Kate Grace Physical Therapy (KGPT), San Diego, treated its first patient in 1985. The therapists at KGPT treat a myriad of knee diagnoses and pathologies, including preoperative and postoperative total knee replacements, ACL reconstruction, meniscus repair or menisectomy, and, of course, patellofemoral dysfunction (PFD). It is common that a patient will be able to either eliminate or prolong the need for surgery as a result of the care they receive at KGPT.

The typical treatment protocol for any knee patient is to receive a thorough evaluation—which includes a postural evaluation, manual therapy, and appropriate modalities—on day one. All therapists spend at least

1 hour with a patient for the initial evaluation and spend at least 30 minutes on hands-on manual therapy for each subsequent visit. All exercise programs and modalities are completed with the patient after the patient sees their therapist. Treatment plans are individually designed, executed, and changed as necessary to provide the best treatment to the patient.

ANALYSIS OF PATELLOFEMORAL DYSFUNCTION

Kate Grace, PT, OPA-C, instructs the patient (soccer player) to perform a test that reproduces her patellofemoral pain.

PFD is the most common knee pathology in the world. One out of every four people suffers from anterior knee pain at some time in their lives. PFD is very often misunderstood, misdiagnosed, and mistreated. Each year, approximately 2.4 million Americans are treated for pain in and around the kneecap. In a great number of these cases, the cause of knee pain is a malaligned patella. The condition can be aggravated by insufficient strength of the quadriceps muscles, increased femoral rotation, postural malalignments, and soft-tissue changes.

The clinical presentation of PFD varies in onset, intensity, and frequency. The pain is often felt in various locations surrounding the patella: medial, lateral, distal, retro, and even posterior. Eccentric activities such as squatting and walking downhill or stairs are typical activities that cause PFD symptoms to arise. Knee pain can often follow prolonged sitting or vigorous sports activities.

Patients with patellofemoral pain generally have one of four patellar malalignments: tilt, glide, anterior/posterior, or rotation. The normal position of the patella is at the distal end of the femur in the interchondylar groove. When a person with a healthy knee contracts their quadriceps, the patella slides up and down through the interchondylar groove with little lateral deviation. If a person has a malalignment, the patella does not track centrally within the groove.

The patient performs the same test immediately after donning the OnTrack knee brace system, with no pain.

Tilt: When tilt occurs, the surface of the patella sits at an abnormal angle at the end of the femur. This causes the patella to ride laterally over the lateral femoral chondyle, which wears down the patella and femoral cartilage.

Glide: With the glide condition, the patella is shifted toward the outside of the joint. Glide can be determined by comparing the medial and lateral portions of the patella to its position relative to the femur. Once again, a glide malalignment will cause irritation to the underside of the patella and the surface of the femur.

Anterior/Posterior: This malalignment occurs when the posterior end of the patella is tilted downward toward the tibia. The posterior tip of the patella can become buried in the fat pad and put pressure on the distal patella tendon. This can result in pain centered at the posterior point of the patella, irritation of the fat pad, and inflammation of the patella tendon.

Rotation: With a rotated patella, the patella's midline is not parallel to the axis of the femur. Rotation of the patella can result in wear and tear on the patellar cartilage.

It is up to us, as the musculoskeletal and therapeutic exercise experts, to solve this challenge for our patients. We all need to make it our goal to go beyond just taking someone's pain away. We must recognize that we can have a profound effect on people's lives by enabling them to perform activities and sports, or to pursue the careers of their dreams. As clinicians, we need to start with a thorough evaluation and examination to identify all of the musculoskeletal challenges, postural malalignments, and soft-tissue factors that are contributing to a patient's PFD.

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Specific determinants include: patella orientation, integrity of lateral structures, VMO/VL strength, femoral rotation, and vertical postural alignment on all three planes. It also is essential that we perform a comparable sign prior to treating our patients to determine the effectiveness of our chosen treatment method. A comparable sign reproduces the patient's pain, and the treatment method should alleviate or eliminate the patient's pain.

There are two things that we must do for the PFD patient, and they should be done in this order:

1. Realign the patella back in the interchondylar groove, put a constant stretch on the lateral retinaculum, and eliminate the pain cycle.
2. Then, in this pain-free environment, develop a thorough manual therapy and therapeutic exercise program to maximize the function of the quadriceps muscles, particularly the VMO muscle.

If you conquer these two items, you will be successful in resolving PFD and returning your patients to functional and athletic activities long-term. In fact, you will be able to eliminate the patient's pain today and give them a method to immediately resolve any future patellofemoral pain.

TREATMENT METHODS

To date, treatment methods have been varied and clinical results have been inconsistent. Nonoperative treatment is usually recommended. Radiographic evidence, as well as positive patient response and clinical trials, have presented compelling evidence that knee pain caused by patellofemoral malalignment can be reduced significantly or eliminated in most cases. Clinical trials were done with 35 subjects performing 10 functional activities with either no brace, a standard patellofemoral brace, or the OnTrack® System. Each subject was tested on three different occasions over an 8-week period. All subjects experienced a significant and, in many cases, a complete elimination of patellofemoral knee pain when using the OnTrack System (Figure 1).

Figure 1. Results of clinical trials showing the low percentage of pain response with the OnTrack system versus a standard brace and a no-brace option.

The OnTrack System is a clinically proven treatment method for PFD. Kate J. Grace, PT, OPA-C, and her business partner, Annie M. Fonte, MBA, developed the OnTrack System in 1996. Kate had a special interest in PFD since, at the time, she had suffered from the problem for 29 years. She had also spent 18 years treating PFD patients and researching the malady.

Annie's perspective was different. She had recently developed PFD symptoms, and Kate was treating her as a patient in their private-practice sports medicine clinic located in San Diego. Annie quickly became frustrated with the so-called "state-of-the-art" treatment protocols available at the time. Taping techniques were difficult for her to do herself, and the tape was very confining and lost its effectiveness after only a few minutes of performing exercises or doing activities. She asked Kate if this is how all people with her problem were treated. Kate answered "yes," and Annie said, "If that's the case, then it has to change!"

The OnTrack System reduces or eliminates pain immediately upon application by using a neoprene cuff, a neoprene strap, adhesive knee patches, and a VMO Activator Kit. Also included in the system is an educational DVD that explains patellar pain, the application of the OnTrack System, and the recommended exercises for rehabilitating knee-area muscles.

The OnTrack System guarantees increased patient compliance over existing taping methods because it is easy for the patient to use and wear, it is comfortable, and it increases functionality through the entire range of motion. The OnTrack System is insurance-reimbursable.

X-rays have shown that in a severe case, the OnTrack System has corrected 9º of tilt and 1 cm of glide. Clinical trials also have shown its effectiveness in eliminating pain, allowing the patient to perform all 10 categories of activities tested. Other independent research has been done using kinematic magnetic resonance imaging and gait testing. All research and radiographic documentation are available upon request.

The OnTrack System is a treatment method that will allow you to reduce and, in most cases, eliminate your PFD patients' pain the very first day you see them. The OnTrack treatment method was created to give you, the clinician, an evidence-based tool that provides your PFD patients immediate pain relief on day one, and allows you to progress them quickly and successfully through a treatment plan.

Photos a through e show the application of the OnTrack system: a) Apply the Velcro and tape patch onto the patient’s patella; b) Pull on the neoprene sleeve with Velcro on the posterior side; c) Attach the bifurcated strap to the Velcro tape patch; d) Stabilize the femur, pull the patella into correct anatomical position; e) Insert the VMO tactile stimulator.

Kate J. Grace, PT, OPA-C, founded Kate Grace Physical Therapy in 1985 and continues to treat patients in her private practice located in San Diego. Grace and her business partner, Annie M. Fonte, MBA, developed the OnTrack System in 1996. They founded OrthoEd in 1996, and they have taught continuing-education courses on patellofemoral dysfunction throughout the world. Grace can be reached at . Fonte can be reached at .