Warm up

Another major win for physiotherapy — curing patellofemoral pain

Karim M Khan

Correspondence to:
Dr Karim M Khan, Professor UBC, Centre for Hip Health and Mobility, Suite 320 - 5950 University Blvd, Vancouver V6T 1Z3, Canada; karim.khan{at}familymed.ubc.ca

Thanks for the positive feedback about BJSM’s recent articles – particularly the January (http://bjsm.bmj.com/content/vol43/issue1) and February (http://bjsm.bmj.com/content/vol43/issue2) issues edited by Professor Steven Blair. Many emails supported the claims that physical activity is the most powerful single medical intervention.¹ The downside is that Neville Owen has made me feel guilty if I sit for a mere 12 hours.² The result? Ageing BJSM editor shuffling around the streets of Vancouver at 10 pm getting his "fix" in 3°C temperatures. The voices of Steven Blair and Art Kramer in my head³ penetrating the usual cacophony, "30–60 minutes a day keeps dementia at bay". "Too late!" you say?

Coincidentally with this month’s cover story, we learn that Jenny McConnell received Australia’s highest honour — the Order of Australia Medal (OAM) — for her "service to physiotherapy as a practitioner and researcher, particularly through the development of innovative musculoskeletal pain management and treatment". Her cataclysmic 1986 paper⁴ timestamps the revolution in managing patellofemoral pain with a focused exercise programme. Young clinicians will have trouble imagining patients hobbled with chronic anterior knee pain being told to "retire" (the 1970s panacea for musculoskeletal pain). The more "enlightened" solution was referral for surgeries ranging from "lateral release" to the gruesome "Macquet procedure". Most unfortunately, one unsatisfied surgical patient actually shot a medical receptionist, ostensibly because of the frustration of chronic knee pain. I apologise for resurrecting painful memories but do so neither flippantly nor gratuitously. I underscore the serious nature of our clinical work and the importance of innovations that improve patients' quality of life.

By providing solutions, physiotherapists, and subsequently enlightened physicians, have reframed patellofemoral pain from a static, degenerative condition to one that results from dynamic "malalignment" or "timing failure". I see parallels with Paul Hodges’ and others changing our perception of the spine from being a "structural stack" to a finely tuned cylinder and much more.⁵

This month, BJSM shares Collins and colleagues’ paper from the BMJ (see page 169),⁶ which investigated a common clinical combination — exercise prescription plus orthoses — for patellofemoral pain. And on the subject of orthoses, please see the evidence-based guide to prescribing running shoes (see page 159).⁷

The scourge of preventable ACL injuries remains ever-present.⁷ If your daughter’s basketball or soccer team is not engaged in preventive programmes,^{7 8} speak to the coach and if that doesn’t work call your Member of Parliament. Still no good? Consider the World Court (officially known as the International Court of Justice — http://www.icj-cij.org). This is serious. You wouldn’t send your kid out cross-country skiing mid-winter in a bikini. Prevention is based on understanding mechanisms and this month we learn about knee joint laxity and its changes during phases of the menstrual cycle from the renowned McCaig Centre at the University of Calgary (see page 174).⁹ And in keeping with Obama’s potentiating stem cell research in the US, (see pages 195 and 221)^{10 11} we examine exercise influences on multipotential stem cells (the MSCs above). Physical activity influences everything!

You’ll love the I-test — BJSM’s new imaging feature (see pages 172 and 173).^{12 13} It vivifies BJSM’s commitment to (a) innovation (research), (b) education (I-test and e-learning) and (c) knowledge translation — highlighting programmes that work. I thank editor colleague Dr Babette Pluim (The Netherlands) and Professor Bruce Forster (Canada) for giving BJSM readers superb educational value. (see page 158); The questions and answers are on different pages to facilitate your placing friendly bets.

This month’s cover pays homage to Da Vinci’s Vitruvian Man (AD 1487) and (http://bjsm.bmj.com/current.dtl) maintains the thread of our virtual theme issue (articles every month) on groin pain. Last month we launched the 3-part "3G" series — groins, gluteals and the greater trochanter as a novel clinical approach to chronic groin pain.^{14 15} Does that pathoanatomical approach simplify it for you? Or are you an advocate of Holmich’s tests,^{16 17} or the Bradshaw camp?¹⁸ Let’s hope that advances for patients soon match up to those we have seen for patellofemoral pain. And next month? Guest editor Dr Jill Cook brings you BJSM’s tendinopathy issue. Please see the new-look homepage and blog for more news! (http://blogs.bmj.com/bjsm/)

Competing interests: None declared.

1. Blair SN. Physical inactivity: the biggest public health problem of the 21st century. Br J Sports Med 2009;43:1–2.[Free Full Text]
2. Owen N, Bauman A, Brown W. Too much sitting: a novel and important predictor of chronic disease risk? Br J Sports Med 2009;43:81–3.
3. Erickson KI, Kramer AF. Aerobic exercise effects on cognitive and neural plasticity in older adults. Br J Sports Med 2009;43:22–4.[Free Full Text]
4. McConnell J. The management of chondromalacia patellae: a long-term solution. Aus J Physio 1986;32:215–23.
5. Hodges P. Transversus abdominis: a different view of the elephant. Br J Sports Med 2008;42:941–4.[Free Full Text]
6. Collins N, Crossley K, Beller E. Foot orthoses and physiotherapy in the treatment of patellofemoral pain syndrome: randomised clinical trial. Br J Sports Med 2009;43:169–71.
7. Renstrom P, Ljungqvist A, Arendt E, et al.. Non-contact ACL injuries in female athletes: an International Olympic Committee current concepts statement. Br J Sports Med 2008;42:394–412.[Abstract/Free Full Text]
8. Soligard T, Myklebust G, Steffen K, et al.. Comprehensive warm-up programme to prevent injuries in young female footballers: cluster randomised controlled trial. BMJ 2008;337:a2469.[Abstract/Free Full Text]
9. Park S-K, Stefanyshyn DJ, Ramage B, et al.. Relationship between knee joint laxity and knee joint mechanics during the menstrual cycle. Br J Sports Med 2009;43:174–9.[Abstract/Free Full Text]
10. Schmidt A, Bierwirth S, Weber S, et al.. Short intensive exercise increases the migratory activity of mesenchymal stem cells. Br J Sports Med 2009;43:195–8.[Abstract/Free Full Text]
11. Lucia A, De La Rosa A, Avila Silván M, et al.. Mobilisation of mesenchymal cells in cardiac patients: is intense exercise necessary? Br J Sports Med 2009;43:221–3.[Abstract/Free Full Text]
12. Waterhouse J, King CR, Chin P, et al.. A 61-year-old man with pain in antecubital fossa after an elbow hyperextension injury. Br J Sports Med 2009;43:172.[Free Full Text]
13. Mann SA, Leith JM, White JH, et al.. Elderly woman with post-traumatic locked shoulder. Br J Sports Med 2009;43:173.[Free Full Text]
14. Falvey E, Franklyn-Miller A, McCrory P. A 3G approach to a 3-dimensional problem. Br J Sports Med 2009;43:145.[Free Full Text]
15. Falvey EC, Franklyn-Miller A, McCrory PR. The greater trochanter triangle; a pathoanatomic approach to the diagnosis of chronic, proximal, lateral, lower pain in athletes. Br J Sports Med 2009;43:146-52.[Abstract/Free Full Text]
16. Holmich P. Long-standing groin pain in sportspeople falls into three primary patterns, a "clinical entity" approach: a prospective study of 207 patients. Br J Sports Med 2007;41:247–52; discussion 252.
17. Holmich P, Holmich LR, Bjerg AM. Clinical examination of athletes with groin pain: an intraobserver and interobserver reliability study. Br J Sports Med 2004;38:446–51.[Abstract/Free Full Text]
18. Bradshaw CJ, Bundy M, Falvey E. The diagnosis of longstanding groin pain: a prospective clinical cohort study. Br J Sports Med 2008;42:551–4.[Free Full Text]

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