Patellofemoral bracing, exercise effective for patients with patellar pain
Round table participants discuss the benefits of bracing in improving hip flexion strength and iliotibial band and iliopsoas flexibility.
Patellofemoral pain is one of the most common disorders affecting the knee. The level of pain patients experience intensifies by ascending and descending stairs, as well as participating in athletic activities.
Nonoperative treatment will significantly improve the level of perceived knee stability and decrease the level of pain experienced in the majority of patients. An exercise program and patellofemoral (PF) bracing have been associated with improved clinical outcomes.
Our panel of experts discusses their experiences.
Clarence L. Shields Jr., MD
Clarence L. Shields Jr., MD: What are the key factors in the rehabilitation of the patient with patellofemoral pain (PFP)?
Stephen J. Nicholas, MD: In the patient with PFP and no associated patellar instability, we feel that hip strength and flexibility are the key factors in successful rehabilitation. Weakness and tightness in the proximal link is too often overlooked in this patient population. An added advantage of this approach is that by de-emphasizing quadriceps exercises, the potential for further aggravating symptoms in rehabilitation is minimized.
The treatment consists of open and closed kinetic chain strength and flexibility exercises for the hip. The hip flexors, abductors, adductors and extensors are progressively strengthened, initially in nonweight-bearing positions, then in weight-bearing positions. By focusing on the maintenance of a stable pelvis while introducing active hip motions, we believe proprioceptive awareness will also be enhanced. If indicated, we will prescribe stretching as per Ober and Thomas tests, along with self-performed ITB and hip flexor stretching.
All patients are given a home exercise program that they perform once daily. The home program parallels the exercises given in the clinic, and each patient is deemed ready to commence a new exercise at home when he/she is able to correctly carry out the movement in the clinic with minimal verbal prompts. As muscle strength and motor control improves, patients progress to complex coordinated motor patterns involving functional activities.
We have had excellent results with this treatment approach. Improvements in hip flexion strength, combined with increased iliotibial band and iliopsoas flexibility, provide excellent results in patients with PFP syndrome.
Shields: How common is PFP among military recruits?
Craig R. Bottoni, MD: Patellofemoral problems are commonly encountered in young military recruits. The most common result of the sudden and often dramatic increased physical activity required in military basic training is overuse injury. Stress fractures, tendonitis and PFP-related pain predominates. The requirement of military recruits to run and march long distances precludes those with PFP-related disability from successfully completing these activities. Servicemen and women who cannot complete the obligatory training are released from active duty to return to the ranks of civilians.
Once servicemen and women make it through the rigors of basic training, the challenges often just begin. For those who choose infantry assignments, the requirements to run and march regularly only increase.
Patellofemoral disability can also restrict a soldier’s ability to complete the regular training required in these types of units. Patellofemoral tracking and pain can also be initiated following trauma, such as a direct blow or fall upon the knee cap(s). The patellofemoral pain resulting from this type of injury can often preclude a soldier’s return to the rigorous activities demanded of infantry soldiers.
Although patellar tracking orthoses and neoprene sleeves with patellar cutouts are often among the first line of treatment options, the high demands of these professionals often limit those with any disability from continuing in this line of work. These soldiers are required to function at a tremendously high level, and the consequences of not being able to complete the mission is potentially disastrous.
Shields: How do patellofemoral braces affect patellar alignment?
John P. Fulkerson, MD: My experience in the last few years is limited to the Trupull braces [DJ Orthopedics], which I helped design, so my comments should be reviewed in this context.
We have taken radiographs before and after Trupull PF bracing and can obtain good reduction of a subluxated patella into the femoral sulcus radiographically. Patients with mild-to-moderate subluxation function better with Trupull PF brace support. I imagine this is true with some other PF braces as well.
The Trupull works well in controlling medial patella subluxation, which tends to be a more subtle drift of the patella medially, most commonly as a complication of surgery. In such patients, a gentle “nudge” of the patella laterally can provide proper entry of the patella into the sulcus in early flexion, thereby avoiding the sudden, functional slide of the patella laterally in early flexion, which can be so disabling in the medial subluxation patient.
Response to PF bracing is helpful in determining the need for realignment surgery. When the degree of instability is so severe that bracing fails to work, surgery becomes more attractive when a patient is functionally disabled.
Shields: Do patellar braces affect quadriceps function?
Patrick Cawley, DSc, OPA, RT: Current brace designs probably do not have any adverse effect on quadriceps function. Conversely, in those patients who get relief of pain with these devices, the use of a brace probably also reduces quadriceps inhibition resulting from this pain.
While there are few prospective investigations of the efficacy of patellofemoral bracing, all of the findings seem to suggest that these braces can significantly reduce symptoms, particularly pain. In particular, the kinematic MRI studies done by Chris Powers at the University of Southern California suggest that, despite their limited effect on patellar kinematics, these braces may actually increase quadriceps utilization and the tolerance of joint reaction forces, thereby increasing function.
In a study for a master’s thesis at the University of Florida on healthy subjects, Haskin said quadriceps activity actually increased when a patellar brace was used. He also suggested that this indicates potential benefits for use of these devices in rehabilitation of PFP.
Shields: When do you use patellar bracing?
Bottoni: At Tripler Army Medical Center, I use a combination of patellar bracing (Genutrain P3) and quadriceps strengthening for chronic patellar instability. In an acute traumatic patellar dislocation, we offer active duty servicemen and women the option of acute surgical repair of the medial patellofemoral ligament.
Nicholas: Patellar bracing may be used in those patients with either PFP syndrome or patellar instability, in which a formal physical therapy program has provided some but not complete relief of symptoms, particularly with activity. Patellar bracing serves as an adjunct to therapy and may alleviate pain in patients with anterior knee pain or with a history of patellar dislocation/instability, especially with any of the following predisposing factors: femoral anteversion, genu valgum, patellofemoral dysplasia, patella alta, pes planus, generalized hyperlaxity, or a high quadriceps angle.
Shields: How should patellar braces be fitted?
Cawley: The fitting of the braces is actually quite straightforward. Most passive brace designs employ a buttress to resist either lateral or medial displacement of the patella. Correct positioning of this buttress is essential for optimal function.
There are also several “dynamic” patellar brace designs employing elastic strapping, tape or mechanical mechanisms to resist displacement of the patella. Placement of these devices is more critical for optimum function, and surgeons should follow manufacturer instructions to the letter. Obviously, a properly sized brace will optimize function. In patients with poor tissue compliance, a fit that accommodates special needs, such as distal circulation, is important.
It is important to point out that patellar braces should serve only as an adjunct to a comprehensive rehabilitation regimen that focuses on flexibility (ie, the IT band, hamstrings, quadriceps, gastroc-soleus and lateral retinaculum), strength (the quadriceps, particularly the VMO), weight loss if indicated, and activity modulation or alteration.
Another adjunct that may be very valuable is the use of foot orthotics, particularly in pronated individuals. It is probably best to coordinate with a physical therapist in the development of a tailored regimen for each patient.
Another issue is brace dependence. In the absence of sufficient information, many patients can become dependent on the brace for pain relief and, ultimately, the conservative approach fails. While clinical evidence of efficacy is sparse, the research that is available indicates that patellar bracing does provide symptomatic relief in most patients.
Shields: What is your experience with patellar taping vs. bracing in athletes?
Fulkerson: We have had good results with taping in short-term physical therapy, but have found that a properly fitted PF brace is more comfortable and adjustable in most athletes for long-term ease of management. Taping is tough on the skin of many athletes over time, but can be very helpful as a supplement to bracing for competition.
For day-to-day use and easy adjustability, I recommend PF bracing in athletes and leave the questions of supplemental taping to our therapists and trainers.
Shields: Can bracing be helpful in the patient with chondromalacia?
Cawley: Based on our available knowledge, the answer to this question is probably yes. Most treatment protocols list the use of a patellar brace as an adjunct to conservative treatment. The limited available clinical evidence would also suggest that patella braces have substantial value in the reduction of symptoms and the facilitation of rehabilitation in these patients. Patellar bracing may offer substantial benefits in conservative treatment, particularly if the chondromalacia is the result of altered mechanics or abnormal patellar tracking.
One other issue that is rarely discussed is the psychological benefit many patients derive from the use of these braces. In many cases, these braces provide not only mechanical support but also the perception of support, which may be just as important.
I would reemphasize that the greatest benefit of these braces is as an adjunct method of pain relief, which facilitates the implementation of a comprehensive rehabilitation protocol.
Nicholas: Patellar bracing is useful in the early stages of physical therapy until muscle balance is restored, or for sporting/strenuous activities. However, in our practice, we usually discourage prolonged use of a patellar brace for daily activities, particularly if patellar instability exists. Patellar braces modify but do not eliminate the underlying causes of severe instability.
Shields: Have you used patellar bracing after surgery?
Fulkerson: The Trupull wrap is very effective after lateral release surgery and is lighter than the traditional compressive dressing. I do not have experience with other PF braces for this purpose.
A light dressing, followed by a Trupull wrap, is optimal following arthroscopic lateral release, as long as the surgeon has obtained meticulous homeostasis with the tourniquet deflated. No brace or dressing will prevent a swollen knee if homeostasis is suboptimal.
Nicholas: In my practice, the use of patellar bracing is limited postoperatively to proximal patellar realignment procedures, either medial imbrication or medial PF ligament repairs. The use of a patellar brace allows for decreased patellar motion in the early postoperative period and protects the repair or reconstruction. We do not use a patellar brace when a distal patellar realignment is performed or after a lateral retinacular release.
Bottoni: I have not regularly seen lateral patellar subluxation following ACL reconstruction; however, I would treat them with quadriceps rehabilitation and, if necessary, a lateral patella tracking brace like Genutrain P3.
Cawley: Patellar tracking problems that develop during physical therapy after ACL or even TKA are related to muscle imbalance. The tracking can be managed with either taping or bracing.
Dr. Fulkerson is a paid consultant to DJ Orthopedics.
For more information:
- Christou EA. Patellar taping increases vastus medialis oblique activity in the presence of patellofemoral pain. J Electro and Kines. 14(4):495-504.
- Lun VM, et al. Effectiveness of patellar bracing for treatment of patellofemoral pain syndrome. Clin J Sport Med. 15(4):235-240.
- Powers CM, et al. The effect of bracing on patellofemoral joint stress during free and fast walking. Amer J Sport Med. 32(1):224-231.
- Shellock FG. Effect of a patella-stabilizing brace of lateral subluxation of the patella: assessment using kinematic MRI. Am J Knee Surg. 13(3):137-143.