chapter 12: Nonoperative Treatment
When home therapy fails, skilled physical therapy can be greatly helpful in patients with anterior knee pain, depending upon the specific diagnosis. The physical therapist can help implement the exercise program by controlling pain and introducing stretches and exercises that the patient can tolerate, thereby making progress without causing aggravation of the problem. Often, this takes considerable creativity on the part of the physical therapist.
Taping the patellofemoral joint can be particularly effective in the hands of a skilled physical therapist. A therapist's taping can provide proprioceptive feedback to the patient, thereby facilitating strengthening. Appropriate taping can also reduce pain to allow more effective exercise. Most patients can learn how to tape their own patella once the therapist has found the most appropriate taping configuration.
Although some patients are able to stretch effectively in a home program, many patients benefit from structured physical therapy to maximize stretching. The physical therapist may implement reflex inhibition techniques, modalities, heat, and other modalities to maximize the benefits of stretching.
Although isokinetic exercise is less important in the patient with patellofemoral pain generally, high‑speed exercise in a pain‑free range of motion concentrically may be helpful in selected patients. Also, isokinetic testing at higher speeds will help to objectify the patient's strength gain. This type of feedback is very important in many patients. Eccentric isokinetic exercise, when carefully monitored, may be particularly beneficial to the patient with patellar tendinitis and retinacular pain as opposed to true articular disease. When there is articular cartilage breakdown, particularly as a source of pain, the therapist should avoid isokinetic eccentric exercise in most cases. In fact, isokinetic exercise, at lower speeds in particular, can be dangerous in such patients and can cause more pain or trouble.
A knowledgeable physical therapist can evaluate the entire kinetic chain. By equalizing leg lengths, balancing foot posture, restoring normal gait, appropriate stretching and strengthening, and restoring normal posture and balance, patellofemoral joint function may be improved and, in most patients, pain will be reduced or eliminated (Fig. 12.10).
Structured aquatic therapy is generally forgiving and often helpful in the patient with resistant patellofemoral pain. In the water, these patients can exercise more effectively using fluid resistance. The water also provides compression around the joint to reduce swelling. Some patients can progress more rapidly into an aerobic exercise plan in a pool program.
The therapist can use creative techniques to help the patient. Training the patient to respond to household stimuli such as a doorbell or phone ringing, a dog barking, or visual cues in the home by contracting the quadriceps muscle (with particular emphasis on the VMO) can help a patient to develop patellar control.
In more severe cases, a transcutaneous nerve stimulator may be helpful for pain control. An electric muscle stimulator can also be helpful in initiating strength gain, but an active program of quadriceps and hamstring strengthening will be far more desirable in the majority of patients. Ultrasound and other modalities are useful, particularly for soft‑tissue mobilization and pain control, to facilitate exercise.
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