Our Patient
Our patient is a 33 year-old female runner who was in training for the New York City Marathon, only three weeks away. She presented with lateral parapatellar knee pain. She had been treated with four weeks of physical therapy exercises and stretching, without any satisfactory results.
The Challenge
With the marathon race just 3 weeks away, there was not enough time to improve the patient’s knee function with physical therapy. We needed to find a solution that would alleviate her knee pain and enhance its function in a short period of time.
Our Diagnostic Process
Physical Exam
During the physical exam, palpation elicited tenderness in the lateral right knee. We evaluated the orientation of the patella, observed quadriceps activation patterns, and conducted a single-leg squat test. Palpation of multiple centers of coordination and fusion in the affected limb indicated dysfunction of the lateral and anterolateral fascial lines.
Diagnostic Ultrasound Exam
An exam using high resolution ultrasound imaging revealed a lateral parapatellar recess effusion – accumulation of excess fluid in the lateral parapatellar recess, located on the outer side of the knee. Everything else appeared normal.
We determined her condition to be lateral patellar compression syndrome, a subset of lateral patellar pain syndrome.
Our Treatment Approach
Treatment for this condition would normally include strengthening of the hip extensors and the vastus medialis obliquus, but it was too close to the marathon to improve muscle strength and coordination with physical therapy.
Given our time constraints, we decided to treat the affected fascial tissues with extracorporeal shockwave therapy (ESWT) to eliminate densifications and restore fascial gliding, since ESWT renders faster results than manual fascial manipulation.
We also took a static mechanical correction approach using hard physiotherapy tape to decrease the lateral patellar tilt.
Results
After two sessions, the patient reported significant improvement in range of motion and decreased pain while walking, but she was reluctant to run. A followup ultrasound exam showed that the effusion had dramatically subsided, but after a trial 5-mile run, the effusion returned.
One day before the marathon, we did an additional session of ESWT using focused, defocused and radial waves, and the patient was able to finish the race without any significant discomfort.
Discussion
We believe that loss of fascial gliding is an integral component of patello femoral pain syndrome, especially in cases where physical therapy is not an option – in this case, just a very short time period before a race.
All previous approaches to PFPS have overlooked the important role of fascia in the ability of the quadriceps muscles to glide, and to balance tracking of the knee cap. We believe that muscle weakness in most cases of PFPS is not true muscle weakness, but rather the inability of muscles to transmit force properly through all of the quadriceps heads and IT band due to ineffective muscle gliding, leading to compression of the lateral knee.
Although we could not find any studies in the literature to support our theory, we did find one case study that had similar results. Our upcoming group study of athletes with PFPS will explore the use of dynamic ultrasound during running, prior to and after fascial manipulation, without any physical therapy.
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