What is the best initial osteopathic manipulative treatment for a patient with patellofemoral pain syndrome?

Osteopathic Manipulative Treatment for Patellofemoral Pain Syndrome

Facilitated positional release of the vastus medialis is the best initial osteopathic manipulative treatment for this patient with patellofemoral pain syndrome.

Understanding the Diagnosis

This 17-year-old soccer player presents with classic signs and symptoms of patellofemoral pain syndrome (PFPS):

• Anterior knee pain worsening with activity
• Pain with prolonged sitting and squatting
• Tenderness along the medial facet of the patella
• Pain with resisted isometric quadriceps contraction
• Lateral patellar glide during terminal extension
• Contralateral pelvic drop during single-leg squat

Rationale for Vastus Medialis Treatment

The vastus medialis oblique (VMO) plays a critical role in patellofemoral mechanics:

• According to the British Journal of Sports Medicine guidelines, quadriceps strengthening exercises, particularly focusing on the VMO, are supported by high certainty evidence for PFPS management 1
• Shear wave elastography studies demonstrate reduced contraction ratio in the vastus medialis oblique in female patients with patellofemoral pain 2
• Facilitated positional release (FPR) of the vastus medialis addresses the muscle imbalance that contributes to lateral patellar tracking observed during the patient's examination

Why Other Options Are Less Appropriate

1. Articulatory technique to the proximal tibiofibular joint (Option A):

   • While tibiofibular joint dysfunction can contribute to knee pain, this patient's primary issue is patellar tracking and quadriceps dysfunction
   • No evidence in the guidelines supports this as a first-line treatment for PFPS

2. Direct action technique on the biceps femoris insertion (Option B):

   • Though hamstring tightness can be a contributing factor to PFPS 3, the physical exam findings more strongly point to VMO dysfunction
   • The lateral patellar glide observed suggests addressing the medial stabilizers first

3. Indirect myofascial release of the iliopsoas muscle (Option D):

   • While hip musculature weakness is a potential risk factor for PFPS 3, and the patient shows contralateral pelvic drop, the more immediate issue is the patellar tracking problem
   • The British Journal of Sports Medicine guidelines recommend addressing the quadriceps mechanism first before progressing to hip-focused interventions 1

Treatment Approach

1. Initial Treatment:

   • Perform facilitated positional release of the vastus medialis to improve muscle function and patellar tracking
   • This technique involves positioning the muscle in ease, applying a brief activating force, and then slowly returning to neutral position

2. Follow-up Interventions:

   • Implement quadriceps strengthening exercises with progressive loading 1
   • Add hip-targeted exercises focusing on abductors and external rotators to address the pelvic drop 1
   • Consider patellofemoral bracing as recommended by the American College of Rheumatology for patients with patellofemoral knee pain 2

3. Education and Load Management:

   • Provide education about PFPS and activity modification
   • Teach load management strategies to allow continued participation in soccer while managing symptoms 1

Common Pitfalls to Avoid

• Focusing only on passive treatments: Ensure active rehabilitation follows the initial OMT
• Neglecting biomechanical factors: Address both knee and hip mechanics
• Rushing progression: Gradually increase activity as symptoms improve 1
• Overlooking patient education: Explain the diagnosis and expected recovery timeline to improve adherence

By starting with facilitated positional release of the vastus medialis and following with a comprehensive rehabilitation program, this young athlete has the best chance of returning to competitive soccer while addressing the underlying biomechanical issues causing her patellofemoral pain.