II articular mechanoreceptors inhibit or facilitate muscle tone.  The neurology and physiology behind the arthrokinetic reflex is a main reason why manipulation is so effective at
treating chronic lower back and neck pain and also why it helps to improve sports and human performance.
A simple way to think about this is that “jammed joints” result in weaker muscles and mobile joints = strong muscles. Joints that are closed or compressed shut down muscles. They have joint dysfunction, either a joint has been strained or is locked up and fixed from  it’s normal motion.   Therefore, you must clear the joint motion in order to fully reflexively turn the muscle back on.

B.  Soft Tissue/ Fascia Release

They have a muscle problem, either the muscle has been “strained” or torn, or repetitively overloaded and has tightened and developed scar tissue over time.

The following link is an article by Dr. William Brady, an ART physician.  In it he discusses the importance of releasing scar tissue.  Hypoxic Fibrous Adhesion Pathway .

C. Functional Corrective Rehab

The need to retrain proper movement patterns.  3000-5000 repetitions to reprogram a movement so it becomes involuntary.
Only then can we “SAFELY” progress to strength training with proper movement and ensure optimal human performance.

Read more in the article Proper Rehab Sequencing and the Janda Approach to Muscle and Joint Pain