Indian Journal of Pain

ORIGINAL ARTICLE
Year
: 2013  |  Volume : 27  |  Issue : 2  |  Page : 75--79

Response of therapeutic exercise and patellar taping on patella position and pain control in the Patellofemoral pain syndrome


Mohammad Hassan Manzer1, Kalpana Zutshi2, Pratip Mandal3,  
1 Department of Physical and Rehabilitation Medicine, Postgraduate Institute of Medical Education and Research, Sector-12, Chandigarh, India
2 Allied Health Sciences, Hamdard University, New Delhi, India
3 Department of Orthopedics, Moolchand Hospital, New Delhi, India

Correspondence Address:
Mohammad Hassan Manzer
Department of Physical and Rehabilitation Medicine, Postgraduate Institute of Medical Education and Research, Sector-12, Chandigarh - 160 012
India

Abstract

Objective: To evaluate the effect of multiple applications of patellar taping over a longer period of time, alone and along with the application of therapeutic exercise on patella position and pain control in Patellofemoral Pain Syndrome (PFPS). Study Design: A different subject pretest-post test, experimental group design. Materials and Methods: Twenty-one subjects participated in the study. The subjects were randomly assigned to one of the three groups: Patellar taping combined with Close Kinetic Chain (CKC) exercise, Patellar taping only, and CKC exercise only (n = 7 in each group). Taping was applied and exercise was performed on a daily basis for three weeks. The measures were obtained on the Visual Analog Scale (VAS) for pain and lateral patellar displacement for patella position. Results: The paired t-test was used for within-group comparison of pre-test and post test measurement and Analysis of Variance (ANOVA) was used for between-group comparisons of the three groups. The result of the study showed that the group receiving patellar taping and CKC exercise had better pain relief (p < .05) than the patellar taping only and CKC exercise only groups. There were no significant differences in terms of patella position in any of the group (p > .05). Conclusion: The combination of daily patella taping along with CKC exercise program for three weeks has been seen to be more effective than only patella taping and only the CKC exercise program, in reducing pain in patients with PFPS. Patella taping alone or in conjunction with CKC exercises is not able to bring any significant change in the patella position in patients with PFPS.



How to cite this article:
Manzer MH, Zutshi K, Mandal P. Response of therapeutic exercise and patellar taping on patella position and pain control in the Patellofemoral pain syndrome.Indian J Pain 2013;27:75-79


How to cite this URL:
Manzer MH, Zutshi K, Mandal P. Response of therapeutic exercise and patellar taping on patella position and pain control in the Patellofemoral pain syndrome. Indian J Pain [serial online] 2013 [cited 2019 Nov 22 ];27:75-79
Available from: http://www.indianjpain.org/text.asp?2013/27/2/75/119337


Full Text

 Introduction



Patellofemoral pain (PFP) is a common condition seen in orthopedic and sports medicine practice with an incidence rate among the general population being as high as 40%. [1] PFPS is a common overuse injury in runners, accounting for nearly 20% of all running related injuries. [2] It is the second most common musculoskeletal complaint presenting to a physical therapist. [3] A laterally positioned patella is a factor frequently cited as contributing to this pathology, because of its potential to overload the lateral articular surfaces of the patellofemoral joint during repetitive movement. [4] Radiological (MRI scan) [5] and clinical measures [6] have shown that in patellofemoral pain, there can be a significant laterally positioned patella. To restore functional efficacy of the patellofemoral joint, maintaining the patellar alignment in the trochlear groove of the femur is necessary. Patellar taping is readily used by the physiotherapist in the treatment of PFPS, [7] but a doubt still exists regarding the mechanism of its action. At present, patellar taping is being extensively used to improve patellar tracking within the femoral groove, [8] as well as stretching of the lateral knee soft tissues making use of the creep phenomenon, [9],[10] allowing the patient to engage in pain-free physical therapy exercise, emphasizing recruitment and strengthening of the vastus medialis oblique (VMO), which has been suggested as a dynamic medial stabilizer and whose insufficiency may increase the lateral pull of the patella. [8],[11] The length of soft tissue can be increased with sustained stretching and the magnitude of increased displacement is dependent on the duration of the applied stretch. [9],[10] The pain-relieving effect of patellar taping can be explained on the basis of temporarily unloading inflamed and sensitive innervated peripatellar tissues.

Objective: To evaluate the effect of multiple applications of patellar taping over a longer period of time, alone and along with the application of therapeutic exercise, on the patella position and pain control in PFPS.

Methods: A total of 21 subjects were selected, 11 male and 10 female subjects. The subjects were randomly divided into three experimental groups (seven subjects in each group).

Method of assigning subjects: The subjects were randomly divided into three experimental groups mentioned herewith:

Group A - Therapeutic exercise only.Group B - Therapeutic exercise + patellar taping.Group C - Patellar taping only.

Study Design: A different subject pretest - post test experimental group design was selected for testing the hypothesis, where a baseline reading was taken prior to the intervention and a final measurement was taken after completion of three weeks. These readings were then compared to find out the effect on independent variables. The outcome measures or dependent variables selected for this study were pain and patella position. These variables were measured using the VAS scale and lateral patellar displacement on a skyline view x-ray.

Outcome Measures: The baseline (pre-intervention) measurement for patellofemoral pain intensity and patella position were taken before commencement of the study. The post intervention measurements were taken three weeks after completion of the study.

Measurement of pain intensity: Pain intensity was assessed using a horizontal visual analog scale. The subjects were asked to mark along the line to denote the level of pain. The distance from mark 0 was calculated in centimeters and recorded. The readings were taken at the baseline (before the treatment) and marked as V0 and at the completion of treatment were marked as V1.

Measurement of patella position: Radiological assessment of the patella was done to quantify the position of the patella in relationship to the bony landmarks of the femoral trochlea. The axial view was taken with the subject in the supine position on the x-ray table, with the knee in 30 degrees of flexion.

The lateral patellar displacement quantifies the position of the medial edge of the patella in the frontal plane relative to the medial femoral condyle in millimeters. Positive lateral patellar displacement values indicate a lateral position of the patella, and negative values indicate a medial position of the patella.

Procedure of application of patellar taping: The knee is cleaned, shaved, and prepared with an adhesive spray. Patellar taping is done with the knee in extension. The 5 cm Therafix Underwrap is first applied directly onto the skin. The 3.8 cm Physiomed tape is the taping material used. The tape is started at the mid lateral border of the patella. It is brought across the face of the patella and secured to the medial border of medial hamstring tendons, while the patella is pulled in a medial direction [Figure 1]. The tape should be removed at night before going to sleep. The tape must be removed slowly and carefully to prevent skin irritation. Apply skin moisturizer overnight. The continuous taping treatment will be applied for three weeks on a daily basis.{Figure 1}

Therapeutic exercise regime: Closed kinetic chain (CKC) terminal knee extension exercises – Starting position is the hip, externally rotated 30 to 45 degrees so that the medial malleolus is in line with the greater trochanter of the femur. The subject will be asked to stand on the lower limb to be exercised and hold on to a stable surface using their hand, while the non-exercise lower limb will be at 90 degrees hip and knee flexion. The subject will be then ordered to flex the extended knee 15 to 20 degrees and hold this position for three to four seconds, then bring to full extension and remain in this position for a three-to-four second rest [Figure 2]. This should be performed 20 times, twice daily. The number of exercises will be increased by five every two days, so that by the end of program (day 21), the subject will be performing 70 semi-squats twice a day.{Figure 2}

Data analysis: Statistical analysis was done using the SPSS 15.0 software. The paired t-test was used for within-group comparison of the pre-test and post test measurement of pain level and lateral displacement of the patella. ANOVA was used for between-group comparison of three groups, to study the changes in pain level and lateral patellar displacement. A statistically significant difference was defined as p less than 0.05 (α = 5%).

Pain Intensity: In Group A, there is a statistically significant difference between V0 and V1 (p < 0.05). The mean improvement in Group A is 1.86. In Group B, there is a statistically significant difference between V0 and V1 (p < 0.05). The mean improvement in Group B is 5.06 ± 0.42. In Group C, there is a statistically significant difference between V0 and V1 (p < 0.05). The mean improvement in Group C is 3.07 ± 0.03. The between-group comparison indicates that there is a statistically significant difference between Group A and Group B (p = .000). There is a statistically significant difference between Group A and Group C (p = .05). Also there is a statistically significant difference between Group B and Group C (p = .005).

Patella Position: In Group A, there is no statistically significant difference between D0 and D1 (p > 0.05). In Group B, there is no statistically significant difference between D0 and D1 (p > 0.05). In Group C, there is no statistically significant difference between D0 and D1 (p > 0.05). Comparison of change in the patellar position between groups indicates no significant difference between any of the groups.

 Discussion



Patellar taping is readily used by physiotherapists in the treatment of PFPS. This study was designed to investigate the effectiveness of patellar taping in multiple applications over longer periods of time. [12] McConnell originally described patellar taping as a part of the treatment program for PFPS and theorized that this technique could alter the patellar position, enhance contraction of the VMO muscle, and hence, decrease pain. [8] The result of this study reveals that three weeks of patellar taping in combination with the CKC exercises significantly reduces the subject's pain (p = .000), although there is no significant improvement in terms of patella position (p = .172). The group receiving only patellar taping also has shown significant reduction in the pain level (p = .000) but there is no significant improvement in terms of patella position (p = .356). The group receiving only CKC exercise has shown reduction in pain level (p = .000), but no significant improvement in terms of patella position (p = .356). Only the group receiving patellar taping in combination with CKC exercises and patellar taping has shown a significant reduction in pain level when compared to the 'only CKC exercise' group. There is no significant improvement in terms of patellar alignment in any of the three groups.

The significant reduction in pain in this study with patellar taping lies in agreement with many previous studies. [13] Bockrath et al., hypothesize that reduction in pain may be related to sensory input from the tape. [14] Evangelos proposed that patellar taping, especially in a medial glide, may contribute positively to the rehabilitation, possibly due to an enhanced support of the medial ligaments of the patellofemoral joint and/or by modulating pain via cutaneous stimulation. Mostamand J et al., found that the reduction of pain following application of patellar tape in subjects with PFPS was associated with a decrease in the net knee moment and consequently a reduction in the Patellofemoral Joint Reaction Force (PFJRF). They concluded that the mechanism of pain reduction by the application of tape could be attributed to the reduction in PFJRF.

Dye has suggested that the pain relieving effect of McConell taping is achieved by temporarily unloading inflamed and sensitive innervated peripatellar tissues rather than permanently changing any malalignment parameter. The inflamed peripatellar tissue has not of course instantly healed, but the restoration of homeostasis is possible if they are protected from further perturbing events for a sufficient length of time. [15] There is no significant improvement in the patellar alignment in this study, either in the taping group or taping combined with the CKC exercise group. This study refutes the proposition that the pain relieving effect of patellar taping occurs by altering the patellar alignment. The result of this study along with the patella position in a majority of subjects contradicts that malalignment is the source of pain in PFPS. The result of this study lies in its agreement with many of the previous studies conducted. [14],[15] Bockrath et al., have found no significant differences in patellofemoral congruency angles or patellar rotation angles before and after tape application. [14] Worrell et al., believe that patellofemoral pain has multiple etiological factors and that patellar alignment is just one factor that can cause patellofemoral pain. [16] Gigante et al., conclude that although patellar taping may well be effective in controlling the anterior knee pain, it does not do so by medializing the patella. [17] Wilson et al., conclude that the use of patellar taping for patients with PFPS for the purpose of pain relief is supported, but for the purpose of mechanically realigning the patella is questioned.

Clinical relevance: The result of this study suggests that taping should be included as a compulsory part of the conservative treatment for PFPS along with the CKC exercises. Every patient in the study has got significant pain relief with the tape application and no side effect has been observed during the course of treatment.

Limitations of the study: Static radiographs were taken in this study because of the lack of resources. Knowledge of the effect of taping during dynamic movement is needed to support or refute our findings in the static condition. There was also no follow up of the subjects in this study.

Future research: Future research is needed to observe the patellar alignment after patellar taping in multiple applications over a longer period of time by means of dynamic radiography and the mechanism of pain relief with McConnell taping must be addressed. A follow up of the cases can be included in the future research.

 Conclusion



The combination of daily patellar taping along with CKC exercise program, for three weeks, has been shown to be more effective than only patellar taping and only the CKC exercise program, in reducing pain in patients with PFPS. Patellar taping alone or even in conjunction with CKC exercises when applied for three weeks is not able to bring any significant change in the patella position.

 Acknowledgment



The author acknowledges the immense help received from the scholars whose articles are cited and included in the reference of this manuscript. The authors are also grateful to the authors /editors/publishers of all those articles, journals, and books from where the literature for this article has been reviewed and discussed.

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