Treatment of Patellofemoral Pain Syndrome

By: Grant Cutchin, ATC, VATL

Patellofemoral pain syndrome (PFPS) is a common knee ailment that causes anterior knee pain. PFPS affects active individuals particularly adolescents and is more likely to affect females. The anterior knee pain caused by PFPS can be described as diffuse and can become pronounced with a number of activities such as running, walking up and down stairs, performing squatting type exercises and sitting for long periods.

Lateral Riding PatellaThere are a number of reasons why one may develop this condition. Some are structural while others are musculoskeletal. Maltracking of the patella is considered to be a key contributor to PFPS. Maltracking of the patella is when the patella tracks laterally or away from the midline of the body. The patella may track laterally for a number of reasons including atrophy of a medial quadriceps muscle, increased Q-angle, weak hip abductors, iliotibial tract length, foot abnormalities and strength imbalance between the quadriceps and hamstrings.

A thorough physical examination by a qualified healthcare provider is required to determine which factors cause PFPS in each case. Likely, it will be a combination of the factors listed. These factors are most commonly corrected in a non-operative manner. For acute treatment and pain relief from PFPS, cryotherapy and non-steroidal anti-inflammatory drugs can be used. For cases of chronic PFPS, tape, braces and orthotics can be used to correct a maltracking patella. McConnell taping technique, Kinesiotape, and patella braces are used to pull the patella towards the mid-line of the body, or medially, to correct for the laterally tracking patella. Orthotics can also be used to correct foot abnormalities which can affect knee mechanics. Physical rehabilitation is an important part in treating PFPS. The rehabilitation can correct for weakness and imbalances noted in the physical examination. For example, if hip abductor weakness is found, a number of exercises should be performed to increase strength in that musculature. Exercises that can increase musculature of the lower extremity include monster walks to increase hip abductor strength, straight leg raises with hip external rotation to increase medial quadriceps activation, and hamstring stretches to increase hamstring length.

McConnell TapeIf these conservative methods do not yield favorable results, surgical procedures can be performed. One of the more popular surgical procedures to treat PFPS is called a lateral release. A lateral release is a procedure where the lateral retinaculum of the knee is cut to remove tension pulling the patella laterally.

Contact your physician or physical therapist if you need help with a personalized treatment plan or have questions about PFPS.

CHKD’s sports program medicine is a comprehensive sports medicine program with services provided solely for athletes under the age of 21.  Call 757-668-PLAY (7529) or visit our website at



Clijsen R, Fuchs J, Taeymans J. Effectiveness of exercise therapy in treatment of patients with patellofemoral pain syndrome: systematic review and meta-analysis. Physical Therapy. 2014;94(12):1697-1708. doi:10.2522/ptj.20130310.

McCarthy MM, Strickland SM. Patellofemoral pain: an update on diagnostic and treatment options. Current Reviews In Musculoskeletal Medicine. 2013;6(2):188-194. doi:10.1007/s12178-013-9159-x.

Petersen W, Ellermann A, Gosele-Koppenburg A, et al. Patellofemoral pain syndrome. Springer. November 2013. Accessed June 18, 2015.

Zhang D, Wu Z, Zuo X, Li J, Huang C. Diagnosis and treatment of excessive lateral pressure syndrome of the patellofemoral joint caused by military training. Orthopaedic Surgery. 2011;3(1):35-39. doi:10.1111/j.1757-7861.2010.00116.x.

Photos used belong to image 1. and Healthwise, Incorporated image 2.

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Sports Physicals: More than Jumping Through a Hoop

By: Dr. Joel S. Brenner, MD, MPH, FAAP

The Preparticipation Physical PPE MonographEvaluation (PPE) or sports physical is an important step in keeping children and adolescents healthy while remaining active. Many times the PPE is looked upon by athletes, parents and coaches as just another form to be signed.  However, there are good reasons it is currently required prior to participation. In fact, it should be performed on all children and adolescents as part of their well visit with their pediatrician or family physician. A young person who is playing recreational sports outside of school or playing with their friends on the playground is not at any lower risk for some of the life-threatening or life-altering conditions screened for than one who is participating in a school sponsored sport.

What are the goals of the PPE?

The main objectives of the PPE is to screen for life-threatening conditions or those that may lead to injuries or illness. In addition the PPE is helpful in determining general health for the young person. For many adolescents the only time they will see their primary care provider is for a sports physical. In fact, up to 80% of male adolescents’ only medical encounter is for a sports physical. Therefore, it is a good entry point to get adolescents into the health care system to help screen for other conditions (i.e. depression) and provide anticipatory guidance.

What is the best setting for a PPE?

Brenner Sports PhysicalsThe PPE should ideally be performed in the medical home (the pediatrician or family physician’s office). The pediatrician has an established relationship and knows the athlete’s entire past medical history including their family history, immunization records and previous laboratory studies. As part of this history they have access to any reports from other medical subspecialists (i.e cardiologists, sports medicine physicians) that may contain pertinent information that could affect their health and ability to participate safely. The physician’s office also provides privacy and a chance to discuss confidential matters that would not be possible in other settings.

The 4th edition of the PPE monograph, coauthored by 6 expert organizations, strongly recommends that the PPE be done in the medical home. However, there has been a prevailing culture that the exams are often performed in the school setting. The reasoning put forth are both financial and convenience. School based exams may be more convenient for those students who do not have a personal physician, lack health insurance or have transportation difficulties. However, many of these factors could be eliminated for a large proportion of the children since in most states they should qualify for health insurance. It is a matter of assisting the family in finding insurance coverage and choosing a pediatrician.

Smith Sports PhysicalsUltimately we do not want a young person not participating in sports or recreational activities due to these factors. Therefore, in these cases a coordinated medical team setting may be helpful. The setting should allow for privacy, a quiet environment, and for one health care provider to review the entire history and perform the physical examination of each individual athlete. Marching 200 student-athletes through a gymnasium or locker room in an hour will not meet this standard and should not be acceptable any longer. The PPE Monograph has further guidance to improve the coordinated medical team approach if necessary.

What forms should be used?

 Ninety-eight percent of the states require a PPE, but only 53% require a specific form. Unfortunately many of the forms lack critical questions as reported in a January 2015 study reported in Pediatrics.  Only 43% of the states addressed all of the recommended personal and family cardiovascular screening questions. It is recommended that history and physical forms published in the PPE monograph (the forms are free online) should be used or at least all of the information should be included in the state form.

Both the athletes and the parent should complete the forms together. Only 20-40% of athletes’ responses agreed with the information given by their parents completing the form. The history form is the most critical part as close to 90% of the medical and musculoskeletal conditions are diagnosed based on history.

Who should get a sports physical?

Unfortunately 70% of young athletes leave organized sports by 13 years of age and many youth sports leagues do not require a PPE. All children and adolescents should be encouraged to be physically active at every well visit. The PPE should be incorporated into every well visit and the same questions critical to the PPE should be addressed.



Bernhardt DT, Roberts WO, eds. PPE Preparticipation Physical Evaluation, Fourth Edition, Elk Grove Village, IL: American Academy of Pediatrics; April 2010.

Caswell S, Cortes N, Chabolla M, Ambegaonkar J, Caswell A, and Brenner JS, “State-Specific Differences in School Sports Preparticipation Physical Evaluation Policies” , Pediatrics 135 (1): 26-32, 2015.



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Type 1 Diabetic Athlete

By: Michael Mosciano, ATC

When the football player came to me during practice, I knew what was going on.  He had that look, I didn’t even ask, I just pulled out his blood glucose meter and gave it to him.  Not only was he a high school varsity athlete, but he is a diabetic too.  He pulled the meter out, pricked his finger and touched the test strip plugged into his meter.  “Are you low?” I asked.  “Yes.” He replied quietly.  I reached into my medical kit and pulled out a tube of oral glucose and tossed it to him.  In my 18 years as an athletic trainer, he was the first type 1 diabetic athlete I have ever had.  Not only did I need to re-educate myself, I needed to establish myself into the already existing team that had been monitoring him since he started high school.

So let’s take a look at what Type 1 Diabetes is and the steps that a diabetic athlete needs to take to compete at any level in sports.

What is Diabetes?

Types 1 diabetes is considered an autoimmune disorder in which the pancreas does not produce insulin (Jimenez, et. el).  Insulin is a protein hormone produced by the pancreas that helps the body to regulate blood glucose levels by causing the body’s cells to take glucose out of the blood.  It is usually diagnosed in childhood and these athletes have to Type 1 Diabetestake external injections of insulin to help maintain proper glucose levels (Parr).

Without the uptake of the glucose from the blood a condition called hyperglycemia will occur. Hyperglycemia when the blood glucose levels increase to dangerous levels.  Over time high blood glucose levels can cause sensation loss in the hands and feet, vision loss and damage to internal organs.

On the other end of the spectrum, diabetics can suffer from hypoglycemia.  Hypoglycemia is an acute decline in blood-sugar, when levels fall below 70mg/dL and can be a severe complication of insulin therapy (Jimenez, et. el).  Physical symptoms include moodiness, shakiness, confusion, and numbness in the arms and hands.   Diabetics must learn to recognize the symptoms to help prevent it from occurring.

Make your Game Plan

The primary goal of diabetic management is to maintain blood-glucose levels consistently in a normal or near normal range (Jimenez, et. el).  To do this the individual must monitor their blood glucose, maintain proper nutrition and make adjustments to insulin intake as needed.  A team management approach for school age athletes can help the athlete achieve their goals.  The team should include the student’s doctor, parents, school nurse, coach, school administrators, and the school’s athletic trainer.

According to the National Athletic Trainers Association guideline for diabetic athletes, their plan should include: blood glucose monitoring, insulin therapy, guidelines for both low blood sugar and high blood sugar, emergency contacts, and a medical alert.

Insulin PumpDiabetic Track Athlete







First thing the athlete needs to do is to talk to their doctor.  Let them know of your fitness and athletic goals.  Work with your doctor to establish blood glucose target ranges, insulin amounts, and diet strategies to help minimize complications.  And develop your plan to achieve those goals.

Athletes should measure their blood glucose levels prior to exercise, to see if they need to consume any additional carbohydrates.  If their blood glucose is low, then they need to additional carbohydrates prior to exercising.  But if they are too high, they should hold off exercise until their levels decrease.

Athletes should always alert their teammates and coaches that they are diabetic and about the signs and symptoms of hypoglycemia.  They will also want to alert opponents and officials about their condition and the possible need for extra breaks to allow for blood testing or carbohydrate consumption during play.  By wearing a medical alert bracelet, this will help alert coaches and medical staff of the athletes condition should a medical emergency occur.

Once they begin exercise, they will need to monitor how they feel.  If they start to feel tired or dizzy, then they will need to recheck their blood glucose levels.  If their blood Athlete checking blood glucoseglucose levels are low, they should alert their coach or athletic trainer about their condition.  Athletes should have some type of high-carbohydrate food with them during games and practices, should their blood glucose levels drop.  Good examples of snacks to have on hand include: fruit juices, sport drinks, fruit, and sugar candy.

While it may seem complicated, diabetes will not limit an individual from playing in sports.  Managing all the demands of the activity, the athlete’s goals, adequate glucose monitoring, and diet and insulin adjustments will allow for a safe and effective athletic performance.  It’s just a matter of finding the right formula that works best for that individual.


National Athletic Trainers’ Association (2007).  National Athletic Trainers’ Association Position Statement: Management of the Athlete With Type 1 Diabetes Mellitus.  Dallas, TX:  Jimenez, C, Corcoran, M, Crawley, J, Hornsby, G, Peer, K, Philbin, R, Riddell, M.

Parr, Brian, (2008) Living with Diabetes.  Retrieved from

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The Skinny on Running Shoes

By: Yuko Kimura-Koenig, ATC

Reasons Why Running Shoes Can Prevent Injuries

Did you know that the right pair of running shoes can help prevent injuries and even help you race faster?

Running ShoesThe massive improvement in human performance over the past several decades has been partly attributed to technology. From low-friction swimsuits and increasingly aerodynamic bicycles to high-tech running shoes, gear keeps getting better. And the athletes who use the right gear keep getting better, too.

For runners, choosing the right pair of shoes is critical. Your running shoe strategy can help prevent injuries and even improve your finish times. As a certified athletic trainer, I work with my runners to develop a well-rounded approach to prevention – and that includes their choice of running shoes.

It’s helpful to recognize shoes as “training tools” that accomplish a specific task. From protecting our feet, reinforcing proper running form, building foot and lower leg strength, and even reducing stress on our feet, shoes are a valuable part of a runner’s training tool kit.

Fit and Feel: How to Choose Running Shoes

Everyone asks, “What are the best kind of running shoes?” And it always depends!

Some runners swear by minimalist shoes, and others swear by more traditional running shoes. But here’s the truth: both minimalist and supportive running shoes can cause injuries if they’re not right for you.

The best solution for most people lies not on either end of this spectrum, but somewhere in the middle. And often, the best choice includes multiple shoes from across the spectrum.

Ultimately, runners should look for three critical characteristics in any pair of shoes:

  1. Foot TypesThe right shoes for your foot type (pronator: flat foot, neutral: between pronator and supinator, supinator: high arch foot).
  2. The shoes that feel good on your feet while running (if possible, buy a pair of shoes you know feel good or run a minute or two in them at the shoe store).
  3. The shoes that you feel smooth and often forget about your shoes because they are not clunky or overly stressing your feet.

So no matter what shoes you choose, focus on fit and how they feel while you’re running. This will mean that you’ll try a lot of different pairs of shoes. Yes, it might be expensive. Yes, it might be time-consuming. But you’ll also figure out exactly what you like and what works best for you.

Variety Helps Prevent Injuries

Let’s recognize that running injuries are technically repetitive stress injuries.  We know that running is repetitive, but how do we reduce the ongoing repetition of our beloved sport?

The secret is variety in your running. Varying as much as possible in your training helps reduce this repetition. You can:

  • Run more trails, with irregular surfaces that force your body to move in slightly different ways.
  • Run a variety of differently paced workouts that alter your form and biomechanics, changing how the forces of running are applied to your legs.
  • Rotate your running shoes!

Different kinds of shoes will alter your running mechanics and that vary the distribution of stress and load on your muscles, joints, and connective tissues.  Rotating shoes is a good general idea anyway because different shoes excel in different roles. For example, a more minimalist shoe might be better for shorter runs to help you focus on technique. Then you could use a more traditional running shoe during your long runs when extra cushioning is helpful.

A shoe with more cushioning will take some of the impact of running and make the muscles and joints of your lower leg work less. So cushioned shoes can help you run more, too – further, farther, and more often.

Ultimately, it’s helpful to expose your body to a wide variety of training stresses – and that certainly includes shoes. Rotating through 2-3 pairs of shoes, particularly for runners prone to foot or lower leg injuries, is a strategy to help the runners stay healthy.

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Football Hydration

By: Kirby Talman, ATC

It’s August and football two-a-days are starting today; have you had enough fluids? You want to make sure your body is properly hydrated to be able to perform to the best of its ability and to prevent the risk of dehydration and other heat illnesses. These are recommendations for fluid replacements for athletes during a sweatEvaporation of sweat from the skin is the primary way the body is cooled down as the core temperature rises during exercise. Sweating is the release of fluids from the body’s glands.  The sweating rate is related to exercise intensity, individual differences, environmental conditions, acclimatization, clothing, and baseline hydration. It’s important that your body has adequate fluids pre-, during, and post- exercise.

football hydrationAccording to the National Athletic Trainers’ Association, the athlete should consume 17 to 20 fluid ounces (fl oz) of water or sports drink 2 to 3 hours prior to exercise. About 10-20 minutes pre-exercise, consume 7 to 10 fl oz of water or sports drink. During exercise, the athlete should consume 7 to 10 oz of water or sports drink every 10 to 20 minutes. If bouts of exercise exceed more than 45 to 50 minutes, include carbohydrates in the drink. The optimal concentration of carbohydrates in the drink should be 6 to 8% per a liter, for example sports drinks. Fruit juices and sodas are not recommended and have concentrations higher than 8%. During games or long distance running, the athlete should consume the most fluids possible to maintain hydration. Fluids should be readability available, flavored football hydration 2to the athlete’s preference, and at a cool temperature. After exercise, athletes should replenish their fluids lost within two hours and no more than six hours.  One way to ensure you are properly hydrated is by the color of your urine. If your urine is clear, or has just a light yellow hue to it, you are doing well on hydration.

If an athlete is not properly hydrated, they are at risk for dehydration and other heat illnesses. Dehydration occurs when the loss of fluids, mostly water, exceeds the amount that is taken in. General signs and symptoms include headache, weakness, dizziness, cramps, chills, vomiting, nausea, and decreased performance. Dehydration occurs when the athlete loses more than 1 to 2% of body weight and if the athlete loses more than 3% they are at risk for other heat illnesses (heat cramps, heat exhaustion, or heat stroke). Proper hydration plays a key role in athletic performance.


Casa, D. J., Armstrong, L. E., Hillman, S. K., et al.  (2000) National Athletic Trainers’ Association Position Statement:  Fluid Replacement for Athletes.  Journal of Athletic Training, 35(2), 212-224.

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