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28 m a s s a g e & b o d y wo r k j a n u a r y/ fe b r u a r y 2 0 2 2 The biomechanical factors mentioned here are considered the most common causes of PFPS. However, psychosocial factors may also contribute to the pain. Anxiety, depression, catastrophizing (thinking things are much worse than they are), and kinesiophobia (fear of movement) may also contribute to the anterior knee pain of PFPS. It is not common for these psychosocial factors to produce pain on their own, but any combination of biomechanical and psychosocial factors should be considered in a complete evaluation. ASSESSMENT The evaluation of PFPS begins with a thorough client history. The most common complaint is pain felt with jumping, running, or climbing and descending stairs. Pain is also likely when the knee remains fl exed for long periods, such as a long car ride or sitting in a movie theater. As noted earlier, the client may also complain of grinding or grating sensations of the patella during knee fl exion or extension movements. You can place your hand lightly on the patella as the client is seated on the edge of the table and move the knee through fl exion and extension. Not much pressure on the patella is needed to feel these grinding sensations. The tissues surrounding the patella, especially the quadriceps retinaculum, may be tender when palpated. You can palpate them with the knee in full passive extension on the treatment table and when the knee is moving through fl exion and extension. Greater tensile loads are on the retinacular tissues during motion, and this increases sensitivity during palpation. It may also be helpful to grasp the patella between your fi ngers and move it from side to side (Image 5). Ideally, the patella should move about half its width to each side. It is not necessarily pathological if it does not move much, but note if it is signifi cantly restricted. Especially, note if it moves easily in a lateral direction but does not move much in a medial direction. This would indicate tightness in the lateral restraining tissues. Also, connective tissue fi bers from the iliotibial band extend into the lateral retinaculum around the quadriceps. So, tightness transmitted through the iliotibial band from the hip abductor and gluteus maximus muscles could also play a role in improper patellar tracking. There are several special orthopedic tests commonly used to evaluate PFPS. However, in recent years their accuracy has been called into question. 3 It appears that Q angle. Image courtesy of Complete Anatomy. 4 vastus medialis fi bers, this portion of the muscle is called the vastus medialis obliquus (VMO). PFPS is closely related to another condition called chondromalacia patella. Chondromalacia is softening and degeneration of the articular cartilage. When the patella is repeatedly pulled against the femoral condyles, as in a tracking disorder, it may cause degradation and breakdown of the articular cartilage on the underside of the patella. Cartilage degeneration is evident with grinding or grating sensations of the patella during knee fl exion and extension. Formerly, the pain of PFPS was blamed on cartilage degeneration. Yet, the hyaline cartilage under the patella is poorly innervated, so it is unlikely that signifi cant knee pain comes from the cartilage degeneration itself in PFPS. However, just under the cartilage is a layer of richly innervated subchondral bone. Pain could certainly result from friction of the subchondral bone. Q angle