INJECTION THERAPY FOR PATELLOFEMORAL JOINT (PFJ) PAIN

What is Patellofemoral joint (PFJ) pain?

Pain at the front of the knee is caused by patellofemoral joint (PFJ) pain. The discomfort is frequently difficult to locate and is felt deep within the joint or ‘behind the knee cap.’ It affects more women than men and is exacerbated by prolonged walking, especially downstairs and/or down hills, as well as crouching, lunging, and running. It gets worse after you’ve been sitting motionless for a time, and the pain is frequently accompanied by clicking. Intermittent swelling can occur as a result of patellofemoral joint pain, however this is not always the case.
 
No formal imaging is necessary for the initial diagnosis, which can be determined solely on the basis of clinical examination. If your discomfort persists, imaging can be used to confirm the diagnosis and check for structural abnormalities, particularly in the cartilage on the back of the knee cap. Surrounding structures such as patella tendinopathy (Jumper’s knee), ITB friction syndrome (Runner’s knee), pes anseurine bursitis, and fat pad inflammation can all be assessed using imaging.
 
Patellofemoral joint pain does not have a quick remedy. A full course of physiotherapy usually relieves patellofemoral joint pain. Hands-on treatment, taping techniques to relieve pain, and a gradual loading programme to increase leg strength and mechanics are all examples of physiotherapy.
 
Ultrasound-guided steroid injections can help with some patellofemoral joint pain. If you have any of the following symptoms, a steroid injection may be necessary:
  
  • Your discomfort is not getting any better.
  • You’re keeping you up at night.
  • if you haven’t improved despite a thorough physiotherapy programme
  • Due to excessive levels of discomfort, you are unable to participate in a physiotherapy programme.
 
Physiotherapy should always be used in conjunction with injections. Hyaluronic acid injections are a non-drug alternative to steroid injections that can also relieve pain.
 

What are the signs and symptoms of Patellofemoral joint (PFJ) pain?

The following are the signs and symptoms of osteoarthritis of the knee:
 
  • Pain at the front of the knee that occurs for no apparent reason
  • Walking downhill, but also squatting, lunging, and running, aggravates the pain.
  • Pain that isn’t relieved by rest
 
If this sounds like you, keep reading…
 

What additional conditions could cause Patellofemoral joint (PFJ) pain?

 If this does not sound like your pain, there are a number of other disorders that can cause pain similar to osteoarthritis in the knee, including:
  
  • Inflammation of the fat pads
  • Meniscal (cartilage) tear
  • Patella tendinopathy (jumper’s knee) is a condition that affects athletes.
  • Friction syndrome of the ITB (runner’s knee)
  • Bursitis of the pes anseurine
 

Patella tendinopathy vs Patellofemoral joint discomfort 

Patellofemoral joint discomfort generates pain in the front of the knee that is difficult to pinpoint, i.e., finding a specific painful place can be challenging, whereas patella tendonopathy pain is highly precise and easy to locate. Simply pressing the tendon on the front of the knee will mimic your symptoms if you have patella tendinopathy. If you don’t have this specific tenderness, it’s unlikely to be patella tendon tendinopathy.
  
In addition, patella tendonopathy discomfort usually improves with exercise and worsens afterward, lasting a few days. Patellofemoral knee joint discomfort, on the other hand, does not usually improve with exercise and often worsens as you continue to exercise.
 

Anatomy of the Knee

 One of the two joints that make up the knee complex is the patellofemoral joint (PFJ). The patella (kneecap bone) is placed in the front of the knee and is in charge of improving the quadriceps’ strength and power (the large muscle group at the front of the thigh).

The patella (kneecap bone) and the femoral condyles of the femur form the patellofemoral joint (two large bony prominences located at the end of the long bone of the upper thigh). The trochlea is a central concave ‘V’ shaped groove created by these two bony prominences that exactly fits the rear of the patella, which is reciprocally convex.

A layer of articular cartilage covers the trochlea and the back of the patella. The smooth, low-friction surface of articular cartilage allows the bones to glide over one another during movement. Articular cartilage requires joint movement to maintain a healthy structure, according to research. However, research has revealed that improper joint loading leads the articular cartilage to change its composition in a detrimental way. This changed composition compromises the structure of the articular cartilage, causing it to thin (Clarke et al., 2003). If this continues, the condition is known as osteoarthritis. According to additional study, keeping excellent flexibility and strength surrounding the joint can help reduce the disease progression linked with osteoarthritis (Hunter et al., 2009).

The most common musculoskeletal disease, affecting up to 15% of the world’s population, is osteoarthritis (Hubbert et al., 2018). It causes pain and impairment, and it is particularly crippling when it affects weight-bearing joints like the hip, knee, or ankle. The hip and knee are the two joints that are most typically afflicted. According to current research, PFJ osteoarthritis accounts for 8% of all instances of osteoarthritis (Kanazawa et al., 2017) and is caused by a variety of causes.

The following are some of the risk factors for patellofemoral osteoarthritis:

  • Sex– Women have a somewhat higher rate of patellofemoral osteoarthritis (13.6 to 24 percent) than males, according to recent studies (11 to 15.4 percent ) (2017, Kanazawa et al.)
  • Age-Patellofemoral osteoarthritis is more common in people in their fifth decade or beyond (Kanazawa et al., 2017)
  • Hip muscle weakness – hip muscle weakness has been linked to an increased risk of patellofemoral osteoarthritis and has been demonstrated to impair lower limb alignment (Souza et al., 2009)
  • Femoral Structure-The ball of the hip joint is formed by the upper end of the femur (the long bone of the thigh). The angle of this ball-shaped end of the femur is altered in some people. Femoral anteversion is a condition that has been associated to an elevated incidence of patellofemoral osteoarthritis (Souza et al., 2009)
  • Position and structure of the patella – if the rear of the patella does not properly line within the trochlea of the femoral condyles, excessive pressure is applied to the articular cartilage, causing osteoarthritis.
  • Weight – a high BMI has been connected to the development of osteoarthritis.
  • During some types of movement, such as running, jumping, and hopping, the patellofemoral joint is repeatedly overloaded.
  • Poor foot biomechanics– Excessive pronation (flat foot) might result in greater pressure through the PFJ due to poor foot biomechanics.

How do you know if you have Patellofemoral arthritis?
Osteoarthritis of the patellofemoral joint is a degenerative condition that might take months or even years to manifest symptoms.

Patellofemoral osteoarthritis is characterised by the following symptoms and features:

  • Walking and stair climbing might increase pain in the front of the knee.
  • When squatting or kneeling, the patella clicks audibly.
  • Around the patella, there is swelling and puffiness.
  • Discomfort and stiffness after periods of inactivity –
  • Patellofemoral pain is often worst first thing in the morning or after lengthy periods of sitting.
  • Poor balance, particularly when standing on one leg — maintaining excellent balance requires lower limb strength. As previously stated, patellofemoral osteoarthritis has been linked to hip weakness.

How is Patellofemoral arthritis diagnosed?
A correct diagnosis of patellofemoral osteoarthritis is necessary. Clinical examination as well as diagnostic imaging are used in the diagnosis of this illness.

Examination in the clinic

The clinical examination allows the clinician to confirm the diagnosis of patellofemoral osteoarthritis and develop a treatment strategy. Patellofemoral osteoarthritis requires physiotherapy as a therapeutic option.

The clinical evaluation identifies factors that may have contributed to the onset of your discomfort and comprises the following steps:

  • An in-depth interview will be done to discover how, what, why, and when your suffering began. You’ll also be asked questions on what makes your symptoms worse and better. To rule out systemic causes of pain, such as rheumatoid arthritis, a complete medical history will be collected. You may be referred for further testing if your clinician detects a systemic cause of your discomfort.
  • Testing knee joint range of motion, examining strength and flexibility of surrounding muscles, palpation (feeling) of the knee structures, and functional testing such as squatting, single leg balancing, gait analysis, and running analysis are all part of the physical examination (if you are runner).

The clinical examination can provide a lot of information, but it can’t diagnose PFJ osteoarthritis conclusively. This will necessitate the use of diagnostic imaging

X-ray

 

You may be referred for an x-ray if your doctor suspects you have osteoarthritis. The gold standard imaging approach for properly identifying the existence and severity of bone and joint pathologies, such as osteoarthritis, is X-ray (see above image).

Diagnostic musculoskeletal ultrasound imaging
Diagnostic musculoskeletal ultrasound imaging has been found to be an extremely useful imaging method for identifying osteoarthritis-related variables. It can detect early-stage osteoarthritic alterations inside the patella’s bony outlines and the trochlear groove. Ultrasound is also useful for detecting swelling (known as ‘effusion’) and joint inflammation (known as’synovitis’) (Kaeley et al., 2020, Wakefield et al., 2000).

Joint Injection’s clinicians have extensive experience and are dual certified in physiotherapy and musculoskeletal sonography. A full clinical examination and diagnostic musculoskeletal ultrasound scan will be done during your initial consultation.

How do we treat Patellofemoral osteoarthritis?

Conservative therapy can effectively control the pain and symptoms of patellofemoral joint pain in the vast majority of people. The two most critical variables in managing osteoarthritis are maintaining excellent flexibility and strength surrounding the afflicted joint (Hunter et al., 2009). The foundation of your treatment should be physiotherapy.

The following are common physiotherapy treatments for patellofemoral joint pain:

  • Strengthening exercises for the hips and knees
  • Stretching techniques for the hips and knees
  • Re-education of biomechanical patterns — this may entail re-education of certain movement patterns.
  • Advice on activity moderation and relative rest
  • Advice on how to manage symptoms using ice and tape
  • To help you manage your pain and symptoms, your doctor may employ joint manipulation, acupuncture, or soft tissue methods. This will make it easier for you to stick to your fitness routine.

Here are a few pointers you might want to try:

  • Avoid worsening your knee discomfort by changing your everyday routines or refraining from activities or hobbies that irritate your knee, such as jogging.
  • Strengthening the muscle of your knees is the cornerstone of conservative treatment.
  • A knee brace with a hole in the front may be an effective pain reliever (although it is not for everyone – see illustration below).
  • To assist relieve discomfort and inflammation, wrap an ice pack or a small bag of peas in a moist towel and place it over your knee.
  • To assist manage your symptoms, try using an anti-inflammatory gel like Voltarol. Before beginning any drug, please consult your pharmacist.

What if conservative management isn’t successful?

If physiotherapy and a gradual home workout regimen haven’t benefited you enough, injectable therapy may be a good option.
Injection therapy can help you rehabilitate your knee in a pain-free environment by reducing pain and inflammation associated with osteoarthritis. 
If you’re suffering from one or more of the following problems, injection treatment can help:
 
  • Pain is keeping you awake at night or preventing you from sleeping.
  • Your daily tasks are being hampered by pain.
  • Your ability to work or participate in leisure activities is being hampered by pain.
  • Your ability to complete your physiotherapy regimen is being hampered by pain.
At Joint Injections, all injections are done under ultrasound guidance. When an injection is conducted under ultrasound guidance, it has been demonstrated to have high levels of accuracy, fewer post-injection problems, and more pain alleviation.
 
Our highly trained team of professionals at Joint Injections are qualified to give ultrasound-guided injections for patellofemoral knee joint pain. All of the clinicians are experienced physiotherapists, musculoskeletal sonographers, independent prescribers, and injection therapists who can do all guided injections the same day. You have the option to self-refer to our service. You are not required to see a doctor beforehand.
For the treatment of patellofemoral osteoarthritis, there are two ultrasound-guided injection options:
 

Corticosteroid injection guided by ultrasound

 An ultrasound machine is used to precisely put the needle during a steroid injection, allowing a combination of corticosteroid (a powerful anti-inflammatory medicine) and short-acting local anaesthesia to be injected straight to the source of your pain. The injection of corticosteroids is an effective treatment for osteoarthritis pain and inflammation.
 

Hyaluronic acid injection with ultrasound guidance

 A natural (non-drug) synthetic version of the joint’s natural lubricant is used in the Hyaluronic acid injection procedure. Hyaluronic acid has also been found to have potent anti-inflammatory qualities, and it is frequently used to treat osteoarthritis instead of corticosteroids.
 
As a stand-alone treatment, injection therapy should be avoided. It is critical that you use the pain-relieving effects of the injection to begin a physiotherapy programme within two weeks for the best long-term results.

 

Joint Injection’s experts are dual-trained, highly specialised physiotherapists and musculoskeletal sonographers with extensive experience diagnosing all knee disorders. We provide a ‘one-stop’ clinic, which means you’ll get an examination, a diagnostic ultrasound, and, if necessary, an ultrasound-guided injection.