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

Best Initial 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. 1

Rationale for Vastus Medialis Treatment

The 17-year-old soccer player's presentation is classic for patellofemoral pain syndrome (PFPS), with:

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

These findings indicate a muscle imbalance affecting patellar tracking. Recent shear wave elastography studies have demonstrated reduced contraction ratio in the vastus medialis oblique (VMO) in female patients with PFPS 1. This muscle imbalance contributes to the lateral patellar tracking observed during the examination.

Why Facilitated Positional Release is Preferred

Facilitated positional release (FPR) of the vastus medialis:

• Directly addresses the primary dysfunction (VMO weakness/dysfunction)
• Helps normalize muscle tone and function
• Improves patellar tracking by enhancing VMO function
• Is non-invasive and well-tolerated as an initial intervention

Why Other Options Are Less Appropriate

1. Articulatory technique to the proximal tibiofibular joint:

   • While proximal tibiofibular joint dysfunction can contribute to knee pain, it is not the primary issue in this case where patellar tracking is the main concern

2. Direct action technique on the biceps femoris insertion:

   • Though hamstring tightness can be a factor in PFPS 2, the patient's presentation with lateral patellar tracking suggests VMO dysfunction is more significant

3. Indirect myofascial release of the iliopsoas muscle:

   • While hip musculature weakness may contribute to PFPS 2, addressing the VMO directly is more important as the initial treatment given the observed lateral patellar tracking

Follow-up Interventions After Initial OMT

After the initial facilitated positional release treatment, a comprehensive approach should include:

1. Quadriceps strengthening exercises:

   • Progressive loading with focus on VMO function 1
   • Shown to be effective in treating PFPS 3

2. Hip-targeted exercises:

   • Focus on abductors and external rotators to address the observed pelvic drop 1
   • Helps correct biomechanical factors contributing to PFPS

3. Patient education:

   • Activity modification and load management strategies 1
   • Explanation of pain mechanisms and rehabilitation goals

4. Consider adjunctive interventions:

   • Patellar taping for short-term pain relief 1
   • Prefabricated foot orthoses if biomechanical factors contribute 1
   • Patellofemoral bracing if needed 1

Common Pitfalls to Avoid

• Excessive rest: Complete rest can lead to muscle atrophy and prolonged recovery 1
• Rushing progression: Advancing exercises too quickly can exacerbate symptoms 1
• Relying solely on passive treatments: Active exercises are essential for long-term success 1
• Ignoring biomechanical factors: The observed pelvic drop indicates potential hip muscle weakness that should be addressed

Monitoring and Progression

• Reassess at 6-8 weeks to determine progress 1
• Consider referral for orthopedic consultation if no improvement after 3 months of consistent therapy 1
• Gradually progress exercise intensity and functional activities as symptoms improve 1