The Clinical Coach: Tendon Needling Protocol for Patellofermoal Rehab

Happy Friday

Last week we hosted our first Cosmetic Dry Needling Course, and it was so much fun show how dry needling can stimulate collagen production at a deeper level and treat wrinkles. We had so much fun that I am thinking about bringing it back in the fall!

Jump on the waitlist here!

Now, onto this week’s topic.

Needling the painful knee and the rehab that follows.

What is…. Patellofemoral pain?

Patellofemoral pain is pain experience at the front of the knee. Usually noted as deep and sharp just under the patella. This pain has been thought of as the result from increased pressure between the patella and the trochlea of the femur.

This is not an overnight event, in most cases. The pain usually starts pin point small, where the patient can point to it. After days or weeks of continued irritation the pain can span the whole patella.

Unfortunately, many clinicians simply slap the PFPS label on the patient, give the patient some stretching, and foam rolling exercises and send them home telling them to “ease off” or stop exercising without addressing the root cause.

We don’t do that here.

How does Patellofemoral Pain happen?

Patellofemoral pain has always been associated with just tight quadriceps. These pull on the patellar tendon and create compression between the patella and the trochlea.

Is that really the case?

While addressing the quadricep is helpful from a rehabilitation setting. IMO there’s a deeper reason these muscles are involved, and it involves the hip and the ankle.

Most Common MOI

Patellofemoral pain can develop due to a variety of reasons:

• Hip biomechanics

• Patellar tracking

• Muscle Imbalances

• Foot mechanics

• Hx of ankle, knee, hip injury

So many factors individually, but what most clinicians and even coaches miss is how the body is reacting to the forces being acted upon.

Now we don’t have to go too deep into the myofascial system and assess the full body. We just have to assess how the patient moves from their core to their feet.

What assessments are we missing?

When patients present to most offices, most doctors will do a thorough work up. They’ll complete a neuro, ortho and even functional assessment. They’ll do specific tests to rule out other conditions or pathologies acting upon the patella.

This is great. However, few doctors will perform a:

• running gait assessment

• single leg jump & land assessment

• two leg jump & land assessment

Why?

Running gait assessments are time consuming, and if you don’t know what you are looking for, you are most likely wasting your time and your patients time and money.

Jump & land assessments are not largely utilized for safety reasons. Wouldn’t want your patient to fall and get injured in office.

But, if you are treating active individuals or athletes, you should be conducting a running gait assessment and a jump & land assessment.

If you are working with a non-athletic population a simple step-up assessment and lunge assessment works great!

Why do we want to do theses?

Two big reasons:

• Assess the tendon capabilities dynamically

• Assess gait mechanics to improve gait and reduce tendon stress.

Muscles and Tissues

As any good clinician you’ll assess the:

• quadriceps

• hamstrings

• adductors

• abductors

• iliotibial band

• patellar tendon

• patellar ligament

• ACL/PCL

• meniscus and joint capsule

Not only to solidify your diagnosis, but also to rule out other pathologies or conditions that may be present.

Patellofemoral Pain is not due to ONE tissue being tight. In my opinion, it’s due to a variety of factors highly related to biomechanical adaptations of both the structure and the tissues surrounding the structure.

If you took our Certified Dry Needling Practitioner course, you know the patellar tendon protocol.

This is part of the treatment for Patellofemoral Pain Syndrome with dry needling.

If you have taken our Certified Dry Needling Practitioner course, you know we don’t needle tendons. We needle around them.

That is exactly what we have been doing with a variety of our soccer players and runners with great success.

Treatment for PFPS

To manage their pain in the first few visits (avg. 4) here’s how we treat PFPS at The Athlete Spot™

Conservative Care

The CDNP PFPS Protocol

What does the needling look like:

I realized I didn’t have a picture of this approach, so here’s my knee:

First and foremost all the needles you see surrounding the patella are pointed towards the hip and inserted at a 10 degree angle to the skin.

Palpation is key.

Now, lets start with the needles south of the patella, bottom two.

These are inserted at 10 degrees to the skin and are running parallel to the border of the ligament. Dependent on how wide the patient’s ligament is, these needles may be more or less far apart from each other.

*This area can be tricky as there is not a lot of skin. We recommend you tent the skin just where you are going to needle and insert your needles in that area.

The needles north of the patella are also inserted at 10 degrees to the skin and follow the lateral margins of the patellar tendon. No need to tend tent the tissue here. Otherwise you’ll end up too superficial.

Again, if your patient has a narrow tendon, the needles will be closer to each other. If you took our Certified Dry Needling Practitioner Course, you should remember how to assess the patellar tendon through palpation. If you didn’t, you can purchase yearly access to our library and learn a few things.

The most superior needle north of the patella is above the patellar tendon itself. It is also inserted at 10 degrees to the skin. The goal is to insert the needle just at the musculotendinous junction of the quadricep and the patella. These needles may look different on your patient dependent on where their MTJ is.

You will still needle trigger points in their respective muscles. I had this gnarly trigger point right there on the VMO (top left of the picture) so I decided to needle it. What a relief!!

These needles are twirled every 3-5 minutes and left in the patient for up to 15 minutes. You can use e-stim on these needles at a low frequency.

Check out our Dry Needling and IMES for more e-stim based protocols.

Non-Conservative Care

It shouldn’t be a surprise that there is a non-conservative approach. And while I am not a fan of it, it’s not about what you like, but what you can do for your patients to help them get better.

Corticosteroid shots have a time and a place. As a healthcare practitioner you need to be aware of when these should be implemented, even if you are not the one administering them.

Corticosteroid shots give you and your patient a very good painless window where a lot of painless rehab can take place. Creating a positive environment to progress your patient through their rehab and help them come out healthier and stronger.

Treatment Plan

We’ve had a lot of questions about treatment plans and lengths. So here’s a shell about what our treatment plan for a young athlete (10-16 years old) might look like.

Length 8-12 weeks (patient dependent)

Week 1-2

• Dry Needling of hyperirritable muscles (quadricep, hamstring, glutes or adductors)

• Dry Needling of PFPS structures (see above)

• Isometric Progressive Rehabilitation at various angles of hip, knee and ankle flexion. (DNS)

Week 3-6

• Progressive Rehabilitation at various angles of hip, knee and ankle flexion (DNS + S&C)

• Introduction of running gait (focused on short runs and painless mechanics)

• Dry Needling of PFPS structures (see above)

Week 7+

• Progressive Rehabilitation cont’d - S&C focused.

• Running Gait progression

• Dry Needling PRN

Clinical Pearls

Orthopedic Exams, Neurological Exams and Functional Assessment are the foundation of every great objective examination.

Don’t forget your patients have unique movement patterns. Assessing those will give you more detailed information to guide your treatment more effectively.

Conclusion

I can’t say I’m a fan of the name of many of the pathologies that we treat, but that should be the LEAST of our worries.

Understanding how the patellofemoral complex absorbs and transmits forces is key to preparing a detailed and tailored rehab program. And now you know how to dry needle for Patellofemoral Pain Syndrome

Until our next issue!

In health and strength,

P.S. If you have questions or comments, feel free to respond to this email. I reply to all emails personally.

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