Monday, April 14, 2008

Diagnosis of Patellar Malalignment: A Work in Progress...

ResearchBlogging.orgIf you've been reading my previous blogs, you'll see that I often need to be dragged kicking and screaming into a adopting traditionally held beliefs of the physical therapy profession. As much as some of my colleagues would like otherwise, I will likely hold on to this stubborn characteristic until the day I croak. The upside to my eternal skepticism is the drive to finding evidence supporting or refuting specific approaches to a clinical problem.

I have previously admitted having guerrilla hands with respect to palpation and assessment of the SI joint. I have another confession: I have the eyes of a fruit bat when it comes to visually assessing patellar alignment in patients with anterior knee pain. I assure you I will try to cease comparing various parts of my anatomy to jungle beasts. It's probably just a phase.

Today's research comes to us from the JOSPT on diagnosing patellar malalignment. Patellar malalignment is thought to be at least one of the mechanisms at play in anterior knee pain. However, in this clinical commentary, Wilson raises considerable questions regarding it's usefulness as a diagnostic tool

  • Contrary to popular belief, the existence of patellar malalignment in subjects with PFPS is uncertain. In fact, the weight of evidence currently suggests otherwise.

  • The non radiological clinical tests most commonly used have been shown to be lacking appropriate scientific qualities and have been deemed clinically unacceptable.

  • Until more scientifically robust measurements have been developed, we should be aware that many of our beliefs with regard to the role of patellar malalignment in the etiology of PFPS are based largely on assumptions and not on evidence. (Wilson, 2007)

If the diagnosis of a patellar malalignment is found to indeed lack clinical utility, shouldn't this also cast equal doubt on the mechanisms surrounding treatments designed to alter the supposed malalignment? Many of us "stretch" the ITB and lateral peripatellar retinacular tissue and "strengthen" the medial quadriceps in an effort to normalize this malalignment, but what if patellar malalignment is not the problem to begin with?

We know many of our treatments seem to lead to positive outcomes for our patients, but we seem to have a long road toward understanding the physiologic mechanisms surrounding the improvements. The solution to conservative management of anterior knee syndromes will likely begin by establishing clear operational diagnostic criteria. This makes a stronger case for continually refining and sharpening our clinical skill set.

Wilson, T. (2007). The Measurement of Patellar Alignment in Patellofemoral Pain Syndrome: Are We Confusing Assumptions With Evidence?. Journal of Orthopaedic and Sports Physical Therapy DOI: 10.2519/jospt.2007.2281

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