Patients with anterior knee pain (AKP) are waiting long periods to see Orthopaedic surgeons for expert advice, few are considered for surgery, most are referred for physiotherapy. This expensive use of a Consultants time increases orthopaedic waiting lists and often delays patients referral to Physiotherapy.
Objectives To develop management strategies by reviewing evidence base and current practice to increase numbers of patients seen in an orthopaedic clinic and improve the cost effectiveness and quality of health care.
Methods Evidence from literature and current practice by expert opinion was collated and analysed; from which evidence-based guidelines for the physiotherapy management of anterior knee pain (AKP) were formulated. Forty patients who presenting to an Orthopaedic clinic with AKP were assessed by a Clinical Specialist Physiotherapist and offered physiotherapy treatment, according to the guidelines. Management and treatment outcomes were audited.
Results 40 extra new patients were assessed in an orthopaedic clinic over 8 months (Age range 11–53 years, mean 25 years, symptom duration ranges 6 months–16 years). 57% of the patients had not received any previous physiotherapy for their AKP. 3 patients were not offered physiotherapy and 3 were transferred to other physiotherapy departments. 5 did not attend a full course of treatment. 29 completed their treatment. Treatment duration ranged from 4–32 weeks, with a mean of 15 weeks. The number of treatments per patient ranged from 3–12 with a mean of 6.
Treatment was tailored to the individual patient and consisted of education and exercises aimed at improving postural alignment, balance and the timing of the vastus medialis obliquis, gluteal and abdominal muscles. Manual therapy techniques and stretches were used to elongate tight structures e.g. hamstring, gastrocneiumi, muscles and ilio-tibial bands and lateral retinaculum. Patello-femoral taping was used in 26% of cases, trigger point acupuncture in 33% of cases to provide some pain relief during their course of rehabilitation and 7% were provided with insoles.
At final assessment of the 29 patients that completed treatment, 52% stated that they were pain free. 22% stated that they were between 70–90% better. 15% stated that they were between 50–70% better. 7% were unresponsive to treatment. A proposal for an integrated care pathway for the management of AKP has been developed from these results and presented to the physiotherapists in Cornwall.
Conclusion Current literature and expert opinion advocates conservative management of anterior knee pain in the form of physiotherapy targeted at reconditioning lower limb musculature to improve patellofemoral biomechanics over surgical intervention. The results of this project support the literature but many patients are not being referred appropriately to Physiotherapists. an integrated care pathway for AKP has the potiential to create a co-ordinated cost effective approach to patient care.
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