|Ahead of print publication
Effect of McConnell patellofemoral pain syndrome protocol on pain and functional disability in tibiofemoral osteoarthritis: A pilot study
Simran A Sutar, Akhil Samson, Tushar J Palekar
Department of Kinesiotherapy and Movement Sciences, Dr. D. Y. Patil College of Physiotherapy, Pune, Maharashtra, India
|Date of Submission||03-Sep-2020|
|Date of Decision||20-Oct-2021|
|Date of Acceptance||24-Oct-2021|
Dr. DY Patil College of Physiotherapy, DY Patil Vidyapeeth, Sant Tukaram Nagar, Plot No BGP/190, Pimpri, Pune - 411 028, Maharashtra
Source of Support: None, Conflict of Interest: None
Introduction: Osteoarthritis (OA) being a common condition is one of the leading causes of musculoskeletal pain and functional disability. Purpose: This purpose of this study was to find the effect of McConnell patellofemoral pain syndrome (PFPS) protocol in participants with Grade 2 tibiofemoral OA. Settings and Design: This was an experimental pilot study and on participants above 40 years of age. Fifteen patients with Grade 2 tibiofemoral OA of knee were included. Subjects and Methods: The participants were screened on the basis of diagnosed case by orthopedician with the help of X-ray. Participants above 40 years of age were selected including both male and female. The changes in the subject's pain and functional disability were evaluated by the Visual Analog Scale (VAS) and The Western Ontario and McMaster Universities OA Index (WOMAC) scale. Statistical Analysis Used: Shapiro − Wilk test was used to check the normality of data and as it was found to be normally distributed, paired t-test used to analyze within group differences by comparing pre- and postreadings of WOMAC and VAS. Results: Participants with grade 2 tibiofemoral OA of knee had a significant decrease in pain and functional disability as seen in VAS scale, P value was 0.0005 and for WOMAC, P value was 0.0001. Conclusion: This study concludes that McConnell PFPS protocol had an upper hand in reducing functional disability and pain in Grade-2 tibiofemoral OA of knee.
Keywords: Grade 2 tibiofemoral osteoarthritis, the Western Ontario and Mcmaster universities osteoarthritis index and mcconnell patellofemoral pain syndrome, Visual Analog Scale
|How to cite this URL:|
Sutar SA, Samson A, Palekar TJ. Effect of McConnell patellofemoral pain syndrome protocol on pain and functional disability in tibiofemoral osteoarthritis: A pilot study. Med J DY Patil Vidyapeeth [Epub ahead of print] [cited 2022 Nov 30]. Available from: https://www.mjdrdypv.org/preprintarticle.asp?id=340564
| Introduction|| |
Osteoarthritis (OA) is defined as “slowly evolving articular disease, which appears to originate in the cartilage and affects the underlying bone and soft tissues.” Knee OA leads to loss of leg musculature strength which can be associated with increase in pain and accelerated progression of knee OA. To maintain and create a mechanical realignment of patella (one of the major risk factors for developing patellofemoral OA), rigid taping is extensively used. This technique was developed by Jenny McConnell to correct the patellofemoral kinematics which gets altered with any knee pathology. This technique is performed by following procedure such as glide, tilt, and/or rotation of patella such that the tape can correct the laterally shifted patella to the medial side by applying medial glide. An adhesive tape is applied across the anterior aspect of the patella, from lateral to medial side pulling the patella on the medial side of the knee. The patellar assessment by Jenny McConnell gives us an insight to understand how patellar malalignment can lead to tibiofemoral dysfunction. The specific exercise protocol recommended by her is underused. In OA knee there is definite muscular imbalance that is often seen. Knee OA can occur in either the patellofemoral joint (PFJ), tibiofemoral joint (TFJ) or both. Duncan et al. reported on the incidence, progression, and sequence of development of radiographic OA in the PFJ with the development of TFJ OA occurring over time. They anticipated that isolated symptomatic PFJ OA may be a reason for future development of TFJ OA, and thus must be targeted for the early management of TFJ OA. Disability of OA knee contributes to quadriceps weakness and pain. Hence, therapeutic taping increases the option for the management of OA knee patients. There is a dearth of literature regarding the use of McConnell patellofemoral pain syndrome (PFPS) protocol for tibiofemoral OA. Hence, this study aimed to use McConnell PFPS protocol on tibiofemoral OA and objective was to determine the effect of same on tibiofemoral OA.
| Subjects and Methods|| |
An experimental pilot study was carried out on 15 participants above 40 years of age and the intervention was given on alternate days for 4 weeks. Clearance from the Institutional Ethical Committee bearing number DYPCPT/ISEC/62/2019 was taken beforehand. Participants were informed about the purpose of the study, and informed consent was obtained from them. The selection of participants was followed according to the inclusion criteria. The inclusion criteria included radiographic OA defined as at-least Grade 2 medial joint space narrowing or Grade 2 tibia or femoral osteophytes, self-reported pain the knee for most of the days of the month, both male and female candidates (>40 years of age), ambulatory subjects, radiologically diagnosed with OA knee by an orthopedician and patients without any knee ROM restriction. The exclusion criteria were patients with more than grade 3 OA on Kellgren − Lawrence Scale, Chondromalacia Patella evident on magnetic resonance imaging, recent knee surgeries, inflammatory knee conditions such as rheumatoid arthritis, PFJ OA, other metabolic bone disease as well as nonambulatory participants. The presence of PFPS was ruled out if the participants had retro or peri-patellar pain, if the pain was reproduced by functional activities such as squatting, stair climbing, and prolonged sitting, any other conditions mimicking anterior knee joint pain. A total number of 15 participants with OA of the knee were recruited for the study using convenient sampling owing to time constraint. The sample size was calculated using standard deviation (SD), Mean and Confidence Interval of Reference Article using WinPepi Software (Version 11.38). It was estimated by using the formula N = (Zα/2) 2 s2/d2; where S was the SD obtained from previous study, and d was the accuracy of estimate or how close to the true mean. Zα/2 is normal deviate for two-tailed alternative hypothesis at a level of significance. The participants were given McConnell PFPS protocol to the affected knee and their pretreatment and posttreatment results were documented. The protocol included applying the tape to the affected knee followed by strengthening exercises specific to Vastus Medialis Obliques (VMO) in weight bearing position (i.e., walk stance) and then for entire quadriceps in step up and step down position producing an eccentric contraction. These strengthening exercises were proposed by Jenny McConnell. Progression was done on weekly basis, i.e., VMO specific strengthening, for first 2 weeks with 10 s hold × 5 repetitions in a span of 2 sets followed by 20 s hold × 10 repetitions in a span of 3 sets for the next 2 weeks. The entire intervention lasted for 4 weeks.
Preassessment was done on participants coming to the institutional medical college. They were screened on the basis of their major complaint of knee pain. The participants were then assessed to find out if they fit in the criteria given above for the study, and their demographic data were collected. This assessment was based on pain complaints and functional disability. If the patient fulfilled the criteria, they were considered a part of the study.
Treatment protocol-3 sessions/week for 4 weeks was set for the participants.
| Method|| |
- For McConnell PFPS protocol:
- Patient's position: Standing
- Therapist position: On the side of the affected knee.
Technique: Three components of patellar orientation were examined-
- Glide component
- Tilt component
- Rotation component.
After assessment of patellar orientation, tape was applied on the subject's knee to correct any of the orientation faults mentioned above [Figure 1]. To correct the glide component, one end of the rigid tape was secured at the lateral edge of patella after applying prewrap. The patella was then pushed medially by therapist's thumb and the other end of the tape was anchored just medial to the medial edge of patella, thereby maintaining the medial glide correction. The tilt correction was done by applying the one end of the rigid tape in the middle of patella after applying prewrap. The therapist then tilted the patella medially with thumb, and the other end of the tape was anchored just medial to the medial edge of patella, thereby maintaining the tilt correction. For correcting the rotational component, the rigid tape was split into two strips. Each strip was put on the center of patella confronting each other with one end of the strip pointing caudally and one confronting cephalad. The therapist then pulled both strips together rotating the patella toward normal rotatory alignment. Not all the patients had faulty alignment in all three aspects. The participants were then made to do exercises specific to VMO with the tape on in two different positions.
- Training in a weight bearing position by the subject standing in a walk-stance position with symptomatic leg forward and the knee flexed to 30 degrees. The subject was instructed to contract the VMO and to relax the lateral hamstrings and the Vastus Lateralis (VL) as much as possible. This position was held for a period of 10 s while the subject supinated the foot just past the mid-position and then allowed the foot to go back into pronation but remaining in a more supinated position. This was repeated for 10 times [Figure 2]
- VMO strengthening using a Stepper: The subject here was instructed to step down from a stepper and then back onto the stepper. This caused the quadriceps muscle of the leg remaining on the step to contract eccentrically first and then concentrically (These exercises can be progressed by altering the height of the step and/or by providing resistance to movement either during treatment adding weight around ankle or at home by either using the weight or wearing a backpack with a known amount of weight inside) [Figure 3]. Postintervention assessment of pain and functional disability was done at the end of 4 weeks.
Shapiro − Wilk test was used to check the normality of the data. As the data were found to be normally distributed, paired t-test was done to analyze within the group differences by comparing pre- and postreadings of WOMAC and Visual Analog Scale (VAS). Data were analyzed using Winpepi Software version 11.65. Data were described as mean and SD according to its normality.
| Results|| |
Fifteen participants who satisfied the selection criteria were included in the study. Four-week intervention of McConnell PFPS protocol was given to all the participants, three sessions per week. Pre- and postreadings were taken. WOMAC and VAS scales were the outcome measures used.
[Table 1] and [Graph 1] shows comparison of pre- and postreadings of WOMAC within the group, paired t-test was applied where P < 0.0001, which is considered to be significant, which suggest that functional disability was reduced postintervention.
|Table 1: The Western Ontario and McMaster Universities Osteoarthritis Index|
Click here to view
[Table 2] and [Graph 2] shows a comparison of pre- and postreadings of VAS within the group, paired t-test was applied where P < 0.0005, which is considered to be significant, which suggest that pain was reduced postintervention.
| Discussion|| |
OA is an inflammatory condition and is a progressive chronic disease which leads to pain and functional disability. It slowly involves articular cartilage and affects the underlying bone and soft tissues. The condition occurs late in life, mainly affecting large weight-bearing joints. The most common group of muscle that undergoes weakness in OA is quadriceps. Baker KR in the year 2004, stated that, there is a relationship between quadriceps weakness and knee OA in all compartments, with the strongest correlation in mixed disease-tibiofemoral and PFJ. Patella has the primary function as an anatomic pulley for the quadriceps muscle in knee joint. It is located between the femoral condyles and the quadriceps tendon hence acts as a spacer and reduces friction and compressive stress on the knee joint by distributing forces evenly to the underlying bone. The extensor mechanism of the knee involves quadriceps muscle group, quadriceps tendon, patella, patellar retinaculum, patellar ligament, and neighboring soft tissues. Injuries to this tendon are very common and comprises chronic degenerative injuries, overuse injuries and acute trauma. The knee joint has a locking and unlocking mechanism. The locking mechanism is done by anterior cruciate ligament and posterior cruciate ligament and occurs as a result of medial rotation of femur at last degree of knee extension. The final medial rotation of the femur when the knee is in full extension describes the screw home mechanism and unlocking occurs as a result of lateral rotation of femur at starting degree of knee flexion and is done by the action of the popliteus., OA is caused due to increase in water content and decrease in proteoglycans from the cartilage matrix. Repeated stress on such cartilage leads to fibrillation. The cartilage starts getting destroyed at the points of contact between the articular surfaces due to grinding mechanism. The bones at the margins of the joint hypertrophies to form a rim of projecting spurs called as osteophytes. The loose flakes of cartilage lead to synovial inflammation and thickening of the capsule and further this leads to deformity and joint stiffness.
Stefanik J et al. in 2016 mentions that it is distinctly possible that medial and lateral TFJ OA are highly driven by frontal plane alignment which is evidenced by the relationship of varus and valgus alignment to medial TFJ OA and lateral TFJ OA, respectively. It is likely that varus or valgus alignment has a protective relationship for medial or lateral TFJ OA and it is possible that this joint compartment can progress to damage which is unlikely in other joint compartment.
Levangie et al. explained that, on TFJ the external forces can substitute the internal forces, and then, the force coming from the floor causes adduction moment on the medial knee joint and thus causes the knee to rotate comparatively more on varus side i.e., adduction. Aberrantly more knee adduction moment leads to the development of medial knee OA. The link between the malalignment of knee and the progression of OA knee has consequences for patients who exist with abnormal anatomical alignment. In OA knee genu varum deformity is common and it occurs due to shifting of weight bearing line to the medial side of knee and further increases load on the medial condyle. Hence, this deformity leads to progression of medial compartment knee OA. Whenever there is laxity in the ligament, the excessive varus motion or increased dynamic activity of the muscles which controls this excessive motion leads to sudden stress around the joint. The flexor group of muscle of knee joint includes hamstrings, i.e., semimembranosus, semitendinosus, biceps femoris, Sartorius, gracilis, popliteus and gastrocnemius and the extensor group of muscles includes quadriceps, i.e., rectus femoris, VL, vastus medialis, and vastus intermedius. As in knee OA, there is significant weakness in quadriceps muscle, strengthening of vastus medialis is very important and due to significant different alignment of the upper and lower fibers of the vastus medialis muscle, the upper fibers are named as Vastus medialis longus and lower fibers are named as VMO. The function of quadriceps muscle is powerfully prejudiced by the patella. According to mechanical efficiency, the role of the patella is to lengthen the moment arm of the quadriceps by increasing the distance between patellar tendon and the quadriceps tendon. As patella acts as an anatomical pulley, it prevents the action line of the quadriceps femoris muscle away from the center of the joint, increasing the angle of pull on the tibia to increase the competence of the quadriceps to generate extension torque. Increasing the moment arm for the quadriceps muscle increases the rotatory component of pull of the quadriceps on the tibia. The quadriceps in addition to creating extension torque also produces an anterior shear of the tibia on the femur. The quadriceps muscle functions differently depending upon the exercise or activity. In closed kinematic strengthening exercise, the quadriceps muscle produces greater force as knee flexion increases.
This study provides evidence to support the use of McConnell PFPS protocol on tibiofemoral OA of knee in managing perceived pain and functional disability. Analysis of outcome measures indicated a significant difference of pre- and postreadings within group (paired t-test) for all variables including VAS (P < 0.0005) and WOMAC (<0.0001).
The study was mainly focused on the tibiofemoral OA of knee. We screened 20 subjects out of which 15 were included in the study according to the inclusion criteria. McConnell PFPS protocol was applied to the affected knee and there was decrease in pain and functional disability which was statistically significant. The study by McConnell J suggests that, the quadriceps muscle is inhibited by pain in the knee joint so that if exercises are painful there may be a detrimental effect on patellar position. Patients with OA have an imbalance between the activity in the VMO and VL components of the quadriceps. Therefore, taping of the patella to enhance contraction of VMO is an essential step in this treatment. Hence, this gives the strong relationship between tibiofemoral and patellofemoral OA that correction patella gives direct impact on strengthening of VMO. This was a pilot study conducted among only 15 patients owing to time constraint. The limitation of the study is the lack of follow-up, and the assessment was carried out immediately after the intervention.
| Conclusion and Recommendation|| |
The study suggest that McConnell PFPS protocol reduced functional disability and pain in Grade-2 tibiofemoral OA and can be a routine intervention for patients with Tibiofemoral OA. However, the results were interpreted at 4 weeks, although a longer follow-up is ideally required to state a valid conclusion
Although this study was not funded by any organizations or personnel, we acknowledge everyone's help in this study.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2]