Current concepts in the management of patellofemoral pain - The role of alignment

Background: Patellofemoral pain is a prevalent and significant clinical problem that is often reported to persist even following evidence based intervention. It is clear therefore that there is much about this complex patient group that is not presently fully understood. This is particularly concerning given the reported links between patellofemoral pain in adolescence and the subsequent development of osteoarthritis and anxiety. Assessment: Clinical assessment has historically focussed on biomechanical factors such as altered lower limb kinematics, muscle weakness and late muscle 'onset or activation' during activity. However when examined it is clear that study findings from patellofemoral populations are often inconsistent. Reasons for this are discussed and specifically the limitations around current 'gold standard' measurement methods, such as motion capture are outlined. A biomechanical approach is applied to demonstrate the importance of ensuring optimal patient alignment during rehabilitation, where optimal is defined as ensuring the most energy efficient muscle or muscles are used by the patient to perform a movement. This in turn ensures that the direction, magnitude and location of load applied to the skeleton during activity is optimal and therefore less likely to lead to injury. Treatment: The role of alignment in patellofemoral pain and the importance of correcting this during rehabilitation is discussed, and examples provided. Validated, reliable, and reproducible methods of measuring skeletal geometry, muscle geometry, muscle force and direction, and kinematics of activity must be developed as a priority in order for us to further our understanding and improve outcomes in this complex clinical population. (C) 2019 Published by Elsevier B.V.