On this episode of the #AskMikeReinold show we talk about how to diagnose patellofemoral pain. Two big areas we like to focus on are ruling other injuries out, and then sub-classifying the different types of patellofemoral pain. To view more episodes, subscribe, and ask your questions, go to mikereinold.com/askmikereinold.
#AskMikeReinold Episode 219: How Do You Diagnose Patellofemoral Pain?
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Mike Reinold: On this episode of the Ask Mike Reinold Show, we talk about classifying patellofemoral pain syndrome, so that way we can come up with the best treatment approach.
Dave Tilley: Marla from Massachusetts asked how do you identify and diagnose patellofemoral syndrome due to its vagueness and wide variety of cases, maybe causes. We’ll say causes. I think there were some typos in that. That on our end. All right. So Marla, so how do we diagnose patellofemoral pain syndrome? And do we even need to diagnose? What does that mean?
Dave Tilley: For this question, we’re going to give it to Lenny. Start off, Len. What are your thoughts?
Lenny Macrina: First off, if her name is Mahler, that’s great in Boston, right? Mahler.
Mike Reinold: Mala.
Lenny Macrina: Mahler.
Mike Reinold: Yeah. Marla. It’s probably Maria. Marla, Maria, I apologize. I apologize if we typed your name wrong, so sorry.
Lenny Macrina: Anyway. Yeah. This is… I think Scott Dye, doctor out in San Francisco calls it the black hole of orthopedics, right? The patellofemoral joint and patellofemoral pain. It is just this wastebasket term of a gazillion different things that could go wrong. And then you go to the doctor’s office, you get some knee pain and you leave with a diagnosis of basically knee pain. That’s what they told you you have, but they put this fancy term, patellofemoral pain syndrome, on the prescription. So you just go to physical therapy, and then it’s up to us to figure out what’s going on because you weren’t a surgical candidate at that time.
Lenny Macrina: For me, when I get somebody like that, it’s going to be figure out why this has happened, right? You can pinpoint potentially the structures, if that even matters. Sometimes it may, because you may miss a meniscus tear or something like that, or patella tendon pain. But to me it’s why is this happening? And to me it’s often a volume thing, right? Did they increase something dramatically in their life? Meaning did they try to train for a marathon? We see that a ton. Did they start a new workout program? Did they go on a hike and they’re not used to going on a hike? You’re looking for something random where there’s a lot of up and down hill, up and down terrain, or something like that.
Lenny Macrina: Those are the big things. I want to know, what have you done recently that has changed in your life? And then after that, I want to figure out potentially what structures are involved, right? In my head, my differential diagnosis is going to be all over the place. I’m going to start looking at… Because it’s general knee pain. There’s no specific area. So I’m going to look at the tela tendon, I’m going to look at fat pads, I’m going to look at plica, I’m going to look at meniscus. I’m going to look at IT band, I’m going to look at quad tendon, I’m going to look at a superior plica versus medial plica. I’m going to look at back. Hello.
Lenny Macrina: I’m going to look at a bunch of different structures, try to pinpoint. I know palpation people are going to say is lacking, but I feel like on some of these structures, I get a pretty good response from people if I can pinpoint the structures. And that’ll allow me to hone in on what I think is going on. And then obviously I’m looking at strength, I’m looking at how they move, so I use our performance system and see how they move and see if I can correlate that to their symptoms.
Lenny Macrina: If they are increasing their squat or a new workout program, can I somehow hone in on, Oh wow, you got a lot of knee valgus going on on one side. Maybe that’s why you have an issue. Try to load them and see if their squat changes in a loaded position versus unloaded. So, so many different things, long winded answer. That’s my approach. And then I’m going to address some of those impairments and maybe their volume issues and try to figure out a way to decrease the volume on the joint and increase their strength in their hips, quads, et cetera.
Mike Reinold: I’m going to throw this at you. Does diagnosis matter?
Lenny Macrina: The diagnosis of patellofemoral pain? Not that diagnosis, but if I can figure out if it’s a meniscus tear, then maybe. I get to keep that in the back of my head, because maybe it was missed. Maybe you just saw your primary care doctor. And they were like, yeah, you have knee pain, you get patellofemoral pain syndrome. So I would say potentially.
Lenny Macrina: But like labor versus rotating cuff in the shoulder, we’re going to try non op rehab. Us as physical therapists are going to treat the impairments, right? And not necessarily the pathology. And so we’re going to go after motion, strength, function, decrease volume on the joint and then build you back up again like we would do with any other joint. You know what I mean?
Mike Reinold: That makes sense.
Dave Tilley: Sub classification matters but not diagnosis. That’s just the one thing I would say.
Mike Reinold: Len brings up a good point, and it wasn’t the first thing that came to my mind. You diagnose other things out versus diagnosing patellofemoral pain in, right? Patellofemoral pain’s a junk term. It could be for anything, but I like how Lenny makes it a point to diagnose things out, like, Hey, let’s make sure we didn’t miss a meniscus. Or, well you just had this evaluation the other day, a PCL tear probably that had patellofemoral pain for a year with an undiagnosed PCL tear.
Mike Reinold: It’s about ruling other things out, which I think is really cool. And then Dave, you want to touch on that? Because I think that’s good. That’s like the sub classification, because man, patellofemoral pain means a lot of different things. If you have a compressive syndrome versus patellar tendonitis, wow. You’re going to completely treat that differently. Right?
Dave Tilley: Yeah, absolutely. And I think, again, this is something I’ve learned from you, Mike, when you put your PDF out and other stuff was thinking about not so much of what exactly is the reason they have pain, but trying to put them into a category of maybe why they have pain, right? This is kind of comes from like the low back world that they were talking about, instability versus sciatic type stuff or whatever, but they’re doing the same thing, which is helpful because you can treat them based on movement. Is this someone who has, like you said, more of a compressive etiology who is very stiff quads, they have a very stiff nature in general, they’re not very lax. And maybe they’re having some issues with the entire patella is getting pushed into the trochlea and that’s the reason that they’re getting uncomfort.
Dave Tilley: Versus the opposite end of the spectrum, which is something we see a lot, which is more of the excessive lateral movement, which is causing some instability or some subluxation because they’re very shallow in their trochlea and they have a lot of excessive motion. They’re very lax. Both could have the exact same type of pain. It kind of hurts around here. I don’t really know what causes it. I didn’t fall, nothing happened. But completely different types of treatment, right? One versus the other. And I think that’s where people should be thinking is more about okay, what are the factors like Lenny said that are contributing here? How can we cluster this into something for a treatment based algorithm, not so much.
Dave Tilley: And I think really overlooked a lot is what I see as different types of growth play and different types of knee pain that all hurt. You can have inferior pole for [inaudible 00:07:24] versus a tibial tubercle versus more of a superior patella. And you might treat those things very differently, but it matters huge about what exercises you choose is for deeper ranges of motion and stuff like that. So don’t think it’s only the adult PFJ. These things are very much in the youth sports as well.
Mike Reinold: Do you think those docs all sat around arguing?
Dave Tilley: Oh my God, the worst.
Mike Reinold: Whose name was going to be on that diagnosis?
Dave Tilley: Yes. No, I did it. No, I looked at the x-ray. No, it was mine.
Mike Reinold: I bet you Johansson was the worst. He was like, no way. If my name’s not on this, I’m going to be [crosstalk 00:07:57].
Dave Tilley: No, was like, I demand to be first.
Mike Reinold: Yeah, right? I’m number one. Johansson-
Dave Tilley: I’m the first author on this paper. I wrote the abstract.
Mike Reinold: You’re last, Johansson. You barely contributed, Johansson. All right. What are we talking about? All right. Think about it this way. I can make it like a huge, very obvious smack in your face. Inferior pole patellar tendonitis versus an osteochondral defect in your patellofemoral joint versus lateral instability of your patella. My Lord, those are three different things, right? Can I say “My Lord” on there? I shouldn’t have said that. My gosh, my golly.
Lenny Macrina: Jeepers.
Mike Reinold: Those are three completely different things, right? That will change a little bit of that. I love it. Lenny jumps in and says, “Let’s make sure not only are we looking at patellofemoral and looking for stuff, but we rule out some other things. That’s amazing, because sometimes other things cause patellofemoral pain too. I love that.
Mike Reinold: Then Dave is a big fan of sub classifying. I think that’s great. I have a ton of stuff on this on my website. I wrote about this a bunch back in the days and expanded a little bit, but the other big resource for this, and I would say this is pretty much still in play believe it or not. I think we’ve learned more since then, but back in 1998, I know that seems crazy. What’s a new grad PT? What year are they born do you think right now? If you’re graduating college right now, what year were you born?
Mike Scaduto: Something like ’96 if you graduated PT school.
Lenny Macrina: Yeah. Around there.
Mike Reinold: That’s awesome. Anyway, yeah. This came out before you were born, but big article by Kevin Wilk, George Davies, Bob Mangine and Terry Malone. Those are like four of the godfathers of sports physical therapy. These guys, back in 1998, this was mind blowing, their thought process that they came out with this. But in JOSPT they had a really landmark article, Patellofemoral disorders, a classification system and clinical guidelines for non-operative rehabilitation. Kevin definitely wrote that title. That’s a big title. But what they did was they tried to say let’s find out the differences. Right? And they had a few. They had patella compression syndrome, they had instability, biomechanical things meaning is it just coming because of proximal and distal, right? Direct trauma, right? If I bang my knee into my desk, which I do weekly, right? And then I come in with patellofemoral pain, that’s a lot different than that athlete that pivoted and sublux their patella laterally, right?
Mike Reinold: The sub classifications I think really help, so you should check out that article and check out my website, just type in for patellofemoral and I think it’s in the main sidebar. I have so much stuff on these things. Look, I think we nailed the question right there just from Lenny and Dave’s perspectives right there from that. It’s important that you try to do your best to give the right treatments, right? You have to make sure you’re ruling out some other things and then you have to try to subclassify it as best you can. And I think that is a good approach.
Mike Reinold: Once you have that, then it all makes sense. If you’re just getting a diagnosis of patellofemoral pain syndrome, and you’re looking at it and the person just says pain, and you’re not trying to differentiate between the types of that, it seems very daunting. Right? It’s very confusing. Where do I start? Do I just do the same thing for everybody? And that doesn’t seem to make sense.
Lenny Macrina: Plus, trust me, when people come to you with that diagnosis, I think they really appreciate if you can somehow explain what it means and maybe some structures that could be involved. People want to know what’s going on with their bodies, not just we’re going to do these exercises because. They want to know what could be causing their pain and how to avoid it in the future. So if it is a fat pad thing, which I think I see a lot, more than people think, then I think they want to know that and appreciate the explanation of what that structure is, how it contributes, and how they can prevent it in the future. So I think it’s helpful.
Mike Reinold: Yeah. No, I agree. Awesome. Great question as always from Marla, I think. Really appreciate it. If you have a question like that, head to MikeReinold.com, click on the podcast link and fill out the form. And in the meantime, do us a big favor, head to iTunes, head to Spotify, which is an awesome place for podcasts right now, by the way. If you’re not trying to listen to podcasts on Spotify yet, you should check it out. They’re doing a really good job. And rate and review us and we’ll see you on the next episode.
Mike Reinold: Ooh, Mike, you almost missed that one.