Patellofemoral Update - Claire Robertson

Summary

Highlights

• Claire Robertson shared insights from her 18-year experience in managing patellofemoral pain 🤓🦵.
• VMO and quadriceps function are important factors in patellofemoral pain management 💡💪.
• Understanding patient-specific load management can prevent long-term issues 🏋️‍♂️🗝️.
• Patient concerns like crepitus need careful explanation to avoid unnecessary anxiety 🎧📚.
• Psychological aspects significantly impact recovery and outcomes, emphasizing proper communication 💬❤️.
• Practical exams and flexible management plans aid effective recovery in diverse patients 🗂️🔄.
• Emphasizing importance of biomechanics, lifestyle factors, and personalized interventions for rehabilitation 📏🏃‍♂️.
• Managing patellofemoral pain is about integrating physical, social, and emotional elements 🌍🩹.
• The presentation bridged academic research with practical therapy insights, enriching ongoing professional development 📚💼.

Key Takeaways

• Understand the distinct characteristics of patellofemoral pain in adolescents versus adults 🧒🏻📊.
• Subjective examination is key in tailoring management strategies for patellofemoral pain 🕵️‍♂️👟.
• Managing exercise load is crucial, especially during peak growth phases in adolescents 🚴📅.
• VMO and quadriceps muscle function are vital in patellofemoral pain management 🤸‍♂️💪.
• Taping can serve as an effective adjunct therapy to reduce pain and improve function 🎗️😊.
• The psychological aspect, including patient education, is critical in effective pain management 🧠🗣️.
• Exercise modifications should be made based on pain levels and functional capability 💪🔄.
• Crepitus is a common concern but not necessarily a sign of severe pathology 🎵❗.
• Effective communication with patients and caregivers is key to successful management outcomes 🗣️👨‍👩‍👧.

Overview

Chapters

• 00:00 - 00:30: Introduction and Housekeeping The chapter begins with a warm welcome to the participants of the webinar on patella moral update with CLA Robertson, organized by Steroplast in collaboration with BASR. The speaker expresses gratitude to the attendees for joining and highlights the diversity of professions and geographical locations represented in the online event. Before diving into the core content, participants are encouraged to introduce themselves in the chat to foster a sense of community and interaction. Housekeeping notes are addressed to ensure a smooth session.
• 01:00 - 03:00: Overview of BASR and Webinar Structure The chapter titled 'Overview of BASR and Webinar Structure' covers the logistics and structure of a webinar session. It lasts approximately 40 minutes and includes a Q&A segment at the end. Participants can post questions in the Q&A box during the session, which can be upvoted by others to prioritize responses. The most popular questions will be addressed first. Additionally, attendees receive a certificate and access to a recording of the session.
• 02:00 - 04:30: Steroplast Introduction and Injury Rehab Network The chapter introduces Steroplast and the Injury Rehab Network. It begins with an aim to deliver information within two weeks. The narrator provides an overview of BASRaT, its role as a professional association, and its function as a regulator for sports rehabilitators and trainers. The organization is noted for providing regular CPD webinars for its associate members and registrants. Apologies are extended to those familiar with these details from previous webinars.
• 05:00 - 05:30: Claire Robertson's Introduction The chapter provides information for healthcare professionals interested in becoming associate members, mentioning a small monthly fee and listing the benefits of membership. The speaker thanks Claire Robertson for her participation in the event and hands over to Andrew for an introduction to Steroplast, emphasizing appreciation for attendee participation in the webinar.
• 05:30 - 11:30: Subject Examination and Clinical Reasoning This chapter involves a presentation on subject examination and clinical reasoning. The speaker introduces themselves as Andrew Watson, leading the sports division at Stero plus Healthcare, known as Ster Sport. The focus of their work is on medical consumables and equipment for sports injuries, among other areas. The session involves sharing expertise and insights in this field.
• 30:00 - 39:00: VMO and Quads Discussion The chapter discusses the collaborations and partnerships with various teams, governing bodies, organizations, and practitioners related to products, items, and equipment, emphasizing pride in these collaborations. Additionally, the chapter introduces the 'injury rehab network,' which has been operational for five years, originating as a local forum in the northwest of England.
• 24:00 - 30:00: Adolescent Patellofemoral Pain The chapter 'Adolescent Patellofemoral Pain' discusses the transition of hosting events from face-to-face to online during the lockdown period, facilitated by an organization named Azat. These events feature world-class expert guest speakers sharing knowledge and expertise on various topics. All past events and presentations are available on both the chapter's website and the Bazat website.
• 28:00 - 33:00: Crepitus in Patellofemoral Pain The chapter titled 'Crepitus in Patellofemoral Pain' discusses the events planned around this topic. It mentions links to previous events, such as post-event blogs, recordings, and presentations. The chapter highlights the success and engagement of the event series throughout the year. Additionally, it expresses gratitude to people who participated and to the experts who shared their time. It notes that there is one more event scheduled for December featuring Dr. Doug Hammond, who will be discussing facial injuries in sport.
• 42:00 - 44:00: Taping and Bracing The chapter titled 'Taping and Bracing' primarily focuses on upcoming events related to sports therapy, particularly in football and rugby. It mentions confirmation from an expert named Doug who will contribute to these events. There is an emphasis on planning events for 2025 and drafting a good schedule. The speaker encourages collaborative efforts, inviting suggestions and ideas, and also extends an invitation to meet at the upcoming Therapy Expo at the end of the month.
• 48:00 - 57:00: Q&A Session The chapter titled 'Q&A Session' features a session where the host thanks CLA for helping with the presentation. CLA is introduced as an experienced practitioner with significant insight into the subjects of the session. The host expresses anticipation for an engaging presentation that everyone will enjoy.

Patellofemoral Update - Claire Robertson Transcription

• 00:00 - 00:30 so as I say good evening everybody and welcome and a big thank you for joining us on today's webinar which is on patella moral update with CLA Robertson today's webinar is brought to you by steroplast in partnership with basr before we start as always we'll run through some housekeeping rules firstly please introduce yourselves in the chat box it's great for everyone to see all the different professions that have joined us today and where everyone is based in the world today's webinar will
• 00:30 - 01:00 last around 40 minutes and then we'll have time for any question anyone has for CLA please pop any questions you have in the Q&A box throughout the presentation and we'll try to get to them all and if you see questions that other people have asked and you'd also like answered you can upvote these by pressing the thumbs up which lets us know the most popular questions and which ones to get to first if we do have a big influx and then finally everyone does get a certificate for today's webinar and the recording for this evening's presentation
• 01:00 - 01:30 and we'll aim to get these out within two weeks so for those of you who who are new to these webinars and don't know much about basat I'll just give a brief overview on who we are and what we do apologies to those who join these webinars regularly and already know about basr so who are Bas rats they are the professional association and regulator for sports rehabilitators and trainers we provide regular CPD webinars for our associate members and registrants so if
• 01:30 - 02:00 you're in a healthcare profession and you're interested in being an associate member please feel free to get in touch it's 5S a month and the benefits are listed on the screen thank you again for joining today I hope everyone enjoys the webinar and a big thank you to CLA for giving up her time this evening as always I'll just hand over to Andrew to do a steroplast introduction thanks very much Sophie um evening everyone thanks very much for for joining us as always great see so
• 02:00 - 02:30 many people registered and joining this presentation live thanks very much CLA for kindly giving up your time and sharing your uh your expertise this evening too um so just a quick introduction as Sophie said for those of you that join these often apologies for repeating what we always say I'm Andrew Watson I lead our work in sport at stero plus Healthcare and our Sports division is a ster sport so we're essentially medical consumables and equipment for Sports in inuries and whole range of different
• 02:30 - 03:00 products and items and Equipment as you can see there um we're really proud to work with a whole range of different teams govering bodies and organizations and and practitioners so please do keep us in mind and let us know if if there's we can help with Sophie if you could just move on please so the injury rehab network uh is now into its fifth year I think and it started as a local forum um man in the northwest of England where
• 03:00 - 03:30 we're based and um it was initially face to face during lockdown um we were pleased to be able to work with azat to take the events online um we've continued to have some fantastic worldclass expert guest speakers who kindly sort share their knowledge and expertise around a whole range of different topics and um on our website you can find all of the um and on the bazat website as well you can find all of the
• 03:30 - 04:00 um links to previous events post event blogs um recordings presentations and things like this so we're nearing the end of our um sort of program of events for for this year and um again you know we've had some great engagement so thanks very much for all the people who who kind get involved and obviously thanks to all the the experts who kind share share their time and we've got one more event um coming up in December um with Dr Doug Hammond who'll be um talking about faci injuries in sport um
• 04:00 - 04:30 he's got expertise in football and and rugby so details of that will be um will be coming out soon literally just today had confirmation from Doug that he can he can do that um so that' be great um we've got events in 2025 we've got a good sort of schedule in draft being planned but please do let us know if you've got any ideas or suggestions and um if you're at therapy Expo um please do come over and say hello um at the end of the month as well and but again
• 04:30 - 05:00 thanks so much CLA for for for helping out this evening and providing a presentation um cla's another sort of a very experienced practitioner um and um with a a huge insight into me and Jes particularly so I'm sure it's going to be a fascinating presentation and hope everyone enjoys it thanks Claire
• 05:00 - 05:30 hi everybody well thanks for giving up some time on your evening to listen to me talking about um pel femal pain um just to sort of contextualize I guess where I'm coming from here I'm a physiotherapist I have worked solely in telal pain for the last 18 years it's a fair number of patelli um I'm researcher in the field
• 05:30 - 06:00 and I run clella which is an education um business for guess what pelli as well so totally immers telal pain and I'll be drawing on all of that in my talk today so I'm hoping we will be able to understand the differences here between adult and adult Adolescent and adult pfp I'm going to give you some useful tips for your subjective examination so your history taking so rather than just thinking yep yeah sounding like telal
• 06:00 - 06:30 pain I'm going to give you some really top tips that will help you then break down this huge umbrella term and I'm going to give you an update on quads VMO and talk about that and then I'm just going to describe when and how of taping and bracing with these patients there all sorts of things I could have talked about but I felt that they hopefully are things that you can just immediately um put into practice and are really clinically useful for you
• 06:30 - 07:00 okay so there we go so what are the key areas of emerging literature at the moment in this field I would say that they are adolescent telepal pain um they are um CPUs uh which is quite a bit of my own research I'll talk about VMO quads the whole debate around that and again I'm going to draw on some my own published work there and um taping and bracing so they're the areas that sort of coming through through some interesting
• 07:00 - 07:30 things so let's start with um the subject examination though so so I'm going to give you my top tips here so I can't draw on loads of literature because there isn't loads of literature on this but I think it's just very very useful what I'm going to talk through now so remember patella femal pain is an umbrella term so we might have an adolescent who's hypermobile who's sedentary and we might have an ultramarathon runner in their 50s they've both got Patel femoral pain but
• 07:30 - 08:00 this clearly is a very different phenomena so we need to have some ways of almost subdividing this in our mind and we're going to do this through clinical reasoning so I've been looking at this for years and years and really this section is around Pat recognition from thousands of patients I've seen so I ask every patient do you have pain when you're sat still with your knee bent some patients will say no that's fine others will say absolutely a dread of train journey of flight Cinema
• 08:00 - 08:30 terrible so if this is their number one problem you've got to ask yourself well when they're SS there's no issue around muscle firing there's no issue around muscle strength shock attenuation very little around foot biomechanics and yet there a lot of the things that we spend a lot of time looking at in this field so I would say with a patient who has Cinema sign you then should be thinking right I must look at that quads flexibility as
• 08:30 - 09:00 part of my physical assessments so these key questions can help formulate in your mind must should and could list I must in my physical examination look in this case at flexibility and so I'll also ask them what happens when you then cross your leg and if they say that's even worse well what's happened there we've all we've done is tensioned up the lateral structures through that hip adduction so it implicates then those and that should
• 09:00 - 09:30 whiz up our priority list to assess the muscle length of that whole ITB complex with its proximal muscular Origins there's another little group here if they mention the cinema sign and then when they take the trousers off you see that they've got an aditus fat pad it might be that the fat pad is stopping the patella going cord out towards the foot during the flexion and the patella is therefore sitting up high on a lot of
• 09:30 - 10:00 load so every patient gets asked that question okay I ask every patient do you have pain on the flat walking on the flat most patients will say no that's not that's not too bad if they say yes this is terrible you'll much more likely to be looking at a fat pad problem so let's stick with the pels though so if they say no Flat's fine I then say what about uphill and downhill and there's a subgroup who say my pain is worse walking uphill now most patella
• 10:00 - 10:30 fromal patients dislike downhill because there's more load on the patella so what's going on here with these few that don't like uphill it's probably about 15 20% and I've looked and looked at this and I think it's two things one is if you have a tight Cal it will drive you to either excessively pronate or lift your heel early in your gate cycle that leads to knee flexion which overloads your patella so if they've got a tight
• 10:30 - 11:00 calve and they're walking uphill that's going to make that even harder so walking uphill must assess the calve the other thing is gluto strength if they are weak and they have gluto deficit whether it's in the frontal plane or the horizontal plane that's going to be exaggerated potentially by the extra demand of going uphill so up your priority list whizzes physical assessment of their Glu function so patients are most think I'm
• 11:00 - 11:30 probably obsessed about shoes because I'm always asking about it but I think it's quite revealing so I always ask are you worse in a higher heel and if they are then is it a thin heel or a wedge because sometimes they might say oh no I'm fine in a wedge it's just a thin heel so that then implicates stability the priority list whiz is stability balance F control some patients are worse than things like ug boots flipflops things with no hind foot
• 11:30 - 12:00 support So then I'm thinking okay I really need to make sure I prioritize assessing the foot here and hind foot some patients might say it's all about cushioning I'm much better in um something with a thick rubbery soil so then that's probably more like to be our older telal patients perhaps with a bit of degenerate change so then they're going to be best with a shoe or an insert that's helping with that shock absorbency so don't just say is it you know is it worse in different shoes just
• 12:00 - 12:30 dig and find out which ones because that again will direct you every patient gets asked about the stairs which way is worse they will all be able to tell you and you've got to admit there's something completely different in the loading going up the stairs to down the stairs we've got a little bit of literature here so in a nutshell pain worse going uphill is implicating Glu deficit much more than foot position
• 12:30 - 13:00 we've also with the stair Ascent got patients that put their foot on the stair and will flip their knee back into hyperextension so always try and watch as well watch them do it are they dropping into a functional vowers are they snapping their knee back what are they doing pain that's worth coming down the stairs is more lik to be a joint surface problem can be a muscle length problem as well it's right at the end of the action and also if they have a what I call a drop if they're loading and as
• 13:00 - 13:30 they descend they drop through a certain range I will say to them does that always happen and if they say yes I'll say does it always happen at that same angle and they will know they have a sense of it and if it does I'm going to just have in my mind they may have an osteochondral defect they may have a conal flap I'd have a lower uh threshold for getting a bit of Imaging on that patient okay a funny one now skinny
• 13:30 - 14:00 jeans or tight clothing often the patients really dislike this and in fact I had a patient today in clinic came in in shorts and said what's what do you like the feeling of trousers on your knee and he said absolutely hate it that's why I'm in shorts all day every day so then I might say is it the tightness and is it bad when you bend your knee which is a compressive vector or is it actually just a feeling of the fabric and it makes skin craw makes
• 14:00 - 14:30 often gives a feeling like burning and then which is like my patient today and then it tells me we've got a neuropathic involvement and I might need to involve my um consultant pain specialist colleagues so funny question but a revealing one and then as always we want to know about how the pain the pattern of the pain so if it's on off I do the stairs it hurts I stop stairs it's gone very mechanical if it's only afterwards later in the day
• 14:30 - 15:00 and particularly in the next day we've got an inflammatory situation going on and I'd want to know bit why why is this neeon Flames if it's not degenerate what's going on something else being missed some of the patients actually say they feel better as they exercise then I'd be thinking actually maybe this is p tendonopathy the tendon warms up performs a bit better watch if they're really tight or tense as they warm up their muscle length and appear is better their tone is better and then I ask all
• 15:00 - 15:30 my patients are you is your sleep affected either getting to sleep or waking you with this problem because sleep disturbance is now there's lot of emerging literature around the relevance of this in terms of actually getting the problem in the first place and also tipping into chronic long-term pain and it's interesting because a lot of the patients with the telal pain have been exercised so their body is used to exercise and
• 15:30 - 16:00 then they stop because of their knee problem and then they can't sleep well because they're not going to the gym anymore so if I saw that kind of pattern emerging I'd be like right priority let's get you in the gym even if they've got huge irritable KN okay let's just do an upper body and core program let's try and reestablish some pattern of exercise again and then look we can't not talk about BMI um the the litat is very
• 16:00 - 16:30 compelling and there's more and more literature coming through again on this but this is a particularly useful paper very straight for paper 686 knees so big paper women in the 50s and 60s all they did was they waved them and MRI them and then they did the same at two and a half years there was no intervention and then they put them into three categories stable weight weight gain or weight loss now look at some of these figures the odds for progression of patella from bone Marion so that's you know what we
• 16:30 - 17:00 often think is associated with pain in in ostearthritis and telal carage defects increased by 62% in the weight gain versus stable weight group massive difference sinovitis again so the covian getting inflamed producing an infusion of from very very Interlink with pain progression of sinovitis was increased by more than two and a half times in the weight gain group compared to the stable
• 17:00 - 17:30 weight group and then curiously these changes in the knee seem to be much more pronounced in the P telal joint so there is something about the effects of increased BMI that really hammers the pelo joints so as much as it's a difficult conversation to have I often say to patients look it's a double win if you manage to lose some weight you will have not only less weight on your knee but you will have less inflammation as well so something we've all got to be mindful
• 17:30 - 18:00 of okay I want to talk about a funny symptom now CPUs quite dear my heart because I've done a lot of research on this but right back 2010 I wrote an editorial basically just saying I think patients get hung up about this I think patients dislike it it's often as much if not more of a problem than the pain itself I was quite encouraged by the conversations that came on the back of that with clinicians saying yeah that's my experience too so that spurred me on
• 18:00 - 18:30 and I applied for a research Grant which I was awarded to do qualitative thematic analysis of patients with normal MRIs but pain and CPUs and I publish this work and here are some of my other quotes means my knee is wearing away it means I have arthritis it's my body's way of telling me to slow down that's not great in a nonarthritic population and recent literature on this as well so
• 18:30 - 19:00 we can see that um on the left here um we've got some quantitative works so they took again the same group as me but sort of did more measurements and they found there was no relationship between crepitus and function physical activity level or Worse pain in the last month or pain climbing the stairs then Pan's group looked more in the OA group and found that kryptus was not associated with higher rools of having a tkr and then Whitman's work here more
• 19:00 - 19:30 recently they did an interesting study where they've got people to um go up down the stairs and then they basically categorized them into pain on the stairs or pain and crepus on the stairs and they found that the group with the pain and crepitus moved with less knee flexion so in other words they were Avo moving in an altered way to avoid the crepitus as opposed to just the pain so what do we do about it so uh we need
• 19:30 - 20:00 to educate we need to educate that it's a normal phenomena but it doesn't correlate with the severity of pathology and we need to encourage them to think the pain is the abnormality but the creis May remain and I do that conversation early doors otherwise it seems like you get to the end and you're happy the Pain's gone and the patient is still a bit not sure about is my knee is still noisy it's it's quite hard to convince them at that point so I ask all the patients if they
• 20:00 - 20:30 mention CPUs I just say what do you think it means and if they say I don't know I don't give it any thought fine move on but if they say well tells me does my KNE is wearing a may I need to be careful it's like my mom who just had a new rep placement whoa we need to do some education otherwise you might get them nice and strong you might get rid of their pain but I bet you they'll still avoid the stairs if their knee is making its noise and that's their belief system so I couldn't really put it better than
• 20:30 - 21:00 this quote from and davier Silver's paper so they say when educating patients about crepitus clinicians should clarify that the sounds they hear have no relationship with pain function or physical activity patients should be educated that they do not need to reduce their level of physical activity or stop physiotherapy because of the need cus and here's the thing I asked every patient in my study if a physio gave you exercise and when you were doing it your
• 21:00 - 21:30 knee made its noise what would you do do you know what happened every single patient said oh I wouldn't do the exercise we do need to be mindful of these fearful um catastrophic mindsets around preators okay so I want to introduce you now to my shopping bag or shopping basket risk factors and Allergy so because the telal pain often creeps on and the patient doesn't know why it's very Harden to make sense of it there's
• 21:30 - 22:00 been recent work by auth called Barber looking at this and the patients were reported huge desire to make sense of the pain so this is the analogy I give them I say look in your shopping basket you may have a bit of um hypermobility or a floppy foot or you know patch of weakness or tightness but when these start coming in and maybe you added more stairs because you moved into a townhouse and maybe you've got a new baby so you're kneeling on the floor
• 22:00 - 22:30 more and maybe actually because of your new baby you're not doing as much exercise and you decondition when we start piling up this shopping basket it can overflow and we need to look at what we can get out of there so look at jet to here she's an elite marathon runner she's won the London Marathon if you can see in these pictures but she's got a huge functional vus so theoretically she should have the T or pain you might argue but she doesn't but being a bit silly about it if she
• 22:30 - 23:00 said I'm fed up with running I'll sit down and eat chocolate for a month and she put on 10 kilos deconditioned and then when messing my running I'm going to go straight back at it maybe she would tip into pel pain a little bit faster than the next person because it's quite a lot sitting in that shopping basket so I think of it as intrinsic extrinsic and psychosocial so intrinsic muscle length muscle strength mind control hypermobility any in them extrinsic Footwear um training
• 23:00 - 23:30 load running surface um stair volume things like that psychosocial and we just been talking about it with sort of the the psychological belief systems crepitus um maybe it's actually that they're on a they're a kid on a sports scholarship and they're worried about dropping out and not being able to perform well so what is in that basket that's how I approach my patients and I have a little shopping basket on my desk at work and I
• 23:30 - 24:00 actually talk about this with the patients and you know what they really get it it really resonates and then they're more likely to leave and do what I ask them to do so now I want to move into the realm of thinking about um adolescence um so what we're going to think about here is the differences between adolescent telal pain and adults and Michael rorth is a d um researcher and he's just dominated this space to be
• 24:00 - 24:30 honest and he's found that um if you look at adolesence with the telepal pain they're either doing basically an absolute ton of sport or very little there's very few kids with the telepal pain who in moderate amounts of exercise so that is a big clue where this is going to go so what am I asking the kids any rest days what happens in school holidays they just stop and do nothing and then go straight back in is the foot correct for the surface they're playing
• 24:30 - 25:00 on if they've got Orthotics do they bother to wear them do they bother to move through between shoes I'm always Keen to know what are the Child's favorite activities and if they're feeling a sense of pressure where is that coming from as a coach parents scholarship themselves and there's also recent literature showing quite a lot of adolescent girls in particular will run excessively because of fear of weight gain so what is driving the volume of exercise so mro did an intervention with
• 25:00 - 25:30 this so he had 151 kids which is good number for a pediatric study age 10 to 14 and the intervention was load Management in essence so zero to four weeks less loow just give the Patell a bit of a rest just functional movement five to X we eight weeks then graded exposure to incremental loading and then building it back up to sport at 9 to 12 weeks and they had some fantastic results at
• 25:30 - 26:00 12 weeks 86% reported a successful outcome and clinically relevant improvements interestingly as well their strength output improved I suspect because they were less koinophobic they were more confident and in total 68% were back playing sport after three months and then up to 81% at 12 months which is fantastic and completely box the trend comparing to the literature so say Ben Smith's work where he's looked at the
• 26:00 - 26:30 natural progression of non-intervention that basically these kids will still have their pain at a year so this is something that I do and this was um a patient of mine recently I have this little grid and I get them to fill it in and it's people often think it's the elites but it's not as very often actually just the soort what I call the sporty kids who are wanted in all the different teams and they also they love and they want to play outside school and maybe they have an active
• 26:30 - 27:00 family life as well and this was um a kid I had recently so they were doing keep fit for school twice a week then they were doing school netball they were doing outside school netball they were doing um uh running clubs um they were doing a part run with Dad on the weekend and a tennis lesson on Sunday and all in all you can see the volume really stacking up so is strength an issue well
• 27:00 - 27:30 interestingly actually if you look at kids they won't demonstrate um compared to AG match subjects an isometric um hip and knee weakness okay so in my opinion the changes particularly around are around poor Mo control particularly at times of growth so I'll get the parents to CH growth so if you look at graphs of prevalence of um things like telal pain in kids an absolute Peak at those peak
• 27:30 - 28:00 times of growth for both boys and girls and then have they got the control to do what they're trying to do you know if they're a net bullet are they going to land with decent control or are they going to land and just flop down into a functional vus so we've mentioned KOB there so we mustn't underestimate it and the sorse has clearly demonstrated that cognitive and physical treatments will give a better result physical alone in other words we've got to explain to our
• 28:00 - 28:30 patients as well and actually if you get um young if you adolescents and also slightly young adults to jump down off a off a box their poor Landing technique is more likely to be associated with kinesophobia fear than weakness so what are we going to do about it so measure it as it starts always good to measure things we've got benchmarks the tamper scale of kinesophobia is readily available online
• 28:30 - 29:00 very easy to use and then what movements they fearful of is it stair descent is it kneeling crouching jumping Landing what are they particularly fearful of can we educate and do some graded exposure to it and this paper was absolutely fabulous so this paper was cus who's a physio teaming up with um a psych a psychologist and they used a psychological model called The Common
• 29:00 - 29:30 Sense model of self-regulation so anything with common sense in the name is good for me and they this model has five cornerstones which are here and I'm going to go through these with you so in P telal World identity would be here's a knee model here's the kneecap sits in this groove just a basic understanding of the anatomy cause Okay so you've started upping the volume of running you've been doing okay you're not having any rest days we've up the load here
• 29:30 - 30:00 lots and lots of load on this patella timelines so how long is it likely to last okay so is it like a week a month is it forever and consequences how could it impact on their life should they let it impact on their life should they stop doing everything should they ignore it and in line with that controllability have they got any sort of say in it can they control it at all so what they did
• 30:00 - 30:30 in this paper was they made an8 minute video um in language that would appeal to adolescent around these things for patellam RO pay and what they found and they sorry they scored them immediately before the video immediately after and two weeks and look at these scores so one viewing of an 8 minute video gave sign significantly lower immediately after but also interesting it two weeks
• 30:30 - 31:00 pain catastrophizing fear avoidance kinesophobia reduction and tyy pain score and vas and there's no physical treatment that's going to do that in eight minutes so I got very excited by this and I emailed the authors and said oh i' you know love this paper could I have a look at your video and they just said no which really irked me so I thought that's fine I can just take these things here on the left hand side and make sure in my education
• 31:00 - 31:30 I'm covering these things off because it might be blindingly obvious to me but why should a patient understand why their knee is suddenly hurting for no reason when they haven't had a big ski wipe out or a fall okay so take your time to educate because if you lower the fear you lower the catastrophizing they're more likely to engage with treatment and move better okay so talking about engagement treat treatment now let's talk about VMO
• 31:30 - 32:00 and quads the mass of literature around this and how ultimately it should impact on clinical practice so even 10 uh what 2005 20 years ago people still arguing is there a VMO is it does it even exist so is it just vast as medialis or does does are the Tuit VB medialis longest and oblas and these two papers came out virtually on top of each other one saying yes they're separate and one's
• 32:00 - 32:30 saying no now Ono's paper said no it does it is separate because there's a different nerve distribution there's a fascial plane between them there's a difference in fiber orientation and they originate of different muscles so okay but these papers were really small cadaveric papers so I set about with an anatomist at St George's where I worked at the time to put this argument bed and this was this paper Angelina here we
• 32:30 - 33:00 ultrasounded 18 KN so much bigger volume and we showed absolutely categorically the VMO is a separate entity however it doesn't mean it can be selectively recruited I'm not saying that we were just observing that the muscle the VMO was a separate entity and we'll talk in a moment as to why that's relevant so is it even a medial stabilizer or
• 33:00 - 33:30 some of the early studies are poor we have to kind of disregard them leaves paper showed that only at 0% activity was the contact pressure altered so we've got to say does that 0% does that ever even happen well it does actually in two scenarios and again if we go back to our history taking we can look to pick these up so pain I don't mean only is just a bit on the stairs I mean on May the 4th I whacked my knee and it
• 33:30 - 34:00 really really hurt I'm talking about a moment of absolute identifiable onset of pain often perhaps as well these other postop patients so what do we know about a sudden onset of pain Paul Hodges actually injected the fat pad with saline to induce pain lovely and watched what happened to the VMO and showed as the pain came on the VMO started to delay and the more pain the more
• 34:00 - 34:30 delay also helps us understand a bit of the taping literature I think so if you tape a knee with no pain doesn't do anything to the VMO but if you tape a knee and decrease pain the VMO kicks in a bit better so what what are the messages here the messages are look out for that very obvious identifiable moment of onset of pain and then think okay that's likely to really disrupt the VMO then we're going to say so I'm not going to do really painful exercises
• 34:30 - 35:00 that's just going to make things worse and I'm going to think about time a day use of pain relief to try and capture those moments where they're less painful there's another scenario here that creates the same thing and that's swelling right back in 84 Maria Stoke showed that 40 Ms is needed in the need to disrupt the vasis Lateralus and only 10 ms to disrupt the vasis medialis so a small amount of trace of diffusion will
• 35:00 - 35:30 affect your functioning of your Dynamic control of your patella so again these are patients with postt trauma postsurgery can identify a moment where their knee became swollen we can potentially here look at icing pre-exercise and lauro's paper here did exactly that they iced and then they exercised and showed that in patients with an affusion they got better quads recruitment better fmo recruitment so that that's got to be worth doing and
• 35:30 - 36:00 ultimately if it's not obvious why there is an infusion you need to be asking that is it actually there's a systemic autoimmune disease is there something that's been not being picked up a ruptured ATL a minuscal tear so ask why is there an infusion here but you might and other people have said well hang on hang on we've got delay VMO firing in healthy subjects um so is it actually elephant so I think van tigin's work helps here he's a
• 36:00 - 36:30 military physio he tracked people coming into the military with no pain and he looked at VMO delay and what he found is that people with VMO delay were actually the first ones to develop the telepal pain which is a huge problem in the military so if you think about my shopping basket if that's already in there and then you lay in running in Boots doing loads of squats running with a pack etc etc the ones with the VMO delay to start with in basket overflowed more quickly had a
• 36:30 - 37:00 problem more quickly so cing back now to the work that I've been involved with really for the last um over a decade now actually so we we set out just to describe the VMO as it said with ultrasound which we did but we found a very curious thing that was that the anatomy varied a lot across our cohort so when I say it vared I'm talking about two things first of all the fiber angles so the angle of the
• 37:00 - 37:30 VMO coming in onella relative to the femur some people it was up at 40° and other people it was right round at 70° some people also only had a third of their patella with a VMO attachment some people it was right down to sort of 90 um 98% right down the medial border of the patella so then we said well this is very interesting I wonder whether this depends how how active you are so we did
• 37:30 - 38:00 another study which is the one at the bottom here the bener field where we did a tegna score which is just a basic score of how active you are and sure enough if you're sedent you're more lik to have a vertical fiber and a small insertion and if you're really athletic you're likely to have a bigger fiber angle and bigger insertion so of course I got super excited at this point said well there's an obvious question we have to answer here and that's can we manipulate that this so we took sedentary people we put them
• 38:00 - 38:30 on a training program a basic PR training program that took them to overload alternate days and sure enough we found that the fibers increase in their um fiber diameter and hence their fiber angle we then I then wanted to know which type of exercise is better potentially and actually Clos chain as long as it was done um to fatigue same as open chain gave the same result we found once they got a bigger architecture the minimum to keep the
• 38:30 - 39:00 change was two exercises twice a week so that's quite good for those patients are quite low in motivation who you might just need something minimal to keep from there we use um EMS we found that closed chain with a stim was better bigger architecture change than just closed chain on its own and I'm just finishing I've just finished some work which we is impr press at the moment it's about to be published and that's um I've done with a female orthopedic surgeon looking
• 39:00 - 39:30 at this architecture in people that dislocate their patelli and what we found is that people that have had one dissocation have poor poor VMO architecture and it's even worse in recurrent dislocators now we're not saying chicken and egg you know we're saying we're not saying the directional causality here we're just saying as an observation but my own personal feeling is that actually it become becomes a secondary risk
• 39:30 - 40:00 factor for dislocation because they're fearful they weaken the fiber angle becomes more vertical and then of course they lose that Dynamic stability from their VMO so we'll be doing more work on that so VMO conclusions so it's still a bit inconclusive but we know we can't just generally talk about a weak VMO in isolation we can point to sudden onset of pain and or swelling relevant um and I think we need to
• 40:00 - 40:30 really move away from concept of fine firing from V Fus medialis obl and vastus lateralis to look at fiber angle and insertion and we'll be doing more work on this so how can you strengthen a very painful knee this is an issue isn't it so we need to certainly not do it every day look at alternate days aiming for light fatigue where possible time of the day I've talked about potentially after ice if they've got a really pain painful
• 40:30 - 41:00 pelop joint you go moving the joint around a lot so static positions and think about angles and what I mean by that is this graph and I particularly want to point out the green line on this graph which is the green line is basically what happens in closed chain so the P telal load goes up quite slowly and then when it reaches about 50° it really escalates so if you have someone with a really s telal joint don't get them doing deep squats and lunges I'd
• 41:00 - 41:30 rather get into 45 degrees with a heavy barbell than 90 degrees with no weight so we can also look at these graphs um with respect to open chain close chain which are different so actually if we just go back if you look at the blue and orange line that's your up open chain and see that real uptic load at between about 0 and 10° so I stay away from terminal extension with open chain so I might do leg extensions
• 41:30 - 42:00 from say 90 to 45 and I might strengthen up the rest of the range 0 to 45 with the leg press I'm aiming for muscular failure still really want to get those muscles tired but I can't afford to really wind the joints up make them sore and you'll lose the patient as well they they won't thank you for that so really think about your angles so if we had someone who is weaker maybe earlier on we might be doing some closed chain work like this we just in that terminal extension range
• 42:00 - 42:30 particularly if it tend to flick into hyp extension and if I want to bring in Synergy between quads and glutes I'll put the band around the feet here not around the ankle around the feet and if they can tolerate it bring them down to a semi Crouch KNE at about 45 degree crab walking side to side okay just to finish off really just want to talk briefly about tape what are we doing when we tape is there
• 42:30 - 43:00 any evidence what tape what technique there's a lot of unknowns here but what I can say is what we know that in some patients tape decreases pain well quite frankly we that in itself is good enough for me if you decrease pain they're going to do better exercise engage better and the patient's happy happy bunny but we also know if you just slap some tape on the knee with no Direction you'll get better kinematics some the effect is sensory
• 43:00 - 43:30 motor and we know that because if we put some just slap some tape on the knee the function sens motor cortex will be more active that has been shown okay so we don't always have to be directional and we may also get the same effect from tubber grip or Pon sleeve canesi tape the evidence base isn't great but it's often popular with patients and my view is if patient comes and they say I do this taping technique and it really helps me I'm not going to change that that's fine by me bracing this is a good brace to know
• 43:30 - 44:00 about this CU brace so it's a pull on sleeve but you'll note this extra bit that loops around the lateral Board of patella so the role of that is to medialize the patella and it's really good if someone's got a lateral patal bone marodin on their scan this paper by caligan took those exact patients and they scan them they put them in this brace and then 6 weeks later they scanned them again and they found a
• 44:00 - 44:30 really tight correlation with decreasing bone Marions and decreas in pain so if you have someone with a slim leg who um well essentially not a leg like that shapes a slim leg who is um up for trying this that you can have some fantastic results so Cube bra have have that one on your radar and finally if we're thinking about exercise for telepal pain what are we thinking about well let's just think quickly around this um Circle here and
• 44:30 - 45:00 this paper wasn't for Pella fromal pain specifically but I love this model and permission has been given by the authors for me to use this so we're going to think about the structure so have they got a shallow trol with a kneecap that moves around a lot and they need lots of stability so gender women with their wi of poweris G more likely to drop into functional valers fear we talked about chop phobia there maturation we talked about our kids and the difference and the more importance
• 45:00 - 45:30 of load Management in the kids motivation how do we motivate how do we get that buying education inflammation we talked about that is it paining actually the next day they got an infusion why is that there fatigue so are we getting them to muscle fatigue and if we're not achieving that do we need to change things up a bit self-efficacy so back to that video explanation education getting them on
• 45:30 - 46:00 board pain we've talked about sudden onset of pain we about trying to avoid a lot of pain in our exercises not mention injury history but particularly relevant for telepal pain is low back pain and ankle inuries because they often really cause a lot of Glu deficit so I ask all my patients about that those two then sport what is their thing what do they want to get back to and can if their badminton players say that they got really sore knees can we as part of their early
• 46:00 - 46:30 rehab getting shadowing badminton that tells them I've listened to you I'm being bespoke to you I've got an eye on the Bon I haven't forgotten about it so when we've considered all of those things then can they initiate can they activate in a way we want then can they integrate that so I don't just want big strong quads I want quads that will work synergistically and well with loots and the Cal then what's their need can I
• 46:30 - 47:00 optimize it for what they need to do they need to do jump Landing are they a skier are they running what is it that they need so that is not for reading right now but that's for long term for any of you real keenes out there that want to know some of the key references from today's talk and really my conclusions be sharp at your questioning use that subjective examination to really pull out some key stuff that you can then zoom in with your physical examination be aware of the differences
• 47:00 - 47:30 between Adolescent and adults the key is that loading with those kids you hear about pain and swelling as a big feature have that in your mind the disruption of the VMO quads and utilize tape and bracing as adjuncts never on their own adjuncts and be realistic about what you're doing and if you haven't had enough of Po after that um there's lots of resources case studies clinical
• 47:30 - 48:00 reasoning blogs all sorts on my website CL for tell also if you're really feeling Keen I do one day courses or if you're in a practice and you'd like to host um I go into practices for two or three hours sometimes and um teach yourself what whatever is helpful um and of course if you're stuck with the patient also feel free to email me via my website as well thank you thank you very much
• 48:00 - 48:30 thank you so much Claire um that presentation was fantastic really really really interesting um there's a few questions flooding in now um so I mean you covered many different aspects I know you said when we were chatting before you could have gone on about probably all of those things in a lot more detail and more um so no but many
• 48:30 - 49:00 areas covered really informative so thank you um so are you happy to take a few questions this evening yeah no problem fantastic um so um I'll go for a couple that have been upvoted um so this is a question from Megan um she says when you deload an adolescent would you advise them to stop sports for 3 to four weeks um or do you go based on a decrease in vas and if so
• 49:00 - 49:30 what level um so if I'm Del loading an adolescent I um it purely depends on what their normal load is like so that chart that I put up put up that that kid in particular I said look you mega fit you don't need to do keep fit just at the moment okay and you know I know you you know I know you like to run with your dad on the Saturday morning but you haven't got got a rest date let's bring that out okay and which is your least
• 49:30 - 50:00 favorite and she was like actually it's a bit cold it's winter I'm not too mad about the tennis on the Sunday and like okay maybe we could temporarily give that a miss so then we've got rid of one two three four sessions in the week okay but if she wasn't too irritable but if I have someone that's very irritable very very sore then I might say actually do you know what let we need to come away also depends what the sport is so if they're doing jump Landing you know or they're doing lot keep fi squats and lunges that's more problematical than
• 50:00 - 50:30 someone that might be doing a spinning class say no that's really useful thank you um thank you so another question um I think this is a really interesting one probably just more from your experience you probably answer this nearly every day um but when a patient asks um what exactly crepitus is how do you explain to them that's such a good question and I would and I cover that my course so in
• 50:30 - 51:00 a nutshell I say there's different things there's there's isolated pots which are bubbles of gas and you know like when people crack their Knuckles there is a sort of a clunk that can be the patella sort of clunking actually into a better position often but the one that tends to wind people up is the fine grating sound and this we can actually bizly look to the engineering world to help us s so in the engineering world there's a thing called slipstick which basically
• 51:00 - 51:30 is the sound that arises when fluid passes through an irregular surface so if we take that it's normal to have some fluffing up of your cartilage and it's normal T sinovial fluid the analogy of the patients is if I have a thick pile carpet and I say to that thick carpets like your nice thick cartilage reinforcement positivity and I and I put put some water on it and then I do that on the carpet that's the noise I'm going
• 51:30 - 52:00 to get and it's okay with it doesn't reflect damage harm yeah no fantastic because I think that's um a really difficult that's such an amazing analogy but such a difficult one to explain to patients sometimes like you say if it's not associated with pain necessarily and I think just following up on that we one thing that came out in my research is some of the patients felt people have been a bit flipping SP it kind of G oh don't worry about that and one patient got really
• 52:00 - 52:30 agitated she said I've told the GP I've told the or consultant I told the Physio and everyone says oh don't worry about that but we have to be careful that we take them see they know that they''re been taken and listen to and take them seriously and explain it otherwise um it just yeah it doesn't help the situation at all yeah absolutely and like you said about that positivity and especially if you're talking about um I mean all the things that you went through at the beginning in terms of walking on the flat stairs the cinema test then the
• 52:30 - 53:00 shopping basket I love that analogy that's fantastic um if you suddenly invest all that time in those things and then they tell you one of their main symptoms and then you're like oh no you know it gives that impression that you're only focused on you know certain things with that so that's a really interesting concept thank you so let me see if there's other ones um this is another question is there
• 53:00 - 53:30 some evidence about the prevalence oforal joint pain together with osgard Schlatter syndrome or Patell tendonopathy well I I think um have I seen a paper that's looked at that specifically no but if we look at the risk factors for them it's you know often um well certainly with Oscar schlatters it's you know excess load qus dominant load in those teenage years that's going to be
• 53:30 - 54:00 the same risk factor for the telal pain and in a way also with um with tendon tendonopathy is again often very interl with um load management and also we know like tight calf that's a risk factor for um telal pain tight quads load that's sort of a bit up and down you know breaks from doing things then straight back in it so actually I I think you often get this sort of overlapping because it's the same rist
• 54:00 - 54:30 same thing's in the shopping basket yeah no definitely thank you thank you um probably a bit more of a specific question um any top tips on glute strength testing yeah so um if you don't have the luxury of dynamometry then um I would do a static resisted um hip abduction inid line but here's the thing I would do it
• 54:30 - 55:00 for 10 seconds don't just do a quick fine because what all you often find is they're like oh that feels like good Force generation and then by like five eight and 10 seconds it's really flagging you think if you're flagging eight seconds what's it like at the end of a 10 kilometer run when it's you know had to work so hard to keep your power level so it flags up that sort of lack of tonic performance they thing often so I do yeah so I would do static resisted straight leg and then keep them inide
• 55:00 - 55:30 line I would then do static resisted external rotation in Shallow hip flexion so like about 20 degrees of hip flexion because that is posterior glue me and then I whiz the knees right up into deep hip flexion I do the static resisted external rotation again and then you are isolating it to glute Max because if you do it in the middle which most people normally do around about 45 5 degrees you've got an overlap of glute me and glute Max and you might just not pick up
• 55:30 - 56:00 that one of them actually is much better than the other one yeah that's really interesting I suppose it allows you to be more specific in the the strengthening exercises or rehab program or protocol that you provide for the patients as well if I find that there and often it's cyclists interesting because they're often very different in and out of the saddle and they know that so say we've got s a cyclist who knows in the saddle leaning forward you know into a lot of hip flexion they is more of a problem
• 56:00 - 56:30 and I find that glut Max is weak as an externa Rotator in that deep hip flexion and that is where I'm going to train them because that's where they need it both in terms of force generation and neuromuscular output so yeah I think it does it should drive the specificity yeah absolutely no thank you um let me just do one last one I'm just conscious of your time and everyone else's as well I know
• 56:30 - 57:00 absolutely um let's see and I suppose this links back to the question I think it's nice quite a nice one to finish off with any tips around um it says convincing here but chatting to adolescence and parents around around reducing the load yeah so what I say this is how I actually literally said say it I say if we just ignore this and plow on you
• 57:00 - 57:30 won't harm your KNE long term but if it you just ignore it and you just plow on with all this load the chances are it will get so sore it will force your hand and then you may not be able to do any of those sports for a while whereas if we just tweak it maybe you know you're a networ player you normally play center can you play wing attack just bring that load down a bit knock out those old bits you're not so keen on in the week if we really clever and we manage that and maybe manage it in your aggressive grow
• 57:30 - 58:00 SPS then you are in control of your KN situation otherwise it's going to be in control of you and that literally is almost word for word how I would say it yeah no fantastic and again I think it's really good advice because sometimes whether it's something that we don't see a lot or if we're bit more Junior in our position um it's hard to have them difficult conversations especially with children who are probably very motivated and parents who are equally as motivated for them as well um so no thank you
• 58:00 - 58:30 that's really interesting absolute pleasure I hope it was useful and you know if anyone wants to pick my brains more they can just yeah look just contact me through the website yeah fantastic well thank you so so much um like I say that presentation will be you know invaluable um to everyone that's listened to it this evening and everyone that listens to it on the recording as well um so I would encourage everyone to reach out obviously to CLA directly like
• 58:30 - 59:00 she say on the website um and um ask myself or Andrew and pop us an email if there are any questions about that as well if you've not managed to get the details from the the webinar um and thank you everyone for joining us this evening as well um it's great to have you all here I think we had about 250 people in tonight's webinar so nice and busy for a Thursday evening that's great oh well thank you thanks so much for the
• 59:00 - 59:30 opportunity um yeah just just thanks very much CLA thanks everyone for joining great job with the Q&A Sophie always um just to quickly summarize and I think cla's done a fantastic presentation you know lots of evidence I've seen all the comments coming in you know people are taking away some some really good U sort of um um ideas can take back into the practice which is which is brilliant so please do
• 59:30 - 60:00 um follow up and yeah look look up cla's website and yeah you know get involved in some more of the educational activity that that CLA is running if you're interested in um in taking this further but it's interesting because we often have presentations around you know a specific environment working with a specific group of athletes or patients whereas this was coming at um a topic from a different angle so looking at you know pemal pain but you know it's um children adults you know athletes so
• 60:00 - 60:30 it's it's in really interesting to get all of your insight into you know how you work with a particular injury but with you know such a diverse range of patients so yeah thanks very much really interesting and thanks everyone for for getting involved thank you once again no problem have a lovely evening everyone and we'll see you on the next webinar see you bye