Clinical Review

BY JEFF BAUER

A large retrospective analysis found a wide variation in opioid prescribing among emergency physicians (EPs) working within the same ED. The study also found that Medicare patients treated by EPs who wrote the most prescriptions for opioids were more likely to use opioids for 6 months after their ED visit than were those treated by EPs who wrote fewer opioid prescriptions.

Researchers evaluated initial visits to an ED by approximately 378,000 Medicare beneficiaries (average age: 68 years) from 2008 through 2011. None of these patients had received a prescription for an opioid in the 6 months before the ED visit, and none of the visits resulted in a hospital admission. Prescriptions for opioids (excluding methadone) were identified by the national drug code in the Medicare Part D database. An opioid prescription was attributed to the treating EP if the patient filled the prescription within 3 days after the ED visit.

Investigators categorized the treating EPs in this study as “high-intensity” or “low-intensity” opioid prescribers by calculating the proportion of all ED visits that resulted in an opioid prescription being filled. They then grouped the EPs into quartiles of opioid prescribing within each hospital. High-intensity prescribers were those in the top quartile of opioid prescribing rates, and low-intensity prescribers were those in the bottom quartile.

The primary outcome was long-term opioid use, defined as 6 months or more of opioids supplied in the 12 months after the initial ED visit. This did not include prescriptions filled within 30 days of the initial visit.

Overall, approximately 215,700 patients were treated by low-intensity prescribers and 162,000 by high-intensity prescribers. In general, the patient characteristics and diagnoses were similar in both groups. The rate of opioid prescribing of high-intensity prescribers was approximately triple the rate of low-intensity prescribers. High-intensity prescribers provided an opioid prescription for 21.4% of ED visits, compared to 7.3% among low-intensity prescribers.

Long-term opioid use at 12 months was significantly higher among patients who had been initially treated by high-intensity prescribers compared to those who had been treated by low-intensity prescribers (1.51% vs 1.16%; unadjusted odds ratio [OR], 1.31). There was minimal change in this difference after the results were adjusted for the patients’ age, race, sex, disability status, and presence of chronic conditions (OR, 1.30). The number needed to harm was calculated as 49, meaning theoretically, for every 49 patients who received a new opioid prescription in the ED, one would become a long-term user. The authors noted, however, that “…prescriptions provided by other physicians in the months after an [ED] visit are necessary for long-term opioid use to take hold.”

Researchers pointed out several limitations to their study. Because the study was observational, it could not establish causality. Researchers were not able to directly attribute opioid prescriptions to the treating EPs, but instead used prescriptions filled within 3 days of an ED visits as a surrogate; some opioid prescriptions could have been written by another clinician, such as the patient’s primary care physician during a follow-up visit. Because the study focused on Medicare patients, the results may not be applicable to younger patients. Based on their analysis, researchers could not determine whether an opioid prescription was appropriate, and therefore they could not quantify the extent of opioid overprescribing.

For more on EPs and opioid prescribing, see “The New Opioid Epidemic and the Law of Unintended Consequences” by Emergency Medicine Editor in Chief Neal Flomenbaum, MD (Emergency Medicine. 2017;49[2]:52) and “The New Opioid Epidemic: Prescriptions, Synthetics, and Street Drugs” by Rama B. Rao, MD and Emergency Medicine Associate Editor, Toxicology Lewis S. Nelson, MD (Emergency Medicine. 2017;49[2]:64-70).

Barnett ML, Olenski AR, Jena AB. Opioid-prescribing patterns of emergency physicians and risk of long-term use. N Engl J Med. 2017;376(7):663-673. doi:10.1056/NEJMsa1610524.

Lower Admission Rates, Other Factors Tied to High Rate of Death Soon After ED Discharge Among Older Adults

BY JEFF BAUER

Each year, approximately 10,000 older adult patients die within 7 days of discharge from an ED in the United States, despite having no obvious life-threatening illness, according to a large retrospective study. Emergency departments with lower rates of inpatient admission from the ED, lower patient volumes, and lower charges had significantly higher rates of death after discharge.

Researchers evaluated Medicare claims data related to slightly more than 10 million ED visits from 2007 to 2012. Because the goal was to study generally healthy patients, the following patients were excluded: individuals who were age 90 years and older; were receiving palliative or hospice care; or had received a life-limiting diagnosis, such as a myocardial infarction (MI) or a malignancy, either in the ED or in the year prior to the ED visit. The primary outcome was death within 7 days after discharge from an ED. The cause of death was determined by linking claims to death certificates; this information was available only for a subset of patients who visited an ED in 2007 or 2008.

Overall, during the 6-year study, 0.12% of discharged patients died within 7 days of discharge; this translates to more than 10,000 early deaths per year nationally. The leading causes of death were atherosclerotic heart disease (13.6%), MI (10.3%), and chronic obstructive pulmonary disease (9.6%).

Emergency departments ranked in the lowest fifth for admission rates admitted 15% of patients, compared to 56% of patients at EDs with the highest admission rates. The early death rate of patients treated at EDs with the lowest rates of inpatient admissions from the ED was 3.4 times higher than the death rate seen in EDs with the highest inpatient admission rates (0.27% vs 0.08%, respectively). This was true despite the fact that EDs with low-admission rates treated healthier patients, as evidenced by the overall 7-day mortality rate of all patients treated in the ED, whether they were admitted or discharged. Emergency departments that saw higher volumes of patients and had higher charges for visits had significantly fewer deaths.

Obermeyer Z, Cohn B, Wilson M, Jena AB, Cutler DM. Early death after discharge from emergency departments: analysis of national US insurance claims data. BMJ. 2017;356:j239. doi:10.1136/bmj.j239.

Tertiary Center Repeat Computed Tomography Scans Find Additional Injuries

MICHELE G. SULLIVAN

FRONTLINE MEDICAL NEWS

Imaging obtained at nontertiary trauma centers (NTCs) probably does not tell the whole story of a trauma patient’s injuries, according to a new retrospective study.

Repeat scans done at a Level 1 trauma center identified new injuries in 76% of patients who were transferred, Morgan Bonds, MD, reported at the annual scientific assembly of the Eastern Association for the Surgery of Trauma. About half of these previously unobserved injuries were considered clinically significant, said Dr Bonds, a surgical resident at the University of Oklahoma, Oklahoma City.

Her study examined imaging and clinical assessment of 203 trauma patients who were initially worked up at an NTC, and then transferred to the Level 1 University of Oklahoma tertiary trauma center (TTC). The facility’s primary radiologist reviewed all of the initial computed tomography (CT) scans while blinded to the NTC interpretation. The initial scans and interpretations were then compared with those done at the TTC.

The team split imaging and interpretation disconnects into four categories:

• Type A errors: A missed injury on the NTC scan. “This represents the expertise and experience of our primary radiologist,” Dr Bonds said.
• Type B errors: Missed injuries on scans where NTC radiologists saw other injuries that the TTC radiologist did not confirm. “This represents the experience of our radiologist and also the inexperience and overreaction of the NTC radiologists.”
• Type C errors: New injuries seen on additional TTC imaging of the same body area. “This represents the quality of the image.”
• Type D errors: New injuries found upon any new imaging, whether of a previously scanned or newly scanned body area. “This represents quality of work-up—the decision of the trauma team to more fully investigate the patient’s injuries, as well as the quality of the CT tech performing the scan.”

During the study period, 203 patients presented at the TTC with prior scans conducted at an NTC.

The mean age of the patients was 43 years; most (67%) were men. The mean Injury Severity Score was 16; 97% had experienced blunt trauma. Shock was present in 3% and a traumatic brain injury in 8%. Repeat scans were most common for neck and cervical spine injuries (54%) and thoracic/lumbar spine injuries (53%), and least common for chest injuries (32%).

An inadequate NTC work-up as judged by the TTC attending was the most common reason for obtaining new images (76%). Poor image quality was the next most common reason (31%).

Among the 203 patients, 99 (49%) had a type A error. Of these injuries missed on the initial scan, 90% were considered to be clinically significant.

Type B errors occurred in 15% of patients. Type C errors (new injuries in different body area) occurred in 54% of patients and, of these, 76% were considered clinically significant. Type D errors (new injuries seen in any imaging of any area) occurred in 73% of patients.

“This study confirms that images are often repeated or completed after having images done at NTCs,” Dr Bonds said. “Relying on NTC image interpretation can lead to undertreating our patients. One potential solution to this issue could be image sharing between NTCs and TTCs. This might reduce both the rate of missed injuries and the need for repeat scans.”

Cutaneous Eruption Reported in Pregnant Woman With Locally Acquired Zika Virus

M. ALEXANDER OTTO

FRONTLINE MEDICAL NEWS

Zika presented in a young, pregnant Florida woman as erythematous follicular macules and papules on the trunk and arms, scattered tender pink papules on the palms, and a few petechiae on the hard palate, according to a report in the New England Journal of Medicine.

The report advises how Zika virus may present during pregnancy. “Medical providers on the front line should be aware of the constellation of symptoms in patients reporting travel to endemic areas, including areas in Southern Florida, where other non-travel-associated cases have been confirmed,” wrote investigators led by Lucy Chen, MD, of the University of Miami.

The 23-year-old woman presented on July 7, 2016 at 23 weeks and 3 days’ gestation with a 3-day history of fever, widespread pruritic rash, and sore throat, which were followed by myalgias and joint pain 2 days later. The cutaneous eruption was noted on physical examination; neither conjunctivitis nor lymphadenopathy was present. The patient and her partner said they had not traveled outside the United States for 2 years.

Zika virus RNA was detected in the woman’s urine and serum specimens with the use of reverse-transcriptase polymerase chain reaction and persisted for 2 weeks in urine samples and for 6 weeks in serum samples. On histopathology, skin lesions revealed a mild perivascular lymphocytic infiltration in the upper dermis, admixed with some neutrophils. Liver and renal functions were normal.

Fetal ultrasonography performed on the day of presentation showed an estimated fetal weight of 644 g (53rd percentile), an estimated head circumference of 221 mm (63rd percentile), and normal intracranial anatomy. Fevers and rash subsided after 3 days of supportive care. Screening for measles, varicella, rubella, syphilis, Epstein-Barr virus, influenza, hepatitis B, hepatitis C, mumps, and dengue was negative.

An initial immunoglobulin M test on July 7 was negative; seroconversion occurred 1 week after presentation and remained positive through delivery.

A full-term infant weighing 2,990 g was delivered vaginally. Neonatal ultrasonography and magnetic resonance imaging of the head showed a normal head size and intracranial anatomy, with no calcifications. Placental tissue was negative for Zika virus, and neonatal laboratory testing revealed no evidence of infection.

The case was confirmed by the Miami-Dade County Department of Health as the first non-travel-associated Zika infection in the United States.

Chen L, Hafeez F, Curry CL, Elgart G. Cutaneous eruption in a U.S. woman with locally acquired Zika virus infection. N Engl J Med. 2017;376(4):400-401. doi:10.1056/NEJMc1610614.

Lab Values Poor Surrogate for Detecting Pediatric Rocky Mountain Spotted Fever in Children

WHITNEY MCKNIGHT

FRONTLINE MEDICAL NEWS

Three fatalities observed in a retrospective analysis of six cases of Rocky Mountain spotted fever (RMSF) in children were associated with either a delayed diagnosis pending laboratory findings or delayed anti-rickettsia treatment, researchers said.

“The fact that all fatal cases died before the convalescent period emphasizes that diagnosis should be based on clinical findings instead of RMSF serologic and histologic testing,” wrote the authors of a study published online in Pediatric Dermatology.

Rechelle Tull of the department of dermatology, Wake Forest University, Winston-Salem, NC, and her colleagues conducted a retrospective review of 3,912 inpatient dermatology consultations over a period of 10 years at a tertiary care center, and identified six patients aged 22 months to 2 years (mean, 5.1 years) diagnosed with RMSF. The patients were evaluated in the months of April, May, and June, and three of the six patients infected with the vector-borne obligate intracellular bacterium, Rickettsia rickettsii, had died within 4 days of hospitalization, according to the authors.

Two of the fatal cases involved delayed anti-rickettsial therapy after the patients were misdiagnosed with group A Streptococcus. None of the six children were initially evaluated for R rickettsii; they averaged three encounters with their clinician before being admitted for acute inpatient care, where they received intravenous doxycycline after nearly a week of symptoms.

“All fatal cases were complicated by neurologic manifestations, including seizures, obtundation, and uncal herniation,” a finding that is consistent with the literature, the authors said.

Although the high-fatality rate might be the result of the small study size, Ms Tull and her coinvestigators concluded that the disease should be considered in all differential diagnoses for children who present with a fever and rash during the summer months in endemic areas, particularly since pediatric cases of the disease are associated with poorer outcomes than adult cases.

Given that RMSF often remains subclinical in its early stages, and typically presents with nonspecific symptoms of fever, rash, headache, and abdominal pain when it does emerge, physicians might be tempted to defer treatment until after serological and histological results are in, as is the standard method. Concerns over doxycycline’s tendency to stain teeth and cause enamel hypoplasia are also common. However, empirical administration could mean the difference between life and death, since treatment within the first 5 days following infection is associated with better outcomes—an algorithm complicated by the fact that symptoms caused by R rickettsii have been known to take as long as 21 days to appear.

In the study, Ms Tull and her colleagues found that the average time between exposure to the tick and the onset of symptoms was 6.6 days (range, 1-21 days).

Currently, there are no diagnostic tests “that reliably diagnose RMSF during the first 7 days of illness,” and most patients “do not develop detectable antibodies until the second week of illness,” the investigators reported. Even then, sensitivity of indirect fluorescent antibody serum testing after the second week of illness is only between 86% and 94%, they noted. Further, the sensitivity of immunohistochemical (IHC) tissue staining has been reported at 70%, and false-negative IHC results are common in acute disease when antibody response is harder to detect.

Ms Tull and her colleagues found that five of the six patients in their study had negative IHC testing; two of the six had positive serum antibody titers. For this reason, they concluded that RMSF diagnosis should be based on “clinical history, examination, and laboratory abnormalities” rather than laboratory testing, and urged that “prompt treatment should be instituted empirically.”

Tull R, Ahn C, Daniel A, Yosipovitch G, Strowd LC. Retrospective study of Rocky Mountain spotted fever in children. Pediatr Dermatol. 2016 Dec 19. doi:10.1111/pde.13053. [Epub ahead of print]

BY JEFF BAUER

A large retrospective analysis found a wide variation in opioid prescribing among emergency physicians (EPs) working within the same ED. The study also found that Medicare patients treated by EPs who wrote the most prescriptions for opioids were more likely to use opioids for 6 months after their ED visit than were those treated by EPs who wrote fewer opioid prescriptions.

Researchers evaluated initial visits to an ED by approximately 378,000 Medicare beneficiaries (average age: 68 years) from 2008 through 2011. None of these patients had received a prescription for an opioid in the 6 months before the ED visit, and none of the visits resulted in a hospital admission. Prescriptions for opioids (excluding methadone) were identified by the national drug code in the Medicare Part D database. An opioid prescription was attributed to the treating EP if the patient filled the prescription within 3 days after the ED visit.

Investigators categorized the treating EPs in this study as “high-intensity” or “low-intensity” opioid prescribers by calculating the proportion of all ED visits that resulted in an opioid prescription being filled. They then grouped the EPs into quartiles of opioid prescribing within each hospital. High-intensity prescribers were those in the top quartile of opioid prescribing rates, and low-intensity prescribers were those in the bottom quartile.

The primary outcome was long-term opioid use, defined as 6 months or more of opioids supplied in the 12 months after the initial ED visit. This did not include prescriptions filled within 30 days of the initial visit.

Overall, approximately 215,700 patients were treated by low-intensity prescribers and 162,000 by high-intensity prescribers. In general, the patient characteristics and diagnoses were similar in both groups. The rate of opioid prescribing of high-intensity prescribers was approximately triple the rate of low-intensity prescribers. High-intensity prescribers provided an opioid prescription for 21.4% of ED visits, compared to 7.3% among low-intensity prescribers.

Long-term opioid use at 12 months was significantly higher among patients who had been initially treated by high-intensity prescribers compared to those who had been treated by low-intensity prescribers (1.51% vs 1.16%; unadjusted odds ratio [OR], 1.31). There was minimal change in this difference after the results were adjusted for the patients’ age, race, sex, disability status, and presence of chronic conditions (OR, 1.30). The number needed to harm was calculated as 49, meaning theoretically, for every 49 patients who received a new opioid prescription in the ED, one would become a long-term user. The authors noted, however, that “…prescriptions provided by other physicians in the months after an [ED] visit are necessary for long-term opioid use to take hold.”

Researchers pointed out several limitations to their study. Because the study was observational, it could not establish causality. Researchers were not able to directly attribute opioid prescriptions to the treating EPs, but instead used prescriptions filled within 3 days of an ED visits as a surrogate; some opioid prescriptions could have been written by another clinician, such as the patient’s primary care physician during a follow-up visit. Because the study focused on Medicare patients, the results may not be applicable to younger patients. Based on their analysis, researchers could not determine whether an opioid prescription was appropriate, and therefore they could not quantify the extent of opioid overprescribing.

For more on EPs and opioid prescribing, see “The New Opioid Epidemic and the Law of Unintended Consequences” by Emergency Medicine Editor in Chief Neal Flomenbaum, MD (Emergency Medicine. 2017;49[2]:52) and “The New Opioid Epidemic: Prescriptions, Synthetics, and Street Drugs” by Rama B. Rao, MD and Emergency Medicine Associate Editor, Toxicology Lewis S. Nelson, MD (Emergency Medicine. 2017;49[2]:64-70).

Barnett ML, Olenski AR, Jena AB. Opioid-prescribing patterns of emergency physicians and risk of long-term use. N Engl J Med. 2017;376(7):663-673. doi:10.1056/NEJMsa1610524.

Lower Admission Rates, Other Factors Tied to High Rate of Death Soon After ED Discharge Among Older Adults

BY JEFF BAUER

Each year, approximately 10,000 older adult patients die within 7 days of discharge from an ED in the United States, despite having no obvious life-threatening illness, according to a large retrospective study. Emergency departments with lower rates of inpatient admission from the ED, lower patient volumes, and lower charges had significantly higher rates of death after discharge.

Researchers evaluated Medicare claims data related to slightly more than 10 million ED visits from 2007 to 2012. Because the goal was to study generally healthy patients, the following patients were excluded: individuals who were age 90 years and older; were receiving palliative or hospice care; or had received a life-limiting diagnosis, such as a myocardial infarction (MI) or a malignancy, either in the ED or in the year prior to the ED visit. The primary outcome was death within 7 days after discharge from an ED. The cause of death was determined by linking claims to death certificates; this information was available only for a subset of patients who visited an ED in 2007 or 2008.

Overall, during the 6-year study, 0.12% of discharged patients died within 7 days of discharge; this translates to more than 10,000 early deaths per year nationally. The leading causes of death were atherosclerotic heart disease (13.6%), MI (10.3%), and chronic obstructive pulmonary disease (9.6%).

Emergency departments ranked in the lowest fifth for admission rates admitted 15% of patients, compared to 56% of patients at EDs with the highest admission rates. The early death rate of patients treated at EDs with the lowest rates of inpatient admissions from the ED was 3.4 times higher than the death rate seen in EDs with the highest inpatient admission rates (0.27% vs 0.08%, respectively). This was true despite the fact that EDs with low-admission rates treated healthier patients, as evidenced by the overall 7-day mortality rate of all patients treated in the ED, whether they were admitted or discharged. Emergency departments that saw higher volumes of patients and had higher charges for visits had significantly fewer deaths.

Obermeyer Z, Cohn B, Wilson M, Jena AB, Cutler DM. Early death after discharge from emergency departments: analysis of national US insurance claims data. BMJ. 2017;356:j239. doi:10.1136/bmj.j239.

Tertiary Center Repeat Computed Tomography Scans Find Additional Injuries

MICHELE G. SULLIVAN

FRONTLINE MEDICAL NEWS

Imaging obtained at nontertiary trauma centers (NTCs) probably does not tell the whole story of a trauma patient’s injuries, according to a new retrospective study.

Repeat scans done at a Level 1 trauma center identified new injuries in 76% of patients who were transferred, Morgan Bonds, MD, reported at the annual scientific assembly of the Eastern Association for the Surgery of Trauma. About half of these previously unobserved injuries were considered clinically significant, said Dr Bonds, a surgical resident at the University of Oklahoma, Oklahoma City.

Her study examined imaging and clinical assessment of 203 trauma patients who were initially worked up at an NTC, and then transferred to the Level 1 University of Oklahoma tertiary trauma center (TTC). The facility’s primary radiologist reviewed all of the initial computed tomography (CT) scans while blinded to the NTC interpretation. The initial scans and interpretations were then compared with those done at the TTC.

The team split imaging and interpretation disconnects into four categories:

• Type A errors: A missed injury on the NTC scan. “This represents the expertise and experience of our primary radiologist,” Dr Bonds said.
• Type B errors: Missed injuries on scans where NTC radiologists saw other injuries that the TTC radiologist did not confirm. “This represents the experience of our radiologist and also the inexperience and overreaction of the NTC radiologists.”
• Type C errors: New injuries seen on additional TTC imaging of the same body area. “This represents the quality of the image.”
• Type D errors: New injuries found upon any new imaging, whether of a previously scanned or newly scanned body area. “This represents quality of work-up—the decision of the trauma team to more fully investigate the patient’s injuries, as well as the quality of the CT tech performing the scan.”

During the study period, 203 patients presented at the TTC with prior scans conducted at an NTC.

The mean age of the patients was 43 years; most (67%) were men. The mean Injury Severity Score was 16; 97% had experienced blunt trauma. Shock was present in 3% and a traumatic brain injury in 8%. Repeat scans were most common for neck and cervical spine injuries (54%) and thoracic/lumbar spine injuries (53%), and least common for chest injuries (32%).

An inadequate NTC work-up as judged by the TTC attending was the most common reason for obtaining new images (76%). Poor image quality was the next most common reason (31%).

Among the 203 patients, 99 (49%) had a type A error. Of these injuries missed on the initial scan, 90% were considered to be clinically significant.

Type B errors occurred in 15% of patients. Type C errors (new injuries in different body area) occurred in 54% of patients and, of these, 76% were considered clinically significant. Type D errors (new injuries seen in any imaging of any area) occurred in 73% of patients.

“This study confirms that images are often repeated or completed after having images done at NTCs,” Dr Bonds said. “Relying on NTC image interpretation can lead to undertreating our patients. One potential solution to this issue could be image sharing between NTCs and TTCs. This might reduce both the rate of missed injuries and the need for repeat scans.”

Cutaneous Eruption Reported in Pregnant Woman With Locally Acquired Zika Virus

M. ALEXANDER OTTO

FRONTLINE MEDICAL NEWS

Zika presented in a young, pregnant Florida woman as erythematous follicular macules and papules on the trunk and arms, scattered tender pink papules on the palms, and a few petechiae on the hard palate, according to a report in the New England Journal of Medicine.

The report advises how Zika virus may present during pregnancy. “Medical providers on the front line should be aware of the constellation of symptoms in patients reporting travel to endemic areas, including areas in Southern Florida, where other non-travel-associated cases have been confirmed,” wrote investigators led by Lucy Chen, MD, of the University of Miami.

The 23-year-old woman presented on July 7, 2016 at 23 weeks and 3 days’ gestation with a 3-day history of fever, widespread pruritic rash, and sore throat, which were followed by myalgias and joint pain 2 days later. The cutaneous eruption was noted on physical examination; neither conjunctivitis nor lymphadenopathy was present. The patient and her partner said they had not traveled outside the United States for 2 years.

Zika virus RNA was detected in the woman’s urine and serum specimens with the use of reverse-transcriptase polymerase chain reaction and persisted for 2 weeks in urine samples and for 6 weeks in serum samples. On histopathology, skin lesions revealed a mild perivascular lymphocytic infiltration in the upper dermis, admixed with some neutrophils. Liver and renal functions were normal.

Fetal ultrasonography performed on the day of presentation showed an estimated fetal weight of 644 g (53rd percentile), an estimated head circumference of 221 mm (63rd percentile), and normal intracranial anatomy. Fevers and rash subsided after 3 days of supportive care. Screening for measles, varicella, rubella, syphilis, Epstein-Barr virus, influenza, hepatitis B, hepatitis C, mumps, and dengue was negative.

An initial immunoglobulin M test on July 7 was negative; seroconversion occurred 1 week after presentation and remained positive through delivery.

A full-term infant weighing 2,990 g was delivered vaginally. Neonatal ultrasonography and magnetic resonance imaging of the head showed a normal head size and intracranial anatomy, with no calcifications. Placental tissue was negative for Zika virus, and neonatal laboratory testing revealed no evidence of infection.

The case was confirmed by the Miami-Dade County Department of Health as the first non-travel-associated Zika infection in the United States.

Chen L, Hafeez F, Curry CL, Elgart G. Cutaneous eruption in a U.S. woman with locally acquired Zika virus infection. N Engl J Med. 2017;376(4):400-401. doi:10.1056/NEJMc1610614.

Lab Values Poor Surrogate for Detecting Pediatric Rocky Mountain Spotted Fever in Children

WHITNEY MCKNIGHT

FRONTLINE MEDICAL NEWS

Three fatalities observed in a retrospective analysis of six cases of Rocky Mountain spotted fever (RMSF) in children were associated with either a delayed diagnosis pending laboratory findings or delayed anti-rickettsia treatment, researchers said.

“The fact that all fatal cases died before the convalescent period emphasizes that diagnosis should be based on clinical findings instead of RMSF serologic and histologic testing,” wrote the authors of a study published online in Pediatric Dermatology.

Rechelle Tull of the department of dermatology, Wake Forest University, Winston-Salem, NC, and her colleagues conducted a retrospective review of 3,912 inpatient dermatology consultations over a period of 10 years at a tertiary care center, and identified six patients aged 22 months to 2 years (mean, 5.1 years) diagnosed with RMSF. The patients were evaluated in the months of April, May, and June, and three of the six patients infected with the vector-borne obligate intracellular bacterium, Rickettsia rickettsii, had died within 4 days of hospitalization, according to the authors.

Two of the fatal cases involved delayed anti-rickettsial therapy after the patients were misdiagnosed with group A Streptococcus. None of the six children were initially evaluated for R rickettsii; they averaged three encounters with their clinician before being admitted for acute inpatient care, where they received intravenous doxycycline after nearly a week of symptoms.

“All fatal cases were complicated by neurologic manifestations, including seizures, obtundation, and uncal herniation,” a finding that is consistent with the literature, the authors said.

Although the high-fatality rate might be the result of the small study size, Ms Tull and her coinvestigators concluded that the disease should be considered in all differential diagnoses for children who present with a fever and rash during the summer months in endemic areas, particularly since pediatric cases of the disease are associated with poorer outcomes than adult cases.

Given that RMSF often remains subclinical in its early stages, and typically presents with nonspecific symptoms of fever, rash, headache, and abdominal pain when it does emerge, physicians might be tempted to defer treatment until after serological and histological results are in, as is the standard method. Concerns over doxycycline’s tendency to stain teeth and cause enamel hypoplasia are also common. However, empirical administration could mean the difference between life and death, since treatment within the first 5 days following infection is associated with better outcomes—an algorithm complicated by the fact that symptoms caused by R rickettsii have been known to take as long as 21 days to appear.

In the study, Ms Tull and her colleagues found that the average time between exposure to the tick and the onset of symptoms was 6.6 days (range, 1-21 days).

Currently, there are no diagnostic tests “that reliably diagnose RMSF during the first 7 days of illness,” and most patients “do not develop detectable antibodies until the second week of illness,” the investigators reported. Even then, sensitivity of indirect fluorescent antibody serum testing after the second week of illness is only between 86% and 94%, they noted. Further, the sensitivity of immunohistochemical (IHC) tissue staining has been reported at 70%, and false-negative IHC results are common in acute disease when antibody response is harder to detect.

Ms Tull and her colleagues found that five of the six patients in their study had negative IHC testing; two of the six had positive serum antibody titers. For this reason, they concluded that RMSF diagnosis should be based on “clinical history, examination, and laboratory abnormalities” rather than laboratory testing, and urged that “prompt treatment should be instituted empirically.”

Tull R, Ahn C, Daniel A, Yosipovitch G, Strowd LC. Retrospective study of Rocky Mountain spotted fever in children. Pediatr Dermatol. 2016 Dec 19. doi:10.1111/pde.13053. [Epub ahead of print]

BY JEFF BAUER

A large retrospective analysis found a wide variation in opioid prescribing among emergency physicians (EPs) working within the same ED. The study also found that Medicare patients treated by EPs who wrote the most prescriptions for opioids were more likely to use opioids for 6 months after their ED visit than were those treated by EPs who wrote fewer opioid prescriptions.

Researchers evaluated initial visits to an ED by approximately 378,000 Medicare beneficiaries (average age: 68 years) from 2008 through 2011. None of these patients had received a prescription for an opioid in the 6 months before the ED visit, and none of the visits resulted in a hospital admission. Prescriptions for opioids (excluding methadone) were identified by the national drug code in the Medicare Part D database. An opioid prescription was attributed to the treating EP if the patient filled the prescription within 3 days after the ED visit.

Investigators categorized the treating EPs in this study as “high-intensity” or “low-intensity” opioid prescribers by calculating the proportion of all ED visits that resulted in an opioid prescription being filled. They then grouped the EPs into quartiles of opioid prescribing within each hospital. High-intensity prescribers were those in the top quartile of opioid prescribing rates, and low-intensity prescribers were those in the bottom quartile.

The primary outcome was long-term opioid use, defined as 6 months or more of opioids supplied in the 12 months after the initial ED visit. This did not include prescriptions filled within 30 days of the initial visit.

Overall, approximately 215,700 patients were treated by low-intensity prescribers and 162,000 by high-intensity prescribers. In general, the patient characteristics and diagnoses were similar in both groups. The rate of opioid prescribing of high-intensity prescribers was approximately triple the rate of low-intensity prescribers. High-intensity prescribers provided an opioid prescription for 21.4% of ED visits, compared to 7.3% among low-intensity prescribers.

Long-term opioid use at 12 months was significantly higher among patients who had been initially treated by high-intensity prescribers compared to those who had been treated by low-intensity prescribers (1.51% vs 1.16%; unadjusted odds ratio [OR], 1.31). There was minimal change in this difference after the results were adjusted for the patients’ age, race, sex, disability status, and presence of chronic conditions (OR, 1.30). The number needed to harm was calculated as 49, meaning theoretically, for every 49 patients who received a new opioid prescription in the ED, one would become a long-term user. The authors noted, however, that “…prescriptions provided by other physicians in the months after an [ED] visit are necessary for long-term opioid use to take hold.”

Researchers pointed out several limitations to their study. Because the study was observational, it could not establish causality. Researchers were not able to directly attribute opioid prescriptions to the treating EPs, but instead used prescriptions filled within 3 days of an ED visits as a surrogate; some opioid prescriptions could have been written by another clinician, such as the patient’s primary care physician during a follow-up visit. Because the study focused on Medicare patients, the results may not be applicable to younger patients. Based on their analysis, researchers could not determine whether an opioid prescription was appropriate, and therefore they could not quantify the extent of opioid overprescribing.

For more on EPs and opioid prescribing, see “The New Opioid Epidemic and the Law of Unintended Consequences” by Emergency Medicine Editor in Chief Neal Flomenbaum, MD (Emergency Medicine. 2017;49[2]:52) and “The New Opioid Epidemic: Prescriptions, Synthetics, and Street Drugs” by Rama B. Rao, MD and Emergency Medicine Associate Editor, Toxicology Lewis S. Nelson, MD (Emergency Medicine. 2017;49[2]:64-70).

Barnett ML, Olenski AR, Jena AB. Opioid-prescribing patterns of emergency physicians and risk of long-term use. N Engl J Med. 2017;376(7):663-673. doi:10.1056/NEJMsa1610524.

Lower Admission Rates, Other Factors Tied to High Rate of Death Soon After ED Discharge Among Older Adults

BY JEFF BAUER

Each year, approximately 10,000 older adult patients die within 7 days of discharge from an ED in the United States, despite having no obvious life-threatening illness, according to a large retrospective study. Emergency departments with lower rates of inpatient admission from the ED, lower patient volumes, and lower charges had significantly higher rates of death after discharge.

Researchers evaluated Medicare claims data related to slightly more than 10 million ED visits from 2007 to 2012. Because the goal was to study generally healthy patients, the following patients were excluded: individuals who were age 90 years and older; were receiving palliative or hospice care; or had received a life-limiting diagnosis, such as a myocardial infarction (MI) or a malignancy, either in the ED or in the year prior to the ED visit. The primary outcome was death within 7 days after discharge from an ED. The cause of death was determined by linking claims to death certificates; this information was available only for a subset of patients who visited an ED in 2007 or 2008.

Overall, during the 6-year study, 0.12% of discharged patients died within 7 days of discharge; this translates to more than 10,000 early deaths per year nationally. The leading causes of death were atherosclerotic heart disease (13.6%), MI (10.3%), and chronic obstructive pulmonary disease (9.6%).

Emergency departments ranked in the lowest fifth for admission rates admitted 15% of patients, compared to 56% of patients at EDs with the highest admission rates. The early death rate of patients treated at EDs with the lowest rates of inpatient admissions from the ED was 3.4 times higher than the death rate seen in EDs with the highest inpatient admission rates (0.27% vs 0.08%, respectively). This was true despite the fact that EDs with low-admission rates treated healthier patients, as evidenced by the overall 7-day mortality rate of all patients treated in the ED, whether they were admitted or discharged. Emergency departments that saw higher volumes of patients and had higher charges for visits had significantly fewer deaths.

Obermeyer Z, Cohn B, Wilson M, Jena AB, Cutler DM. Early death after discharge from emergency departments: analysis of national US insurance claims data. BMJ. 2017;356:j239. doi:10.1136/bmj.j239.

Tertiary Center Repeat Computed Tomography Scans Find Additional Injuries

MICHELE G. SULLIVAN

FRONTLINE MEDICAL NEWS

Imaging obtained at nontertiary trauma centers (NTCs) probably does not tell the whole story of a trauma patient’s injuries, according to a new retrospective study.

Repeat scans done at a Level 1 trauma center identified new injuries in 76% of patients who were transferred, Morgan Bonds, MD, reported at the annual scientific assembly of the Eastern Association for the Surgery of Trauma. About half of these previously unobserved injuries were considered clinically significant, said Dr Bonds, a surgical resident at the University of Oklahoma, Oklahoma City.

Her study examined imaging and clinical assessment of 203 trauma patients who were initially worked up at an NTC, and then transferred to the Level 1 University of Oklahoma tertiary trauma center (TTC). The facility’s primary radiologist reviewed all of the initial computed tomography (CT) scans while blinded to the NTC interpretation. The initial scans and interpretations were then compared with those done at the TTC.

The team split imaging and interpretation disconnects into four categories:

• Type A errors: A missed injury on the NTC scan. “This represents the expertise and experience of our primary radiologist,” Dr Bonds said.
• Type B errors: Missed injuries on scans where NTC radiologists saw other injuries that the TTC radiologist did not confirm. “This represents the experience of our radiologist and also the inexperience and overreaction of the NTC radiologists.”
• Type C errors: New injuries seen on additional TTC imaging of the same body area. “This represents the quality of the image.”
• Type D errors: New injuries found upon any new imaging, whether of a previously scanned or newly scanned body area. “This represents quality of work-up—the decision of the trauma team to more fully investigate the patient’s injuries, as well as the quality of the CT tech performing the scan.”

During the study period, 203 patients presented at the TTC with prior scans conducted at an NTC.

The mean age of the patients was 43 years; most (67%) were men. The mean Injury Severity Score was 16; 97% had experienced blunt trauma. Shock was present in 3% and a traumatic brain injury in 8%. Repeat scans were most common for neck and cervical spine injuries (54%) and thoracic/lumbar spine injuries (53%), and least common for chest injuries (32%).

An inadequate NTC work-up as judged by the TTC attending was the most common reason for obtaining new images (76%). Poor image quality was the next most common reason (31%).

Among the 203 patients, 99 (49%) had a type A error. Of these injuries missed on the initial scan, 90% were considered to be clinically significant.

Type B errors occurred in 15% of patients. Type C errors (new injuries in different body area) occurred in 54% of patients and, of these, 76% were considered clinically significant. Type D errors (new injuries seen in any imaging of any area) occurred in 73% of patients.

“This study confirms that images are often repeated or completed after having images done at NTCs,” Dr Bonds said. “Relying on NTC image interpretation can lead to undertreating our patients. One potential solution to this issue could be image sharing between NTCs and TTCs. This might reduce both the rate of missed injuries and the need for repeat scans.”

Cutaneous Eruption Reported in Pregnant Woman With Locally Acquired Zika Virus

M. ALEXANDER OTTO

FRONTLINE MEDICAL NEWS

Zika presented in a young, pregnant Florida woman as erythematous follicular macules and papules on the trunk and arms, scattered tender pink papules on the palms, and a few petechiae on the hard palate, according to a report in the New England Journal of Medicine.

The report advises how Zika virus may present during pregnancy. “Medical providers on the front line should be aware of the constellation of symptoms in patients reporting travel to endemic areas, including areas in Southern Florida, where other non-travel-associated cases have been confirmed,” wrote investigators led by Lucy Chen, MD, of the University of Miami.

The 23-year-old woman presented on July 7, 2016 at 23 weeks and 3 days’ gestation with a 3-day history of fever, widespread pruritic rash, and sore throat, which were followed by myalgias and joint pain 2 days later. The cutaneous eruption was noted on physical examination; neither conjunctivitis nor lymphadenopathy was present. The patient and her partner said they had not traveled outside the United States for 2 years.

Zika virus RNA was detected in the woman’s urine and serum specimens with the use of reverse-transcriptase polymerase chain reaction and persisted for 2 weeks in urine samples and for 6 weeks in serum samples. On histopathology, skin lesions revealed a mild perivascular lymphocytic infiltration in the upper dermis, admixed with some neutrophils. Liver and renal functions were normal.

Fetal ultrasonography performed on the day of presentation showed an estimated fetal weight of 644 g (53rd percentile), an estimated head circumference of 221 mm (63rd percentile), and normal intracranial anatomy. Fevers and rash subsided after 3 days of supportive care. Screening for measles, varicella, rubella, syphilis, Epstein-Barr virus, influenza, hepatitis B, hepatitis C, mumps, and dengue was negative.

An initial immunoglobulin M test on July 7 was negative; seroconversion occurred 1 week after presentation and remained positive through delivery.

A full-term infant weighing 2,990 g was delivered vaginally. Neonatal ultrasonography and magnetic resonance imaging of the head showed a normal head size and intracranial anatomy, with no calcifications. Placental tissue was negative for Zika virus, and neonatal laboratory testing revealed no evidence of infection.

The case was confirmed by the Miami-Dade County Department of Health as the first non-travel-associated Zika infection in the United States.

Chen L, Hafeez F, Curry CL, Elgart G. Cutaneous eruption in a U.S. woman with locally acquired Zika virus infection. N Engl J Med. 2017;376(4):400-401. doi:10.1056/NEJMc1610614.

Lab Values Poor Surrogate for Detecting Pediatric Rocky Mountain Spotted Fever in Children

WHITNEY MCKNIGHT

FRONTLINE MEDICAL NEWS

Three fatalities observed in a retrospective analysis of six cases of Rocky Mountain spotted fever (RMSF) in children were associated with either a delayed diagnosis pending laboratory findings or delayed anti-rickettsia treatment, researchers said.

“The fact that all fatal cases died before the convalescent period emphasizes that diagnosis should be based on clinical findings instead of RMSF serologic and histologic testing,” wrote the authors of a study published online in Pediatric Dermatology.

Rechelle Tull of the department of dermatology, Wake Forest University, Winston-Salem, NC, and her colleagues conducted a retrospective review of 3,912 inpatient dermatology consultations over a period of 10 years at a tertiary care center, and identified six patients aged 22 months to 2 years (mean, 5.1 years) diagnosed with RMSF. The patients were evaluated in the months of April, May, and June, and three of the six patients infected with the vector-borne obligate intracellular bacterium, Rickettsia rickettsii, had died within 4 days of hospitalization, according to the authors.

Two of the fatal cases involved delayed anti-rickettsial therapy after the patients were misdiagnosed with group A Streptococcus. None of the six children were initially evaluated for R rickettsii; they averaged three encounters with their clinician before being admitted for acute inpatient care, where they received intravenous doxycycline after nearly a week of symptoms.

“All fatal cases were complicated by neurologic manifestations, including seizures, obtundation, and uncal herniation,” a finding that is consistent with the literature, the authors said.

Although the high-fatality rate might be the result of the small study size, Ms Tull and her coinvestigators concluded that the disease should be considered in all differential diagnoses for children who present with a fever and rash during the summer months in endemic areas, particularly since pediatric cases of the disease are associated with poorer outcomes than adult cases.

Given that RMSF often remains subclinical in its early stages, and typically presents with nonspecific symptoms of fever, rash, headache, and abdominal pain when it does emerge, physicians might be tempted to defer treatment until after serological and histological results are in, as is the standard method. Concerns over doxycycline’s tendency to stain teeth and cause enamel hypoplasia are also common. However, empirical administration could mean the difference between life and death, since treatment within the first 5 days following infection is associated with better outcomes—an algorithm complicated by the fact that symptoms caused by R rickettsii have been known to take as long as 21 days to appear.

In the study, Ms Tull and her colleagues found that the average time between exposure to the tick and the onset of symptoms was 6.6 days (range, 1-21 days).

Currently, there are no diagnostic tests “that reliably diagnose RMSF during the first 7 days of illness,” and most patients “do not develop detectable antibodies until the second week of illness,” the investigators reported. Even then, sensitivity of indirect fluorescent antibody serum testing after the second week of illness is only between 86% and 94%, they noted. Further, the sensitivity of immunohistochemical (IHC) tissue staining has been reported at 70%, and false-negative IHC results are common in acute disease when antibody response is harder to detect.

Ms Tull and her colleagues found that five of the six patients in their study had negative IHC testing; two of the six had positive serum antibody titers. For this reason, they concluded that RMSF diagnosis should be based on “clinical history, examination, and laboratory abnormalities” rather than laboratory testing, and urged that “prompt treatment should be instituted empirically.”

Tull R, Ahn C, Daniel A, Yosipovitch G, Strowd LC. Retrospective study of Rocky Mountain spotted fever in children. Pediatr Dermatol. 2016 Dec 19. doi:10.1111/pde.13053. [Epub ahead of print]

From the Department of Neuropsychiatry and Behavioral Sceince, University of South Carolina School of Medicine, Columbia, SC.

Abstract

• Objective: To review the identification, clinical assessment and treatment of patients with late-life depression.
• Methods: Review of the literature.
• Results: Depressive symptoms are present in up to 1 in 4 older adults. Comprehensive evaluation of depressive symptoms in this population often requires a multidisciplinary and collaborative approach between primary care, mental health, and other ancillary providers. Key aspects include a detailed history, physical and mental status examinations, cognitive and functional status assessment, and suicide risk assessment. Treatment options include anti-depressants, psychotherapy, and electroconvulsive therapy.
• Conclusion: A systematic approach to evaluating depressive symptoms in the elderly can enhance timely recognition and treatment.

Key words: Late-life depression; clinical assessment; antidepressants; psychotherapy; electroconvulsive therapy.

The U.S. population is aging, and with this comes the potential for increased health care needs. In 2014, there were over 46 million Americans age 65 and over (14.5% of the U.S. population). This number is projected to increase to 88 million by the year 2050 [1]. One in 4 older adults suffers with depressive symptoms that cause distress and functional impairment [2]. The World Health Organization Global Burden of Disease Study found depressive disorders to be the leading cause of disability-adjusted life years (DALYs) and the second leading cause of years lived with disability (YLDs). The burden of disease due to depressive disorders increased by 37.5% between 1990 and 2010, and 10.4% was attributable to aging [3]. These figures underscore the importance of accurate assessment and treatment of depression in the elderly. In this article, we review the identification, clinical assessment, and treatment of patients with late-life depression.

Diagnostic Criteria

Prevalence

It is estimated that 1% to 4% of community-dwelling adults age 65 and older suffer from MDD, with women more likely to be affected than men (prevalence of 4.4% vs. 2.7) [2,5–7]. This estimate is low compared with lifetime prevalence of almost 20% in the general adult population [8]. However, when depressive symptoms that do not meet criteria for MDD are considered, prevalence rates increase up to 25% [2,9]. These estimates also vary by clinical setting, with the highest rates (up to 40%) among elderly patients in long-term care facilities [10,11]. While individuals with subsyndromal depression may experience fewer symptoms than those with MDD, clinically significant distress persists, impacting health and functional status. Depression is associated with overall poor social or occupational functioning, cognitive decline, increased health care utilization and cost, increased morbidity and mortality from medical illness, and increased suicide mortality [5,9,10,12].

Identifying LLD

Accurate identification of LLD also requires recognition of the differences in the presentation of LLD compared with onset in earlier life. Depression in younger adults is often marked by depressed mood and loss of interest [18]. In contrast, older adults may present with increased anger or irritability [5]. Younger adults are more likely to report suicidal thoughts while older patients report feelings of hopelessness and thoughts of death [18]. LLD is often characterized by increased somatic complaints, hypochondriasis, or pain [5,18,19]. Another major difference lies in the presentation of cognitive difficulties. Younger patients typically complain of poor concentration or indecisiveness. Geriatric patients may present with cognitive changes including objective findings of slower processing speed and executive dysfunction on neuropsychological testing [17].

Depression rating scales may aid in identification of LLD. They are not a substitute for clinical diagnosis but can be useful as screening tools. Two commonly utilized depression rating scales are the Geriatric Depression Scale (GDS) and the Patient Health Questionnaire-9 (PHQ-9). GDS is a 30-item instrument developed specifically for older adults. Shorter 15-item, 5-item, and 4-item versions exist. The scale utilizes a Yes/No format and can be self- or clinician-administered [20]. One advantage of the GDS lies in its focus on psychological and cognitive aspects of depression rather than neurovegetative symptoms that may overlap with medical illnesses common in older adults [21]. The PHQ-9 is a 9-item self- or clinician-administered screening tool designed for use in primary care settings and has also been validated in geriatric populations [22,23]. The 9 items on this scale correspond to the DSM-5 criteria for major depression. A shorter 2-item version (PHQ-2) has also been validated, and a positive screen on this test should prompt administration of the full-length version. Both versions have approximately 80% sensitivity and specificity in detecting depression. An added advantage of PHQ-9 over GDS is that it can be useful in monitoring treatment response over time [22,23]

Comprehensive Assessment of LLD

The comprehensive assessment of patients with LLD can be carried out by health professionals in both mental health or primary care settings. In a multidisciplinary approach, psychiatrists and mental health professionals have collaborated with primary care providers using depression care managers with successful outcomes in managing depression in older adults [24,25]. Complete evaluation of a patient with suspected LLD begins with a history and physical and mental status examination. Other essential components of the evaluation include assessment of cognition, functional status, and suicide risk. Laboratory and neuroimaging studies may be necessary as well. Due to the comprehensive nature of this assessment, a multidisciplinary approach with collaboration between primary care, psychiatry, psychology, and ancillary services such as social work may be necessary. Multiple patient interactions may be required to complete a thorough evaluation.

History and Mental Status Examination

As with many other psychiatric illnesses, LLD is a clinical diagnosis. A careful history should be obtained initially utilizing open-ended questions. This should be followed by more directed questions as indicated to elicit the presence of depressive symptoms. The history should be obtained from the patient. A relevant collateral informant can be invaluable in the assessment, especially in cases where there is a comorbid neurocognitive disorder. However, the patient’s informed consent must be obtained prior to obtaining collateral information whenever possible. Psychosocial stressors that may have precipitated or may be perpetuating symptoms should be explored. Such stressors may include recent changes in living situation, loss of social support, recent deaths, or financial difficulties. Biological precipitants also need to be explored including presence of physical illness, depressogenic medications, and comorbid alcohol or other substance use. The patient’s past psychiatric history, psychiatric hospitalizations, and past medication trials should be ascertained. Any family history of depression, other psychiatric disorders, substance use disorders, and suicide attempts should be documented. A full mental status exam including cognitive assessment should be completed [21,26].

Cognitive Assessment

Cognitive impairment can be associated with LLD and may be due to the underlying depression or represent a comorbid neurocognitive disorder. Furthermore, the burden of medical illness as well as cerebrovascular and cardiovascular risk factors have been linked to executive dysfunction and reduced processing speed in individuals with LDD [27,28]. Distinguishing between these can be challenging; however, chronology of symptom onset is often helpful. Depression is more likely the etiology of cognitive impairment when depressive symptoms precede onset of cognitive deficits. This type of cognitive impairment is termed dementia syndrome of depression and may improve with treatment of depression [5]. Some patients may progress to develop major cognitive decline, and it remains unclear whether LLD represents a risk factor or prodrome to developing a major neurocognitive disorder [29]. On the other hand, if depression develops later in the course of cognitive decline, there may be an underlying neurocognitive disorder [17]. Up to 20% of individuals with major neurocognitive disorder due to Alzheimer’s disease also have major depression [11]. For these reasons, concomitant assessment of cognition is essential to the evaluation of the older adult presenting with depressive symptoms [30]. Cognitive domains that may be affected include learning and memory, language, attention, perceptual motor abilities, social cognition, and executive function [4]. Many of these domains can be assessed during the mental status examination, with brief cognitive screening tools, or with formal neuropsychological testing.

While there are numerous cognitive screening tools, some commonly used, brief tools include the Mini-Cog, the Folstein Mini-Mental State Exam (MMSE), and the Montreal Cognitive Assessment (MoCA). The Mini-Cog consists of a 3-item registration, delayed recall, and clock drawing test and has several advantages over other screening tools. It is a brief test (taking approximately 3 minutes to administer) with good sensitivity and specificity of 80% or greater. Compared with other cognitive screening tools, it is less influenced by level of education, language, or cultural background [31–33]. The MMSE is a longer screening tool consisting of 19 items and requires about 10 minutes to administer. Unlike the Mini-Cog, performance on the MMSE can be affected by level of education and cultural background. However, the MMSE can be administered serially to monitor changes in cognition over time [34,35]. The MoCA is a 10-minute cognitive screening tool first developed to detect mild cognitive impairment (MCI) [36]. The MoCA consists of 7 subscore sections covering visuospatial/executive function, naming, memory (delayed recall), attention, language, abstraction, and orientation. The total score is 30, and 1 point is added to the score if the testing subject has less than high school/12 years of education. The MoCA has demonstrated better sensitivity than the MMSE for the detection of MCI [36]. Elderly patients with depression often perform poorly on these cognitive screening tests due to apathy and poor effort.

Functional Assessment

The diagnosis of LLD requires that symptoms cause significant distress or interfere with functioning. A functional assessment is especially important in the evaluation of the older adult in that it allows clinicians to determine an individual’s ability to live independently and attend to daily needs. Basic activities of daily living (ADLs) include bathing, dressing, grooming, toileting, and self-transferring. Instrumental activities of daily living (IADLs) include more complex daily activities such as preparing meals, administering medications, driving, managing finances, and using simple electronics such as the telephone or remote control [26]. Impairment in IADLs is associated with increased depression severity. Conversely, the severity of depressive symptoms along with associated cognitive impairment predicts IADL impairment [37]. The Philadelphia Multilevel Assessment Instrument is a tool that can aid in the assessment of ADLs and IADLs and has been utilized in studies examining disability in depressed elderly patients [37,38]. Other available scales to quantify functional status include OARS Physical Activities of Daily Living, OARS Instrumental Activities of Daily Living Scale, and Direct Assessment of Functional Status Scale [26].

Suicide Assessment

Assessment for suicidality is an integral part of all psychiatric evaluations and is especially important in the evaluation of the depressed older adult. According to the Centers for Disease Control and Prevention, the suicide rate for individuals age 65 and older is 16.6 per 100,000, a figure that is comparable to that for individuals 18–64 years of age [39]. Non-Hispanic Caucasian males age 85 and older have the highest rate of completed suicide (56.5 per 100,000), underscoring the importance of a thorough suicide assessment [39]. Suicidality can range from passive thoughts of death and wishing that one were not alive, to active thoughts of self-harm with plan and intent. A Canadian study found 2% of community-dwelling adults age 55 and older had suicidal thoughts over a 12-month period and, of these, 28% had major depression [40]. A suicide assessment begins with inquiring about the presence of suicidal thoughts, plans, and intent. The 3 most frequently used methods of completed suicide in the elderly are firearms (28%), hanging (24%) and poisoning (21%) [41]. Access to weapons or other lethal means of self-harm such has hoarding of medications should be ascertained.

A complete suicide assessment requires attention to suicide risk factors, protective factors, and warning signs of impending suicide. Risk factors for suicide in the older adult include mood disorders, chronic medical illnesses and associated functional impairment, chronic pain, and psychosocial factors such as social isolation [42]. Mood disorders are present in 54% to 87% of cases of completed suicide, with major depression being the most common [42]. Chronic medical illness and pain can result in functional impairment leading to feelings of excessive guilt or being a burden to loved ones. Protective factors such as social connectedness, spirituality, religious beliefs, and cultural attitudes against suicide may serve as buffers against these risk factors [43]. Warning signs of impending suicide may indicate preparations for suicide and include feelings of hopelessness or lack of purpose, feeling trapped, talking about death, threatening suicide, agitation, social withdrawal, increased substance use and reckless behavior. Warning signs should prompt action to ensure the safety of the individual [44,45].

Physical Examination, Laboratory Studies, and Neuroimaging

Evaluation of LLD is not complete without a physical examination and ancillary studies to identify underlying medical conditions possibly contributing to or mimicking depressive symptoms. Routine laboratory studies include complete blood count, complete metabolic panel, thyroid studies, and urine drug screen. Signs and symptoms of underlying medical conditions may necessitate further laboratory studies [46]. Neuroimaging may reveal signs of cerebrovascular disease which can predispose, precipitate, or perpetuate depression in older adults [47].

Treatment

Treatment of LLD can take many forms and occur in various settings. Geriatric psychiatrists have expertise in the assessment and treatment of mental illness in the elderly. Workforce estimates for 2010 revealed 1 geriatric psychiatrist per 10,000 adults age 75 and over. This figure is estimated to decrease to 0.5 per 10,000 by the year 2030, underscoring the importance of increasing the knowledge base of clinicians across specialties who provide care to the depressed elderly [48]. The primary care setting is often the locus of care for depression in older adults; however, studies suggest that patients are often left untreated or undertreated [49]. Collaborative care models whereby mental health care is integrated into primary care have been shown to improve outcomes. The Prevention of Suicide in Primary Care Elderly: Collaborative Trial (PROSPECT) study found that use of care managers to assist primary care providers in identification of depression, offer algorithm-based treatment recommendations, monitor symptoms and medication side effects, and provide follow-up yielded improvement in outcomes. Patients in the intervention group were more likely to receive pharmacotherapy or psychotherapy, achieve remission, and showed greater decline in suicidal ideation [50]. Similar results were found in the Improving Mood-Promoting Access to Collaborative Treatment (IMPACT) study in which intervention patients treated under a collaborative care model showed lower depression severity, less functional impairment, and greater reduction in depressive symptoms [25].

Just as a collaborative care model can lead to improved outcomes, the overall strategy of treating depression must be multifaceted. The biopsychosocial model of disease first described in the 1970s emphasizes biological and psychosocial determinants of illness that must be addressed when treatment is considered [51]. This includes nonmodifiable biological factors such as age, gender, and genetic predisposition that may affect treatment options, as well as modifiable biological factors such as comorbid medical illness, medications, or substance use disorders. Psychological factors that can affect depressive symptoms include coping skills and defense mechanisms in the face of stressful life events. Social factors including the role of culture, environment, and family dynamics in disease presentation must be considered as well [52].

Pharmacologic Treatment of LLD

The primary pharmacologic treatment for depression is antidepressants. Treatment consists of 3 phases—acute, continuation, and maintenance. In the acute phase, the goal is remission of current symptoms and restoration of function. The continuation phase, extending up to 6 months after remission, aims to prevent relapse back into a depressive episode. Maintenance therapy is geared at preventing recurrence of future depressive episodes [53]. Studies have found a 50% risk of relapse after 1 episode of depression and 80% after 2 episodes. Up to 20% will develop chronic symptoms. For this reason, maintenance therapy is often necessary for recurrent depression [54].

While cognitive impairment may affect antidepressant efficacy, age does not appear to be a determinant. Gildengers et al examined antidepressant response in young, middle, and older-old patients and found no significant difference in response rates [59]. Early onset versus late onset of first depressive episode also does not predict antidepressant response in patients age 55 and over [60]. There is scant evidence for efficacy of antidepressants in depressed patients with neurocognitive disorders. A 2002 Cochrane review with 4 studies in the meta-analysis (n = 137) concluded that there was weak support for antidepressant efficacy in this population [61]. A 2011 meta-analysis with 330 participants also yielded inconclusive results [62]. The paucity of evidence for antidepressant efficacy in depressed patients with neurocognitive disorders should prompt careful consideration of potential benefits versus adverse effects.

Antidepressants are generally well tolerated in older adults. Side effects vary by medication and contribute to discontinuation in up to 25% of new users (versus 22% for new users who discontinue for reasons other than side effects) [63]. Potential adverse effects shared by most SSRIs and SNRIs include GI disturbance (nausea, diarrhea or constipation), sexual dysfunction, headache, and sleep disturbance [64,65]. In addition, abrupt discontinuation can precipitate serotonin withdrawal syndrome characterized by sensory disturbance (paresthesia, tremor, and irritability) as well as headache, lightheadedness, diaphoresis, insomnia, and agitation. Other medication-specific side effects include risk of seizure with bupropion and sedation with mirtazapine [65].

Despite superiority of antidepressants to placebo in treating depression, up to one-third of patients may not respond to a trial of antidepressants. Sequential treatment protocols such as switching to a different antidepressant or augmentation can increase the proportion of antidepressant responders [66–68]. Studies have found particularly favorable response to augmentation with lithium, with one study achieving a 33% remission rate in treatment- resistant geriatric depression [67,69]. Other pharmacologic augmentation strategies include the addition of mood stabilizers such as lamotrigine, antipsychotics (aripiprazole, olanzapine, quetiapine, and risperidone), and psychostimulants [70–73]. Electroconvulsive therapy (ECT) is a nonpharmacologic option for treatment-resistant depression that will be reviewed later.

Psychotherapeutic and Psychosocial Interventions

Psychotherapeutic interventions have demonstrated efficacy in the treatment of geriatric depression, including but not limited to cognitive behavioral therapy (CBT), interpersonal therapy (IPT), problem-solving therapy (PST), reminiscence and life review, and brief psychodynamic psychotherapy [74]. Some older adults may prefer psychotherapy to pharmacologic treatment (57% vs. 43%) [75]. Potential benefits of psychotherapy include ability to directly address psychosocial stressors that may precipitate or perpetuate depressive symptoms. In addition, psychotherapy is associated with few to no side effects and avoids drug interactions. Barriers to employing psychotherapy may include cost and access to trained psychotherapists [76]. Efficacy of several psychotherapeutic approaches in the care of older depressed adults has been examined. CBT, brief psychodynamic psychotherapy, and IPT will be briefly reviewed here.

CBT. Cognitive therapy was first described by Aaron Beck in the 1960s [77]. It is a highly structured therapy built on the premise that beliefs and assumptions an individual holds can influence emotions and behavior. CBT aims to identify maladaptive belief systems, test the validity of these cognitive distortions, and help individuals formulate more realistic cognitions [78]. Symptom improvement results from addressing these cognitive aspects as well as integration of behavioral activation and skills training to overcome maladaptive behavioral patterns [78]. CBT approaches have been applied to older adults with depression and results show acceptability [79] and efficacy in this population [80–82]. A 2008 Cochrane review (n = 153) found CBT to be superior to waitlist controls [82].

Brief psychodynamic psychotherapy. Brief psychodynamic psychotherapy, unlike highly structured CBT, aims to alter behavior by examining how past experiences and unresolved conflicts influence current emotions and behavior. While studies on application to the treatment of geriatric depression are scarce, limited data demonstrate efficacy in treating geriatric depression [81] and no significant difference in outcomes when compared to CBT [82].

IPT. Like CBT, IPT is a structured time-limited psychotherapeutic treatment approach first developed in the late 1960s by Klerman and Weissman [83]. IPT focuses on the impact of interpersonal relationships on depressive symptoms and examines 4 domains: interpersonal conflict, interpersonal deficits, role transitions, and grief [74].

Studies have shown efficacy of IPT in reducing depressive symptoms in the elderly when compared to usual care [84]. Reynolds et al found IPT combined with nortriptyline (a tricyclic antidepressant) to be superior to either nortriptyline alone or IPT alone in preventing recurrent depressive episodes [85]. Interestingly, a similar study investigating the efficacy of IPT in combination with paroxetine (an SSRI) failed to show added benefit of IPT in preventing recurrence, suggesting that further studies are needed [86].

Psychosocial interventions are integral in the care of the elderly depressed patient. Studies have shown positive benefits of aerobic exercise on depressive symptoms [87]. Yoga, Tai Chi, and other mindfulness-based exercises can increase sense of emotional and physical wellbeing [88–90]. Spirituality, religious beliefs, and involvement with a faith group may be protective against development of mental illness while at the same time provide avenues for increased social connectedness [91]. These and other avenues for socialization should be encouraged as part of the treatment plan for older depressed patients [92]

Electroconvulsive Therapy

ECT is indicated for the treatment of mood and psychotic disorders and has demonstrated efficacy in the treatment of severe depression [93]. It is typically initiated when patients fail to respond to pharmacotherapy and psychotherapy. Circumstances in which ECT can be considered first-line treatment include situations that require a rapid response (severe inanition, weight loss, or suicidality), situations where risks of ECT are lower than that of alternative treatments, previous positive response to ECT, or strong patient preference [94]. ECT is performed under general anesthesia and involves the induction of a generalized tonic-clonic seizure, which is theorized to enhance serotonergic, noradrenergic, and dopaminergic neurotransmission. A typical course of ECT involves treatments 3 times a week for an average of 6 to 12 treatments in total [95]. Elderly patients and those suffering from severe depression with psychotic features respond more robustly to ECT [93,96]. Estimated remission rates after an ECT series have been higher than 80% [93], making this modality the most effective treatment for severe depression to date.

Conclusion

As the population continues to age, clinicians are increasingly likely to encounter patients with late-life depression. A thorough evaluation includes not only assessment of depressive symptoms, but also cognitive, functional, and suicide assessment. Treatment options include pharmaco-therapy, psychotherapy, and in some cases electroconvulsive therapy. Utilization of assessment and treatment nuances unique to the geriatric population, with a multidisciplinary and collaborative approach involving primary care, mental health, and other ancillary providers, will serve to ultimately enhance patient care.

Corresponding author: Corresponding author: Juliet Glover, MD, Dept. of Neuropsychiatry and Behavioral Science, Univ. of South Carolina School of Medicine, 15 Medical Park, Suite 301, Columbia, SC 29203, [email protected].

Financial disclosures: None reported.

Author contributions: conception and design, JAG, SS; drafting of article, JAG, SS; critical revision of the article, JAG, SS.

From the Department of Neuropsychiatry and Behavioral Sceince, University of South Carolina School of Medicine, Columbia, SC.

Abstract

• Objective: To review the identification, clinical assessment and treatment of patients with late-life depression.
• Methods: Review of the literature.
• Results: Depressive symptoms are present in up to 1 in 4 older adults. Comprehensive evaluation of depressive symptoms in this population often requires a multidisciplinary and collaborative approach between primary care, mental health, and other ancillary providers. Key aspects include a detailed history, physical and mental status examinations, cognitive and functional status assessment, and suicide risk assessment. Treatment options include anti-depressants, psychotherapy, and electroconvulsive therapy.
• Conclusion: A systematic approach to evaluating depressive symptoms in the elderly can enhance timely recognition and treatment.

Key words: Late-life depression; clinical assessment; antidepressants; psychotherapy; electroconvulsive therapy.

The U.S. population is aging, and with this comes the potential for increased health care needs. In 2014, there were over 46 million Americans age 65 and over (14.5% of the U.S. population). This number is projected to increase to 88 million by the year 2050 [1]. One in 4 older adults suffers with depressive symptoms that cause distress and functional impairment [2]. The World Health Organization Global Burden of Disease Study found depressive disorders to be the leading cause of disability-adjusted life years (DALYs) and the second leading cause of years lived with disability (YLDs). The burden of disease due to depressive disorders increased by 37.5% between 1990 and 2010, and 10.4% was attributable to aging [3]. These figures underscore the importance of accurate assessment and treatment of depression in the elderly. In this article, we review the identification, clinical assessment, and treatment of patients with late-life depression.

Diagnostic Criteria

Prevalence

It is estimated that 1% to 4% of community-dwelling adults age 65 and older suffer from MDD, with women more likely to be affected than men (prevalence of 4.4% vs. 2.7) [2,5–7]. This estimate is low compared with lifetime prevalence of almost 20% in the general adult population [8]. However, when depressive symptoms that do not meet criteria for MDD are considered, prevalence rates increase up to 25% [2,9]. These estimates also vary by clinical setting, with the highest rates (up to 40%) among elderly patients in long-term care facilities [10,11]. While individuals with subsyndromal depression may experience fewer symptoms than those with MDD, clinically significant distress persists, impacting health and functional status. Depression is associated with overall poor social or occupational functioning, cognitive decline, increased health care utilization and cost, increased morbidity and mortality from medical illness, and increased suicide mortality [5,9,10,12].

Identifying LLD

Accurate identification of LLD also requires recognition of the differences in the presentation of LLD compared with onset in earlier life. Depression in younger adults is often marked by depressed mood and loss of interest [18]. In contrast, older adults may present with increased anger or irritability [5]. Younger adults are more likely to report suicidal thoughts while older patients report feelings of hopelessness and thoughts of death [18]. LLD is often characterized by increased somatic complaints, hypochondriasis, or pain [5,18,19]. Another major difference lies in the presentation of cognitive difficulties. Younger patients typically complain of poor concentration or indecisiveness. Geriatric patients may present with cognitive changes including objective findings of slower processing speed and executive dysfunction on neuropsychological testing [17].

Depression rating scales may aid in identification of LLD. They are not a substitute for clinical diagnosis but can be useful as screening tools. Two commonly utilized depression rating scales are the Geriatric Depression Scale (GDS) and the Patient Health Questionnaire-9 (PHQ-9). GDS is a 30-item instrument developed specifically for older adults. Shorter 15-item, 5-item, and 4-item versions exist. The scale utilizes a Yes/No format and can be self- or clinician-administered [20]. One advantage of the GDS lies in its focus on psychological and cognitive aspects of depression rather than neurovegetative symptoms that may overlap with medical illnesses common in older adults [21]. The PHQ-9 is a 9-item self- or clinician-administered screening tool designed for use in primary care settings and has also been validated in geriatric populations [22,23]. The 9 items on this scale correspond to the DSM-5 criteria for major depression. A shorter 2-item version (PHQ-2) has also been validated, and a positive screen on this test should prompt administration of the full-length version. Both versions have approximately 80% sensitivity and specificity in detecting depression. An added advantage of PHQ-9 over GDS is that it can be useful in monitoring treatment response over time [22,23]

Comprehensive Assessment of LLD

The comprehensive assessment of patients with LLD can be carried out by health professionals in both mental health or primary care settings. In a multidisciplinary approach, psychiatrists and mental health professionals have collaborated with primary care providers using depression care managers with successful outcomes in managing depression in older adults [24,25]. Complete evaluation of a patient with suspected LLD begins with a history and physical and mental status examination. Other essential components of the evaluation include assessment of cognition, functional status, and suicide risk. Laboratory and neuroimaging studies may be necessary as well. Due to the comprehensive nature of this assessment, a multidisciplinary approach with collaboration between primary care, psychiatry, psychology, and ancillary services such as social work may be necessary. Multiple patient interactions may be required to complete a thorough evaluation.

History and Mental Status Examination

As with many other psychiatric illnesses, LLD is a clinical diagnosis. A careful history should be obtained initially utilizing open-ended questions. This should be followed by more directed questions as indicated to elicit the presence of depressive symptoms. The history should be obtained from the patient. A relevant collateral informant can be invaluable in the assessment, especially in cases where there is a comorbid neurocognitive disorder. However, the patient’s informed consent must be obtained prior to obtaining collateral information whenever possible. Psychosocial stressors that may have precipitated or may be perpetuating symptoms should be explored. Such stressors may include recent changes in living situation, loss of social support, recent deaths, or financial difficulties. Biological precipitants also need to be explored including presence of physical illness, depressogenic medications, and comorbid alcohol or other substance use. The patient’s past psychiatric history, psychiatric hospitalizations, and past medication trials should be ascertained. Any family history of depression, other psychiatric disorders, substance use disorders, and suicide attempts should be documented. A full mental status exam including cognitive assessment should be completed [21,26].

Cognitive Assessment

Cognitive impairment can be associated with LLD and may be due to the underlying depression or represent a comorbid neurocognitive disorder. Furthermore, the burden of medical illness as well as cerebrovascular and cardiovascular risk factors have been linked to executive dysfunction and reduced processing speed in individuals with LDD [27,28]. Distinguishing between these can be challenging; however, chronology of symptom onset is often helpful. Depression is more likely the etiology of cognitive impairment when depressive symptoms precede onset of cognitive deficits. This type of cognitive impairment is termed dementia syndrome of depression and may improve with treatment of depression [5]. Some patients may progress to develop major cognitive decline, and it remains unclear whether LLD represents a risk factor or prodrome to developing a major neurocognitive disorder [29]. On the other hand, if depression develops later in the course of cognitive decline, there may be an underlying neurocognitive disorder [17]. Up to 20% of individuals with major neurocognitive disorder due to Alzheimer’s disease also have major depression [11]. For these reasons, concomitant assessment of cognition is essential to the evaluation of the older adult presenting with depressive symptoms [30]. Cognitive domains that may be affected include learning and memory, language, attention, perceptual motor abilities, social cognition, and executive function [4]. Many of these domains can be assessed during the mental status examination, with brief cognitive screening tools, or with formal neuropsychological testing.

While there are numerous cognitive screening tools, some commonly used, brief tools include the Mini-Cog, the Folstein Mini-Mental State Exam (MMSE), and the Montreal Cognitive Assessment (MoCA). The Mini-Cog consists of a 3-item registration, delayed recall, and clock drawing test and has several advantages over other screening tools. It is a brief test (taking approximately 3 minutes to administer) with good sensitivity and specificity of 80% or greater. Compared with other cognitive screening tools, it is less influenced by level of education, language, or cultural background [31–33]. The MMSE is a longer screening tool consisting of 19 items and requires about 10 minutes to administer. Unlike the Mini-Cog, performance on the MMSE can be affected by level of education and cultural background. However, the MMSE can be administered serially to monitor changes in cognition over time [34,35]. The MoCA is a 10-minute cognitive screening tool first developed to detect mild cognitive impairment (MCI) [36]. The MoCA consists of 7 subscore sections covering visuospatial/executive function, naming, memory (delayed recall), attention, language, abstraction, and orientation. The total score is 30, and 1 point is added to the score if the testing subject has less than high school/12 years of education. The MoCA has demonstrated better sensitivity than the MMSE for the detection of MCI [36]. Elderly patients with depression often perform poorly on these cognitive screening tests due to apathy and poor effort.

Functional Assessment

The diagnosis of LLD requires that symptoms cause significant distress or interfere with functioning. A functional assessment is especially important in the evaluation of the older adult in that it allows clinicians to determine an individual’s ability to live independently and attend to daily needs. Basic activities of daily living (ADLs) include bathing, dressing, grooming, toileting, and self-transferring. Instrumental activities of daily living (IADLs) include more complex daily activities such as preparing meals, administering medications, driving, managing finances, and using simple electronics such as the telephone or remote control [26]. Impairment in IADLs is associated with increased depression severity. Conversely, the severity of depressive symptoms along with associated cognitive impairment predicts IADL impairment [37]. The Philadelphia Multilevel Assessment Instrument is a tool that can aid in the assessment of ADLs and IADLs and has been utilized in studies examining disability in depressed elderly patients [37,38]. Other available scales to quantify functional status include OARS Physical Activities of Daily Living, OARS Instrumental Activities of Daily Living Scale, and Direct Assessment of Functional Status Scale [26].

Suicide Assessment

Assessment for suicidality is an integral part of all psychiatric evaluations and is especially important in the evaluation of the depressed older adult. According to the Centers for Disease Control and Prevention, the suicide rate for individuals age 65 and older is 16.6 per 100,000, a figure that is comparable to that for individuals 18–64 years of age [39]. Non-Hispanic Caucasian males age 85 and older have the highest rate of completed suicide (56.5 per 100,000), underscoring the importance of a thorough suicide assessment [39]. Suicidality can range from passive thoughts of death and wishing that one were not alive, to active thoughts of self-harm with plan and intent. A Canadian study found 2% of community-dwelling adults age 55 and older had suicidal thoughts over a 12-month period and, of these, 28% had major depression [40]. A suicide assessment begins with inquiring about the presence of suicidal thoughts, plans, and intent. The 3 most frequently used methods of completed suicide in the elderly are firearms (28%), hanging (24%) and poisoning (21%) [41]. Access to weapons or other lethal means of self-harm such has hoarding of medications should be ascertained.

A complete suicide assessment requires attention to suicide risk factors, protective factors, and warning signs of impending suicide. Risk factors for suicide in the older adult include mood disorders, chronic medical illnesses and associated functional impairment, chronic pain, and psychosocial factors such as social isolation [42]. Mood disorders are present in 54% to 87% of cases of completed suicide, with major depression being the most common [42]. Chronic medical illness and pain can result in functional impairment leading to feelings of excessive guilt or being a burden to loved ones. Protective factors such as social connectedness, spirituality, religious beliefs, and cultural attitudes against suicide may serve as buffers against these risk factors [43]. Warning signs of impending suicide may indicate preparations for suicide and include feelings of hopelessness or lack of purpose, feeling trapped, talking about death, threatening suicide, agitation, social withdrawal, increased substance use and reckless behavior. Warning signs should prompt action to ensure the safety of the individual [44,45].

Physical Examination, Laboratory Studies, and Neuroimaging

Evaluation of LLD is not complete without a physical examination and ancillary studies to identify underlying medical conditions possibly contributing to or mimicking depressive symptoms. Routine laboratory studies include complete blood count, complete metabolic panel, thyroid studies, and urine drug screen. Signs and symptoms of underlying medical conditions may necessitate further laboratory studies [46]. Neuroimaging may reveal signs of cerebrovascular disease which can predispose, precipitate, or perpetuate depression in older adults [47].

Treatment

Treatment of LLD can take many forms and occur in various settings. Geriatric psychiatrists have expertise in the assessment and treatment of mental illness in the elderly. Workforce estimates for 2010 revealed 1 geriatric psychiatrist per 10,000 adults age 75 and over. This figure is estimated to decrease to 0.5 per 10,000 by the year 2030, underscoring the importance of increasing the knowledge base of clinicians across specialties who provide care to the depressed elderly [48]. The primary care setting is often the locus of care for depression in older adults; however, studies suggest that patients are often left untreated or undertreated [49]. Collaborative care models whereby mental health care is integrated into primary care have been shown to improve outcomes. The Prevention of Suicide in Primary Care Elderly: Collaborative Trial (PROSPECT) study found that use of care managers to assist primary care providers in identification of depression, offer algorithm-based treatment recommendations, monitor symptoms and medication side effects, and provide follow-up yielded improvement in outcomes. Patients in the intervention group were more likely to receive pharmacotherapy or psychotherapy, achieve remission, and showed greater decline in suicidal ideation [50]. Similar results were found in the Improving Mood-Promoting Access to Collaborative Treatment (IMPACT) study in which intervention patients treated under a collaborative care model showed lower depression severity, less functional impairment, and greater reduction in depressive symptoms [25].

Just as a collaborative care model can lead to improved outcomes, the overall strategy of treating depression must be multifaceted. The biopsychosocial model of disease first described in the 1970s emphasizes biological and psychosocial determinants of illness that must be addressed when treatment is considered [51]. This includes nonmodifiable biological factors such as age, gender, and genetic predisposition that may affect treatment options, as well as modifiable biological factors such as comorbid medical illness, medications, or substance use disorders. Psychological factors that can affect depressive symptoms include coping skills and defense mechanisms in the face of stressful life events. Social factors including the role of culture, environment, and family dynamics in disease presentation must be considered as well [52].

Pharmacologic Treatment of LLD

The primary pharmacologic treatment for depression is antidepressants. Treatment consists of 3 phases—acute, continuation, and maintenance. In the acute phase, the goal is remission of current symptoms and restoration of function. The continuation phase, extending up to 6 months after remission, aims to prevent relapse back into a depressive episode. Maintenance therapy is geared at preventing recurrence of future depressive episodes [53]. Studies have found a 50% risk of relapse after 1 episode of depression and 80% after 2 episodes. Up to 20% will develop chronic symptoms. For this reason, maintenance therapy is often necessary for recurrent depression [54].

While cognitive impairment may affect antidepressant efficacy, age does not appear to be a determinant. Gildengers et al examined antidepressant response in young, middle, and older-old patients and found no significant difference in response rates [59]. Early onset versus late onset of first depressive episode also does not predict antidepressant response in patients age 55 and over [60]. There is scant evidence for efficacy of antidepressants in depressed patients with neurocognitive disorders. A 2002 Cochrane review with 4 studies in the meta-analysis (n = 137) concluded that there was weak support for antidepressant efficacy in this population [61]. A 2011 meta-analysis with 330 participants also yielded inconclusive results [62]. The paucity of evidence for antidepressant efficacy in depressed patients with neurocognitive disorders should prompt careful consideration of potential benefits versus adverse effects.

Antidepressants are generally well tolerated in older adults. Side effects vary by medication and contribute to discontinuation in up to 25% of new users (versus 22% for new users who discontinue for reasons other than side effects) [63]. Potential adverse effects shared by most SSRIs and SNRIs include GI disturbance (nausea, diarrhea or constipation), sexual dysfunction, headache, and sleep disturbance [64,65]. In addition, abrupt discontinuation can precipitate serotonin withdrawal syndrome characterized by sensory disturbance (paresthesia, tremor, and irritability) as well as headache, lightheadedness, diaphoresis, insomnia, and agitation. Other medication-specific side effects include risk of seizure with bupropion and sedation with mirtazapine [65].

Despite superiority of antidepressants to placebo in treating depression, up to one-third of patients may not respond to a trial of antidepressants. Sequential treatment protocols such as switching to a different antidepressant or augmentation can increase the proportion of antidepressant responders [66–68]. Studies have found particularly favorable response to augmentation with lithium, with one study achieving a 33% remission rate in treatment- resistant geriatric depression [67,69]. Other pharmacologic augmentation strategies include the addition of mood stabilizers such as lamotrigine, antipsychotics (aripiprazole, olanzapine, quetiapine, and risperidone), and psychostimulants [70–73]. Electroconvulsive therapy (ECT) is a nonpharmacologic option for treatment-resistant depression that will be reviewed later.

Psychotherapeutic and Psychosocial Interventions

Psychotherapeutic interventions have demonstrated efficacy in the treatment of geriatric depression, including but not limited to cognitive behavioral therapy (CBT), interpersonal therapy (IPT), problem-solving therapy (PST), reminiscence and life review, and brief psychodynamic psychotherapy [74]. Some older adults may prefer psychotherapy to pharmacologic treatment (57% vs. 43%) [75]. Potential benefits of psychotherapy include ability to directly address psychosocial stressors that may precipitate or perpetuate depressive symptoms. In addition, psychotherapy is associated with few to no side effects and avoids drug interactions. Barriers to employing psychotherapy may include cost and access to trained psychotherapists [76]. Efficacy of several psychotherapeutic approaches in the care of older depressed adults has been examined. CBT, brief psychodynamic psychotherapy, and IPT will be briefly reviewed here.

CBT. Cognitive therapy was first described by Aaron Beck in the 1960s [77]. It is a highly structured therapy built on the premise that beliefs and assumptions an individual holds can influence emotions and behavior. CBT aims to identify maladaptive belief systems, test the validity of these cognitive distortions, and help individuals formulate more realistic cognitions [78]. Symptom improvement results from addressing these cognitive aspects as well as integration of behavioral activation and skills training to overcome maladaptive behavioral patterns [78]. CBT approaches have been applied to older adults with depression and results show acceptability [79] and efficacy in this population [80–82]. A 2008 Cochrane review (n = 153) found CBT to be superior to waitlist controls [82].

Brief psychodynamic psychotherapy. Brief psychodynamic psychotherapy, unlike highly structured CBT, aims to alter behavior by examining how past experiences and unresolved conflicts influence current emotions and behavior. While studies on application to the treatment of geriatric depression are scarce, limited data demonstrate efficacy in treating geriatric depression [81] and no significant difference in outcomes when compared to CBT [82].

IPT. Like CBT, IPT is a structured time-limited psychotherapeutic treatment approach first developed in the late 1960s by Klerman and Weissman [83]. IPT focuses on the impact of interpersonal relationships on depressive symptoms and examines 4 domains: interpersonal conflict, interpersonal deficits, role transitions, and grief [74].

Studies have shown efficacy of IPT in reducing depressive symptoms in the elderly when compared to usual care [84]. Reynolds et al found IPT combined with nortriptyline (a tricyclic antidepressant) to be superior to either nortriptyline alone or IPT alone in preventing recurrent depressive episodes [85]. Interestingly, a similar study investigating the efficacy of IPT in combination with paroxetine (an SSRI) failed to show added benefit of IPT in preventing recurrence, suggesting that further studies are needed [86].

Psychosocial interventions are integral in the care of the elderly depressed patient. Studies have shown positive benefits of aerobic exercise on depressive symptoms [87]. Yoga, Tai Chi, and other mindfulness-based exercises can increase sense of emotional and physical wellbeing [88–90]. Spirituality, religious beliefs, and involvement with a faith group may be protective against development of mental illness while at the same time provide avenues for increased social connectedness [91]. These and other avenues for socialization should be encouraged as part of the treatment plan for older depressed patients [92]

Electroconvulsive Therapy

ECT is indicated for the treatment of mood and psychotic disorders and has demonstrated efficacy in the treatment of severe depression [93]. It is typically initiated when patients fail to respond to pharmacotherapy and psychotherapy. Circumstances in which ECT can be considered first-line treatment include situations that require a rapid response (severe inanition, weight loss, or suicidality), situations where risks of ECT are lower than that of alternative treatments, previous positive response to ECT, or strong patient preference [94]. ECT is performed under general anesthesia and involves the induction of a generalized tonic-clonic seizure, which is theorized to enhance serotonergic, noradrenergic, and dopaminergic neurotransmission. A typical course of ECT involves treatments 3 times a week for an average of 6 to 12 treatments in total [95]. Elderly patients and those suffering from severe depression with psychotic features respond more robustly to ECT [93,96]. Estimated remission rates after an ECT series have been higher than 80% [93], making this modality the most effective treatment for severe depression to date.

Conclusion

As the population continues to age, clinicians are increasingly likely to encounter patients with late-life depression. A thorough evaluation includes not only assessment of depressive symptoms, but also cognitive, functional, and suicide assessment. Treatment options include pharmaco-therapy, psychotherapy, and in some cases electroconvulsive therapy. Utilization of assessment and treatment nuances unique to the geriatric population, with a multidisciplinary and collaborative approach involving primary care, mental health, and other ancillary providers, will serve to ultimately enhance patient care.

Corresponding author: Corresponding author: Juliet Glover, MD, Dept. of Neuropsychiatry and Behavioral Science, Univ. of South Carolina School of Medicine, 15 Medical Park, Suite 301, Columbia, SC 29203, [email protected].

Financial disclosures: None reported.

Author contributions: conception and design, JAG, SS; drafting of article, JAG, SS; critical revision of the article, JAG, SS.

From the Department of Neuropsychiatry and Behavioral Sceince, University of South Carolina School of Medicine, Columbia, SC.

Abstract

• Objective: To review the identification, clinical assessment and treatment of patients with late-life depression.
• Methods: Review of the literature.
• Results: Depressive symptoms are present in up to 1 in 4 older adults. Comprehensive evaluation of depressive symptoms in this population often requires a multidisciplinary and collaborative approach between primary care, mental health, and other ancillary providers. Key aspects include a detailed history, physical and mental status examinations, cognitive and functional status assessment, and suicide risk assessment. Treatment options include anti-depressants, psychotherapy, and electroconvulsive therapy.
• Conclusion: A systematic approach to evaluating depressive symptoms in the elderly can enhance timely recognition and treatment.

Key words: Late-life depression; clinical assessment; antidepressants; psychotherapy; electroconvulsive therapy.

The U.S. population is aging, and with this comes the potential for increased health care needs. In 2014, there were over 46 million Americans age 65 and over (14.5% of the U.S. population). This number is projected to increase to 88 million by the year 2050 [1]. One in 4 older adults suffers with depressive symptoms that cause distress and functional impairment [2]. The World Health Organization Global Burden of Disease Study found depressive disorders to be the leading cause of disability-adjusted life years (DALYs) and the second leading cause of years lived with disability (YLDs). The burden of disease due to depressive disorders increased by 37.5% between 1990 and 2010, and 10.4% was attributable to aging [3]. These figures underscore the importance of accurate assessment and treatment of depression in the elderly. In this article, we review the identification, clinical assessment, and treatment of patients with late-life depression.

Diagnostic Criteria

Prevalence

It is estimated that 1% to 4% of community-dwelling adults age 65 and older suffer from MDD, with women more likely to be affected than men (prevalence of 4.4% vs. 2.7) [2,5–7]. This estimate is low compared with lifetime prevalence of almost 20% in the general adult population [8]. However, when depressive symptoms that do not meet criteria for MDD are considered, prevalence rates increase up to 25% [2,9]. These estimates also vary by clinical setting, with the highest rates (up to 40%) among elderly patients in long-term care facilities [10,11]. While individuals with subsyndromal depression may experience fewer symptoms than those with MDD, clinically significant distress persists, impacting health and functional status. Depression is associated with overall poor social or occupational functioning, cognitive decline, increased health care utilization and cost, increased morbidity and mortality from medical illness, and increased suicide mortality [5,9,10,12].

Identifying LLD

Accurate identification of LLD also requires recognition of the differences in the presentation of LLD compared with onset in earlier life. Depression in younger adults is often marked by depressed mood and loss of interest [18]. In contrast, older adults may present with increased anger or irritability [5]. Younger adults are more likely to report suicidal thoughts while older patients report feelings of hopelessness and thoughts of death [18]. LLD is often characterized by increased somatic complaints, hypochondriasis, or pain [5,18,19]. Another major difference lies in the presentation of cognitive difficulties. Younger patients typically complain of poor concentration or indecisiveness. Geriatric patients may present with cognitive changes including objective findings of slower processing speed and executive dysfunction on neuropsychological testing [17].

Depression rating scales may aid in identification of LLD. They are not a substitute for clinical diagnosis but can be useful as screening tools. Two commonly utilized depression rating scales are the Geriatric Depression Scale (GDS) and the Patient Health Questionnaire-9 (PHQ-9). GDS is a 30-item instrument developed specifically for older adults. Shorter 15-item, 5-item, and 4-item versions exist. The scale utilizes a Yes/No format and can be self- or clinician-administered [20]. One advantage of the GDS lies in its focus on psychological and cognitive aspects of depression rather than neurovegetative symptoms that may overlap with medical illnesses common in older adults [21]. The PHQ-9 is a 9-item self- or clinician-administered screening tool designed for use in primary care settings and has also been validated in geriatric populations [22,23]. The 9 items on this scale correspond to the DSM-5 criteria for major depression. A shorter 2-item version (PHQ-2) has also been validated, and a positive screen on this test should prompt administration of the full-length version. Both versions have approximately 80% sensitivity and specificity in detecting depression. An added advantage of PHQ-9 over GDS is that it can be useful in monitoring treatment response over time [22,23]

Comprehensive Assessment of LLD

The comprehensive assessment of patients with LLD can be carried out by health professionals in both mental health or primary care settings. In a multidisciplinary approach, psychiatrists and mental health professionals have collaborated with primary care providers using depression care managers with successful outcomes in managing depression in older adults [24,25]. Complete evaluation of a patient with suspected LLD begins with a history and physical and mental status examination. Other essential components of the evaluation include assessment of cognition, functional status, and suicide risk. Laboratory and neuroimaging studies may be necessary as well. Due to the comprehensive nature of this assessment, a multidisciplinary approach with collaboration between primary care, psychiatry, psychology, and ancillary services such as social work may be necessary. Multiple patient interactions may be required to complete a thorough evaluation.

History and Mental Status Examination

As with many other psychiatric illnesses, LLD is a clinical diagnosis. A careful history should be obtained initially utilizing open-ended questions. This should be followed by more directed questions as indicated to elicit the presence of depressive symptoms. The history should be obtained from the patient. A relevant collateral informant can be invaluable in the assessment, especially in cases where there is a comorbid neurocognitive disorder. However, the patient’s informed consent must be obtained prior to obtaining collateral information whenever possible. Psychosocial stressors that may have precipitated or may be perpetuating symptoms should be explored. Such stressors may include recent changes in living situation, loss of social support, recent deaths, or financial difficulties. Biological precipitants also need to be explored including presence of physical illness, depressogenic medications, and comorbid alcohol or other substance use. The patient’s past psychiatric history, psychiatric hospitalizations, and past medication trials should be ascertained. Any family history of depression, other psychiatric disorders, substance use disorders, and suicide attempts should be documented. A full mental status exam including cognitive assessment should be completed [21,26].

Cognitive Assessment

Cognitive impairment can be associated with LLD and may be due to the underlying depression or represent a comorbid neurocognitive disorder. Furthermore, the burden of medical illness as well as cerebrovascular and cardiovascular risk factors have been linked to executive dysfunction and reduced processing speed in individuals with LDD [27,28]. Distinguishing between these can be challenging; however, chronology of symptom onset is often helpful. Depression is more likely the etiology of cognitive impairment when depressive symptoms precede onset of cognitive deficits. This type of cognitive impairment is termed dementia syndrome of depression and may improve with treatment of depression [5]. Some patients may progress to develop major cognitive decline, and it remains unclear whether LLD represents a risk factor or prodrome to developing a major neurocognitive disorder [29]. On the other hand, if depression develops later in the course of cognitive decline, there may be an underlying neurocognitive disorder [17]. Up to 20% of individuals with major neurocognitive disorder due to Alzheimer’s disease also have major depression [11]. For these reasons, concomitant assessment of cognition is essential to the evaluation of the older adult presenting with depressive symptoms [30]. Cognitive domains that may be affected include learning and memory, language, attention, perceptual motor abilities, social cognition, and executive function [4]. Many of these domains can be assessed during the mental status examination, with brief cognitive screening tools, or with formal neuropsychological testing.

While there are numerous cognitive screening tools, some commonly used, brief tools include the Mini-Cog, the Folstein Mini-Mental State Exam (MMSE), and the Montreal Cognitive Assessment (MoCA). The Mini-Cog consists of a 3-item registration, delayed recall, and clock drawing test and has several advantages over other screening tools. It is a brief test (taking approximately 3 minutes to administer) with good sensitivity and specificity of 80% or greater. Compared with other cognitive screening tools, it is less influenced by level of education, language, or cultural background [31–33]. The MMSE is a longer screening tool consisting of 19 items and requires about 10 minutes to administer. Unlike the Mini-Cog, performance on the MMSE can be affected by level of education and cultural background. However, the MMSE can be administered serially to monitor changes in cognition over time [34,35]. The MoCA is a 10-minute cognitive screening tool first developed to detect mild cognitive impairment (MCI) [36]. The MoCA consists of 7 subscore sections covering visuospatial/executive function, naming, memory (delayed recall), attention, language, abstraction, and orientation. The total score is 30, and 1 point is added to the score if the testing subject has less than high school/12 years of education. The MoCA has demonstrated better sensitivity than the MMSE for the detection of MCI [36]. Elderly patients with depression often perform poorly on these cognitive screening tests due to apathy and poor effort.

Functional Assessment

The diagnosis of LLD requires that symptoms cause significant distress or interfere with functioning. A functional assessment is especially important in the evaluation of the older adult in that it allows clinicians to determine an individual’s ability to live independently and attend to daily needs. Basic activities of daily living (ADLs) include bathing, dressing, grooming, toileting, and self-transferring. Instrumental activities of daily living (IADLs) include more complex daily activities such as preparing meals, administering medications, driving, managing finances, and using simple electronics such as the telephone or remote control [26]. Impairment in IADLs is associated with increased depression severity. Conversely, the severity of depressive symptoms along with associated cognitive impairment predicts IADL impairment [37]. The Philadelphia Multilevel Assessment Instrument is a tool that can aid in the assessment of ADLs and IADLs and has been utilized in studies examining disability in depressed elderly patients [37,38]. Other available scales to quantify functional status include OARS Physical Activities of Daily Living, OARS Instrumental Activities of Daily Living Scale, and Direct Assessment of Functional Status Scale [26].

Suicide Assessment

Assessment for suicidality is an integral part of all psychiatric evaluations and is especially important in the evaluation of the depressed older adult. According to the Centers for Disease Control and Prevention, the suicide rate for individuals age 65 and older is 16.6 per 100,000, a figure that is comparable to that for individuals 18–64 years of age [39]. Non-Hispanic Caucasian males age 85 and older have the highest rate of completed suicide (56.5 per 100,000), underscoring the importance of a thorough suicide assessment [39]. Suicidality can range from passive thoughts of death and wishing that one were not alive, to active thoughts of self-harm with plan and intent. A Canadian study found 2% of community-dwelling adults age 55 and older had suicidal thoughts over a 12-month period and, of these, 28% had major depression [40]. A suicide assessment begins with inquiring about the presence of suicidal thoughts, plans, and intent. The 3 most frequently used methods of completed suicide in the elderly are firearms (28%), hanging (24%) and poisoning (21%) [41]. Access to weapons or other lethal means of self-harm such has hoarding of medications should be ascertained.

A complete suicide assessment requires attention to suicide risk factors, protective factors, and warning signs of impending suicide. Risk factors for suicide in the older adult include mood disorders, chronic medical illnesses and associated functional impairment, chronic pain, and psychosocial factors such as social isolation [42]. Mood disorders are present in 54% to 87% of cases of completed suicide, with major depression being the most common [42]. Chronic medical illness and pain can result in functional impairment leading to feelings of excessive guilt or being a burden to loved ones. Protective factors such as social connectedness, spirituality, religious beliefs, and cultural attitudes against suicide may serve as buffers against these risk factors [43]. Warning signs of impending suicide may indicate preparations for suicide and include feelings of hopelessness or lack of purpose, feeling trapped, talking about death, threatening suicide, agitation, social withdrawal, increased substance use and reckless behavior. Warning signs should prompt action to ensure the safety of the individual [44,45].

Physical Examination, Laboratory Studies, and Neuroimaging

Evaluation of LLD is not complete without a physical examination and ancillary studies to identify underlying medical conditions possibly contributing to or mimicking depressive symptoms. Routine laboratory studies include complete blood count, complete metabolic panel, thyroid studies, and urine drug screen. Signs and symptoms of underlying medical conditions may necessitate further laboratory studies [46]. Neuroimaging may reveal signs of cerebrovascular disease which can predispose, precipitate, or perpetuate depression in older adults [47].

Treatment

Treatment of LLD can take many forms and occur in various settings. Geriatric psychiatrists have expertise in the assessment and treatment of mental illness in the elderly. Workforce estimates for 2010 revealed 1 geriatric psychiatrist per 10,000 adults age 75 and over. This figure is estimated to decrease to 0.5 per 10,000 by the year 2030, underscoring the importance of increasing the knowledge base of clinicians across specialties who provide care to the depressed elderly [48]. The primary care setting is often the locus of care for depression in older adults; however, studies suggest that patients are often left untreated or undertreated [49]. Collaborative care models whereby mental health care is integrated into primary care have been shown to improve outcomes. The Prevention of Suicide in Primary Care Elderly: Collaborative Trial (PROSPECT) study found that use of care managers to assist primary care providers in identification of depression, offer algorithm-based treatment recommendations, monitor symptoms and medication side effects, and provide follow-up yielded improvement in outcomes. Patients in the intervention group were more likely to receive pharmacotherapy or psychotherapy, achieve remission, and showed greater decline in suicidal ideation [50]. Similar results were found in the Improving Mood-Promoting Access to Collaborative Treatment (IMPACT) study in which intervention patients treated under a collaborative care model showed lower depression severity, less functional impairment, and greater reduction in depressive symptoms [25].

Just as a collaborative care model can lead to improved outcomes, the overall strategy of treating depression must be multifaceted. The biopsychosocial model of disease first described in the 1970s emphasizes biological and psychosocial determinants of illness that must be addressed when treatment is considered [51]. This includes nonmodifiable biological factors such as age, gender, and genetic predisposition that may affect treatment options, as well as modifiable biological factors such as comorbid medical illness, medications, or substance use disorders. Psychological factors that can affect depressive symptoms include coping skills and defense mechanisms in the face of stressful life events. Social factors including the role of culture, environment, and family dynamics in disease presentation must be considered as well [52].

Pharmacologic Treatment of LLD

The primary pharmacologic treatment for depression is antidepressants. Treatment consists of 3 phases—acute, continuation, and maintenance. In the acute phase, the goal is remission of current symptoms and restoration of function. The continuation phase, extending up to 6 months after remission, aims to prevent relapse back into a depressive episode. Maintenance therapy is geared at preventing recurrence of future depressive episodes [53]. Studies have found a 50% risk of relapse after 1 episode of depression and 80% after 2 episodes. Up to 20% will develop chronic symptoms. For this reason, maintenance therapy is often necessary for recurrent depression [54].

While cognitive impairment may affect antidepressant efficacy, age does not appear to be a determinant. Gildengers et al examined antidepressant response in young, middle, and older-old patients and found no significant difference in response rates [59]. Early onset versus late onset of first depressive episode also does not predict antidepressant response in patients age 55 and over [60]. There is scant evidence for efficacy of antidepressants in depressed patients with neurocognitive disorders. A 2002 Cochrane review with 4 studies in the meta-analysis (n = 137) concluded that there was weak support for antidepressant efficacy in this population [61]. A 2011 meta-analysis with 330 participants also yielded inconclusive results [62]. The paucity of evidence for antidepressant efficacy in depressed patients with neurocognitive disorders should prompt careful consideration of potential benefits versus adverse effects.

Antidepressants are generally well tolerated in older adults. Side effects vary by medication and contribute to discontinuation in up to 25% of new users (versus 22% for new users who discontinue for reasons other than side effects) [63]. Potential adverse effects shared by most SSRIs and SNRIs include GI disturbance (nausea, diarrhea or constipation), sexual dysfunction, headache, and sleep disturbance [64,65]. In addition, abrupt discontinuation can precipitate serotonin withdrawal syndrome characterized by sensory disturbance (paresthesia, tremor, and irritability) as well as headache, lightheadedness, diaphoresis, insomnia, and agitation. Other medication-specific side effects include risk of seizure with bupropion and sedation with mirtazapine [65].

Despite superiority of antidepressants to placebo in treating depression, up to one-third of patients may not respond to a trial of antidepressants. Sequential treatment protocols such as switching to a different antidepressant or augmentation can increase the proportion of antidepressant responders [66–68]. Studies have found particularly favorable response to augmentation with lithium, with one study achieving a 33% remission rate in treatment- resistant geriatric depression [67,69]. Other pharmacologic augmentation strategies include the addition of mood stabilizers such as lamotrigine, antipsychotics (aripiprazole, olanzapine, quetiapine, and risperidone), and psychostimulants [70–73]. Electroconvulsive therapy (ECT) is a nonpharmacologic option for treatment-resistant depression that will be reviewed later.

Psychotherapeutic and Psychosocial Interventions

Psychotherapeutic interventions have demonstrated efficacy in the treatment of geriatric depression, including but not limited to cognitive behavioral therapy (CBT), interpersonal therapy (IPT), problem-solving therapy (PST), reminiscence and life review, and brief psychodynamic psychotherapy [74]. Some older adults may prefer psychotherapy to pharmacologic treatment (57% vs. 43%) [75]. Potential benefits of psychotherapy include ability to directly address psychosocial stressors that may precipitate or perpetuate depressive symptoms. In addition, psychotherapy is associated with few to no side effects and avoids drug interactions. Barriers to employing psychotherapy may include cost and access to trained psychotherapists [76]. Efficacy of several psychotherapeutic approaches in the care of older depressed adults has been examined. CBT, brief psychodynamic psychotherapy, and IPT will be briefly reviewed here.

CBT. Cognitive therapy was first described by Aaron Beck in the 1960s [77]. It is a highly structured therapy built on the premise that beliefs and assumptions an individual holds can influence emotions and behavior. CBT aims to identify maladaptive belief systems, test the validity of these cognitive distortions, and help individuals formulate more realistic cognitions [78]. Symptom improvement results from addressing these cognitive aspects as well as integration of behavioral activation and skills training to overcome maladaptive behavioral patterns [78]. CBT approaches have been applied to older adults with depression and results show acceptability [79] and efficacy in this population [80–82]. A 2008 Cochrane review (n = 153) found CBT to be superior to waitlist controls [82].

Brief psychodynamic psychotherapy. Brief psychodynamic psychotherapy, unlike highly structured CBT, aims to alter behavior by examining how past experiences and unresolved conflicts influence current emotions and behavior. While studies on application to the treatment of geriatric depression are scarce, limited data demonstrate efficacy in treating geriatric depression [81] and no significant difference in outcomes when compared to CBT [82].

IPT. Like CBT, IPT is a structured time-limited psychotherapeutic treatment approach first developed in the late 1960s by Klerman and Weissman [83]. IPT focuses on the impact of interpersonal relationships on depressive symptoms and examines 4 domains: interpersonal conflict, interpersonal deficits, role transitions, and grief [74].

Studies have shown efficacy of IPT in reducing depressive symptoms in the elderly when compared to usual care [84]. Reynolds et al found IPT combined with nortriptyline (a tricyclic antidepressant) to be superior to either nortriptyline alone or IPT alone in preventing recurrent depressive episodes [85]. Interestingly, a similar study investigating the efficacy of IPT in combination with paroxetine (an SSRI) failed to show added benefit of IPT in preventing recurrence, suggesting that further studies are needed [86].

Psychosocial interventions are integral in the care of the elderly depressed patient. Studies have shown positive benefits of aerobic exercise on depressive symptoms [87]. Yoga, Tai Chi, and other mindfulness-based exercises can increase sense of emotional and physical wellbeing [88–90]. Spirituality, religious beliefs, and involvement with a faith group may be protective against development of mental illness while at the same time provide avenues for increased social connectedness [91]. These and other avenues for socialization should be encouraged as part of the treatment plan for older depressed patients [92]

Electroconvulsive Therapy

ECT is indicated for the treatment of mood and psychotic disorders and has demonstrated efficacy in the treatment of severe depression [93]. It is typically initiated when patients fail to respond to pharmacotherapy and psychotherapy. Circumstances in which ECT can be considered first-line treatment include situations that require a rapid response (severe inanition, weight loss, or suicidality), situations where risks of ECT are lower than that of alternative treatments, previous positive response to ECT, or strong patient preference [94]. ECT is performed under general anesthesia and involves the induction of a generalized tonic-clonic seizure, which is theorized to enhance serotonergic, noradrenergic, and dopaminergic neurotransmission. A typical course of ECT involves treatments 3 times a week for an average of 6 to 12 treatments in total [95]. Elderly patients and those suffering from severe depression with psychotic features respond more robustly to ECT [93,96]. Estimated remission rates after an ECT series have been higher than 80% [93], making this modality the most effective treatment for severe depression to date.

Conclusion

As the population continues to age, clinicians are increasingly likely to encounter patients with late-life depression. A thorough evaluation includes not only assessment of depressive symptoms, but also cognitive, functional, and suicide assessment. Treatment options include pharmaco-therapy, psychotherapy, and in some cases electroconvulsive therapy. Utilization of assessment and treatment nuances unique to the geriatric population, with a multidisciplinary and collaborative approach involving primary care, mental health, and other ancillary providers, will serve to ultimately enhance patient care.

Corresponding author: Corresponding author: Juliet Glover, MD, Dept. of Neuropsychiatry and Behavioral Science, Univ. of South Carolina School of Medicine, 15 Medical Park, Suite 301, Columbia, SC 29203, [email protected].

Financial disclosures: None reported.

Author contributions: conception and design, JAG, SS; drafting of article, JAG, SS; critical revision of the article, JAG, SS.

From the University of Colorado Denver, Aurora, CO.

Abstract

• Objective: To provide evidence-based guidance on strategies that are likely or unlikely to be successful in navigating HPV vaccine conversations with patients and parents.
• Methods: Nonsystematic review of the literature.
• Results: This review highlights some of the most recent innovations in provider HPV vaccine communication and describes provider communication strategies that have been found to improve adolescent vaccination rates in rigorous scientific studies. Promising strategies for which additional research is needed and strategies that probably do not work are also described. 
• Conclusion: By understanding what works, what may work, and what not to do when it comes to communicating with families about HPV vaccines, providers can be better prepared for maximizing the impact they can have on adolescent HPV vaccination rates.

Key words: human papillomavirus; vaccine hesitancy; health communication; parents; immunization.

In the United States, more than 14 million people newly acquire genital human papillomavirus (HPV) annually, and 75 million Americans are infected at any given time [1]. As the most common sexually transmitted disease, more than 80% of sexually active U.S. adults are estimated to be infected with HPV by the age of 50 [1,2]. Although the majority of infections are “silent” and resolve without clinical sequelae, a proportion of infected individuals will go on to develop HPV-related diseases. In women, these include cervical cancer and pre-cancer (ie, abnormal Pap smears); cancers of the vagina, vulva, anus, and oropharynx; and genital warts [3]. Males also bear a high burden of HPV-related disease in the form of penile, anal, and oropharyngeal cancers, as well as genital warts [3]. While once thought of as primarily a “woman’s disease” [4], recent research demonstrates men are also significantly impacted by HPV—particularly in the form of oropharyngeal cancers, which are 2 to 3 times more common in men than in women [5]. In fact, it is estimated by the year 2020 more men will die of HPV-related oropharyngeal cancer than women will die of cervical cancer [6,7]. The combined cost of HPV-associated cancers and other conditions is estimated to be $8 billion per year in the United States [8–11].

HPV Vaccines

Effective HPV vaccines have been available for females aged 9 to 26 years since 2006 (bivalent and quadrivalent vaccines) and for males aged 9 to 26 since 2010 (quadrivalent vaccine only) [12]. These vaccines have been shown in clinical trials to be highly efficacious in preventing HPV infection, cervical pre-cancer, and anal, vaginal, penile, and vulvar cancers caused by the HPV types covered in the vaccine [2]. Although their effectiveness against head and neck cancer has not been studied in clinical trials, most experts believe that these vaccines will also provide protection against at least a proportion of these cancers [13,14]. In 2015 the U.S. Food and Drug Administration approved licensure of a 9-valent HPV vaccine that will soon replace the quadrivalent vaccine in the U.S. market [15]. The 9-valent vaccine is licensed for both males and females aged 9 to 26 and is expected to prevent an even higher proportion of HPV-related cancers than earlier HPV vaccines due to the protection against 5 additional oncogenic HPV types [15].

Despite the potential of HPV vaccines to drastically reduce the incidence of HPV-related cancers and other diseases, these vaccines are not being as widely used in the United States as was hoped. The most recent national data from 2015 demonstrates that only 41.9% of girls and 28.1% of boys have received all 3 doses recommended in the HPV vaccine series [16]. This level of vaccine utilization is significantly lower than the Healthy People 2020 goal of 80% coverage [17], and also significantly lower than that of other developed countries such as Australia and the United Kingdom, which have achieved vaccination levels of ~70% among their target adolescent populations [18,19]. In the future, these low vaccination levels will likely be mitigated somewhat by the recent approval from the FDA and recent recommendation from the Advisory Committee on Immunization Practices (ACIP) for only 2 doses of the 9-valent HPV vaccine (spaced 6 to 12 months apart) for adolescents less than 15 years of age [20,21]. Three doses are still recommended for those aged 15 to 26 years.

Provider Communication About HPV Vaccines

How providers communicate with parents and patients about HPV vaccines is a key influential factor driving current U.S. adolescent HPV vaccination levels [22,23]. Numerous studies demonstrate that a provider’s recommendation generally has the largest impact on whether or not an adolescent receives the vaccine, even above that of parent factors such as attitudes and beliefs about the vaccine and patient characteristics such as age and insurance status [23–31]. Moreover, parents consistently cite their adolescent’s provider as one of the most trusted and impactful resources for obtaining vaccine information [22,32].

Unfortunately, research also shows that providers often fail to adequately recommend the HPV vaccine for their patients, especially for 11 to 12 year olds for whom the vaccine is preferentially recommended [33,34]. For example, in a national study of parents done in 2013, not being recommended by a provider was one of the top 5 reasons parents of males and of females aged 11 to 17 gave for not getting their adolescent vaccinated against HPV [35]. Supporting this also is a 2014 study of 776 pediatricians and family medicine providers nationally, in which Gilkey and colleagues found that more than 1 out of 4 providers did not highly endorse the HPV vaccine for 11 to 12 year olds despite this having been the recommended practice from ACIP for the prior 8 years for girls and 4 years for boys. This is in comparison to the other adolescents vaccines that were reported in the same study as being endorsed highly by these providers > 95% of the time [36].

Recognizing that providers’ HPV vaccine recommendations are often suboptimal, researchers have begun to define what components comprise “high-quality” HPV vaccine recommendations. This has been operationalized by one research group as (1) timeliness—routinely recommending the vaccine starting when the patient is ≤ 12 years; (2) consistency—recommending the vaccine for all eligible adolescents as opposed to an approach based on providers’ perception of their patients’ risk for HPV infection; (3) urgency—recommending that the vaccine be given on the same day the vaccine is being discussed, rather than offering the option of getting it at a future visit; and (4) strength—using language that clearly conveys that the provider believes the vaccine is very important for the adolescent to receive. A national study of primary care providers done in 2014 examined how frequently these quality components were implemented [37]. The results were startling and discouraging. Nearly half of providers (49%) reported they usually recommended that 11 to 12 year olds get the vaccine at a later visit, 41% used a risk-based approach for deciding when to recommend the vaccine, 27% did not tell the parents the vaccine was “very or extremely important,” and a large proportion did not start routinely recommending the vaccine before the age of 13 (39% for male patients and 25% for females) [37].

Much research has now accumulated to explain the underlying reasons why providers may not give consistent and high-quality HPV vaccine recommendations to all eligible adolescents [22]. Issues such as providers’ own knowledge about HPV-related diseases, personal beliefs about the vaccine’s safety and necessity, concern that a discussion about the vaccine will necessitate a discussion about adolescent sexuality with the parent, belief that parents will not want their child vaccinated if asked, perceptions that a provider can adequately select those patients most “in need” of HPV vaccination, and concern that raising the vaccine discussion with vaccine-hesitant parents will result in prolonged discussions have been shown to impact whether and how providers communicate about HPV vaccination during clinical visits [22,36–45]. Now that these barriers have been defined and described, there is a great need to use this knowledge to develop and evaluate interventions that help to mitigate these barriers and improve providers’ vaccine communication abilities. Such interventions are needed not only for HPV, but for all vaccines [46,47].

Possible Strategies for Helping Providers Communicate About HPV Vaccines

Before discussing these interventions, it is worth noting that several of the passive and active strategies have been shown in clinical trials to improve adolescent HPV vaccination rates. Although these are beyond the scope of this article, inclusion of these strategies should certainly be considered by any practice as a mechanism to increase vaccination levels, especially given that the most successful interventions to improve vaccination levels consist of multiple components [48]. Also useful is a recently described “taxonomy of vaccine communication interventions” that provides additional perspective on the scope and complexity of interventions to improve vaccine delivery [49]. There are several well-written review articles that describe interventions that focus on passive and active strategies at the practice or community level [50–52].

Interpersonal Communication Strategies Shown to Increase HPV Vaccination

Presumptive Communication

One of the first studies to examine the specific “way” in which providers communicate about vaccines focused not on HPV but rather on young childhood vaccines. In 2013 Opel and colleagues performed a study in which they taped clinical encounters between a pediatrician and a parent of a child aged 1 to 19 months [53]. Of the 111 encounters recorded, 50% of parents were classified as vaccine hesitant. Parents were aware they were being taped but not aware that the overall purpose of the study was to examine providers’ communication related to vaccination. The researchers found that providers generally used one of 2 communication styles to introduce the vaccine discussion. The first, called the “presumptive” style, assumed that parents would agree to vaccination and presented the vaccines as routine (ie, “We have to do some shots today”). The second style, called “participatory,” was more parent-oriented and used language suggesting shared decision-making (ie, “So what do you want to do about shots today?”). The study showed that the odds of resisting the provider’s vaccine recommendations were significantly higher when providers used a participatory approach than a presumptive one, suggesting that even small changes in language can have a major impact on the likelihood of vaccination. However, given the study design, causality between providers’ recommendation style and parents vaccination decisions could not be delineated.

In 2015 Moss and colleagues performed a study that examined the use of these 2 communication styles with regard to HPV vaccination [54]. This study used data from the 2010 National Immunization Survey–Teen, a national survey on childhood vaccination that includes provider verification of vaccines given [16]. Researchers categorized provider vaccine communication styles into “provider-driven,” which was similar to the presumptive style described Opel, and “patient-driven,” which was similar to Opel’s permissive style. Parents who received a more provider-driven style of HPV vaccine recommendation were far more likely to have allowed their adolescent to be vaccinated than those receiving patient-driven recommendations [54]. Further supporting this communication approach are results from a qualitative study done by Hughes and colleagues in which triads of mothers, adolescents, and providers were interviewed after a preventive care visit to assess the communication that occurred regarding HPV vaccination [39]. Providers’ communication style was categorized into 1 of 3 groups: paternalistic (clinician makes the vaccination decision and communicates this to the family); informed (patient and family gathers information from the clinician and other sources to reach a vaccination decision); and shared (medical and personal information is exchanged between the provider and family and then a decision is reached jointly). Providers who typically adopted the paternalistic approach perceived that they had the highest success in convincing parents to vaccinate—a perception that was confirmed in quantitative assessments of vaccination status among adolescents in the study sample [39]. Our own research demonstrates that learning and implementing a presumptive/paternalistic HPV vaccine recommendation style is easy for primary care providers to do and is perceived as often shortening the time taken during clinical visits to discuss the vaccine [55,56]. Thus, providers should consider opening the HPV vaccine conversation using this approach, and then turning to some of the other communication techniques described below when met with parental resistance or questions.

Motivational Interviewing

A second communication technique that seems effective for promoting HPV vaccination, especially for vaccine hesitant parents, is motivational interviewing. Motivational interviewing describes a communication technique in which the provider leverages a parents’ or patients’ intrinsic motivation to engage in a preferred health behavior [57]. Motivational interviewing was originally developed to combat substance abuse [58,59] but has subsequently been successfully applied to a number of other health issues [60–64]. There is growing interest from public health and medical providers in using this technique for increasing vaccination [39,65–68]. Our research group performed a large, cluster-randomized controlled trial of 16 pediatric and family medicine clinics to examine the impact of a provider communication “toolkit” on adolescent HPV vaccine series initiation and completion [50,69]. The toolkit consisted of motivational interviewing training for providers related to HPV vaccination and training on 3 tangible resources providers could also use with parents—an HPV fact sheet, an HPV vaccine decision aid, and an educational website. Results from the study demonstrated that motivational interviewing was the toolkit component most widely utilized by providers and was also perceived as being the most useful. More importantly, HPV vaccine series initiation levels were significantly higher among adolescents in practices receiving the toolkit than in control practices. There was no impact on HPV vaccine series completion (unpublished results). The usefulness of motivational interviewing for vaccination is further supported by a small study in which community pharmacists receiving motivational interviewing training for adult vaccination reported significantly higher patient readiness to receive vaccines following their interaction with the pharmacist than those who did not receive the training [70]. Finally, Perkins et al performed a cluster randomized controlled trial that evaluated the impact of a provider-focused intervention on adolescent HPV vaccination rates. The intervention included frequent provider support meetings, education on HPV infection and vaccination, feedback on providers’ individual HPV vaccination rates, provider incentives, and “basic motivational interviewing principles with vaccine-hesitant parents.” HPV vaccination series initiation and completion rates were significantly higher in intervention practices than controls, and this effect was sustained for at least 6 months after the active intervention period was over [67]. However, it was unknown how much the motivational interviewing contributed to these results. Based on the above information, and the long history of success of motivational interviewing for improving patient compliance with other recommended health behaviors, this technique appears to have a reasonable evidence base and should be considered for communicating with families that express resistance to HPV vaccination.

Personalized Communication

Parents’ reasons for not having their adolescent vaccinated against HPV are often complex and multifactorial [71,72]. Personalized approaches are needed to account for each parent’s unique informational needs, beliefs, and prior experiences [65]. Unfortunately, given the short amount of time allotted for clinical visits, it is often difficult to provide adequate information to parents during these encounters [73–75]. Indeed, concern about prolonged HPV vaccine discussions has been identified as an important barrier for providers that cause some to forgo recommending the vaccine [36,75].

One potential solution to this issue is to leverage technology in the form of web-based interventions that use software to tailor materials to each individual’s unique informational needs. Feasibility for this idea comes from the knowledge that many parents already use the web to research health issues related to their children [76], and that doctors’ offices are increasingly using patient portals and other web-based resources to help parents prepare for upcoming visits, especially those focused on health maintenance [77,78]. Tailored messaging interventions have been shown across populations and health issues to generally result in superior adherence with health behaviors when compared to untailored controls [79–82]. Several researchers have thus begun exploring whether such a personalized communication strategy may be similarly effective for adolescent HPV vaccination [50,83–85]. As an example, Maertens and colleagues used community-based participatory research techniques to develop a web-based tailored messaging intervention for Latinos regarding HPV vaccination [86]. A subsequent randomized controlled trial of the intervention in over 1200 parents of adolescents and young adults demonstrated that the intervention improved participants’ intentions to vaccinate compared to usual care [87], and among adolescents, higher HPV vaccine series initiation levels (unpublished data). Although additional work is needed to understand the feasibility of implementing such an intervention more broadly, additional support for the usefulness of a tailored messaging approach comes from a study of female university students that demonstrated higher HPV vaccination intentions after exposure to tailored information compared to untailored information. However, the impact on actual HPV vaccine utilization was not measured in the study [84]. Contrasting results were found in a different study of university students where researchers failed to find an impact of message tailoring on HPV vaccination utilization. However, this study was limited by a low response rate (~50%) to the follow up survey where vaccination status was assessed, and also by overall low levels of HPV vaccine initiation among the entire study sample (8%) [85]. Given the low number of studies in this area, and some conflicting data, additional research is needed to better understand the impact of personalized communication on HPV vaccination levels. However, results from these studies suggest that a modest benefit may be achieved with this approach, especially if coupled with other, evidence-based, clinic-level interventions to promote vaccination (eg, vaccine reminders, extended office hours), as is suggested by the Task Force on Community Preventive Services [48].

Focusing Communication on Cancer Prevention

HPV vaccines are unique in that they are only 1 of 2 vaccines for cancer prevention (the other being hepatitis B). Provider and parent surveys suggest that while most providers do mention cancer prevention when discussing HPV vaccines [40,88,89], this may be more commonly done with female patients than males [22]. Focusing on cancer prevention rather than sexual transmissibility is a communication technique suggested by the Centers for Disease Control and Prevention (CDC) as many parents cite this aspect of the vaccine as one of the most compelling reasons for vaccinating [45,90]. CDC’s “You are the Key” program [91] uses cancer prevention as a central theme in their physician and patient communication materials, based on significant prior market research on the acceptability and impact of such messages among parents and providers. In 2016 Malo and colleagues tested the potential impact of brief messages related to HPV vaccination, including cancer prevention messages, among a national sample of 776 medical providers and 1504 parents of adolescents [92]. In addition to their potential to motivate parents to vaccination, associations between parental endorsement of each message and their adolescent’s vaccination status were also examined. The cancer prevention messages were among those most highly endorsed by both parents and providers as being motivating for parents to get their adolescent vaccinated. More importantly, among parents these endorsements were associated with a significantly higher likelihood of the adolescent having been vaccinated against HPV. Interestingly, one of the briefest messages in the study, “I [the physician] strongly believe in the importance of this cancer preventing vaccine for [child’s name],” was perceived as the most persuasive message by parents.

Further support for the positive impact of framing HPV vaccines primarily as cancer prevention comes from another national study of 1495 parents of 11 to 17 year olds that examined 3 measures of quality of their adolescent provider’s HPV vaccine recommendation, and the relationship between recommendation quality and likelihood of adolescent HPV vaccination [40]. The 3 quality indicators assessed included providing information about cancer prevention, encouraging the vaccine “strongly,” and recommending it be given on the same day as it was being discussed. While 49% of parents reported receiving no HPV vaccine recommendation from their adolescents’ provider, of those that did, 86% received a cancer prevention message. Parents who had been given high quality recommendations that included either 2 or 3 of the quality indicator measures had over 9 times the odds of vaccine series initiation and 3 times the odds of vaccine series follow through than those who had not received any recommendation, and also significantly higher odds of vaccination than parents who had received low quality recommendations (ie, included only 1 indicator). Taken together, these results suggest that focusing discussions about HPV vaccines on their ability to prevent cancer is likely to be persuasive for some parents.

Strategies That Are Promising But Not Thoroughly Tested

Helping Parents Create Vaccination Plans

A recent commentary suggested that instead of focusing on changing beliefs or “educating” parents and patients about the need for a given vaccine, perhaps a better way to craft interventions for increasing vaccination is to focus on structuring the environment to make vaccination “easy” [93,94]. Examples of this include strategies such as extended office hours and making the vaccine available in other locations such as schools and pharmacies, both of which have been shown in some populations and settings to improve vaccine utilization [48,95]. One aspect of structuring a vaccine-conducive environment that relates to provider communication is helping parents create “implementation intentions” for future vaccination visits. In its most obvious form, this would mean providers provide office resources that facilitate making an appointment for the next dose in the HPV vaccine series during a clinic visit where the first dose was provided. But such an approach could also potentially extend to parents who are on the fence about the vaccine—to make an appointment before the parent leaves the office with an unvaccinated child to either re-discuss the vaccine in the future or to actually start the vaccine series. Support for such a strategy comes primarily from the social sciences, which suggest that implementation intentions work by increasing attention to specific cues to action, making it more likely that that the cue will be acted upon [96–98]. Creating implementation intentions has been shown to be helpful for improving adherence with a variety of health behaviors [99–105], and there is a growing evidence base related to how implementation intentions may facilitate vaccination specifically. For example Vet and colleagues performed a randomized controlled trial among 616 men who have sex with men with either strong or weak intentions to receive the hepatitis B vaccine [106]. Half of the participants were asked to create an implementation intention plan where they described when, where and how they would obtain the vaccine. Those in the control arm were not given this prompt. Regardless of whether their initial vaccination intention was weak or strong, those who had been asked to create an implementation plan had more than double the likelihood of actually getting the vaccine than participants who did not receive the implementation plan prompt. Similarly, a study of influenza vaccination rates among corporate employees found that those who were asked to write down the day and time they planned to go to employee health to get the free vaccine were somewhat more likely (4% higher) to be vaccinated than those who did not receive this prompt [107]. In addition, a study of elderly individuals found that influenza vaccination rates were significantly higher among those who had received “action instructions” on how, when and where to get the vaccine than those who did not [108]. These studies suggest that helping parents craft a definitive follow-up plan regarding vaccination could have a significant impact on vaccination rates—particularly for vaccines like HPV that require multiple doses.

Treating all Adolescent Vaccines the Same

Prior research has demonstrated that providers often communicate differently about HPV vaccines than other adolescent vaccines such as the tetanus-diphtheria-pertussis (Tdap) and meningococcal (MCV) vaccines [22,36]. Providers often tend to discuss the HPV vaccine last among these 3 vaccines, provide weaker endorsements of the vaccine, and pre-emptively give much more detail about the HPV compared to the other vaccines, even in the absence of a parent’s request for additional information [36,39,41]. The CDC and the American Academy of Pediatrics now suggest putting HPV at the beginning or middle of the list of vaccines recommended to the adolescent (ie, “HPV, Tdap and MCV”), and treating all recommended vaccines equivalently in terms of the level of detail provided to parents in the absence of a parent’s request for more information [109,110]. Through these suggestions have face validity, their specific impact on HPV vaccination rates, and on patient and provider satisfaction with the visit have yet to be evaluated.

Strategies that Probably Don’t Work

Presenting Myths and Facts

Research related to promoting other vaccines provides insight into communication activities that probably would not work well for promoting HPV vaccination. A 2012 study by Nyhan and colleagues examined the impact of 2 different messages related to influenza vaccines on participants’ beliefs about the vaccine’s safety and intentions to get vaccinated [111]. One group received information to correct the commonly held belief that influenza vaccine can cause the flu while the other received information about the risks associated with contracting an influenza infection. While the correction of myths did improve participants’ perceptions of the vaccine’s safety, information about influenza dangers did not. Neither message impacted intentions to vaccinate in the study subjects overall. However, in sub-analyses the correction of myths actually decreased intentions to vaccinate among those with high baseline levels of concern about the vaccine’s side effects—that is, among those most concerned that the flu vaccine can give someone the flu, correcting this myth actually decreased the likelihood that they would receive the vaccine. Similar findings have been reported in other studies related to vaccination [112–114], and suggest that the “threat” generated by providing information opposing a person’s beliefs may actually entrench these beliefs further as part of the threat response—a phenomenon known as attitude polarization [115]. These results also are consistent with the concept of negativity bias, which posits that negative information influences people’s risk perceptions more than positive information, and that the more strongly a risk is attempted to be negated, the lower the effectiveness and perceived trust of the information [116].

Using Fear Appeals

One tactic that has been suggested by some as a way to promote vaccination is to provide graphic depictions of the possible sequelae of vaccine-preventable diseases. The thought behind this idea is that because vaccination is so successful, most parents will have never experienced significant impacts from vaccine preventable diseases that, in the past, had been a major motivator for parents to vaccinate. Thus, in order to counter beliefs about “controversial” issues like vaccination, highly emotionally compelling and engaging information may be especially useful. This is a common tactic used by anti-vaccination groups to spread their own messages [117]. However, several studies suggested that using “fear appeals” (aka scare tactics) such as this to promote vaccination can actually have a negative effect on vaccination intentions. For example, in a 2011 study of a nationally representative sample of parents of children < 18 years, 4 different message formats were tested for their impact on parental intentions to vaccinate a future child with the measles-mumps-rubella vaccine (MMR) [113]. Message formats included correcting the misinformation that MMR causes autism, presenting information on MMR-related disease risk, providing a dramatic narrative about a child endangered by measles, and showing pictures of infants affected by these diseases. Counter to the study’s hypotheses, the dramatic narrative message actually increased parents’ perceptions that MMR vaccines had serious side effects, and the pictures increased parents’ belief that the MMR vaccine could cause autism. These counter-intuitive results are consistent with other studies that have examined the impact of message framing on adults’ vaccination intentions for HPV and influenza [108,118,119]. Taken together, fear appeals seem unlikely to sway many hesitant parents towards HPV vaccination.

Looking Into the Future

Moving forward, additional interventions to improve providers’ ability to communicate with families about HPV vaccination will undoubtedly be developed. A major area of interest in this regard is leveraging the power of technology and the internet, including using social media, mobile technologies, and online interventions to augment the provider/parent interaction that occurs during the clinical visit [50,120]. Web-based approaches have the benefit of generally being low cost and easy to disseminate to large populations. Such interventions have already been developed for a number of other health issues, some of which have proven effective [121,122]. However, use of the internet to promote healthy behaviors in general, and vaccination specifically, is still in its infancy. There is still much to be learned about how to create effective web-based tools, how to engage patients with them, and how to assess their impact on health outcomes [123].

Another interesting area for future research is identifying psychological “levers” to motivate parents’ vaccination intentions [94]. One example is focusing on using parents’ values (ie, protecting my child from harm) as an intervention target rather than beliefs or attitudes. This is because values tend to be inherent and static over time, compared to beliefs and attitudes, which are subject to change depending on the context [124]. Prior research has shown that interventions that leverage values rather than facts can be an effective way to overcome beliefs that are highly emotional or controversial, and that individuals are more likely to trust sources and individuals with shared values than those without [125], suggesting that this may be a useful way to motivate parents toward vaccinating their children. Self-affirmation is another example of a psychological lever that has a significant evidence base from the social science literature as a helpful tool for moving patients towards a desired health behavior [126,127], but it has not been extensively applied to the field of vaccination. Researchers in the field of vaccine delivery are increasingly recognizing the potential value of these unique intervention approaches [101,128–134], and it may be fruitful in the future to more closely examine the efficacy of interventions that target things like values, self-affirmation or other psychological levers to change parents’ HPV vaccination behaviors.

A final notable area for intervention research related to HPV vaccination is the use of video games. Although not likely to be used directly during patient visits, this strategy could be conceptualized as a potential way to augment the information conveyed to a parent by a provider directly during a clinical encounter. A meta-analysis from 2016 identified 16 different “serious” video games that were used to train and educate users about specific vaccine preventable diseases (usually influenza, none for HPV) and the need for vaccination [135]. In many of them, the objective of the game was to protect a virtual community from a vaccine preventable disease and/or manage outbreaks. Only 2 of the games evaluated outcomes in the short term (ie, at the time the game was being played). None have evaluated longer-term impacts such as vaccination intention or utilization. In the era of “plugged in” parents and adolescents, video games represent a unique but understudied mechanism for helping providers “communicate,” albeit indirectly, with families about the need for vaccination. Imagine providing a prescription to an HPV-vaccine hesitant family to “go play Zombie Wars HPV!” One would expect the curiosity factor alone would result in significant engagement with this intervention tool.

Conclusion

With persistently lagging HPV vaccination rates among U.S. adolescents, there is a growing need for effective interventions to improve adolescent HPV vaccine utilization. How providers communicate with families is one of the most influential factors in parents’ vaccination decisions. Emerging research is beginning to delineate potentially effective communication techniques such as presumptive approaches to making the vaccine recommendation, framing the vaccine as cancer preventing, and using motivational interviewing and personalized messaging when met with parental vaccine resistance. Moving forward the list of evidence-based interventions to improve providers’ HPV vaccine communication is likely to grow, and to increasingly leverage technology based solutions. However, given the complexities of the vaccination decision [136] and the ever growing spread of vaccine hesitancy [137], it is unlikely that a single intervention approach will be effective for getting adolescent HPV vaccine levels up to the national goal of 80% coverage. As has been recognized in the past, the most effective interventions for HPV vaccination in the future are likely to be multicomponent, including not only provider communication strategies but also clinic-, community-, and parent-level interventions [48].

Corresponding author: Amanda Dempsey, MD, PhD, MPH, 13199 East Montview Blvd, Suite 300, Aurora, CO 80045, [email protected].

Financial disclosures: None reported.

From the University of Colorado Denver, Aurora, CO.

Abstract

• Objective: To provide evidence-based guidance on strategies that are likely or unlikely to be successful in navigating HPV vaccine conversations with patients and parents.
• Methods: Nonsystematic review of the literature.
• Results: This review highlights some of the most recent innovations in provider HPV vaccine communication and describes provider communication strategies that have been found to improve adolescent vaccination rates in rigorous scientific studies. Promising strategies for which additional research is needed and strategies that probably do not work are also described. 
• Conclusion: By understanding what works, what may work, and what not to do when it comes to communicating with families about HPV vaccines, providers can be better prepared for maximizing the impact they can have on adolescent HPV vaccination rates.

Key words: human papillomavirus; vaccine hesitancy; health communication; parents; immunization.

In the United States, more than 14 million people newly acquire genital human papillomavirus (HPV) annually, and 75 million Americans are infected at any given time [1]. As the most common sexually transmitted disease, more than 80% of sexually active U.S. adults are estimated to be infected with HPV by the age of 50 [1,2]. Although the majority of infections are “silent” and resolve without clinical sequelae, a proportion of infected individuals will go on to develop HPV-related diseases. In women, these include cervical cancer and pre-cancer (ie, abnormal Pap smears); cancers of the vagina, vulva, anus, and oropharynx; and genital warts [3]. Males also bear a high burden of HPV-related disease in the form of penile, anal, and oropharyngeal cancers, as well as genital warts [3]. While once thought of as primarily a “woman’s disease” [4], recent research demonstrates men are also significantly impacted by HPV—particularly in the form of oropharyngeal cancers, which are 2 to 3 times more common in men than in women [5]. In fact, it is estimated by the year 2020 more men will die of HPV-related oropharyngeal cancer than women will die of cervical cancer [6,7]. The combined cost of HPV-associated cancers and other conditions is estimated to be $8 billion per year in the United States [8–11].

HPV Vaccines

Effective HPV vaccines have been available for females aged 9 to 26 years since 2006 (bivalent and quadrivalent vaccines) and for males aged 9 to 26 since 2010 (quadrivalent vaccine only) [12]. These vaccines have been shown in clinical trials to be highly efficacious in preventing HPV infection, cervical pre-cancer, and anal, vaginal, penile, and vulvar cancers caused by the HPV types covered in the vaccine [2]. Although their effectiveness against head and neck cancer has not been studied in clinical trials, most experts believe that these vaccines will also provide protection against at least a proportion of these cancers [13,14]. In 2015 the U.S. Food and Drug Administration approved licensure of a 9-valent HPV vaccine that will soon replace the quadrivalent vaccine in the U.S. market [15]. The 9-valent vaccine is licensed for both males and females aged 9 to 26 and is expected to prevent an even higher proportion of HPV-related cancers than earlier HPV vaccines due to the protection against 5 additional oncogenic HPV types [15].

Despite the potential of HPV vaccines to drastically reduce the incidence of HPV-related cancers and other diseases, these vaccines are not being as widely used in the United States as was hoped. The most recent national data from 2015 demonstrates that only 41.9% of girls and 28.1% of boys have received all 3 doses recommended in the HPV vaccine series [16]. This level of vaccine utilization is significantly lower than the Healthy People 2020 goal of 80% coverage [17], and also significantly lower than that of other developed countries such as Australia and the United Kingdom, which have achieved vaccination levels of ~70% among their target adolescent populations [18,19]. In the future, these low vaccination levels will likely be mitigated somewhat by the recent approval from the FDA and recent recommendation from the Advisory Committee on Immunization Practices (ACIP) for only 2 doses of the 9-valent HPV vaccine (spaced 6 to 12 months apart) for adolescents less than 15 years of age [20,21]. Three doses are still recommended for those aged 15 to 26 years.

Provider Communication About HPV Vaccines

How providers communicate with parents and patients about HPV vaccines is a key influential factor driving current U.S. adolescent HPV vaccination levels [22,23]. Numerous studies demonstrate that a provider’s recommendation generally has the largest impact on whether or not an adolescent receives the vaccine, even above that of parent factors such as attitudes and beliefs about the vaccine and patient characteristics such as age and insurance status [23–31]. Moreover, parents consistently cite their adolescent’s provider as one of the most trusted and impactful resources for obtaining vaccine information [22,32].

Unfortunately, research also shows that providers often fail to adequately recommend the HPV vaccine for their patients, especially for 11 to 12 year olds for whom the vaccine is preferentially recommended [33,34]. For example, in a national study of parents done in 2013, not being recommended by a provider was one of the top 5 reasons parents of males and of females aged 11 to 17 gave for not getting their adolescent vaccinated against HPV [35]. Supporting this also is a 2014 study of 776 pediatricians and family medicine providers nationally, in which Gilkey and colleagues found that more than 1 out of 4 providers did not highly endorse the HPV vaccine for 11 to 12 year olds despite this having been the recommended practice from ACIP for the prior 8 years for girls and 4 years for boys. This is in comparison to the other adolescents vaccines that were reported in the same study as being endorsed highly by these providers > 95% of the time [36].

Recognizing that providers’ HPV vaccine recommendations are often suboptimal, researchers have begun to define what components comprise “high-quality” HPV vaccine recommendations. This has been operationalized by one research group as (1) timeliness—routinely recommending the vaccine starting when the patient is ≤ 12 years; (2) consistency—recommending the vaccine for all eligible adolescents as opposed to an approach based on providers’ perception of their patients’ risk for HPV infection; (3) urgency—recommending that the vaccine be given on the same day the vaccine is being discussed, rather than offering the option of getting it at a future visit; and (4) strength—using language that clearly conveys that the provider believes the vaccine is very important for the adolescent to receive. A national study of primary care providers done in 2014 examined how frequently these quality components were implemented [37]. The results were startling and discouraging. Nearly half of providers (49%) reported they usually recommended that 11 to 12 year olds get the vaccine at a later visit, 41% used a risk-based approach for deciding when to recommend the vaccine, 27% did not tell the parents the vaccine was “very or extremely important,” and a large proportion did not start routinely recommending the vaccine before the age of 13 (39% for male patients and 25% for females) [37].

Much research has now accumulated to explain the underlying reasons why providers may not give consistent and high-quality HPV vaccine recommendations to all eligible adolescents [22]. Issues such as providers’ own knowledge about HPV-related diseases, personal beliefs about the vaccine’s safety and necessity, concern that a discussion about the vaccine will necessitate a discussion about adolescent sexuality with the parent, belief that parents will not want their child vaccinated if asked, perceptions that a provider can adequately select those patients most “in need” of HPV vaccination, and concern that raising the vaccine discussion with vaccine-hesitant parents will result in prolonged discussions have been shown to impact whether and how providers communicate about HPV vaccination during clinical visits [22,36–45]. Now that these barriers have been defined and described, there is a great need to use this knowledge to develop and evaluate interventions that help to mitigate these barriers and improve providers’ vaccine communication abilities. Such interventions are needed not only for HPV, but for all vaccines [46,47].

Possible Strategies for Helping Providers Communicate About HPV Vaccines

Before discussing these interventions, it is worth noting that several of the passive and active strategies have been shown in clinical trials to improve adolescent HPV vaccination rates. Although these are beyond the scope of this article, inclusion of these strategies should certainly be considered by any practice as a mechanism to increase vaccination levels, especially given that the most successful interventions to improve vaccination levels consist of multiple components [48]. Also useful is a recently described “taxonomy of vaccine communication interventions” that provides additional perspective on the scope and complexity of interventions to improve vaccine delivery [49]. There are several well-written review articles that describe interventions that focus on passive and active strategies at the practice or community level [50–52].

Interpersonal Communication Strategies Shown to Increase HPV Vaccination

Presumptive Communication

One of the first studies to examine the specific “way” in which providers communicate about vaccines focused not on HPV but rather on young childhood vaccines. In 2013 Opel and colleagues performed a study in which they taped clinical encounters between a pediatrician and a parent of a child aged 1 to 19 months [53]. Of the 111 encounters recorded, 50% of parents were classified as vaccine hesitant. Parents were aware they were being taped but not aware that the overall purpose of the study was to examine providers’ communication related to vaccination. The researchers found that providers generally used one of 2 communication styles to introduce the vaccine discussion. The first, called the “presumptive” style, assumed that parents would agree to vaccination and presented the vaccines as routine (ie, “We have to do some shots today”). The second style, called “participatory,” was more parent-oriented and used language suggesting shared decision-making (ie, “So what do you want to do about shots today?”). The study showed that the odds of resisting the provider’s vaccine recommendations were significantly higher when providers used a participatory approach than a presumptive one, suggesting that even small changes in language can have a major impact on the likelihood of vaccination. However, given the study design, causality between providers’ recommendation style and parents vaccination decisions could not be delineated.

In 2015 Moss and colleagues performed a study that examined the use of these 2 communication styles with regard to HPV vaccination [54]. This study used data from the 2010 National Immunization Survey–Teen, a national survey on childhood vaccination that includes provider verification of vaccines given [16]. Researchers categorized provider vaccine communication styles into “provider-driven,” which was similar to the presumptive style described Opel, and “patient-driven,” which was similar to Opel’s permissive style. Parents who received a more provider-driven style of HPV vaccine recommendation were far more likely to have allowed their adolescent to be vaccinated than those receiving patient-driven recommendations [54]. Further supporting this communication approach are results from a qualitative study done by Hughes and colleagues in which triads of mothers, adolescents, and providers were interviewed after a preventive care visit to assess the communication that occurred regarding HPV vaccination [39]. Providers’ communication style was categorized into 1 of 3 groups: paternalistic (clinician makes the vaccination decision and communicates this to the family); informed (patient and family gathers information from the clinician and other sources to reach a vaccination decision); and shared (medical and personal information is exchanged between the provider and family and then a decision is reached jointly). Providers who typically adopted the paternalistic approach perceived that they had the highest success in convincing parents to vaccinate—a perception that was confirmed in quantitative assessments of vaccination status among adolescents in the study sample [39]. Our own research demonstrates that learning and implementing a presumptive/paternalistic HPV vaccine recommendation style is easy for primary care providers to do and is perceived as often shortening the time taken during clinical visits to discuss the vaccine [55,56]. Thus, providers should consider opening the HPV vaccine conversation using this approach, and then turning to some of the other communication techniques described below when met with parental resistance or questions.

Motivational Interviewing

A second communication technique that seems effective for promoting HPV vaccination, especially for vaccine hesitant parents, is motivational interviewing. Motivational interviewing describes a communication technique in which the provider leverages a parents’ or patients’ intrinsic motivation to engage in a preferred health behavior [57]. Motivational interviewing was originally developed to combat substance abuse [58,59] but has subsequently been successfully applied to a number of other health issues [60–64]. There is growing interest from public health and medical providers in using this technique for increasing vaccination [39,65–68]. Our research group performed a large, cluster-randomized controlled trial of 16 pediatric and family medicine clinics to examine the impact of a provider communication “toolkit” on adolescent HPV vaccine series initiation and completion [50,69]. The toolkit consisted of motivational interviewing training for providers related to HPV vaccination and training on 3 tangible resources providers could also use with parents—an HPV fact sheet, an HPV vaccine decision aid, and an educational website. Results from the study demonstrated that motivational interviewing was the toolkit component most widely utilized by providers and was also perceived as being the most useful. More importantly, HPV vaccine series initiation levels were significantly higher among adolescents in practices receiving the toolkit than in control practices. There was no impact on HPV vaccine series completion (unpublished results). The usefulness of motivational interviewing for vaccination is further supported by a small study in which community pharmacists receiving motivational interviewing training for adult vaccination reported significantly higher patient readiness to receive vaccines following their interaction with the pharmacist than those who did not receive the training [70]. Finally, Perkins et al performed a cluster randomized controlled trial that evaluated the impact of a provider-focused intervention on adolescent HPV vaccination rates. The intervention included frequent provider support meetings, education on HPV infection and vaccination, feedback on providers’ individual HPV vaccination rates, provider incentives, and “basic motivational interviewing principles with vaccine-hesitant parents.” HPV vaccination series initiation and completion rates were significantly higher in intervention practices than controls, and this effect was sustained for at least 6 months after the active intervention period was over [67]. However, it was unknown how much the motivational interviewing contributed to these results. Based on the above information, and the long history of success of motivational interviewing for improving patient compliance with other recommended health behaviors, this technique appears to have a reasonable evidence base and should be considered for communicating with families that express resistance to HPV vaccination.

Personalized Communication

Parents’ reasons for not having their adolescent vaccinated against HPV are often complex and multifactorial [71,72]. Personalized approaches are needed to account for each parent’s unique informational needs, beliefs, and prior experiences [65]. Unfortunately, given the short amount of time allotted for clinical visits, it is often difficult to provide adequate information to parents during these encounters [73–75]. Indeed, concern about prolonged HPV vaccine discussions has been identified as an important barrier for providers that cause some to forgo recommending the vaccine [36,75].

One potential solution to this issue is to leverage technology in the form of web-based interventions that use software to tailor materials to each individual’s unique informational needs. Feasibility for this idea comes from the knowledge that many parents already use the web to research health issues related to their children [76], and that doctors’ offices are increasingly using patient portals and other web-based resources to help parents prepare for upcoming visits, especially those focused on health maintenance [77,78]. Tailored messaging interventions have been shown across populations and health issues to generally result in superior adherence with health behaviors when compared to untailored controls [79–82]. Several researchers have thus begun exploring whether such a personalized communication strategy may be similarly effective for adolescent HPV vaccination [50,83–85]. As an example, Maertens and colleagues used community-based participatory research techniques to develop a web-based tailored messaging intervention for Latinos regarding HPV vaccination [86]. A subsequent randomized controlled trial of the intervention in over 1200 parents of adolescents and young adults demonstrated that the intervention improved participants’ intentions to vaccinate compared to usual care [87], and among adolescents, higher HPV vaccine series initiation levels (unpublished data). Although additional work is needed to understand the feasibility of implementing such an intervention more broadly, additional support for the usefulness of a tailored messaging approach comes from a study of female university students that demonstrated higher HPV vaccination intentions after exposure to tailored information compared to untailored information. However, the impact on actual HPV vaccine utilization was not measured in the study [84]. Contrasting results were found in a different study of university students where researchers failed to find an impact of message tailoring on HPV vaccination utilization. However, this study was limited by a low response rate (~50%) to the follow up survey where vaccination status was assessed, and also by overall low levels of HPV vaccine initiation among the entire study sample (8%) [85]. Given the low number of studies in this area, and some conflicting data, additional research is needed to better understand the impact of personalized communication on HPV vaccination levels. However, results from these studies suggest that a modest benefit may be achieved with this approach, especially if coupled with other, evidence-based, clinic-level interventions to promote vaccination (eg, vaccine reminders, extended office hours), as is suggested by the Task Force on Community Preventive Services [48].

Focusing Communication on Cancer Prevention

HPV vaccines are unique in that they are only 1 of 2 vaccines for cancer prevention (the other being hepatitis B). Provider and parent surveys suggest that while most providers do mention cancer prevention when discussing HPV vaccines [40,88,89], this may be more commonly done with female patients than males [22]. Focusing on cancer prevention rather than sexual transmissibility is a communication technique suggested by the Centers for Disease Control and Prevention (CDC) as many parents cite this aspect of the vaccine as one of the most compelling reasons for vaccinating [45,90]. CDC’s “You are the Key” program [91] uses cancer prevention as a central theme in their physician and patient communication materials, based on significant prior market research on the acceptability and impact of such messages among parents and providers. In 2016 Malo and colleagues tested the potential impact of brief messages related to HPV vaccination, including cancer prevention messages, among a national sample of 776 medical providers and 1504 parents of adolescents [92]. In addition to their potential to motivate parents to vaccination, associations between parental endorsement of each message and their adolescent’s vaccination status were also examined. The cancer prevention messages were among those most highly endorsed by both parents and providers as being motivating for parents to get their adolescent vaccinated. More importantly, among parents these endorsements were associated with a significantly higher likelihood of the adolescent having been vaccinated against HPV. Interestingly, one of the briefest messages in the study, “I [the physician] strongly believe in the importance of this cancer preventing vaccine for [child’s name],” was perceived as the most persuasive message by parents.

Further support for the positive impact of framing HPV vaccines primarily as cancer prevention comes from another national study of 1495 parents of 11 to 17 year olds that examined 3 measures of quality of their adolescent provider’s HPV vaccine recommendation, and the relationship between recommendation quality and likelihood of adolescent HPV vaccination [40]. The 3 quality indicators assessed included providing information about cancer prevention, encouraging the vaccine “strongly,” and recommending it be given on the same day as it was being discussed. While 49% of parents reported receiving no HPV vaccine recommendation from their adolescents’ provider, of those that did, 86% received a cancer prevention message. Parents who had been given high quality recommendations that included either 2 or 3 of the quality indicator measures had over 9 times the odds of vaccine series initiation and 3 times the odds of vaccine series follow through than those who had not received any recommendation, and also significantly higher odds of vaccination than parents who had received low quality recommendations (ie, included only 1 indicator). Taken together, these results suggest that focusing discussions about HPV vaccines on their ability to prevent cancer is likely to be persuasive for some parents.

Strategies That Are Promising But Not Thoroughly Tested

Helping Parents Create Vaccination Plans

A recent commentary suggested that instead of focusing on changing beliefs or “educating” parents and patients about the need for a given vaccine, perhaps a better way to craft interventions for increasing vaccination is to focus on structuring the environment to make vaccination “easy” [93,94]. Examples of this include strategies such as extended office hours and making the vaccine available in other locations such as schools and pharmacies, both of which have been shown in some populations and settings to improve vaccine utilization [48,95]. One aspect of structuring a vaccine-conducive environment that relates to provider communication is helping parents create “implementation intentions” for future vaccination visits. In its most obvious form, this would mean providers provide office resources that facilitate making an appointment for the next dose in the HPV vaccine series during a clinic visit where the first dose was provided. But such an approach could also potentially extend to parents who are on the fence about the vaccine—to make an appointment before the parent leaves the office with an unvaccinated child to either re-discuss the vaccine in the future or to actually start the vaccine series. Support for such a strategy comes primarily from the social sciences, which suggest that implementation intentions work by increasing attention to specific cues to action, making it more likely that that the cue will be acted upon [96–98]. Creating implementation intentions has been shown to be helpful for improving adherence with a variety of health behaviors [99–105], and there is a growing evidence base related to how implementation intentions may facilitate vaccination specifically. For example Vet and colleagues performed a randomized controlled trial among 616 men who have sex with men with either strong or weak intentions to receive the hepatitis B vaccine [106]. Half of the participants were asked to create an implementation intention plan where they described when, where and how they would obtain the vaccine. Those in the control arm were not given this prompt. Regardless of whether their initial vaccination intention was weak or strong, those who had been asked to create an implementation plan had more than double the likelihood of actually getting the vaccine than participants who did not receive the implementation plan prompt. Similarly, a study of influenza vaccination rates among corporate employees found that those who were asked to write down the day and time they planned to go to employee health to get the free vaccine were somewhat more likely (4% higher) to be vaccinated than those who did not receive this prompt [107]. In addition, a study of elderly individuals found that influenza vaccination rates were significantly higher among those who had received “action instructions” on how, when and where to get the vaccine than those who did not [108]. These studies suggest that helping parents craft a definitive follow-up plan regarding vaccination could have a significant impact on vaccination rates—particularly for vaccines like HPV that require multiple doses.

Treating all Adolescent Vaccines the Same

Prior research has demonstrated that providers often communicate differently about HPV vaccines than other adolescent vaccines such as the tetanus-diphtheria-pertussis (Tdap) and meningococcal (MCV) vaccines [22,36]. Providers often tend to discuss the HPV vaccine last among these 3 vaccines, provide weaker endorsements of the vaccine, and pre-emptively give much more detail about the HPV compared to the other vaccines, even in the absence of a parent’s request for additional information [36,39,41]. The CDC and the American Academy of Pediatrics now suggest putting HPV at the beginning or middle of the list of vaccines recommended to the adolescent (ie, “HPV, Tdap and MCV”), and treating all recommended vaccines equivalently in terms of the level of detail provided to parents in the absence of a parent’s request for more information [109,110]. Through these suggestions have face validity, their specific impact on HPV vaccination rates, and on patient and provider satisfaction with the visit have yet to be evaluated.

Strategies that Probably Don’t Work

Presenting Myths and Facts

Research related to promoting other vaccines provides insight into communication activities that probably would not work well for promoting HPV vaccination. A 2012 study by Nyhan and colleagues examined the impact of 2 different messages related to influenza vaccines on participants’ beliefs about the vaccine’s safety and intentions to get vaccinated [111]. One group received information to correct the commonly held belief that influenza vaccine can cause the flu while the other received information about the risks associated with contracting an influenza infection. While the correction of myths did improve participants’ perceptions of the vaccine’s safety, information about influenza dangers did not. Neither message impacted intentions to vaccinate in the study subjects overall. However, in sub-analyses the correction of myths actually decreased intentions to vaccinate among those with high baseline levels of concern about the vaccine’s side effects—that is, among those most concerned that the flu vaccine can give someone the flu, correcting this myth actually decreased the likelihood that they would receive the vaccine. Similar findings have been reported in other studies related to vaccination [112–114], and suggest that the “threat” generated by providing information opposing a person’s beliefs may actually entrench these beliefs further as part of the threat response—a phenomenon known as attitude polarization [115]. These results also are consistent with the concept of negativity bias, which posits that negative information influences people’s risk perceptions more than positive information, and that the more strongly a risk is attempted to be negated, the lower the effectiveness and perceived trust of the information [116].

Using Fear Appeals

One tactic that has been suggested by some as a way to promote vaccination is to provide graphic depictions of the possible sequelae of vaccine-preventable diseases. The thought behind this idea is that because vaccination is so successful, most parents will have never experienced significant impacts from vaccine preventable diseases that, in the past, had been a major motivator for parents to vaccinate. Thus, in order to counter beliefs about “controversial” issues like vaccination, highly emotionally compelling and engaging information may be especially useful. This is a common tactic used by anti-vaccination groups to spread their own messages [117]. However, several studies suggested that using “fear appeals” (aka scare tactics) such as this to promote vaccination can actually have a negative effect on vaccination intentions. For example, in a 2011 study of a nationally representative sample of parents of children < 18 years, 4 different message formats were tested for their impact on parental intentions to vaccinate a future child with the measles-mumps-rubella vaccine (MMR) [113]. Message formats included correcting the misinformation that MMR causes autism, presenting information on MMR-related disease risk, providing a dramatic narrative about a child endangered by measles, and showing pictures of infants affected by these diseases. Counter to the study’s hypotheses, the dramatic narrative message actually increased parents’ perceptions that MMR vaccines had serious side effects, and the pictures increased parents’ belief that the MMR vaccine could cause autism. These counter-intuitive results are consistent with other studies that have examined the impact of message framing on adults’ vaccination intentions for HPV and influenza [108,118,119]. Taken together, fear appeals seem unlikely to sway many hesitant parents towards HPV vaccination.

Looking Into the Future

Moving forward, additional interventions to improve providers’ ability to communicate with families about HPV vaccination will undoubtedly be developed. A major area of interest in this regard is leveraging the power of technology and the internet, including using social media, mobile technologies, and online interventions to augment the provider/parent interaction that occurs during the clinical visit [50,120]. Web-based approaches have the benefit of generally being low cost and easy to disseminate to large populations. Such interventions have already been developed for a number of other health issues, some of which have proven effective [121,122]. However, use of the internet to promote healthy behaviors in general, and vaccination specifically, is still in its infancy. There is still much to be learned about how to create effective web-based tools, how to engage patients with them, and how to assess their impact on health outcomes [123].

Another interesting area for future research is identifying psychological “levers” to motivate parents’ vaccination intentions [94]. One example is focusing on using parents’ values (ie, protecting my child from harm) as an intervention target rather than beliefs or attitudes. This is because values tend to be inherent and static over time, compared to beliefs and attitudes, which are subject to change depending on the context [124]. Prior research has shown that interventions that leverage values rather than facts can be an effective way to overcome beliefs that are highly emotional or controversial, and that individuals are more likely to trust sources and individuals with shared values than those without [125], suggesting that this may be a useful way to motivate parents toward vaccinating their children. Self-affirmation is another example of a psychological lever that has a significant evidence base from the social science literature as a helpful tool for moving patients towards a desired health behavior [126,127], but it has not been extensively applied to the field of vaccination. Researchers in the field of vaccine delivery are increasingly recognizing the potential value of these unique intervention approaches [101,128–134], and it may be fruitful in the future to more closely examine the efficacy of interventions that target things like values, self-affirmation or other psychological levers to change parents’ HPV vaccination behaviors.

A final notable area for intervention research related to HPV vaccination is the use of video games. Although not likely to be used directly during patient visits, this strategy could be conceptualized as a potential way to augment the information conveyed to a parent by a provider directly during a clinical encounter. A meta-analysis from 2016 identified 16 different “serious” video games that were used to train and educate users about specific vaccine preventable diseases (usually influenza, none for HPV) and the need for vaccination [135]. In many of them, the objective of the game was to protect a virtual community from a vaccine preventable disease and/or manage outbreaks. Only 2 of the games evaluated outcomes in the short term (ie, at the time the game was being played). None have evaluated longer-term impacts such as vaccination intention or utilization. In the era of “plugged in” parents and adolescents, video games represent a unique but understudied mechanism for helping providers “communicate,” albeit indirectly, with families about the need for vaccination. Imagine providing a prescription to an HPV-vaccine hesitant family to “go play Zombie Wars HPV!” One would expect the curiosity factor alone would result in significant engagement with this intervention tool.

Conclusion

With persistently lagging HPV vaccination rates among U.S. adolescents, there is a growing need for effective interventions to improve adolescent HPV vaccine utilization. How providers communicate with families is one of the most influential factors in parents’ vaccination decisions. Emerging research is beginning to delineate potentially effective communication techniques such as presumptive approaches to making the vaccine recommendation, framing the vaccine as cancer preventing, and using motivational interviewing and personalized messaging when met with parental vaccine resistance. Moving forward the list of evidence-based interventions to improve providers’ HPV vaccine communication is likely to grow, and to increasingly leverage technology based solutions. However, given the complexities of the vaccination decision [136] and the ever growing spread of vaccine hesitancy [137], it is unlikely that a single intervention approach will be effective for getting adolescent HPV vaccine levels up to the national goal of 80% coverage. As has been recognized in the past, the most effective interventions for HPV vaccination in the future are likely to be multicomponent, including not only provider communication strategies but also clinic-, community-, and parent-level interventions [48].

Corresponding author: Amanda Dempsey, MD, PhD, MPH, 13199 East Montview Blvd, Suite 300, Aurora, CO 80045, [email protected].

Financial disclosures: None reported.

From the University of Colorado Denver, Aurora, CO.

Abstract

• Objective: To provide evidence-based guidance on strategies that are likely or unlikely to be successful in navigating HPV vaccine conversations with patients and parents.
• Methods: Nonsystematic review of the literature.
• Results: This review highlights some of the most recent innovations in provider HPV vaccine communication and describes provider communication strategies that have been found to improve adolescent vaccination rates in rigorous scientific studies. Promising strategies for which additional research is needed and strategies that probably do not work are also described. 
• Conclusion: By understanding what works, what may work, and what not to do when it comes to communicating with families about HPV vaccines, providers can be better prepared for maximizing the impact they can have on adolescent HPV vaccination rates.

Key words: human papillomavirus; vaccine hesitancy; health communication; parents; immunization.

In the United States, more than 14 million people newly acquire genital human papillomavirus (HPV) annually, and 75 million Americans are infected at any given time [1]. As the most common sexually transmitted disease, more than 80% of sexually active U.S. adults are estimated to be infected with HPV by the age of 50 [1,2]. Although the majority of infections are “silent” and resolve without clinical sequelae, a proportion of infected individuals will go on to develop HPV-related diseases. In women, these include cervical cancer and pre-cancer (ie, abnormal Pap smears); cancers of the vagina, vulva, anus, and oropharynx; and genital warts [3]. Males also bear a high burden of HPV-related disease in the form of penile, anal, and oropharyngeal cancers, as well as genital warts [3]. While once thought of as primarily a “woman’s disease” [4], recent research demonstrates men are also significantly impacted by HPV—particularly in the form of oropharyngeal cancers, which are 2 to 3 times more common in men than in women [5]. In fact, it is estimated by the year 2020 more men will die of HPV-related oropharyngeal cancer than women will die of cervical cancer [6,7]. The combined cost of HPV-associated cancers and other conditions is estimated to be $8 billion per year in the United States [8–11].

HPV Vaccines

Effective HPV vaccines have been available for females aged 9 to 26 years since 2006 (bivalent and quadrivalent vaccines) and for males aged 9 to 26 since 2010 (quadrivalent vaccine only) [12]. These vaccines have been shown in clinical trials to be highly efficacious in preventing HPV infection, cervical pre-cancer, and anal, vaginal, penile, and vulvar cancers caused by the HPV types covered in the vaccine [2]. Although their effectiveness against head and neck cancer has not been studied in clinical trials, most experts believe that these vaccines will also provide protection against at least a proportion of these cancers [13,14]. In 2015 the U.S. Food and Drug Administration approved licensure of a 9-valent HPV vaccine that will soon replace the quadrivalent vaccine in the U.S. market [15]. The 9-valent vaccine is licensed for both males and females aged 9 to 26 and is expected to prevent an even higher proportion of HPV-related cancers than earlier HPV vaccines due to the protection against 5 additional oncogenic HPV types [15].

Despite the potential of HPV vaccines to drastically reduce the incidence of HPV-related cancers and other diseases, these vaccines are not being as widely used in the United States as was hoped. The most recent national data from 2015 demonstrates that only 41.9% of girls and 28.1% of boys have received all 3 doses recommended in the HPV vaccine series [16]. This level of vaccine utilization is significantly lower than the Healthy People 2020 goal of 80% coverage [17], and also significantly lower than that of other developed countries such as Australia and the United Kingdom, which have achieved vaccination levels of ~70% among their target adolescent populations [18,19]. In the future, these low vaccination levels will likely be mitigated somewhat by the recent approval from the FDA and recent recommendation from the Advisory Committee on Immunization Practices (ACIP) for only 2 doses of the 9-valent HPV vaccine (spaced 6 to 12 months apart) for adolescents less than 15 years of age [20,21]. Three doses are still recommended for those aged 15 to 26 years.

Provider Communication About HPV Vaccines

How providers communicate with parents and patients about HPV vaccines is a key influential factor driving current U.S. adolescent HPV vaccination levels [22,23]. Numerous studies demonstrate that a provider’s recommendation generally has the largest impact on whether or not an adolescent receives the vaccine, even above that of parent factors such as attitudes and beliefs about the vaccine and patient characteristics such as age and insurance status [23–31]. Moreover, parents consistently cite their adolescent’s provider as one of the most trusted and impactful resources for obtaining vaccine information [22,32].

Unfortunately, research also shows that providers often fail to adequately recommend the HPV vaccine for their patients, especially for 11 to 12 year olds for whom the vaccine is preferentially recommended [33,34]. For example, in a national study of parents done in 2013, not being recommended by a provider was one of the top 5 reasons parents of males and of females aged 11 to 17 gave for not getting their adolescent vaccinated against HPV [35]. Supporting this also is a 2014 study of 776 pediatricians and family medicine providers nationally, in which Gilkey and colleagues found that more than 1 out of 4 providers did not highly endorse the HPV vaccine for 11 to 12 year olds despite this having been the recommended practice from ACIP for the prior 8 years for girls and 4 years for boys. This is in comparison to the other adolescents vaccines that were reported in the same study as being endorsed highly by these providers > 95% of the time [36].

Recognizing that providers’ HPV vaccine recommendations are often suboptimal, researchers have begun to define what components comprise “high-quality” HPV vaccine recommendations. This has been operationalized by one research group as (1) timeliness—routinely recommending the vaccine starting when the patient is ≤ 12 years; (2) consistency—recommending the vaccine for all eligible adolescents as opposed to an approach based on providers’ perception of their patients’ risk for HPV infection; (3) urgency—recommending that the vaccine be given on the same day the vaccine is being discussed, rather than offering the option of getting it at a future visit; and (4) strength—using language that clearly conveys that the provider believes the vaccine is very important for the adolescent to receive. A national study of primary care providers done in 2014 examined how frequently these quality components were implemented [37]. The results were startling and discouraging. Nearly half of providers (49%) reported they usually recommended that 11 to 12 year olds get the vaccine at a later visit, 41% used a risk-based approach for deciding when to recommend the vaccine, 27% did not tell the parents the vaccine was “very or extremely important,” and a large proportion did not start routinely recommending the vaccine before the age of 13 (39% for male patients and 25% for females) [37].

Much research has now accumulated to explain the underlying reasons why providers may not give consistent and high-quality HPV vaccine recommendations to all eligible adolescents [22]. Issues such as providers’ own knowledge about HPV-related diseases, personal beliefs about the vaccine’s safety and necessity, concern that a discussion about the vaccine will necessitate a discussion about adolescent sexuality with the parent, belief that parents will not want their child vaccinated if asked, perceptions that a provider can adequately select those patients most “in need” of HPV vaccination, and concern that raising the vaccine discussion with vaccine-hesitant parents will result in prolonged discussions have been shown to impact whether and how providers communicate about HPV vaccination during clinical visits [22,36–45]. Now that these barriers have been defined and described, there is a great need to use this knowledge to develop and evaluate interventions that help to mitigate these barriers and improve providers’ vaccine communication abilities. Such interventions are needed not only for HPV, but for all vaccines [46,47].

Possible Strategies for Helping Providers Communicate About HPV Vaccines

Before discussing these interventions, it is worth noting that several of the passive and active strategies have been shown in clinical trials to improve adolescent HPV vaccination rates. Although these are beyond the scope of this article, inclusion of these strategies should certainly be considered by any practice as a mechanism to increase vaccination levels, especially given that the most successful interventions to improve vaccination levels consist of multiple components [48]. Also useful is a recently described “taxonomy of vaccine communication interventions” that provides additional perspective on the scope and complexity of interventions to improve vaccine delivery [49]. There are several well-written review articles that describe interventions that focus on passive and active strategies at the practice or community level [50–52].

Interpersonal Communication Strategies Shown to Increase HPV Vaccination

Presumptive Communication

One of the first studies to examine the specific “way” in which providers communicate about vaccines focused not on HPV but rather on young childhood vaccines. In 2013 Opel and colleagues performed a study in which they taped clinical encounters between a pediatrician and a parent of a child aged 1 to 19 months [53]. Of the 111 encounters recorded, 50% of parents were classified as vaccine hesitant. Parents were aware they were being taped but not aware that the overall purpose of the study was to examine providers’ communication related to vaccination. The researchers found that providers generally used one of 2 communication styles to introduce the vaccine discussion. The first, called the “presumptive” style, assumed that parents would agree to vaccination and presented the vaccines as routine (ie, “We have to do some shots today”). The second style, called “participatory,” was more parent-oriented and used language suggesting shared decision-making (ie, “So what do you want to do about shots today?”). The study showed that the odds of resisting the provider’s vaccine recommendations were significantly higher when providers used a participatory approach than a presumptive one, suggesting that even small changes in language can have a major impact on the likelihood of vaccination. However, given the study design, causality between providers’ recommendation style and parents vaccination decisions could not be delineated.

In 2015 Moss and colleagues performed a study that examined the use of these 2 communication styles with regard to HPV vaccination [54]. This study used data from the 2010 National Immunization Survey–Teen, a national survey on childhood vaccination that includes provider verification of vaccines given [16]. Researchers categorized provider vaccine communication styles into “provider-driven,” which was similar to the presumptive style described Opel, and “patient-driven,” which was similar to Opel’s permissive style. Parents who received a more provider-driven style of HPV vaccine recommendation were far more likely to have allowed their adolescent to be vaccinated than those receiving patient-driven recommendations [54]. Further supporting this communication approach are results from a qualitative study done by Hughes and colleagues in which triads of mothers, adolescents, and providers were interviewed after a preventive care visit to assess the communication that occurred regarding HPV vaccination [39]. Providers’ communication style was categorized into 1 of 3 groups: paternalistic (clinician makes the vaccination decision and communicates this to the family); informed (patient and family gathers information from the clinician and other sources to reach a vaccination decision); and shared (medical and personal information is exchanged between the provider and family and then a decision is reached jointly). Providers who typically adopted the paternalistic approach perceived that they had the highest success in convincing parents to vaccinate—a perception that was confirmed in quantitative assessments of vaccination status among adolescents in the study sample [39]. Our own research demonstrates that learning and implementing a presumptive/paternalistic HPV vaccine recommendation style is easy for primary care providers to do and is perceived as often shortening the time taken during clinical visits to discuss the vaccine [55,56]. Thus, providers should consider opening the HPV vaccine conversation using this approach, and then turning to some of the other communication techniques described below when met with parental resistance or questions.

Motivational Interviewing

A second communication technique that seems effective for promoting HPV vaccination, especially for vaccine hesitant parents, is motivational interviewing. Motivational interviewing describes a communication technique in which the provider leverages a parents’ or patients’ intrinsic motivation to engage in a preferred health behavior [57]. Motivational interviewing was originally developed to combat substance abuse [58,59] but has subsequently been successfully applied to a number of other health issues [60–64]. There is growing interest from public health and medical providers in using this technique for increasing vaccination [39,65–68]. Our research group performed a large, cluster-randomized controlled trial of 16 pediatric and family medicine clinics to examine the impact of a provider communication “toolkit” on adolescent HPV vaccine series initiation and completion [50,69]. The toolkit consisted of motivational interviewing training for providers related to HPV vaccination and training on 3 tangible resources providers could also use with parents—an HPV fact sheet, an HPV vaccine decision aid, and an educational website. Results from the study demonstrated that motivational interviewing was the toolkit component most widely utilized by providers and was also perceived as being the most useful. More importantly, HPV vaccine series initiation levels were significantly higher among adolescents in practices receiving the toolkit than in control practices. There was no impact on HPV vaccine series completion (unpublished results). The usefulness of motivational interviewing for vaccination is further supported by a small study in which community pharmacists receiving motivational interviewing training for adult vaccination reported significantly higher patient readiness to receive vaccines following their interaction with the pharmacist than those who did not receive the training [70]. Finally, Perkins et al performed a cluster randomized controlled trial that evaluated the impact of a provider-focused intervention on adolescent HPV vaccination rates. The intervention included frequent provider support meetings, education on HPV infection and vaccination, feedback on providers’ individual HPV vaccination rates, provider incentives, and “basic motivational interviewing principles with vaccine-hesitant parents.” HPV vaccination series initiation and completion rates were significantly higher in intervention practices than controls, and this effect was sustained for at least 6 months after the active intervention period was over [67]. However, it was unknown how much the motivational interviewing contributed to these results. Based on the above information, and the long history of success of motivational interviewing for improving patient compliance with other recommended health behaviors, this technique appears to have a reasonable evidence base and should be considered for communicating with families that express resistance to HPV vaccination.

Personalized Communication

Parents’ reasons for not having their adolescent vaccinated against HPV are often complex and multifactorial [71,72]. Personalized approaches are needed to account for each parent’s unique informational needs, beliefs, and prior experiences [65]. Unfortunately, given the short amount of time allotted for clinical visits, it is often difficult to provide adequate information to parents during these encounters [73–75]. Indeed, concern about prolonged HPV vaccine discussions has been identified as an important barrier for providers that cause some to forgo recommending the vaccine [36,75].

One potential solution to this issue is to leverage technology in the form of web-based interventions that use software to tailor materials to each individual’s unique informational needs. Feasibility for this idea comes from the knowledge that many parents already use the web to research health issues related to their children [76], and that doctors’ offices are increasingly using patient portals and other web-based resources to help parents prepare for upcoming visits, especially those focused on health maintenance [77,78]. Tailored messaging interventions have been shown across populations and health issues to generally result in superior adherence with health behaviors when compared to untailored controls [79–82]. Several researchers have thus begun exploring whether such a personalized communication strategy may be similarly effective for adolescent HPV vaccination [50,83–85]. As an example, Maertens and colleagues used community-based participatory research techniques to develop a web-based tailored messaging intervention for Latinos regarding HPV vaccination [86]. A subsequent randomized controlled trial of the intervention in over 1200 parents of adolescents and young adults demonstrated that the intervention improved participants’ intentions to vaccinate compared to usual care [87], and among adolescents, higher HPV vaccine series initiation levels (unpublished data). Although additional work is needed to understand the feasibility of implementing such an intervention more broadly, additional support for the usefulness of a tailored messaging approach comes from a study of female university students that demonstrated higher HPV vaccination intentions after exposure to tailored information compared to untailored information. However, the impact on actual HPV vaccine utilization was not measured in the study [84]. Contrasting results were found in a different study of university students where researchers failed to find an impact of message tailoring on HPV vaccination utilization. However, this study was limited by a low response rate (~50%) to the follow up survey where vaccination status was assessed, and also by overall low levels of HPV vaccine initiation among the entire study sample (8%) [85]. Given the low number of studies in this area, and some conflicting data, additional research is needed to better understand the impact of personalized communication on HPV vaccination levels. However, results from these studies suggest that a modest benefit may be achieved with this approach, especially if coupled with other, evidence-based, clinic-level interventions to promote vaccination (eg, vaccine reminders, extended office hours), as is suggested by the Task Force on Community Preventive Services [48].

Focusing Communication on Cancer Prevention

HPV vaccines are unique in that they are only 1 of 2 vaccines for cancer prevention (the other being hepatitis B). Provider and parent surveys suggest that while most providers do mention cancer prevention when discussing HPV vaccines [40,88,89], this may be more commonly done with female patients than males [22]. Focusing on cancer prevention rather than sexual transmissibility is a communication technique suggested by the Centers for Disease Control and Prevention (CDC) as many parents cite this aspect of the vaccine as one of the most compelling reasons for vaccinating [45,90]. CDC’s “You are the Key” program [91] uses cancer prevention as a central theme in their physician and patient communication materials, based on significant prior market research on the acceptability and impact of such messages among parents and providers. In 2016 Malo and colleagues tested the potential impact of brief messages related to HPV vaccination, including cancer prevention messages, among a national sample of 776 medical providers and 1504 parents of adolescents [92]. In addition to their potential to motivate parents to vaccination, associations between parental endorsement of each message and their adolescent’s vaccination status were also examined. The cancer prevention messages were among those most highly endorsed by both parents and providers as being motivating for parents to get their adolescent vaccinated. More importantly, among parents these endorsements were associated with a significantly higher likelihood of the adolescent having been vaccinated against HPV. Interestingly, one of the briefest messages in the study, “I [the physician] strongly believe in the importance of this cancer preventing vaccine for [child’s name],” was perceived as the most persuasive message by parents.

Further support for the positive impact of framing HPV vaccines primarily as cancer prevention comes from another national study of 1495 parents of 11 to 17 year olds that examined 3 measures of quality of their adolescent provider’s HPV vaccine recommendation, and the relationship between recommendation quality and likelihood of adolescent HPV vaccination [40]. The 3 quality indicators assessed included providing information about cancer prevention, encouraging the vaccine “strongly,” and recommending it be given on the same day as it was being discussed. While 49% of parents reported receiving no HPV vaccine recommendation from their adolescents’ provider, of those that did, 86% received a cancer prevention message. Parents who had been given high quality recommendations that included either 2 or 3 of the quality indicator measures had over 9 times the odds of vaccine series initiation and 3 times the odds of vaccine series follow through than those who had not received any recommendation, and also significantly higher odds of vaccination than parents who had received low quality recommendations (ie, included only 1 indicator). Taken together, these results suggest that focusing discussions about HPV vaccines on their ability to prevent cancer is likely to be persuasive for some parents.

Strategies That Are Promising But Not Thoroughly Tested

Helping Parents Create Vaccination Plans

A recent commentary suggested that instead of focusing on changing beliefs or “educating” parents and patients about the need for a given vaccine, perhaps a better way to craft interventions for increasing vaccination is to focus on structuring the environment to make vaccination “easy” [93,94]. Examples of this include strategies such as extended office hours and making the vaccine available in other locations such as schools and pharmacies, both of which have been shown in some populations and settings to improve vaccine utilization [48,95]. One aspect of structuring a vaccine-conducive environment that relates to provider communication is helping parents create “implementation intentions” for future vaccination visits. In its most obvious form, this would mean providers provide office resources that facilitate making an appointment for the next dose in the HPV vaccine series during a clinic visit where the first dose was provided. But such an approach could also potentially extend to parents who are on the fence about the vaccine—to make an appointment before the parent leaves the office with an unvaccinated child to either re-discuss the vaccine in the future or to actually start the vaccine series. Support for such a strategy comes primarily from the social sciences, which suggest that implementation intentions work by increasing attention to specific cues to action, making it more likely that that the cue will be acted upon [96–98]. Creating implementation intentions has been shown to be helpful for improving adherence with a variety of health behaviors [99–105], and there is a growing evidence base related to how implementation intentions may facilitate vaccination specifically. For example Vet and colleagues performed a randomized controlled trial among 616 men who have sex with men with either strong or weak intentions to receive the hepatitis B vaccine [106]. Half of the participants were asked to create an implementation intention plan where they described when, where and how they would obtain the vaccine. Those in the control arm were not given this prompt. Regardless of whether their initial vaccination intention was weak or strong, those who had been asked to create an implementation plan had more than double the likelihood of actually getting the vaccine than participants who did not receive the implementation plan prompt. Similarly, a study of influenza vaccination rates among corporate employees found that those who were asked to write down the day and time they planned to go to employee health to get the free vaccine were somewhat more likely (4% higher) to be vaccinated than those who did not receive this prompt [107]. In addition, a study of elderly individuals found that influenza vaccination rates were significantly higher among those who had received “action instructions” on how, when and where to get the vaccine than those who did not [108]. These studies suggest that helping parents craft a definitive follow-up plan regarding vaccination could have a significant impact on vaccination rates—particularly for vaccines like HPV that require multiple doses.

Treating all Adolescent Vaccines the Same

Prior research has demonstrated that providers often communicate differently about HPV vaccines than other adolescent vaccines such as the tetanus-diphtheria-pertussis (Tdap) and meningococcal (MCV) vaccines [22,36]. Providers often tend to discuss the HPV vaccine last among these 3 vaccines, provide weaker endorsements of the vaccine, and pre-emptively give much more detail about the HPV compared to the other vaccines, even in the absence of a parent’s request for additional information [36,39,41]. The CDC and the American Academy of Pediatrics now suggest putting HPV at the beginning or middle of the list of vaccines recommended to the adolescent (ie, “HPV, Tdap and MCV”), and treating all recommended vaccines equivalently in terms of the level of detail provided to parents in the absence of a parent’s request for more information [109,110]. Through these suggestions have face validity, their specific impact on HPV vaccination rates, and on patient and provider satisfaction with the visit have yet to be evaluated.

Strategies that Probably Don’t Work

Presenting Myths and Facts

Research related to promoting other vaccines provides insight into communication activities that probably would not work well for promoting HPV vaccination. A 2012 study by Nyhan and colleagues examined the impact of 2 different messages related to influenza vaccines on participants’ beliefs about the vaccine’s safety and intentions to get vaccinated [111]. One group received information to correct the commonly held belief that influenza vaccine can cause the flu while the other received information about the risks associated with contracting an influenza infection. While the correction of myths did improve participants’ perceptions of the vaccine’s safety, information about influenza dangers did not. Neither message impacted intentions to vaccinate in the study subjects overall. However, in sub-analyses the correction of myths actually decreased intentions to vaccinate among those with high baseline levels of concern about the vaccine’s side effects—that is, among those most concerned that the flu vaccine can give someone the flu, correcting this myth actually decreased the likelihood that they would receive the vaccine. Similar findings have been reported in other studies related to vaccination [112–114], and suggest that the “threat” generated by providing information opposing a person’s beliefs may actually entrench these beliefs further as part of the threat response—a phenomenon known as attitude polarization [115]. These results also are consistent with the concept of negativity bias, which posits that negative information influences people’s risk perceptions more than positive information, and that the more strongly a risk is attempted to be negated, the lower the effectiveness and perceived trust of the information [116].

Using Fear Appeals

One tactic that has been suggested by some as a way to promote vaccination is to provide graphic depictions of the possible sequelae of vaccine-preventable diseases. The thought behind this idea is that because vaccination is so successful, most parents will have never experienced significant impacts from vaccine preventable diseases that, in the past, had been a major motivator for parents to vaccinate. Thus, in order to counter beliefs about “controversial” issues like vaccination, highly emotionally compelling and engaging information may be especially useful. This is a common tactic used by anti-vaccination groups to spread their own messages [117]. However, several studies suggested that using “fear appeals” (aka scare tactics) such as this to promote vaccination can actually have a negative effect on vaccination intentions. For example, in a 2011 study of a nationally representative sample of parents of children < 18 years, 4 different message formats were tested for their impact on parental intentions to vaccinate a future child with the measles-mumps-rubella vaccine (MMR) [113]. Message formats included correcting the misinformation that MMR causes autism, presenting information on MMR-related disease risk, providing a dramatic narrative about a child endangered by measles, and showing pictures of infants affected by these diseases. Counter to the study’s hypotheses, the dramatic narrative message actually increased parents’ perceptions that MMR vaccines had serious side effects, and the pictures increased parents’ belief that the MMR vaccine could cause autism. These counter-intuitive results are consistent with other studies that have examined the impact of message framing on adults’ vaccination intentions for HPV and influenza [108,118,119]. Taken together, fear appeals seem unlikely to sway many hesitant parents towards HPV vaccination.

Looking Into the Future

Moving forward, additional interventions to improve providers’ ability to communicate with families about HPV vaccination will undoubtedly be developed. A major area of interest in this regard is leveraging the power of technology and the internet, including using social media, mobile technologies, and online interventions to augment the provider/parent interaction that occurs during the clinical visit [50,120]. Web-based approaches have the benefit of generally being low cost and easy to disseminate to large populations. Such interventions have already been developed for a number of other health issues, some of which have proven effective [121,122]. However, use of the internet to promote healthy behaviors in general, and vaccination specifically, is still in its infancy. There is still much to be learned about how to create effective web-based tools, how to engage patients with them, and how to assess their impact on health outcomes [123].

Another interesting area for future research is identifying psychological “levers” to motivate parents’ vaccination intentions [94]. One example is focusing on using parents’ values (ie, protecting my child from harm) as an intervention target rather than beliefs or attitudes. This is because values tend to be inherent and static over time, compared to beliefs and attitudes, which are subject to change depending on the context [124]. Prior research has shown that interventions that leverage values rather than facts can be an effective way to overcome beliefs that are highly emotional or controversial, and that individuals are more likely to trust sources and individuals with shared values than those without [125], suggesting that this may be a useful way to motivate parents toward vaccinating their children. Self-affirmation is another example of a psychological lever that has a significant evidence base from the social science literature as a helpful tool for moving patients towards a desired health behavior [126,127], but it has not been extensively applied to the field of vaccination. Researchers in the field of vaccine delivery are increasingly recognizing the potential value of these unique intervention approaches [101,128–134], and it may be fruitful in the future to more closely examine the efficacy of interventions that target things like values, self-affirmation or other psychological levers to change parents’ HPV vaccination behaviors.

A final notable area for intervention research related to HPV vaccination is the use of video games. Although not likely to be used directly during patient visits, this strategy could be conceptualized as a potential way to augment the information conveyed to a parent by a provider directly during a clinical encounter. A meta-analysis from 2016 identified 16 different “serious” video games that were used to train and educate users about specific vaccine preventable diseases (usually influenza, none for HPV) and the need for vaccination [135]. In many of them, the objective of the game was to protect a virtual community from a vaccine preventable disease and/or manage outbreaks. Only 2 of the games evaluated outcomes in the short term (ie, at the time the game was being played). None have evaluated longer-term impacts such as vaccination intention or utilization. In the era of “plugged in” parents and adolescents, video games represent a unique but understudied mechanism for helping providers “communicate,” albeit indirectly, with families about the need for vaccination. Imagine providing a prescription to an HPV-vaccine hesitant family to “go play Zombie Wars HPV!” One would expect the curiosity factor alone would result in significant engagement with this intervention tool.

Conclusion

With persistently lagging HPV vaccination rates among U.S. adolescents, there is a growing need for effective interventions to improve adolescent HPV vaccine utilization. How providers communicate with families is one of the most influential factors in parents’ vaccination decisions. Emerging research is beginning to delineate potentially effective communication techniques such as presumptive approaches to making the vaccine recommendation, framing the vaccine as cancer preventing, and using motivational interviewing and personalized messaging when met with parental vaccine resistance. Moving forward the list of evidence-based interventions to improve providers’ HPV vaccine communication is likely to grow, and to increasingly leverage technology based solutions. However, given the complexities of the vaccination decision [136] and the ever growing spread of vaccine hesitancy [137], it is unlikely that a single intervention approach will be effective for getting adolescent HPV vaccine levels up to the national goal of 80% coverage. As has been recognized in the past, the most effective interventions for HPV vaccination in the future are likely to be multicomponent, including not only provider communication strategies but also clinic-, community-, and parent-level interventions [48].

Corresponding author: Amanda Dempsey, MD, PhD, MPH, 13199 East Montview Blvd, Suite 300, Aurora, CO 80045, [email protected].

Financial disclosures: None reported.

Take-Home Points

• Patellofemoral disorders should be classified and diagnosed according to specific diagnostic categories (eg, lateral patellar compression syndrome) based on etiology rather than nondescriptive terminology (eg, internal derangement, patellofemoral pain syndrome).
• Patellofemoral dysplasia defines a spectrum of abnormalities ranging from the mild lateral patellar compression syndrome to the severe recurrent patellar dislocation.
• There is an inverse relationship between patient activity level and underlying patellofemoral dysplasia. This relationship determines threshold levels for each patient becoming symptomatic.
• Patients should be examined for 7 physical abnormalities, and if present, in what severity. These 7 are: vastus medialis obliquus deficiency, medial patellofemoral ligament laxity, lateral retinaculum tightness, increased quadriceps angle, hip abductor weakness, patella alta, and trochlear dysplasia.
• Advanced imaging is rarely, if ever, needed to make a diagnosis or to formulate an initial treatment plan for these common patellofemoral disorders.

To diagnose any disease or disorder implies an understanding of the condition’s cause(s), which should then lead to a logical treatment plan. For all too long, however, the diagnosis and treatment of patellofemoral disorders have been hampered by diagnoses that lack specific definitions based on etiology. A few of these are: internal derangement, chondromalacia patellae, patellar maltracking, and patellofemoral pain syndrome.

To simplify the diagnosis of patellofemoral disorders, we use a clinical classification based on etiology. This system’s defined diagnostic categories are useful in identifying probable cause(s), which can be appropriately evaluated and treated (Table).¹ In simple terms, the philosophy of this approach is to try to find out what’s wrong, and try to fix it!

This clinical classification provides a framework for common patellofemoral conditions that are more easily diagnosed, yet is intentionally incomplete omitting rare conditions (eg, tumors, metabolic bone disease, neurologic conditions).

Patellofemoral Dysplasia

Patellofemoral dysplasia (or extensor mechanism malfunction) is a cluster of physical abnormalities relating to the patellofemoral joint that vary from mild to severe and affect the normal function of that joint. As such, patellofemoral dysplasia itself should be considered on a continuum of mild to severe. To simplify the diagnosis, the clinician should systematically identify these factors and their severity. Armed with this information, the clinician can make the diagnosis and formulate a logical treatment plan for each individual patient.

This article focuses on 7 physical abnormalities that are most likely developmental and that can be identified through physical and radiologic examination. When and how each patient with patellofemoral dysplasia becomes symptomatic are determined by 2 key factors: patellofemoral dysplasia severity and activity level (sedentary to strenuous), in an inverse relationship (Figure 1).²

Seven Key Patellofemoral Physical Abnormalities

Of the 7 commonly identified physical abnormalities that affect the normal functioning of the patellofemoral joint, 5 are discovered by physical examination and 2 by radiography; CT and MRI are seldom needed in the initial evaluation. The most accurate and objective method should be used to assess the presence and severity of each abnormality.

The 7 abnormalities are vastus medialis obliquus (VMO) deficiency, medial patellofemoral ligament (MPFL) laxity, lateral retinaculum (LR) tightness, increased quadriceps (Q) angle, hip abductor weakness, patella alta, and trochlear dysplasia. We list these not in order of importance but in the order in which they are usually encountered during initial evaluation. We advocate for examining both knees including axial patellofemoral radiographs because patellofemoral disorders are frequently bilateral. It is helpful to use an abnormality checklist so none are forgotten. Also useful is a simple shorthand for findings: 0 = normal (no abnormality), 1 = mild abnormality, 2 = moderate abnormality, 3 = severe abnormality, with the right knee always recorded first (R/L). For example, severe left MPFL laxity is recorded as 0/3. Numerical values (eg, Q angles) can be directly recorded in this manner: 14°/23°.

1. Vastus Medialis Obliquus Deficiency

VMO deficiency is best seen as the sitting patient actively maintains the unsupported foot and leg at 30° knee flexion. Normally, the VMO inserts into the upper half or third of the medial edge of the patella; a deficient VMO inserts higher into the medial edge of the quadriceps tendon, or it is absent and leaves a characteristic hollow at the medial edge of the patella (Figure 2).⁴

2. Medial Patellofemoral Ligament Laxity

MPFL laxity is assessed with the lateral glide test. Again, the patient sits, but with quadriceps relaxed and foot and leg supported at 30° knee flexion. With the clinician mentally dividing the patella into vertical quadrants and pushing the patella laterally, the normal patella moves about 1 quadrant or 1 fingerbreadth. Severe MPFL laxity often elicits a positive apprehension response during the test. (Tip: Many patients are unable to relax the quadriceps while sitting; therefore, examine them supine and lift the knee into 30° flexion.) Such laxity usually means the MPFL was torn in a previous dislocation and remains elongated, leaving the patella vulnerable to repeated dislocations. The clinician should be alert to the possibility of hyperelastosis (Ehlers-Danlos syndrome) and a hyper-mobile patella. The opposite limb should be evaluated for asymmetric laxity.

3. Lateral Retinaculum Tightness

LR tightness is assessed with the medial glide test, again with the quadriceps relaxed and the knee supported at 30° flexion. With a normal LR, the patella can be pushed medially about 1 quadrant or 1 fingerbreadth. Some clinicians prefer the lateral tilt-up test, in which the lateral edge of the patella is lifted up, but this method is more difficult to quantify, is affected by the cross-sectional shape of the patella, and lacks consistency.

4. Increased Quadriceps Angle

The Q angle is one of the most important factors in the normal functioning of the patellofemoral joint. For more than a century,⁸ multiple operations have been used successfully to move the tibial tubercle (TT) and patellar ligament from a lateral position to a medial position thereby decreasing the Q angle. It is only logical to measure this angle at every knee examination to check for an abnormal increase, and the degree. The term quadriceps angle, or Q angle, was first used in 1964 by Brattström,⁷ who defined it as the “supplemental angle” to the valgus angle formed by the “quadriceps’ resultant” (line of force or vector) “+ patella + ligamentum patellae”. This might be called the dynamic Q angle. With there being no clinical method of measuring the “quadriceps line of force”, or quadriceps vector, clinicians used a line from the anterior superior iliac spine to the center of the patella, yet still called it the Q angle. By convention, this anatomical Q angle has been accepted as the Q angle.

Because the Q angle is the only clinical measurement of TT lateralization at initial evaluation, its measurement should be standardized, accurate, and simple to perform. Placing the patient supine with the lower limb in neutral rotation (patella anterior) and the knee in full extension standardizes the position. In full extension, the tibia reaches its maximum external rotation owing to the terminal “screw home” mechanism. The clinician should center the patella to the trochlear groove (TG) while measuring the Q angle, as it is the relationship of the TT to the trochlea, not to the patella, that is important. If LR tightness prevents the patella from centering, that fact should be recorded during the medial glide test for LR tightness.

5. Hip Abductor Weakness

The step-down test is easily performed in the office by having the patient stand on a short stool or stair and then slowly step down with the opposite limb to just touch the heel and slowly arise again. A positive test is indicated by the Trendelenburg sign, with the pelvis dropping down and away from the symptomatic supporting limb, the flexing knee collapsing into valgus, and the patient tending to wobble and lack stability (Figure 4).¹⁶

6. Patella Alta

Patella alta not only allows the patella to escape the confines of the trochlea earlier during active knee extension increasing the risk of patellar dislocation, but also decreases the contact footprint with the trochlea, increasing the patellofemoral joint reaction force and potentially causing patellofemoral pain and even secondary chondrosis. The simplest way to assess patellar height is with a lateral radiograph of the knee. The 3 popular methods (Insall-Salvati, Caton-Deschamps, Blackburn-Peel) all put the normal patellar height ratio at approximately 1:1, ± 20%. Berg and colleagues¹⁸ compared radiologic techniques for measuring patellar height ratio and found that Blackburn-Peel was the most accurate, reliable, and reproducible method.

7. Trochlear Dysplasia

Trochlear dysplasia, most simply a flattening of the TG, is perhaps the most important factor effecting normal patellofemoral function. However, it remains the most difficult to correctly address surgically. Senavongse and Amis¹⁹ conducted a cadaveric study demonstrating the prime importance of the TG. They found patellar stability was reduced 30% by releasing the VMO, 49% by cutting the MPFL in full knee extension, and 70% by flattening the trochlea. The most common, successful operations for correcting patellar instability depend on changing other factors that guide patellar excursion to compensate for this trochlear flattening.

The simplest way to assess trochlear dysplasia is to measure the sulcus angle on an accurate axial view radiograph of the knee at 45° flexion (Merchant view).²⁰ Dejour and colleagues²¹ popularized a technique of assessing and classifying trochlear dysplasia from a true lateral radiograph of the knee, which has the advantage of showing the trochlear at its proximal extent. Davies and colleagues²² evaluated the Dejour technique, along with patellar tilt, patellar height, and sulcus angle, to identify a rapid and reproducible radiologic feature that would indicate the need for further analysis by other imaging studies (eg, CT, MRI). They found that, if the sulcus angle was normal, analysis of other radiologic features was unlikely to reveal additional useful information. They also showed a correlation of increasing sulcus angle and severity of those other dysplasia features. Merchant and colleagues²⁰ found a mean normal sulcus angle of 138º (SD, 6º; range, 126º-150º), and Aglietti and colleagues²³ confirmed those findings with nearly identical values (mean, 137º; SD, 6º; range, 116º-151º).

Diagnosis and Initial Treatment Plan

Patellofemoral disorders generally are divided into patellofemoral pain and instability, but these 2 diagnostic categories are too broad to be useful. Patellofemoral pain is a symptom. Patellofemoral pain syndrome should never be used as a diagnosis because there is no accepted definition for the cluster of findings that customarily defines a syndrome. At initial evaluation, after the easily diagnosed causes of anterior knee pain (eg, prepatellar bursitis, TT apophysitis, patellar and quadriceps tendinitis) have been ruled out, the clinician should consider types of patellofemoral dysplasia for a presumptive diagnosis, which will then lead to a logical treatment program for each identified disorder. With a presumptive diagnosis established, almost all patients suffering from chronic anterior knee pain without history of injury are treated initially with rest, ice, and nonsteroidal anti-inflammatory drugs to restore joint homeostasis.³

Lateral Patellar Compression Syndrome

In 1975, Ficat and colleagues²⁴ described features of what they called syndrome d’hyperpression externe de la rotule. Two years later, Ficat and Hungerford²⁵ defined the syndrome as one “in which the patella is well centered in the trochlear sulcus and stable, but in which there is a functional lateralization onto a physiologically and often anatomically predominant lateral facet.” Using the tools we have described here, the clinician usually finds the cause(s) of this “functional lateralization.” Four abnormalities—VMO deficiency, LR tightness, increased standardized Q angle, and hip abductor weakness—can cause functional lateralization either alone when severe or in combination when mild or moderate.

For a presumptive diagnosis of LPCS, initial treatment is nonoperative, and successful in about 90% of patients. It should be obvious that most patients with chronic anterior knee pain have quadriceps atrophy. Physical therapy should be specifically focused on quadriceps strengthening, with absolutely no stress placed on the patellofemoral joint in flexion initially, and on hip abductor strengthening. Progressive resistive isometric quadriceps exercises can be performed with a weight-bench technique (Figures 5A-5D).²⁶

Chronic Subluxation of Patella

With the use of axial patellofemoral radiographs (Merchant views),²⁰ the clinician can determine if the “patella is well centered in the trochlear sulcus and stable” (an important part of the definition of LPCS). If the patient has no symptoms of recurrent instability or patellar dislocation, and these radiographs show a laterally subluxed patella (one not well centered in the trochlea), the diagnosis is most likely CSP, a moderate form of patellofemoral dysplasia (section II of the Table). In addition to the 4 abnormalities used in the diagnosis of LPCS (mentioned earlier), trochlear dysplasia also comes into play in the diagnosis of CSP. Just as the other abnormalities can vary from mild to severe, trochlear dysplasia can vary from mild (slightly shallow sulcus angle) to severe (flat or even convex sulcus angle). As the sulcus becomes shallower, the patella slides more laterally, increasing the likelihood of patellar dislocation.

As the patient with CSP gives no history of episodic patellar instability, treatment for CSP is almost identical to that for LPCS, with the primary focus on isometric quadriceps strengthening (DeHaven isometric exercises)²⁷ and hip abductor muscle strengthening. In the presence of CSP radiographically, it is important to use McConnell taping and/or patellar bracing during muscular strengthening. A patient who achieves 20-lb isometric quadriceps strength, demonstrates a normal step-down test, and is assumed to be asymptomatic can be allowed to return to sports activities with use of a patellar brace. The patient should be counseled that there is an increased risk for patellar dislocation because of this chronic subluxation and the shallower sulcus.

As in LPCS, CSP symptoms that persist after dynamic strength is regained may require surgical intervention. The severity of identified abnormal factors (tight LR, increased Q angle, trochlear dysplasia) guides the surgeon in selecting appropriate corrective technique(s).

Recurrent Dislocation of Patella

Admittedly, given the number and subtlety of abnormal factors, the diagnosis of LPCS as a cause of patellofemoral pain can be challenging. However, RDP is at the opposite end of the spectrum. A history of prior patellar dislocation(s) almost always makes the diagnosis of RDP easier. The patient occasionally complains of a recurrent symptom, the knee “going out” or “giving way,” indicating that the diagnosis might be RDP. By carefully asking what the patient was doing and what happened when the knee “went out”, the clinician may be able to determine if the injury stemmed from sudden patellar pain causing reflex inhibition of the quadriceps or was a true dislocation. Both may be described as “going out” or “giving way”.

Assessment for the same 7 abnormalities helps establish the diagnosis, a logical treatment plan, and a guide for indicated surgery. The diagnostic focus is MPFL laxity and trochlear dysplasia. Prior lateral dislocation of the patella almost always requires rupture of the normal MPFL. The infrequent exception is a patient with hyper-elasticity of the skin and multiple joints (Ehlers-Danlos syndrome). Trochlear dysplasia is a significant risk factor for patellar dislocation. If the trochlea is normal and there is no MPFL laxity, the diagnosis of RDP should be questioned.

If surgery is indicated, the surgeon uses a list of the patient’s abnormalities and their severity as a guide in selecting reconstructive techniques. The more abnormalities found and the greater the severity of each, the more techniques are needed to achieve success. Preoperative exercises help speed postoperative recovery by addressing quadriceps and hip abductor weakness. In addition, an active exercise program gives the surgeon insight into the patient’s desire for and commitment to recovery. Other physical abnormalities to be considered in preoperative planning include MPFL laxity, LR tightness, increased Q angle, patella alta, and trochlear dysplasia.

Surgical tips: 1. When releasing the LR, never cut the vastus lateralis tendon, as this has a high likelihood of causing iatrogenic medial patellar subluxation.²⁹ 2. When medializing the TT, consider compensating for a shallow trochlea by “over-correcting” the Q angle to 5° to 10° measured with a surgical goniometer intraoperatively.

Summary

Basing clinical classification of disorders on etiology is a simple and effective way to diagnose common patellofemoral conditions. Identifying and rating the severity of patellofemoral dysplasia, using 7 commonly found physical abnormalities, guide the physician to a proper diagnosis and down logical treatment pathways. These principles should be incorporated into the routine evaluation of patellofemoral disorders to optimize diagnosis, formulate a treatment plan, and improve patient outcomes. After all, this is what our patients are asking us to do: Try to find what’s wrong, and then try to fix it!

Am J Orthop. 2017;46(2):68-75. Copyright Frontline Medical Communications Inc. 2017. All rights reserved.

Take-Home Points

• Patellofemoral disorders should be classified and diagnosed according to specific diagnostic categories (eg, lateral patellar compression syndrome) based on etiology rather than nondescriptive terminology (eg, internal derangement, patellofemoral pain syndrome).
• Patellofemoral dysplasia defines a spectrum of abnormalities ranging from the mild lateral patellar compression syndrome to the severe recurrent patellar dislocation.
• There is an inverse relationship between patient activity level and underlying patellofemoral dysplasia. This relationship determines threshold levels for each patient becoming symptomatic.
• Patients should be examined for 7 physical abnormalities, and if present, in what severity. These 7 are: vastus medialis obliquus deficiency, medial patellofemoral ligament laxity, lateral retinaculum tightness, increased quadriceps angle, hip abductor weakness, patella alta, and trochlear dysplasia.
• Advanced imaging is rarely, if ever, needed to make a diagnosis or to formulate an initial treatment plan for these common patellofemoral disorders.

To diagnose any disease or disorder implies an understanding of the condition’s cause(s), which should then lead to a logical treatment plan. For all too long, however, the diagnosis and treatment of patellofemoral disorders have been hampered by diagnoses that lack specific definitions based on etiology. A few of these are: internal derangement, chondromalacia patellae, patellar maltracking, and patellofemoral pain syndrome.

To simplify the diagnosis of patellofemoral disorders, we use a clinical classification based on etiology. This system’s defined diagnostic categories are useful in identifying probable cause(s), which can be appropriately evaluated and treated (Table).¹ In simple terms, the philosophy of this approach is to try to find out what’s wrong, and try to fix it!

This clinical classification provides a framework for common patellofemoral conditions that are more easily diagnosed, yet is intentionally incomplete omitting rare conditions (eg, tumors, metabolic bone disease, neurologic conditions).

Patellofemoral Dysplasia

Patellofemoral dysplasia (or extensor mechanism malfunction) is a cluster of physical abnormalities relating to the patellofemoral joint that vary from mild to severe and affect the normal function of that joint. As such, patellofemoral dysplasia itself should be considered on a continuum of mild to severe. To simplify the diagnosis, the clinician should systematically identify these factors and their severity. Armed with this information, the clinician can make the diagnosis and formulate a logical treatment plan for each individual patient.

This article focuses on 7 physical abnormalities that are most likely developmental and that can be identified through physical and radiologic examination. When and how each patient with patellofemoral dysplasia becomes symptomatic are determined by 2 key factors: patellofemoral dysplasia severity and activity level (sedentary to strenuous), in an inverse relationship (Figure 1).²

Seven Key Patellofemoral Physical Abnormalities

Of the 7 commonly identified physical abnormalities that affect the normal functioning of the patellofemoral joint, 5 are discovered by physical examination and 2 by radiography; CT and MRI are seldom needed in the initial evaluation. The most accurate and objective method should be used to assess the presence and severity of each abnormality.

The 7 abnormalities are vastus medialis obliquus (VMO) deficiency, medial patellofemoral ligament (MPFL) laxity, lateral retinaculum (LR) tightness, increased quadriceps (Q) angle, hip abductor weakness, patella alta, and trochlear dysplasia. We list these not in order of importance but in the order in which they are usually encountered during initial evaluation. We advocate for examining both knees including axial patellofemoral radiographs because patellofemoral disorders are frequently bilateral. It is helpful to use an abnormality checklist so none are forgotten. Also useful is a simple shorthand for findings: 0 = normal (no abnormality), 1 = mild abnormality, 2 = moderate abnormality, 3 = severe abnormality, with the right knee always recorded first (R/L). For example, severe left MPFL laxity is recorded as 0/3. Numerical values (eg, Q angles) can be directly recorded in this manner: 14°/23°.

1. Vastus Medialis Obliquus Deficiency

VMO deficiency is best seen as the sitting patient actively maintains the unsupported foot and leg at 30° knee flexion. Normally, the VMO inserts into the upper half or third of the medial edge of the patella; a deficient VMO inserts higher into the medial edge of the quadriceps tendon, or it is absent and leaves a characteristic hollow at the medial edge of the patella (Figure 2).⁴

2. Medial Patellofemoral Ligament Laxity

MPFL laxity is assessed with the lateral glide test. Again, the patient sits, but with quadriceps relaxed and foot and leg supported at 30° knee flexion. With the clinician mentally dividing the patella into vertical quadrants and pushing the patella laterally, the normal patella moves about 1 quadrant or 1 fingerbreadth. Severe MPFL laxity often elicits a positive apprehension response during the test. (Tip: Many patients are unable to relax the quadriceps while sitting; therefore, examine them supine and lift the knee into 30° flexion.) Such laxity usually means the MPFL was torn in a previous dislocation and remains elongated, leaving the patella vulnerable to repeated dislocations. The clinician should be alert to the possibility of hyperelastosis (Ehlers-Danlos syndrome) and a hyper-mobile patella. The opposite limb should be evaluated for asymmetric laxity.

3. Lateral Retinaculum Tightness

LR tightness is assessed with the medial glide test, again with the quadriceps relaxed and the knee supported at 30° flexion. With a normal LR, the patella can be pushed medially about 1 quadrant or 1 fingerbreadth. Some clinicians prefer the lateral tilt-up test, in which the lateral edge of the patella is lifted up, but this method is more difficult to quantify, is affected by the cross-sectional shape of the patella, and lacks consistency.

4. Increased Quadriceps Angle

The Q angle is one of the most important factors in the normal functioning of the patellofemoral joint. For more than a century,⁸ multiple operations have been used successfully to move the tibial tubercle (TT) and patellar ligament from a lateral position to a medial position thereby decreasing the Q angle. It is only logical to measure this angle at every knee examination to check for an abnormal increase, and the degree. The term quadriceps angle, or Q angle, was first used in 1964 by Brattström,⁷ who defined it as the “supplemental angle” to the valgus angle formed by the “quadriceps’ resultant” (line of force or vector) “+ patella + ligamentum patellae”. This might be called the dynamic Q angle. With there being no clinical method of measuring the “quadriceps line of force”, or quadriceps vector, clinicians used a line from the anterior superior iliac spine to the center of the patella, yet still called it the Q angle. By convention, this anatomical Q angle has been accepted as the Q angle.

Because the Q angle is the only clinical measurement of TT lateralization at initial evaluation, its measurement should be standardized, accurate, and simple to perform. Placing the patient supine with the lower limb in neutral rotation (patella anterior) and the knee in full extension standardizes the position. In full extension, the tibia reaches its maximum external rotation owing to the terminal “screw home” mechanism. The clinician should center the patella to the trochlear groove (TG) while measuring the Q angle, as it is the relationship of the TT to the trochlea, not to the patella, that is important. If LR tightness prevents the patella from centering, that fact should be recorded during the medial glide test for LR tightness.

5. Hip Abductor Weakness

The step-down test is easily performed in the office by having the patient stand on a short stool or stair and then slowly step down with the opposite limb to just touch the heel and slowly arise again. A positive test is indicated by the Trendelenburg sign, with the pelvis dropping down and away from the symptomatic supporting limb, the flexing knee collapsing into valgus, and the patient tending to wobble and lack stability (Figure 4).¹⁶

6. Patella Alta

Patella alta not only allows the patella to escape the confines of the trochlea earlier during active knee extension increasing the risk of patellar dislocation, but also decreases the contact footprint with the trochlea, increasing the patellofemoral joint reaction force and potentially causing patellofemoral pain and even secondary chondrosis. The simplest way to assess patellar height is with a lateral radiograph of the knee. The 3 popular methods (Insall-Salvati, Caton-Deschamps, Blackburn-Peel) all put the normal patellar height ratio at approximately 1:1, ± 20%. Berg and colleagues¹⁸ compared radiologic techniques for measuring patellar height ratio and found that Blackburn-Peel was the most accurate, reliable, and reproducible method.

7. Trochlear Dysplasia

Trochlear dysplasia, most simply a flattening of the TG, is perhaps the most important factor effecting normal patellofemoral function. However, it remains the most difficult to correctly address surgically. Senavongse and Amis¹⁹ conducted a cadaveric study demonstrating the prime importance of the TG. They found patellar stability was reduced 30% by releasing the VMO, 49% by cutting the MPFL in full knee extension, and 70% by flattening the trochlea. The most common, successful operations for correcting patellar instability depend on changing other factors that guide patellar excursion to compensate for this trochlear flattening.

The simplest way to assess trochlear dysplasia is to measure the sulcus angle on an accurate axial view radiograph of the knee at 45° flexion (Merchant view).²⁰ Dejour and colleagues²¹ popularized a technique of assessing and classifying trochlear dysplasia from a true lateral radiograph of the knee, which has the advantage of showing the trochlear at its proximal extent. Davies and colleagues²² evaluated the Dejour technique, along with patellar tilt, patellar height, and sulcus angle, to identify a rapid and reproducible radiologic feature that would indicate the need for further analysis by other imaging studies (eg, CT, MRI). They found that, if the sulcus angle was normal, analysis of other radiologic features was unlikely to reveal additional useful information. They also showed a correlation of increasing sulcus angle and severity of those other dysplasia features. Merchant and colleagues²⁰ found a mean normal sulcus angle of 138º (SD, 6º; range, 126º-150º), and Aglietti and colleagues²³ confirmed those findings with nearly identical values (mean, 137º; SD, 6º; range, 116º-151º).

Diagnosis and Initial Treatment Plan

Patellofemoral disorders generally are divided into patellofemoral pain and instability, but these 2 diagnostic categories are too broad to be useful. Patellofemoral pain is a symptom. Patellofemoral pain syndrome should never be used as a diagnosis because there is no accepted definition for the cluster of findings that customarily defines a syndrome. At initial evaluation, after the easily diagnosed causes of anterior knee pain (eg, prepatellar bursitis, TT apophysitis, patellar and quadriceps tendinitis) have been ruled out, the clinician should consider types of patellofemoral dysplasia for a presumptive diagnosis, which will then lead to a logical treatment program for each identified disorder. With a presumptive diagnosis established, almost all patients suffering from chronic anterior knee pain without history of injury are treated initially with rest, ice, and nonsteroidal anti-inflammatory drugs to restore joint homeostasis.³

Lateral Patellar Compression Syndrome

In 1975, Ficat and colleagues²⁴ described features of what they called syndrome d’hyperpression externe de la rotule. Two years later, Ficat and Hungerford²⁵ defined the syndrome as one “in which the patella is well centered in the trochlear sulcus and stable, but in which there is a functional lateralization onto a physiologically and often anatomically predominant lateral facet.” Using the tools we have described here, the clinician usually finds the cause(s) of this “functional lateralization.” Four abnormalities—VMO deficiency, LR tightness, increased standardized Q angle, and hip abductor weakness—can cause functional lateralization either alone when severe or in combination when mild or moderate.

For a presumptive diagnosis of LPCS, initial treatment is nonoperative, and successful in about 90% of patients. It should be obvious that most patients with chronic anterior knee pain have quadriceps atrophy. Physical therapy should be specifically focused on quadriceps strengthening, with absolutely no stress placed on the patellofemoral joint in flexion initially, and on hip abductor strengthening. Progressive resistive isometric quadriceps exercises can be performed with a weight-bench technique (Figures 5A-5D).²⁶

Chronic Subluxation of Patella

With the use of axial patellofemoral radiographs (Merchant views),²⁰ the clinician can determine if the “patella is well centered in the trochlear sulcus and stable” (an important part of the definition of LPCS). If the patient has no symptoms of recurrent instability or patellar dislocation, and these radiographs show a laterally subluxed patella (one not well centered in the trochlea), the diagnosis is most likely CSP, a moderate form of patellofemoral dysplasia (section II of the Table). In addition to the 4 abnormalities used in the diagnosis of LPCS (mentioned earlier), trochlear dysplasia also comes into play in the diagnosis of CSP. Just as the other abnormalities can vary from mild to severe, trochlear dysplasia can vary from mild (slightly shallow sulcus angle) to severe (flat or even convex sulcus angle). As the sulcus becomes shallower, the patella slides more laterally, increasing the likelihood of patellar dislocation.

As the patient with CSP gives no history of episodic patellar instability, treatment for CSP is almost identical to that for LPCS, with the primary focus on isometric quadriceps strengthening (DeHaven isometric exercises)²⁷ and hip abductor muscle strengthening. In the presence of CSP radiographically, it is important to use McConnell taping and/or patellar bracing during muscular strengthening. A patient who achieves 20-lb isometric quadriceps strength, demonstrates a normal step-down test, and is assumed to be asymptomatic can be allowed to return to sports activities with use of a patellar brace. The patient should be counseled that there is an increased risk for patellar dislocation because of this chronic subluxation and the shallower sulcus.

As in LPCS, CSP symptoms that persist after dynamic strength is regained may require surgical intervention. The severity of identified abnormal factors (tight LR, increased Q angle, trochlear dysplasia) guides the surgeon in selecting appropriate corrective technique(s).

Recurrent Dislocation of Patella

Admittedly, given the number and subtlety of abnormal factors, the diagnosis of LPCS as a cause of patellofemoral pain can be challenging. However, RDP is at the opposite end of the spectrum. A history of prior patellar dislocation(s) almost always makes the diagnosis of RDP easier. The patient occasionally complains of a recurrent symptom, the knee “going out” or “giving way,” indicating that the diagnosis might be RDP. By carefully asking what the patient was doing and what happened when the knee “went out”, the clinician may be able to determine if the injury stemmed from sudden patellar pain causing reflex inhibition of the quadriceps or was a true dislocation. Both may be described as “going out” or “giving way”.

Assessment for the same 7 abnormalities helps establish the diagnosis, a logical treatment plan, and a guide for indicated surgery. The diagnostic focus is MPFL laxity and trochlear dysplasia. Prior lateral dislocation of the patella almost always requires rupture of the normal MPFL. The infrequent exception is a patient with hyper-elasticity of the skin and multiple joints (Ehlers-Danlos syndrome). Trochlear dysplasia is a significant risk factor for patellar dislocation. If the trochlea is normal and there is no MPFL laxity, the diagnosis of RDP should be questioned.

If surgery is indicated, the surgeon uses a list of the patient’s abnormalities and their severity as a guide in selecting reconstructive techniques. The more abnormalities found and the greater the severity of each, the more techniques are needed to achieve success. Preoperative exercises help speed postoperative recovery by addressing quadriceps and hip abductor weakness. In addition, an active exercise program gives the surgeon insight into the patient’s desire for and commitment to recovery. Other physical abnormalities to be considered in preoperative planning include MPFL laxity, LR tightness, increased Q angle, patella alta, and trochlear dysplasia.

Surgical tips: 1. When releasing the LR, never cut the vastus lateralis tendon, as this has a high likelihood of causing iatrogenic medial patellar subluxation.²⁹ 2. When medializing the TT, consider compensating for a shallow trochlea by “over-correcting” the Q angle to 5° to 10° measured with a surgical goniometer intraoperatively.

Summary

Basing clinical classification of disorders on etiology is a simple and effective way to diagnose common patellofemoral conditions. Identifying and rating the severity of patellofemoral dysplasia, using 7 commonly found physical abnormalities, guide the physician to a proper diagnosis and down logical treatment pathways. These principles should be incorporated into the routine evaluation of patellofemoral disorders to optimize diagnosis, formulate a treatment plan, and improve patient outcomes. After all, this is what our patients are asking us to do: Try to find what’s wrong, and then try to fix it!

Am J Orthop. 2017;46(2):68-75. Copyright Frontline Medical Communications Inc. 2017. All rights reserved.

Take-Home Points

• Patellofemoral disorders should be classified and diagnosed according to specific diagnostic categories (eg, lateral patellar compression syndrome) based on etiology rather than nondescriptive terminology (eg, internal derangement, patellofemoral pain syndrome).
• Patellofemoral dysplasia defines a spectrum of abnormalities ranging from the mild lateral patellar compression syndrome to the severe recurrent patellar dislocation.
• There is an inverse relationship between patient activity level and underlying patellofemoral dysplasia. This relationship determines threshold levels for each patient becoming symptomatic.
• Patients should be examined for 7 physical abnormalities, and if present, in what severity. These 7 are: vastus medialis obliquus deficiency, medial patellofemoral ligament laxity, lateral retinaculum tightness, increased quadriceps angle, hip abductor weakness, patella alta, and trochlear dysplasia.
• Advanced imaging is rarely, if ever, needed to make a diagnosis or to formulate an initial treatment plan for these common patellofemoral disorders.

To diagnose any disease or disorder implies an understanding of the condition’s cause(s), which should then lead to a logical treatment plan. For all too long, however, the diagnosis and treatment of patellofemoral disorders have been hampered by diagnoses that lack specific definitions based on etiology. A few of these are: internal derangement, chondromalacia patellae, patellar maltracking, and patellofemoral pain syndrome.

To simplify the diagnosis of patellofemoral disorders, we use a clinical classification based on etiology. This system’s defined diagnostic categories are useful in identifying probable cause(s), which can be appropriately evaluated and treated (Table).¹ In simple terms, the philosophy of this approach is to try to find out what’s wrong, and try to fix it!

This clinical classification provides a framework for common patellofemoral conditions that are more easily diagnosed, yet is intentionally incomplete omitting rare conditions (eg, tumors, metabolic bone disease, neurologic conditions).

Patellofemoral Dysplasia

Patellofemoral dysplasia (or extensor mechanism malfunction) is a cluster of physical abnormalities relating to the patellofemoral joint that vary from mild to severe and affect the normal function of that joint. As such, patellofemoral dysplasia itself should be considered on a continuum of mild to severe. To simplify the diagnosis, the clinician should systematically identify these factors and their severity. Armed with this information, the clinician can make the diagnosis and formulate a logical treatment plan for each individual patient.

This article focuses on 7 physical abnormalities that are most likely developmental and that can be identified through physical and radiologic examination. When and how each patient with patellofemoral dysplasia becomes symptomatic are determined by 2 key factors: patellofemoral dysplasia severity and activity level (sedentary to strenuous), in an inverse relationship (Figure 1).²

Seven Key Patellofemoral Physical Abnormalities

Of the 7 commonly identified physical abnormalities that affect the normal functioning of the patellofemoral joint, 5 are discovered by physical examination and 2 by radiography; CT and MRI are seldom needed in the initial evaluation. The most accurate and objective method should be used to assess the presence and severity of each abnormality.

The 7 abnormalities are vastus medialis obliquus (VMO) deficiency, medial patellofemoral ligament (MPFL) laxity, lateral retinaculum (LR) tightness, increased quadriceps (Q) angle, hip abductor weakness, patella alta, and trochlear dysplasia. We list these not in order of importance but in the order in which they are usually encountered during initial evaluation. We advocate for examining both knees including axial patellofemoral radiographs because patellofemoral disorders are frequently bilateral. It is helpful to use an abnormality checklist so none are forgotten. Also useful is a simple shorthand for findings: 0 = normal (no abnormality), 1 = mild abnormality, 2 = moderate abnormality, 3 = severe abnormality, with the right knee always recorded first (R/L). For example, severe left MPFL laxity is recorded as 0/3. Numerical values (eg, Q angles) can be directly recorded in this manner: 14°/23°.

1. Vastus Medialis Obliquus Deficiency

VMO deficiency is best seen as the sitting patient actively maintains the unsupported foot and leg at 30° knee flexion. Normally, the VMO inserts into the upper half or third of the medial edge of the patella; a deficient VMO inserts higher into the medial edge of the quadriceps tendon, or it is absent and leaves a characteristic hollow at the medial edge of the patella (Figure 2).⁴

2. Medial Patellofemoral Ligament Laxity

MPFL laxity is assessed with the lateral glide test. Again, the patient sits, but with quadriceps relaxed and foot and leg supported at 30° knee flexion. With the clinician mentally dividing the patella into vertical quadrants and pushing the patella laterally, the normal patella moves about 1 quadrant or 1 fingerbreadth. Severe MPFL laxity often elicits a positive apprehension response during the test. (Tip: Many patients are unable to relax the quadriceps while sitting; therefore, examine them supine and lift the knee into 30° flexion.) Such laxity usually means the MPFL was torn in a previous dislocation and remains elongated, leaving the patella vulnerable to repeated dislocations. The clinician should be alert to the possibility of hyperelastosis (Ehlers-Danlos syndrome) and a hyper-mobile patella. The opposite limb should be evaluated for asymmetric laxity.

3. Lateral Retinaculum Tightness

LR tightness is assessed with the medial glide test, again with the quadriceps relaxed and the knee supported at 30° flexion. With a normal LR, the patella can be pushed medially about 1 quadrant or 1 fingerbreadth. Some clinicians prefer the lateral tilt-up test, in which the lateral edge of the patella is lifted up, but this method is more difficult to quantify, is affected by the cross-sectional shape of the patella, and lacks consistency.

4. Increased Quadriceps Angle

The Q angle is one of the most important factors in the normal functioning of the patellofemoral joint. For more than a century,⁸ multiple operations have been used successfully to move the tibial tubercle (TT) and patellar ligament from a lateral position to a medial position thereby decreasing the Q angle. It is only logical to measure this angle at every knee examination to check for an abnormal increase, and the degree. The term quadriceps angle, or Q angle, was first used in 1964 by Brattström,⁷ who defined it as the “supplemental angle” to the valgus angle formed by the “quadriceps’ resultant” (line of force or vector) “+ patella + ligamentum patellae”. This might be called the dynamic Q angle. With there being no clinical method of measuring the “quadriceps line of force”, or quadriceps vector, clinicians used a line from the anterior superior iliac spine to the center of the patella, yet still called it the Q angle. By convention, this anatomical Q angle has been accepted as the Q angle.

Because the Q angle is the only clinical measurement of TT lateralization at initial evaluation, its measurement should be standardized, accurate, and simple to perform. Placing the patient supine with the lower limb in neutral rotation (patella anterior) and the knee in full extension standardizes the position. In full extension, the tibia reaches its maximum external rotation owing to the terminal “screw home” mechanism. The clinician should center the patella to the trochlear groove (TG) while measuring the Q angle, as it is the relationship of the TT to the trochlea, not to the patella, that is important. If LR tightness prevents the patella from centering, that fact should be recorded during the medial glide test for LR tightness.

5. Hip Abductor Weakness

The step-down test is easily performed in the office by having the patient stand on a short stool or stair and then slowly step down with the opposite limb to just touch the heel and slowly arise again. A positive test is indicated by the Trendelenburg sign, with the pelvis dropping down and away from the symptomatic supporting limb, the flexing knee collapsing into valgus, and the patient tending to wobble and lack stability (Figure 4).¹⁶

6. Patella Alta

Patella alta not only allows the patella to escape the confines of the trochlea earlier during active knee extension increasing the risk of patellar dislocation, but also decreases the contact footprint with the trochlea, increasing the patellofemoral joint reaction force and potentially causing patellofemoral pain and even secondary chondrosis. The simplest way to assess patellar height is with a lateral radiograph of the knee. The 3 popular methods (Insall-Salvati, Caton-Deschamps, Blackburn-Peel) all put the normal patellar height ratio at approximately 1:1, ± 20%. Berg and colleagues¹⁸ compared radiologic techniques for measuring patellar height ratio and found that Blackburn-Peel was the most accurate, reliable, and reproducible method.

7. Trochlear Dysplasia

Trochlear dysplasia, most simply a flattening of the TG, is perhaps the most important factor effecting normal patellofemoral function. However, it remains the most difficult to correctly address surgically. Senavongse and Amis¹⁹ conducted a cadaveric study demonstrating the prime importance of the TG. They found patellar stability was reduced 30% by releasing the VMO, 49% by cutting the MPFL in full knee extension, and 70% by flattening the trochlea. The most common, successful operations for correcting patellar instability depend on changing other factors that guide patellar excursion to compensate for this trochlear flattening.

The simplest way to assess trochlear dysplasia is to measure the sulcus angle on an accurate axial view radiograph of the knee at 45° flexion (Merchant view).²⁰ Dejour and colleagues²¹ popularized a technique of assessing and classifying trochlear dysplasia from a true lateral radiograph of the knee, which has the advantage of showing the trochlear at its proximal extent. Davies and colleagues²² evaluated the Dejour technique, along with patellar tilt, patellar height, and sulcus angle, to identify a rapid and reproducible radiologic feature that would indicate the need for further analysis by other imaging studies (eg, CT, MRI). They found that, if the sulcus angle was normal, analysis of other radiologic features was unlikely to reveal additional useful information. They also showed a correlation of increasing sulcus angle and severity of those other dysplasia features. Merchant and colleagues²⁰ found a mean normal sulcus angle of 138º (SD, 6º; range, 126º-150º), and Aglietti and colleagues²³ confirmed those findings with nearly identical values (mean, 137º; SD, 6º; range, 116º-151º).

Diagnosis and Initial Treatment Plan

Patellofemoral disorders generally are divided into patellofemoral pain and instability, but these 2 diagnostic categories are too broad to be useful. Patellofemoral pain is a symptom. Patellofemoral pain syndrome should never be used as a diagnosis because there is no accepted definition for the cluster of findings that customarily defines a syndrome. At initial evaluation, after the easily diagnosed causes of anterior knee pain (eg, prepatellar bursitis, TT apophysitis, patellar and quadriceps tendinitis) have been ruled out, the clinician should consider types of patellofemoral dysplasia for a presumptive diagnosis, which will then lead to a logical treatment program for each identified disorder. With a presumptive diagnosis established, almost all patients suffering from chronic anterior knee pain without history of injury are treated initially with rest, ice, and nonsteroidal anti-inflammatory drugs to restore joint homeostasis.³

Lateral Patellar Compression Syndrome

In 1975, Ficat and colleagues²⁴ described features of what they called syndrome d’hyperpression externe de la rotule. Two years later, Ficat and Hungerford²⁵ defined the syndrome as one “in which the patella is well centered in the trochlear sulcus and stable, but in which there is a functional lateralization onto a physiologically and often anatomically predominant lateral facet.” Using the tools we have described here, the clinician usually finds the cause(s) of this “functional lateralization.” Four abnormalities—VMO deficiency, LR tightness, increased standardized Q angle, and hip abductor weakness—can cause functional lateralization either alone when severe or in combination when mild or moderate.

For a presumptive diagnosis of LPCS, initial treatment is nonoperative, and successful in about 90% of patients. It should be obvious that most patients with chronic anterior knee pain have quadriceps atrophy. Physical therapy should be specifically focused on quadriceps strengthening, with absolutely no stress placed on the patellofemoral joint in flexion initially, and on hip abductor strengthening. Progressive resistive isometric quadriceps exercises can be performed with a weight-bench technique (Figures 5A-5D).²⁶

Chronic Subluxation of Patella

With the use of axial patellofemoral radiographs (Merchant views),²⁰ the clinician can determine if the “patella is well centered in the trochlear sulcus and stable” (an important part of the definition of LPCS). If the patient has no symptoms of recurrent instability or patellar dislocation, and these radiographs show a laterally subluxed patella (one not well centered in the trochlea), the diagnosis is most likely CSP, a moderate form of patellofemoral dysplasia (section II of the Table). In addition to the 4 abnormalities used in the diagnosis of LPCS (mentioned earlier), trochlear dysplasia also comes into play in the diagnosis of CSP. Just as the other abnormalities can vary from mild to severe, trochlear dysplasia can vary from mild (slightly shallow sulcus angle) to severe (flat or even convex sulcus angle). As the sulcus becomes shallower, the patella slides more laterally, increasing the likelihood of patellar dislocation.

As the patient with CSP gives no history of episodic patellar instability, treatment for CSP is almost identical to that for LPCS, with the primary focus on isometric quadriceps strengthening (DeHaven isometric exercises)²⁷ and hip abductor muscle strengthening. In the presence of CSP radiographically, it is important to use McConnell taping and/or patellar bracing during muscular strengthening. A patient who achieves 20-lb isometric quadriceps strength, demonstrates a normal step-down test, and is assumed to be asymptomatic can be allowed to return to sports activities with use of a patellar brace. The patient should be counseled that there is an increased risk for patellar dislocation because of this chronic subluxation and the shallower sulcus.

As in LPCS, CSP symptoms that persist after dynamic strength is regained may require surgical intervention. The severity of identified abnormal factors (tight LR, increased Q angle, trochlear dysplasia) guides the surgeon in selecting appropriate corrective technique(s).

Recurrent Dislocation of Patella

Admittedly, given the number and subtlety of abnormal factors, the diagnosis of LPCS as a cause of patellofemoral pain can be challenging. However, RDP is at the opposite end of the spectrum. A history of prior patellar dislocation(s) almost always makes the diagnosis of RDP easier. The patient occasionally complains of a recurrent symptom, the knee “going out” or “giving way,” indicating that the diagnosis might be RDP. By carefully asking what the patient was doing and what happened when the knee “went out”, the clinician may be able to determine if the injury stemmed from sudden patellar pain causing reflex inhibition of the quadriceps or was a true dislocation. Both may be described as “going out” or “giving way”.

Assessment for the same 7 abnormalities helps establish the diagnosis, a logical treatment plan, and a guide for indicated surgery. The diagnostic focus is MPFL laxity and trochlear dysplasia. Prior lateral dislocation of the patella almost always requires rupture of the normal MPFL. The infrequent exception is a patient with hyper-elasticity of the skin and multiple joints (Ehlers-Danlos syndrome). Trochlear dysplasia is a significant risk factor for patellar dislocation. If the trochlea is normal and there is no MPFL laxity, the diagnosis of RDP should be questioned.

If surgery is indicated, the surgeon uses a list of the patient’s abnormalities and their severity as a guide in selecting reconstructive techniques. The more abnormalities found and the greater the severity of each, the more techniques are needed to achieve success. Preoperative exercises help speed postoperative recovery by addressing quadriceps and hip abductor weakness. In addition, an active exercise program gives the surgeon insight into the patient’s desire for and commitment to recovery. Other physical abnormalities to be considered in preoperative planning include MPFL laxity, LR tightness, increased Q angle, patella alta, and trochlear dysplasia.

Surgical tips: 1. When releasing the LR, never cut the vastus lateralis tendon, as this has a high likelihood of causing iatrogenic medial patellar subluxation.²⁹ 2. When medializing the TT, consider compensating for a shallow trochlea by “over-correcting” the Q angle to 5° to 10° measured with a surgical goniometer intraoperatively.

Summary

Basing clinical classification of disorders on etiology is a simple and effective way to diagnose common patellofemoral conditions. Identifying and rating the severity of patellofemoral dysplasia, using 7 commonly found physical abnormalities, guide the physician to a proper diagnosis and down logical treatment pathways. These principles should be incorporated into the routine evaluation of patellofemoral disorders to optimize diagnosis, formulate a treatment plan, and improve patient outcomes. After all, this is what our patients are asking us to do: Try to find what’s wrong, and then try to fix it!

Am J Orthop. 2017;46(2):68-75. Copyright Frontline Medical Communications Inc. 2017. All rights reserved.

Take-Home Points

• Use fluoroscopy, isometry, or both to double-check the femoral attachment point. Failure to do so can lead to an overtensioned or undertensioned graft caused by anisometric graft placement.
• To minimize the risk of fracture, avoid drilling transverse tunnels across the patella.
• Do not “pre-tension” the medial patellofemoral ligament graft. There should be little or no tension in the graft when the patella is centered in the groove, regardless of the angle of knee flexion.
• The angle of knee flexion during securing of the graft may be important for inaccurate femoral tunnel placement. Before final fixation of the graft, always range the knee fully to make sure full passive motion will be possible once the graft is secured.
• Understanding the anatomy of the MPFL is key before considering reconstructing: That is, fluoroscopy only suggests a “cloud” to begin assessment of the femoral attachment site and is secondary to anatomic references and check of length changes between the attachment point through range of motion. New studies demonstrate the patellar attachment is broad and extends proximally from the historical patellar attachment site to an equal distance along the distal quadriceps.

The medial patellofemoral ligament (MPFL), which is essential in preventing lateral patellar instability, becomes torn in almost 100% of dislocation events.¹ Therefore, in cases of failed nonoperative management, this important constraint should be reconstructed. Reconstruction is technically challenging, precision is needed to avoid postoperative complications, and a thorough understanding of the native MPFL anatomy is paramount.

As a thickening of the medial patellar retinaculum, the MPFL connects the medial patella to the medial femur. The femoral insertion has been described a few ways. In a cadaveric study, LaPrade and colleagues² noted that it inserts 1.9 mm anterior and 3.2 mm distal to the adductor tubercle. Radiographically, the attachment has been described by Schöttle and colleagues³ and Stephen and colleagues.⁴ These techniques are discussed in more detail later.

The MPFL is a static restraint to lateral patellar translation—it acts only as a checkrein. It functions mainly in 0° to 30° of knee flexion because once the patella engages the trochlear groove, the bony articulation guides the patella during the rest of knee flexion.⁵ Most authors agree that the native MPFL is mostly isometric, and the re-created ligament should replicate it.^6,7 Using cadaveric specimens, Steensen and colleagues⁶ found that, from 0° to 90° of knee flexion, the distance from the inferior patellar attachment to the superior femoral attachment changed only 1.1 mm.

Biomechanical studies have shown that a MPFL graft with excessive tension predisposes to postoperative abnormal patellofemoral contact pressures, which cause anterior knee pain, loss of knee flexion, and patellofemoral chondrosis.^8-10 Furthermore, an overtensioned graft can cause iatrogenic medial patellar subluxation, and an undertensioned graft may still allow for pathologic lateral patellar translation.

Anatomical Bony Insertions

Femoral Insertion

Precise localization of the proper anatomical femoral attachment of the MPFL is a crucial step in reconstruction.¹¹ Small errors in femoral location have resulted in significant loss of graft isometry, increased patellofemoral contact pressures in cadaveric models,^4,7 and increased rates of failure after both MPFL repair¹² and reconstruction.¹³ Several methods for confirming proper femoral location during surgery have been described; these methods help obviate the need for large formal dissection of the medial knee.

In a cadaveric study, Schöttle and colleagues³ described a reproducible radiographic point that precisely identifies the appropriate femoral location for MPFL graft placement. The point is located on a standard true lateral radiograph of the distal femur. First, a line is drawn extending the posterior cortex of the femur distally. Next, 2 lines are drawn perpendicular to the first: one intersecting the posterior point of the Blumensaat line, the other intersecting the transition between the posterior femoral condyle and the posterior femoral cortex³ (Figure 1).

Patellar Insertion

The patellar attachment of the MPFL has received considerably less attention than the femoral attachment.¹¹ Anatomical studies have shown that the MPFL inserts on the superomedial half to third of the patella, in addition to a portion inserting on the undersurface of the vastus medialis.¹⁷

Troubleshooting

It is essential to check graft tension through full knee ROM and observe how the graft behaves in order to prevent iatrogenic complications¹¹ (Figures 6A, 6B).

If the graft is secured in high degrees of knee flexion, and the femoral location is not anatomical, a different phenomenon occurs when the knee is brought back into extension. For proximal femoral tunnels, the graft loosens in knee extension and may lead to continued lateral patellar instability. On the other hand, a distal femoral tunnel may result in iatrogenic medial patellar subluxation as the graft becomes too tight in extension.

Correct Amount of Graft Tension

Overtightening the MPFL during fixation is an easy but avoidable mistake. Unlike the anterior cruciate ligament, the MPFL should not be secured while applying maximum tension. Stephen and colleagues⁷ and Beck and colleagues⁸ found that tension of only 2 N (~0.5 lb) is needed to accurately re-create the biomechanics of the native graft.

The amount of tension may inadvertently be increased by an interference screw, which tends to pull the graft into the femoral tunnel during insertion. Attention should be given to watching and palpating the graft as the screw is inserted, especially during the last few turns. Turning the screw half a turn backwards after full insertion can release this increased tension and help avoid overtensioning.

Correct Amount of Knee Flexion

This is probably the least studied aspect of MPFL reconstruction. Recommendations range from 0° to 90° of knee flexion during fixation.^7,25-30 Most recommendations are surgeon preference, or are based on a sound rationale that lacks supporting research. Tensioning in full extension has been advocated for assessing for the appropriate amount of lateral patellar translation.²⁷ Authors who endorse deeper knee flexion (60°-90°) think that, because the patella engages a deeper trochlear groove in increased flexion, the bony articulation can be used to establish graft length.^30,31

Our cadaveric study showed that lower degrees of knee flexion are safest for minimizing the effect of a malpositioned femoral tunnel.²⁶ If femoral tunnel location is not exactly anatomical, any errors are magnified (with even worse graft mechanics) the deeper in flexion the graft is fixed. Once the patella engages the trochlear groove, at about 30° of knee flexion, this can assist in establishing correct graft length. Therefore, we recommend fixation of the graft in 30° to 45° of knee flexion. Our study results also showed that, if femoral tunnel location is anatomical, the graft will be mostly isometric through knee ROM, and, therefore, amount of initial knee flexion does not affect graft behavior.

Regardless of knee flexion chosen, it is imperative to take the knee through full ROM after fixation to ensure the graft does not excessively loosen or tighten in flexion or extension.

Conclusion

MPFL reconstruction is fraught with errors and technical nuances that may be underappreciated. Accurately locating the femoral insertion is crucial to a biomechanically sound graft, and this location should be scrutinized during surgery with accurate radiographs or bony landmarks and verified with knee ROM. Although there is no clear gold standard for fixation and graft options, the graft should be secured while pulling very little tension (2 N) and with the knee in 30° to 45° of flexion to minimize the effect of any inaccuracies in femoral location. Overall, most patients do well after MPFL reconstruction, and attention to surgical technical detail helps maximize the chances of a satisfactory outcome.

Am J Orthop. 2017;46(2):76-81. Copyright Frontline Medical Communications Inc. 2017. All rights reserved.

Take-Home Points

• Use fluoroscopy, isometry, or both to double-check the femoral attachment point. Failure to do so can lead to an overtensioned or undertensioned graft caused by anisometric graft placement.
• To minimize the risk of fracture, avoid drilling transverse tunnels across the patella.
• Do not “pre-tension” the medial patellofemoral ligament graft. There should be little or no tension in the graft when the patella is centered in the groove, regardless of the angle of knee flexion.
• The angle of knee flexion during securing of the graft may be important for inaccurate femoral tunnel placement. Before final fixation of the graft, always range the knee fully to make sure full passive motion will be possible once the graft is secured.
• Understanding the anatomy of the MPFL is key before considering reconstructing: That is, fluoroscopy only suggests a “cloud” to begin assessment of the femoral attachment site and is secondary to anatomic references and check of length changes between the attachment point through range of motion. New studies demonstrate the patellar attachment is broad and extends proximally from the historical patellar attachment site to an equal distance along the distal quadriceps.

The medial patellofemoral ligament (MPFL), which is essential in preventing lateral patellar instability, becomes torn in almost 100% of dislocation events.¹ Therefore, in cases of failed nonoperative management, this important constraint should be reconstructed. Reconstruction is technically challenging, precision is needed to avoid postoperative complications, and a thorough understanding of the native MPFL anatomy is paramount.

As a thickening of the medial patellar retinaculum, the MPFL connects the medial patella to the medial femur. The femoral insertion has been described a few ways. In a cadaveric study, LaPrade and colleagues² noted that it inserts 1.9 mm anterior and 3.2 mm distal to the adductor tubercle. Radiographically, the attachment has been described by Schöttle and colleagues³ and Stephen and colleagues.⁴ These techniques are discussed in more detail later.

The MPFL is a static restraint to lateral patellar translation—it acts only as a checkrein. It functions mainly in 0° to 30° of knee flexion because once the patella engages the trochlear groove, the bony articulation guides the patella during the rest of knee flexion.⁵ Most authors agree that the native MPFL is mostly isometric, and the re-created ligament should replicate it.^6,7 Using cadaveric specimens, Steensen and colleagues⁶ found that, from 0° to 90° of knee flexion, the distance from the inferior patellar attachment to the superior femoral attachment changed only 1.1 mm.

Biomechanical studies have shown that a MPFL graft with excessive tension predisposes to postoperative abnormal patellofemoral contact pressures, which cause anterior knee pain, loss of knee flexion, and patellofemoral chondrosis.^8-10 Furthermore, an overtensioned graft can cause iatrogenic medial patellar subluxation, and an undertensioned graft may still allow for pathologic lateral patellar translation.

Anatomical Bony Insertions

Femoral Insertion

Precise localization of the proper anatomical femoral attachment of the MPFL is a crucial step in reconstruction.¹¹ Small errors in femoral location have resulted in significant loss of graft isometry, increased patellofemoral contact pressures in cadaveric models,^4,7 and increased rates of failure after both MPFL repair¹² and reconstruction.¹³ Several methods for confirming proper femoral location during surgery have been described; these methods help obviate the need for large formal dissection of the medial knee.

In a cadaveric study, Schöttle and colleagues³ described a reproducible radiographic point that precisely identifies the appropriate femoral location for MPFL graft placement. The point is located on a standard true lateral radiograph of the distal femur. First, a line is drawn extending the posterior cortex of the femur distally. Next, 2 lines are drawn perpendicular to the first: one intersecting the posterior point of the Blumensaat line, the other intersecting the transition between the posterior femoral condyle and the posterior femoral cortex³ (Figure 1).

Patellar Insertion

The patellar attachment of the MPFL has received considerably less attention than the femoral attachment.¹¹ Anatomical studies have shown that the MPFL inserts on the superomedial half to third of the patella, in addition to a portion inserting on the undersurface of the vastus medialis.¹⁷

Troubleshooting

It is essential to check graft tension through full knee ROM and observe how the graft behaves in order to prevent iatrogenic complications¹¹ (Figures 6A, 6B).

If the graft is secured in high degrees of knee flexion, and the femoral location is not anatomical, a different phenomenon occurs when the knee is brought back into extension. For proximal femoral tunnels, the graft loosens in knee extension and may lead to continued lateral patellar instability. On the other hand, a distal femoral tunnel may result in iatrogenic medial patellar subluxation as the graft becomes too tight in extension.

Correct Amount of Graft Tension

Overtightening the MPFL during fixation is an easy but avoidable mistake. Unlike the anterior cruciate ligament, the MPFL should not be secured while applying maximum tension. Stephen and colleagues⁷ and Beck and colleagues⁸ found that tension of only 2 N (~0.5 lb) is needed to accurately re-create the biomechanics of the native graft.

The amount of tension may inadvertently be increased by an interference screw, which tends to pull the graft into the femoral tunnel during insertion. Attention should be given to watching and palpating the graft as the screw is inserted, especially during the last few turns. Turning the screw half a turn backwards after full insertion can release this increased tension and help avoid overtensioning.

Correct Amount of Knee Flexion

This is probably the least studied aspect of MPFL reconstruction. Recommendations range from 0° to 90° of knee flexion during fixation.^7,25-30 Most recommendations are surgeon preference, or are based on a sound rationale that lacks supporting research. Tensioning in full extension has been advocated for assessing for the appropriate amount of lateral patellar translation.²⁷ Authors who endorse deeper knee flexion (60°-90°) think that, because the patella engages a deeper trochlear groove in increased flexion, the bony articulation can be used to establish graft length.^30,31

Our cadaveric study showed that lower degrees of knee flexion are safest for minimizing the effect of a malpositioned femoral tunnel.²⁶ If femoral tunnel location is not exactly anatomical, any errors are magnified (with even worse graft mechanics) the deeper in flexion the graft is fixed. Once the patella engages the trochlear groove, at about 30° of knee flexion, this can assist in establishing correct graft length. Therefore, we recommend fixation of the graft in 30° to 45° of knee flexion. Our study results also showed that, if femoral tunnel location is anatomical, the graft will be mostly isometric through knee ROM, and, therefore, amount of initial knee flexion does not affect graft behavior.

Regardless of knee flexion chosen, it is imperative to take the knee through full ROM after fixation to ensure the graft does not excessively loosen or tighten in flexion or extension.

Conclusion

MPFL reconstruction is fraught with errors and technical nuances that may be underappreciated. Accurately locating the femoral insertion is crucial to a biomechanically sound graft, and this location should be scrutinized during surgery with accurate radiographs or bony landmarks and verified with knee ROM. Although there is no clear gold standard for fixation and graft options, the graft should be secured while pulling very little tension (2 N) and with the knee in 30° to 45° of flexion to minimize the effect of any inaccuracies in femoral location. Overall, most patients do well after MPFL reconstruction, and attention to surgical technical detail helps maximize the chances of a satisfactory outcome.

Am J Orthop. 2017;46(2):76-81. Copyright Frontline Medical Communications Inc. 2017. All rights reserved.

Take-Home Points

• Use fluoroscopy, isometry, or both to double-check the femoral attachment point. Failure to do so can lead to an overtensioned or undertensioned graft caused by anisometric graft placement.
• To minimize the risk of fracture, avoid drilling transverse tunnels across the patella.
• Do not “pre-tension” the medial patellofemoral ligament graft. There should be little or no tension in the graft when the patella is centered in the groove, regardless of the angle of knee flexion.
• The angle of knee flexion during securing of the graft may be important for inaccurate femoral tunnel placement. Before final fixation of the graft, always range the knee fully to make sure full passive motion will be possible once the graft is secured.
• Understanding the anatomy of the MPFL is key before considering reconstructing: That is, fluoroscopy only suggests a “cloud” to begin assessment of the femoral attachment site and is secondary to anatomic references and check of length changes between the attachment point through range of motion. New studies demonstrate the patellar attachment is broad and extends proximally from the historical patellar attachment site to an equal distance along the distal quadriceps.

The medial patellofemoral ligament (MPFL), which is essential in preventing lateral patellar instability, becomes torn in almost 100% of dislocation events.¹ Therefore, in cases of failed nonoperative management, this important constraint should be reconstructed. Reconstruction is technically challenging, precision is needed to avoid postoperative complications, and a thorough understanding of the native MPFL anatomy is paramount.

As a thickening of the medial patellar retinaculum, the MPFL connects the medial patella to the medial femur. The femoral insertion has been described a few ways. In a cadaveric study, LaPrade and colleagues² noted that it inserts 1.9 mm anterior and 3.2 mm distal to the adductor tubercle. Radiographically, the attachment has been described by Schöttle and colleagues³ and Stephen and colleagues.⁴ These techniques are discussed in more detail later.

The MPFL is a static restraint to lateral patellar translation—it acts only as a checkrein. It functions mainly in 0° to 30° of knee flexion because once the patella engages the trochlear groove, the bony articulation guides the patella during the rest of knee flexion.⁵ Most authors agree that the native MPFL is mostly isometric, and the re-created ligament should replicate it.^6,7 Using cadaveric specimens, Steensen and colleagues⁶ found that, from 0° to 90° of knee flexion, the distance from the inferior patellar attachment to the superior femoral attachment changed only 1.1 mm.

Biomechanical studies have shown that a MPFL graft with excessive tension predisposes to postoperative abnormal patellofemoral contact pressures, which cause anterior knee pain, loss of knee flexion, and patellofemoral chondrosis.^8-10 Furthermore, an overtensioned graft can cause iatrogenic medial patellar subluxation, and an undertensioned graft may still allow for pathologic lateral patellar translation.

Anatomical Bony Insertions

Femoral Insertion

Precise localization of the proper anatomical femoral attachment of the MPFL is a crucial step in reconstruction.¹¹ Small errors in femoral location have resulted in significant loss of graft isometry, increased patellofemoral contact pressures in cadaveric models,^4,7 and increased rates of failure after both MPFL repair¹² and reconstruction.¹³ Several methods for confirming proper femoral location during surgery have been described; these methods help obviate the need for large formal dissection of the medial knee.

In a cadaveric study, Schöttle and colleagues³ described a reproducible radiographic point that precisely identifies the appropriate femoral location for MPFL graft placement. The point is located on a standard true lateral radiograph of the distal femur. First, a line is drawn extending the posterior cortex of the femur distally. Next, 2 lines are drawn perpendicular to the first: one intersecting the posterior point of the Blumensaat line, the other intersecting the transition between the posterior femoral condyle and the posterior femoral cortex³ (Figure 1).

Patellar Insertion

The patellar attachment of the MPFL has received considerably less attention than the femoral attachment.¹¹ Anatomical studies have shown that the MPFL inserts on the superomedial half to third of the patella, in addition to a portion inserting on the undersurface of the vastus medialis.¹⁷

Troubleshooting

It is essential to check graft tension through full knee ROM and observe how the graft behaves in order to prevent iatrogenic complications¹¹ (Figures 6A, 6B).

If the graft is secured in high degrees of knee flexion, and the femoral location is not anatomical, a different phenomenon occurs when the knee is brought back into extension. For proximal femoral tunnels, the graft loosens in knee extension and may lead to continued lateral patellar instability. On the other hand, a distal femoral tunnel may result in iatrogenic medial patellar subluxation as the graft becomes too tight in extension.

Correct Amount of Graft Tension

Overtightening the MPFL during fixation is an easy but avoidable mistake. Unlike the anterior cruciate ligament, the MPFL should not be secured while applying maximum tension. Stephen and colleagues⁷ and Beck and colleagues⁸ found that tension of only 2 N (~0.5 lb) is needed to accurately re-create the biomechanics of the native graft.

The amount of tension may inadvertently be increased by an interference screw, which tends to pull the graft into the femoral tunnel during insertion. Attention should be given to watching and palpating the graft as the screw is inserted, especially during the last few turns. Turning the screw half a turn backwards after full insertion can release this increased tension and help avoid overtensioning.

Correct Amount of Knee Flexion

This is probably the least studied aspect of MPFL reconstruction. Recommendations range from 0° to 90° of knee flexion during fixation.^7,25-30 Most recommendations are surgeon preference, or are based on a sound rationale that lacks supporting research. Tensioning in full extension has been advocated for assessing for the appropriate amount of lateral patellar translation.²⁷ Authors who endorse deeper knee flexion (60°-90°) think that, because the patella engages a deeper trochlear groove in increased flexion, the bony articulation can be used to establish graft length.^30,31

Our cadaveric study showed that lower degrees of knee flexion are safest for minimizing the effect of a malpositioned femoral tunnel.²⁶ If femoral tunnel location is not exactly anatomical, any errors are magnified (with even worse graft mechanics) the deeper in flexion the graft is fixed. Once the patella engages the trochlear groove, at about 30° of knee flexion, this can assist in establishing correct graft length. Therefore, we recommend fixation of the graft in 30° to 45° of knee flexion. Our study results also showed that, if femoral tunnel location is anatomical, the graft will be mostly isometric through knee ROM, and, therefore, amount of initial knee flexion does not affect graft behavior.

Regardless of knee flexion chosen, it is imperative to take the knee through full ROM after fixation to ensure the graft does not excessively loosen or tighten in flexion or extension.

Conclusion

MPFL reconstruction is fraught with errors and technical nuances that may be underappreciated. Accurately locating the femoral insertion is crucial to a biomechanically sound graft, and this location should be scrutinized during surgery with accurate radiographs or bony landmarks and verified with knee ROM. Although there is no clear gold standard for fixation and graft options, the graft should be secured while pulling very little tension (2 N) and with the knee in 30° to 45° of flexion to minimize the effect of any inaccuracies in femoral location. Overall, most patients do well after MPFL reconstruction, and attention to surgical technical detail helps maximize the chances of a satisfactory outcome.

Am J Orthop. 2017;46(2):76-81. Copyright Frontline Medical Communications Inc. 2017. All rights reserved.

Take-Home Points

• Ensure that relative rest and activity modification allow the knee to stay within the available “envelope of function” of the joint.
• Careful physical examination is imperative to assess strength, flexibility, and altered movement patterns, which in many cases are all part of the etiology of AKP.
• Patience and perseverance are paramount. Patients need to clearly understand the goals of rehabilitation as well as the concepts related to “envelope of function” so they can continue to keep themselves within this envelope. This education is crucial to their success.
• Only once a patient has been brought into the pain-free functional envelope can rehabilitation be redirected to expanding the envelope toward the patient’s particular goals.

• Quantity does not equal quality. To create an appropriate care plan, the physician must assess the adequacy of the patient’s rehabilitation thus far—ask specific questions about the types of exercises the patient is doing in physical therapy and quickly assess strength with a few simple in-office tests.

Anterior knee pain (AKP) is a common presentation. Although the exact etiology and nature of AKP continue to be poorly understood, overuse principles can be useful in directing treatment. In overuse injury, repetitive submaximal or subclinical trauma results in macroscopic trauma, microscopic trauma, or both. The structural tissue unit is damaged or its clinical responsiveness is exceeded, which can lead to pain or movement dysfunction. Overuse injuries commonly have an endogenous source, mechanical circumstances in which the musculoskeletal tissue is subjected to more tensile force or stress than the tissue can tolerate. The approach to treatment and rehabilitation of AKP is best facilitated with a thorough understanding of the concept of tissue homeostasis and the “envelope of function.”

Although the cause of AKP is multifactorial, the contributions of muscle strength deficits, diminished neuromuscular control, and altered muscle firing patterns to the development and severity of AKP are well established.^1-5 The hallmark of nonoperative management of AKP is physiotherapy that re-establishes strength, neuromuscular control, muscle activation, and optimal biomechanics during daily activities, advancing to graded levels of sporting activities.

The purpose of this paper is to discuss the factors associated with the diminished neuromuscular control observed in AKP and to review appropriate rehabilitation concepts for patients with AKP. Practical tools are provided to aid the surgeon to identify neuromuscular deficits in the clinic setting, along with assessing the adequacy of prior therapy and the need for further rehabilitation.

Common Neuromuscular Deficits in AKP

Weakness of the knee extensor muscles has long been implicated as the main issue in AKP, and therefore the focus of rehabilitation has been on muscle strengthening, especially of the vastus medialis obliquus. Research has found that knee extensor weakness is not only a characteristic of patients with AKP but a risk factor for developing AKP.⁴ Restoration of knee extensor strength and function is essential for recovery.⁶ Another issue in AKP may be incorrect firing of the knee extensor muscles. Altered vastus medialis obliquus response time and a motor control deficit of the quadriceps musculature have been demonstrated.^7,8 Restoration of knee extensor strength, though important, is too often the sole focus of some rehabilitation programs.

Hip muscle weakness has also been implicated as an important component of AKP.^9-12 Impaired gluteal muscle function can lead to increased hip joint adduction and internal rotation during activities such as stair climbing, squatting, and sports.^9,10,13 In a systematic review, Meira and Brumitt¹² concluded that hip strength and position are linked to AKP and that patients with AKP present with a common deficit once symptomatic. The dysfunction in neuromuscular control in AKP may also stem from disordered firing sequences in the muscles. A systematic review of hip electromyographic studies found moderate to strong evidence that gluteus medius muscle activity is delayed and of shorter duration during stair ascent and descent in patients with AKP.¹¹ The study also found some evidence that this activity is delayed and of shorter duration during running and that gluteus maximus muscle activity is increased during stair descent. The authors recommended that interventions focused on correcting these deficits—such as hip strengthening, biofeedback, and gait retraining—should be included in AKP treatment and research.

In recent AKP research, the core, including hip and abdominal muscles, demonstrated decreased strength and altered recruitment patterns during functional movement.^14,15 The authors recommended including core strengthening and core stability exercises in AKP management. In combination, these knee extensor, hip, and core strength deficits in patients with AKP lead to altered movement patterns during functional activities and may in turn exacerbate symptoms. Addressing both the strength deficits and the recruitment patterns of these core and lower extremity muscles is essential for optimizing rehabilitation and limiting recurrence of AKP symptoms.

Stretching to improve muscle tendon length is another component of AKP treatment. Reduced quadriceps muscle length has been implicated as a cause of AKP and is a common finding in symptomatic patients.¹⁶ In addition, a recent randomized controlled trial found decreased hip flexibility in patients with AKP.¹⁷ It is important to assess the flexibility of the gastrocnemius, soleus, quadriceps, and hamstrings muscles and the iliotibial band, as well as the hip flexors, extensors, and rotators, so that rehabilitation can be designed to address any specific deficits in range of motion (ROM).^16-23 In patients with AKP, it is also important to address muscle tendon length deficits and strengthening simultaneously to avoid exceeding the available envelope of function. Gaining full ROM at joints can facilitate increasing strength gains²⁴ and potentially improve the synergy of muscle contractions during functional activities.

Appropriate Rehabilitation in AKP

Appropriate rehabilitation addresses all identified strength and flexibility deficits in order to improve functional biomechanics and normalize altered body movement patterns during daily activities (eg, walking, squatting, stair climbing). Often, if part of the kinetic chain is weak or injured, the body engages in an activity by “working around” the injured body part. This change often results in faulty body mechanics or altered movement patterns. In AKP, these modified biomechanics can result in pain centered on the patella and associated soft-tissue structures. In developing ways to compensate for strength and ROM deficits, patients with AKP exacerbate their symptoms. In long-standing AKP, these compensatory strategies are most often unintentional and ingrained.

The main role of physical therapists is to identify any faulty movement patterns, dissect the underlying neuromuscular causes of these deficits, and build an individualized rehabilitation program. Physical therapy should be customized to the patient’s level of strength and fitness and whenever possible should be made challenging (and fun!) for the patient. The exercises should be increased in intensity and duration as the patient improves strength, endurance, and control in the activities. The patient’s response to each intervention will help guide exercise progression and define the need for further treatments.

Patients should be assessed for overuse patterns. Overuse can occur with repetitive exercise activity, such as running, or with repetitive work activity that involves lifting, squatting, or stair climbing. It is important to modify or reduce such activity to ensure that a patient with AKP remains within an envelope of pain-free function. Once the patient is functioning in this envelope, rehabilitation can be redirected to expand it, while improving strength, coordination, balance, and overall dynamic control of the core and lower limbs.

The purpose of any rehabilitation program is to build strength through the entire kinetic chain, focusing on hip and core strength initially, and then adding concentric and eccentric lower limb strength. Having a strong base from which to initiate lower limb movements makes correct lower limb form more likely to follow. Corrected muscle firing patterns allow for appropriate sequencing of the muscle activation needed for proper movements. Corrected muscle tendon lengths allow for optimal firing of the muscles controlling the lower limb, and for the flexibility needed for everyday ROM and biomechanics. Patients with AKP require re-education of movements that occur during daily functional activities, including gait. Once correct movement patterns are established in daily activities, it is important to address sporting or work-related activities. This is one important reason to ensure that physiotherapy visits are distributed over time and that patient-centered goals are addressed during each visit. In addition, during therapy, it is essential to reexamine body movement patterns to identify any relapse to prior dysfunction as the intensity or frequency of activity increases.

In AKP management, the dosage and duration of exercise prescriptions are challenging, and patience and perseverance are paramount. The initial goal of therapy is to increase strength and ROM to enable practice of correct motion in daily activities (eg, stair climbing, sitting, and walking). The physical therapist’s challenge is to teach correct motion within the envelope of function, as described by Dye.²⁵ Pain is not gain, and all exercises must be performed without pain to avoid flaring symptoms. The patient and the therapist must collaborate to complete a pain free rehabilitation program, and must operate within that zone. Providing prescriptions with specific goals may be helpful. Example goals are, “Increase core and lower extremity strength to achieve squatting without medial collapse of knee,” “Hip and core strengthening and endurance,” “Equal quadriceps strength and girth,” and “Functional movement retraining.”

Assessing Adequacy of Rehabilitation in AKP

When a patient presents with a diagnosis of AKP, it can be difficult to establish whether a prior rehabilitation program was appropriate. The fact that a patient attended physiotherapy says nothing about the quality of the therapy provided. Neither does the number of sessions attended. To assess the quality of the rehabilitation and determine if there are any major deficits in neuromuscular function, the physician can perform a simple battery of screening tests (Figure 1).²⁶

More advanced tests can be used to better understand the neuromuscular function of the patient with AKP and tease out specific deficits. Figure 2²⁶ describes some of these tests and the typical compensatory motions seen in patients with altered movement patterns.

Am J Orthop. 2017;46(2):82-86. Copyright Frontline Medical Communications Inc. 2017. All rights reserved.

Take-Home Points

• Ensure that relative rest and activity modification allow the knee to stay within the available “envelope of function” of the joint.
• Careful physical examination is imperative to assess strength, flexibility, and altered movement patterns, which in many cases are all part of the etiology of AKP.
• Patience and perseverance are paramount. Patients need to clearly understand the goals of rehabilitation as well as the concepts related to “envelope of function” so they can continue to keep themselves within this envelope. This education is crucial to their success.
• Only once a patient has been brought into the pain-free functional envelope can rehabilitation be redirected to expanding the envelope toward the patient’s particular goals.

• Quantity does not equal quality. To create an appropriate care plan, the physician must assess the adequacy of the patient’s rehabilitation thus far—ask specific questions about the types of exercises the patient is doing in physical therapy and quickly assess strength with a few simple in-office tests.

Anterior knee pain (AKP) is a common presentation. Although the exact etiology and nature of AKP continue to be poorly understood, overuse principles can be useful in directing treatment. In overuse injury, repetitive submaximal or subclinical trauma results in macroscopic trauma, microscopic trauma, or both. The structural tissue unit is damaged or its clinical responsiveness is exceeded, which can lead to pain or movement dysfunction. Overuse injuries commonly have an endogenous source, mechanical circumstances in which the musculoskeletal tissue is subjected to more tensile force or stress than the tissue can tolerate. The approach to treatment and rehabilitation of AKP is best facilitated with a thorough understanding of the concept of tissue homeostasis and the “envelope of function.”

Although the cause of AKP is multifactorial, the contributions of muscle strength deficits, diminished neuromuscular control, and altered muscle firing patterns to the development and severity of AKP are well established.^1-5 The hallmark of nonoperative management of AKP is physiotherapy that re-establishes strength, neuromuscular control, muscle activation, and optimal biomechanics during daily activities, advancing to graded levels of sporting activities.

The purpose of this paper is to discuss the factors associated with the diminished neuromuscular control observed in AKP and to review appropriate rehabilitation concepts for patients with AKP. Practical tools are provided to aid the surgeon to identify neuromuscular deficits in the clinic setting, along with assessing the adequacy of prior therapy and the need for further rehabilitation.

Common Neuromuscular Deficits in AKP

Weakness of the knee extensor muscles has long been implicated as the main issue in AKP, and therefore the focus of rehabilitation has been on muscle strengthening, especially of the vastus medialis obliquus. Research has found that knee extensor weakness is not only a characteristic of patients with AKP but a risk factor for developing AKP.⁴ Restoration of knee extensor strength and function is essential for recovery.⁶ Another issue in AKP may be incorrect firing of the knee extensor muscles. Altered vastus medialis obliquus response time and a motor control deficit of the quadriceps musculature have been demonstrated.^7,8 Restoration of knee extensor strength, though important, is too often the sole focus of some rehabilitation programs.

Hip muscle weakness has also been implicated as an important component of AKP.^9-12 Impaired gluteal muscle function can lead to increased hip joint adduction and internal rotation during activities such as stair climbing, squatting, and sports.^9,10,13 In a systematic review, Meira and Brumitt¹² concluded that hip strength and position are linked to AKP and that patients with AKP present with a common deficit once symptomatic. The dysfunction in neuromuscular control in AKP may also stem from disordered firing sequences in the muscles. A systematic review of hip electromyographic studies found moderate to strong evidence that gluteus medius muscle activity is delayed and of shorter duration during stair ascent and descent in patients with AKP.¹¹ The study also found some evidence that this activity is delayed and of shorter duration during running and that gluteus maximus muscle activity is increased during stair descent. The authors recommended that interventions focused on correcting these deficits—such as hip strengthening, biofeedback, and gait retraining—should be included in AKP treatment and research.

In recent AKP research, the core, including hip and abdominal muscles, demonstrated decreased strength and altered recruitment patterns during functional movement.^14,15 The authors recommended including core strengthening and core stability exercises in AKP management. In combination, these knee extensor, hip, and core strength deficits in patients with AKP lead to altered movement patterns during functional activities and may in turn exacerbate symptoms. Addressing both the strength deficits and the recruitment patterns of these core and lower extremity muscles is essential for optimizing rehabilitation and limiting recurrence of AKP symptoms.

Stretching to improve muscle tendon length is another component of AKP treatment. Reduced quadriceps muscle length has been implicated as a cause of AKP and is a common finding in symptomatic patients.¹⁶ In addition, a recent randomized controlled trial found decreased hip flexibility in patients with AKP.¹⁷ It is important to assess the flexibility of the gastrocnemius, soleus, quadriceps, and hamstrings muscles and the iliotibial band, as well as the hip flexors, extensors, and rotators, so that rehabilitation can be designed to address any specific deficits in range of motion (ROM).^16-23 In patients with AKP, it is also important to address muscle tendon length deficits and strengthening simultaneously to avoid exceeding the available envelope of function. Gaining full ROM at joints can facilitate increasing strength gains²⁴ and potentially improve the synergy of muscle contractions during functional activities.

Appropriate Rehabilitation in AKP

Appropriate rehabilitation addresses all identified strength and flexibility deficits in order to improve functional biomechanics and normalize altered body movement patterns during daily activities (eg, walking, squatting, stair climbing). Often, if part of the kinetic chain is weak or injured, the body engages in an activity by “working around” the injured body part. This change often results in faulty body mechanics or altered movement patterns. In AKP, these modified biomechanics can result in pain centered on the patella and associated soft-tissue structures. In developing ways to compensate for strength and ROM deficits, patients with AKP exacerbate their symptoms. In long-standing AKP, these compensatory strategies are most often unintentional and ingrained.

The main role of physical therapists is to identify any faulty movement patterns, dissect the underlying neuromuscular causes of these deficits, and build an individualized rehabilitation program. Physical therapy should be customized to the patient’s level of strength and fitness and whenever possible should be made challenging (and fun!) for the patient. The exercises should be increased in intensity and duration as the patient improves strength, endurance, and control in the activities. The patient’s response to each intervention will help guide exercise progression and define the need for further treatments.

Patients should be assessed for overuse patterns. Overuse can occur with repetitive exercise activity, such as running, or with repetitive work activity that involves lifting, squatting, or stair climbing. It is important to modify or reduce such activity to ensure that a patient with AKP remains within an envelope of pain-free function. Once the patient is functioning in this envelope, rehabilitation can be redirected to expand it, while improving strength, coordination, balance, and overall dynamic control of the core and lower limbs.

The purpose of any rehabilitation program is to build strength through the entire kinetic chain, focusing on hip and core strength initially, and then adding concentric and eccentric lower limb strength. Having a strong base from which to initiate lower limb movements makes correct lower limb form more likely to follow. Corrected muscle firing patterns allow for appropriate sequencing of the muscle activation needed for proper movements. Corrected muscle tendon lengths allow for optimal firing of the muscles controlling the lower limb, and for the flexibility needed for everyday ROM and biomechanics. Patients with AKP require re-education of movements that occur during daily functional activities, including gait. Once correct movement patterns are established in daily activities, it is important to address sporting or work-related activities. This is one important reason to ensure that physiotherapy visits are distributed over time and that patient-centered goals are addressed during each visit. In addition, during therapy, it is essential to reexamine body movement patterns to identify any relapse to prior dysfunction as the intensity or frequency of activity increases.

In AKP management, the dosage and duration of exercise prescriptions are challenging, and patience and perseverance are paramount. The initial goal of therapy is to increase strength and ROM to enable practice of correct motion in daily activities (eg, stair climbing, sitting, and walking). The physical therapist’s challenge is to teach correct motion within the envelope of function, as described by Dye.²⁵ Pain is not gain, and all exercises must be performed without pain to avoid flaring symptoms. The patient and the therapist must collaborate to complete a pain free rehabilitation program, and must operate within that zone. Providing prescriptions with specific goals may be helpful. Example goals are, “Increase core and lower extremity strength to achieve squatting without medial collapse of knee,” “Hip and core strengthening and endurance,” “Equal quadriceps strength and girth,” and “Functional movement retraining.”

Assessing Adequacy of Rehabilitation in AKP

When a patient presents with a diagnosis of AKP, it can be difficult to establish whether a prior rehabilitation program was appropriate. The fact that a patient attended physiotherapy says nothing about the quality of the therapy provided. Neither does the number of sessions attended. To assess the quality of the rehabilitation and determine if there are any major deficits in neuromuscular function, the physician can perform a simple battery of screening tests (Figure 1).²⁶

More advanced tests can be used to better understand the neuromuscular function of the patient with AKP and tease out specific deficits. Figure 2²⁶ describes some of these tests and the typical compensatory motions seen in patients with altered movement patterns.

Am J Orthop. 2017;46(2):82-86. Copyright Frontline Medical Communications Inc. 2017. All rights reserved.

Take-Home Points

• Ensure that relative rest and activity modification allow the knee to stay within the available “envelope of function” of the joint.
• Careful physical examination is imperative to assess strength, flexibility, and altered movement patterns, which in many cases are all part of the etiology of AKP.
• Patience and perseverance are paramount. Patients need to clearly understand the goals of rehabilitation as well as the concepts related to “envelope of function” so they can continue to keep themselves within this envelope. This education is crucial to their success.
• Only once a patient has been brought into the pain-free functional envelope can rehabilitation be redirected to expanding the envelope toward the patient’s particular goals.

• Quantity does not equal quality. To create an appropriate care plan, the physician must assess the adequacy of the patient’s rehabilitation thus far—ask specific questions about the types of exercises the patient is doing in physical therapy and quickly assess strength with a few simple in-office tests.

Anterior knee pain (AKP) is a common presentation. Although the exact etiology and nature of AKP continue to be poorly understood, overuse principles can be useful in directing treatment. In overuse injury, repetitive submaximal or subclinical trauma results in macroscopic trauma, microscopic trauma, or both. The structural tissue unit is damaged or its clinical responsiveness is exceeded, which can lead to pain or movement dysfunction. Overuse injuries commonly have an endogenous source, mechanical circumstances in which the musculoskeletal tissue is subjected to more tensile force or stress than the tissue can tolerate. The approach to treatment and rehabilitation of AKP is best facilitated with a thorough understanding of the concept of tissue homeostasis and the “envelope of function.”

Although the cause of AKP is multifactorial, the contributions of muscle strength deficits, diminished neuromuscular control, and altered muscle firing patterns to the development and severity of AKP are well established.^1-5 The hallmark of nonoperative management of AKP is physiotherapy that re-establishes strength, neuromuscular control, muscle activation, and optimal biomechanics during daily activities, advancing to graded levels of sporting activities.

The purpose of this paper is to discuss the factors associated with the diminished neuromuscular control observed in AKP and to review appropriate rehabilitation concepts for patients with AKP. Practical tools are provided to aid the surgeon to identify neuromuscular deficits in the clinic setting, along with assessing the adequacy of prior therapy and the need for further rehabilitation.

Common Neuromuscular Deficits in AKP

Weakness of the knee extensor muscles has long been implicated as the main issue in AKP, and therefore the focus of rehabilitation has been on muscle strengthening, especially of the vastus medialis obliquus. Research has found that knee extensor weakness is not only a characteristic of patients with AKP but a risk factor for developing AKP.⁴ Restoration of knee extensor strength and function is essential for recovery.⁶ Another issue in AKP may be incorrect firing of the knee extensor muscles. Altered vastus medialis obliquus response time and a motor control deficit of the quadriceps musculature have been demonstrated.^7,8 Restoration of knee extensor strength, though important, is too often the sole focus of some rehabilitation programs.

Hip muscle weakness has also been implicated as an important component of AKP.^9-12 Impaired gluteal muscle function can lead to increased hip joint adduction and internal rotation during activities such as stair climbing, squatting, and sports.^9,10,13 In a systematic review, Meira and Brumitt¹² concluded that hip strength and position are linked to AKP and that patients with AKP present with a common deficit once symptomatic. The dysfunction in neuromuscular control in AKP may also stem from disordered firing sequences in the muscles. A systematic review of hip electromyographic studies found moderate to strong evidence that gluteus medius muscle activity is delayed and of shorter duration during stair ascent and descent in patients with AKP.¹¹ The study also found some evidence that this activity is delayed and of shorter duration during running and that gluteus maximus muscle activity is increased during stair descent. The authors recommended that interventions focused on correcting these deficits—such as hip strengthening, biofeedback, and gait retraining—should be included in AKP treatment and research.

In recent AKP research, the core, including hip and abdominal muscles, demonstrated decreased strength and altered recruitment patterns during functional movement.^14,15 The authors recommended including core strengthening and core stability exercises in AKP management. In combination, these knee extensor, hip, and core strength deficits in patients with AKP lead to altered movement patterns during functional activities and may in turn exacerbate symptoms. Addressing both the strength deficits and the recruitment patterns of these core and lower extremity muscles is essential for optimizing rehabilitation and limiting recurrence of AKP symptoms.

Stretching to improve muscle tendon length is another component of AKP treatment. Reduced quadriceps muscle length has been implicated as a cause of AKP and is a common finding in symptomatic patients.¹⁶ In addition, a recent randomized controlled trial found decreased hip flexibility in patients with AKP.¹⁷ It is important to assess the flexibility of the gastrocnemius, soleus, quadriceps, and hamstrings muscles and the iliotibial band, as well as the hip flexors, extensors, and rotators, so that rehabilitation can be designed to address any specific deficits in range of motion (ROM).^16-23 In patients with AKP, it is also important to address muscle tendon length deficits and strengthening simultaneously to avoid exceeding the available envelope of function. Gaining full ROM at joints can facilitate increasing strength gains²⁴ and potentially improve the synergy of muscle contractions during functional activities.

Appropriate Rehabilitation in AKP

Appropriate rehabilitation addresses all identified strength and flexibility deficits in order to improve functional biomechanics and normalize altered body movement patterns during daily activities (eg, walking, squatting, stair climbing). Often, if part of the kinetic chain is weak or injured, the body engages in an activity by “working around” the injured body part. This change often results in faulty body mechanics or altered movement patterns. In AKP, these modified biomechanics can result in pain centered on the patella and associated soft-tissue structures. In developing ways to compensate for strength and ROM deficits, patients with AKP exacerbate their symptoms. In long-standing AKP, these compensatory strategies are most often unintentional and ingrained.

The main role of physical therapists is to identify any faulty movement patterns, dissect the underlying neuromuscular causes of these deficits, and build an individualized rehabilitation program. Physical therapy should be customized to the patient’s level of strength and fitness and whenever possible should be made challenging (and fun!) for the patient. The exercises should be increased in intensity and duration as the patient improves strength, endurance, and control in the activities. The patient’s response to each intervention will help guide exercise progression and define the need for further treatments.

Patients should be assessed for overuse patterns. Overuse can occur with repetitive exercise activity, such as running, or with repetitive work activity that involves lifting, squatting, or stair climbing. It is important to modify or reduce such activity to ensure that a patient with AKP remains within an envelope of pain-free function. Once the patient is functioning in this envelope, rehabilitation can be redirected to expand it, while improving strength, coordination, balance, and overall dynamic control of the core and lower limbs.

The purpose of any rehabilitation program is to build strength through the entire kinetic chain, focusing on hip and core strength initially, and then adding concentric and eccentric lower limb strength. Having a strong base from which to initiate lower limb movements makes correct lower limb form more likely to follow. Corrected muscle firing patterns allow for appropriate sequencing of the muscle activation needed for proper movements. Corrected muscle tendon lengths allow for optimal firing of the muscles controlling the lower limb, and for the flexibility needed for everyday ROM and biomechanics. Patients with AKP require re-education of movements that occur during daily functional activities, including gait. Once correct movement patterns are established in daily activities, it is important to address sporting or work-related activities. This is one important reason to ensure that physiotherapy visits are distributed over time and that patient-centered goals are addressed during each visit. In addition, during therapy, it is essential to reexamine body movement patterns to identify any relapse to prior dysfunction as the intensity or frequency of activity increases.

In AKP management, the dosage and duration of exercise prescriptions are challenging, and patience and perseverance are paramount. The initial goal of therapy is to increase strength and ROM to enable practice of correct motion in daily activities (eg, stair climbing, sitting, and walking). The physical therapist’s challenge is to teach correct motion within the envelope of function, as described by Dye.²⁵ Pain is not gain, and all exercises must be performed without pain to avoid flaring symptoms. The patient and the therapist must collaborate to complete a pain free rehabilitation program, and must operate within that zone. Providing prescriptions with specific goals may be helpful. Example goals are, “Increase core and lower extremity strength to achieve squatting without medial collapse of knee,” “Hip and core strengthening and endurance,” “Equal quadriceps strength and girth,” and “Functional movement retraining.”

Assessing Adequacy of Rehabilitation in AKP

When a patient presents with a diagnosis of AKP, it can be difficult to establish whether a prior rehabilitation program was appropriate. The fact that a patient attended physiotherapy says nothing about the quality of the therapy provided. Neither does the number of sessions attended. To assess the quality of the rehabilitation and determine if there are any major deficits in neuromuscular function, the physician can perform a simple battery of screening tests (Figure 1).²⁶

More advanced tests can be used to better understand the neuromuscular function of the patient with AKP and tease out specific deficits. Figure 2²⁶ describes some of these tests and the typical compensatory motions seen in patients with altered movement patterns.

Am J Orthop. 2017;46(2):82-86. Copyright Frontline Medical Communications Inc. 2017. All rights reserved.

Take-Home Points

• MPFL repair has the best results with isolated ligament avulsions in first-time dislocations. This can be demonstrated on MRI and verified at the time of arthroscopy.
• Recurrent dislocations, even if acute, have a higher failure rate with MPFL repair. In this setting, MPFL reconstruction provides more consistent outcomes.
• In cases of chronic lateral patellar dislocation, imbrication may be enough when other associated procedures have sufficiently stabilized the patella without the need for a strong soft-tissue checkrein.
• Femoral-sided repairs are more challenging due to the need to optimize the insertion point on the femur, as small changes in positioning can cause increased stress on the repaired tissue and lead to failure.
• If a repair is to have a chance to work, it must be performed at the site of the tear. Thus, preoperative planning and intraoperative inspection is important to precisely identify the site, which can involve intrasubstance and multifocal injuries as well as the femoral and patellar complex attachments.

The medial patellofemoral ligament (MPFL) is the primary soft-tissue restraint to lateral patellar translation.¹ In cases of first-time acute lateral patellar dislocation, injury to the MPFL is described as the essential lesion, occurring in almost 100% of cases.^2-4 Because of the relatively high frequency of recurrent instability after first-time acute lateral patellar dislocation,^5-7 much research has been focused on MPFL repair and reconstruction.^8-11 Although the clinical results of isolated MPFL repair are highly variable, this variability is likely secondary to relatively inconsistent clinical indications for repair, with repair described for patients with acute as well as chronic or recurrent instability.^10-13 From these early successes and failures, much has been learned about the appropriate indications for MPFL repair as well as medial retinacular “reefing” or imbrication in the chronic setting.

Relevant Anatomy

The MPFL is an extracapsular thickening of the medial retinacular structures and can be most consistently identified just distal to the vastus medialis obliquus, running within layer 2 of the medial side of the knee (using the often-referenced layer system popularized by Warren and Marshall¹⁴). The MPFL origin on the medial aspect of the femur falls within a well-defined saddle between the adductor tubercle and the medial epicondyle.¹⁵ From this relatively narrow origin, the MPFL broadens before attaching to the proximal one-third of the medial aspect of the patella.

Over the past 2 decades, the osseous anatomy surrounding the femoral origin of the MPFL has been of much interest in large part because of the increasing popularity of MPFL reconstruction. Although useful for MPFL reconstruction, the vast amount of literature and our improved understanding of this anatomical region can be extrapolated to MPFL repair. The radiographic landmarks described by Schöttle and colleagues¹⁶ have advanced our knowledge of the femoral origin of the MPFL, with fluoroscopic guidance allowing for more limited dissection and increased accuracy of repair for femoral-sided MPFL injuries.

Location of MPFL Injury

Understanding and appreciating the specific location of the MPFL injury are paramount to successful MPFL repair. Unfortunately, the location and pattern of MPFL injury cannot be consistently predicted. Although early surgical dissections described femoral-sided injuries as the most common injury site,⁴ more recent studies using magnetic resonance imaging (MRI) have described a more even distribution of MPFL injury patterns, which include patella-based ruptures, femoral-based ruptures, intrasubstance ruptures, and multifocal injuries.¹⁷ In addition, age and skeletal maturity likely play a role in the MPFL injury location, as skeletally immature patients more often have patella-based ruptures.^2,18,19 In acute MPFL repair, MRI appears to be the most accurate imaging modality for determining the patella- or femoral-based injuries most amenable to repair and for identifying clinically significant osteochondral lesions, which are not uncommon after first-time patellar dislocation.^20,21

Medial Reefing, Imbrication, and Advancement

Medial reefing, imbrication, and advancement, collectively referred to as proximal realignment procedures, describe a variety of techniques that essentially shorten or tighten the medial retinacular structures.^22-24 Although the terms cover a variety of similar surgical techniques and are often used interchangeably in the literature, imbrication, or overlapping of adjacent edges, is the single most accurate term used to define this spectrum of procedures. These procedures historically were performed in the setting of chronic or recurrent patellar instability, with the primary goal being to imbricate the attenuated medial retinaculum, which includes the MPFL. However, the procedure has had good clinical outcomes when performed in isolation for patients with normal bony anatomy.²⁵ Such anatomy is rare in chronic or recurrent dislocators, and these proximal soft-tissue procedures are often combined with other osseous realignment procedures, including distal realignment, trochleoplasty, and distal femoral osteotomy.²⁶

Discussion

MPFL Repair: Indications and Surgical Technique

Although optimal management of first-time patellar dislocation continues to be a topic for debate, the frequency of recurrent instability,^7,27 particularly in young patients, has led some to advocate early surgical management.^9,28 A clear indication for early operative intervention is the presence of a large osteochondral lesion that can undergo fixation or is causing persistent mechanical symptoms with recurrent effusion (Figures 1A, 1B).

Numerous open and arthroscopic MPFL repair techniques have been described.^10,30-33 Nevertheless, comparative studies are limited, and the greatest debate about MPFL repair continues to be appropriate indications. Arthroscopic MPFL repair can be technically demanding and can fully visualize only patella-based injuries. In addition, all-arthroscopic repair techniques may place suture material in the joint, which causes concern regarding suture irritation. As a result, the majority of MPFL repair techniques described in the literature use an open approach, which typically includes a 4-cm to 5-cm longitudinal incision along the medial aspect of the patella. Sharp dissection is carried down through the medial retinaculum to the underlying joint capsule. The plane between the medial retinaculum and the underlying joint capsule is bluntly developed posteriorly until the medial epicondyle and the adductor tubercle are palpated. For a patella-based rupture, the MPFL is defined within layer 2, and 2 suture anchors are placed within the superior third of the patella. Although there are other patellar fixation methods, suture anchors provide adequate fixation with minimal risk of iatrogenic patellar fracture. With anchors in place, horizontal mattress sutures are placed in the stump of the MPFL. For femoral-based ruptures, the same surgical exposure is used to identify the MPFL. However, depending on the size of the incision and the mobility of the tissue, a second incision can be made posterior and parallel to the first—best achieved using a spinal needle to fluoroscopically localize Schöttle’s point.¹⁶ An incision is made in line with the spinal needle, and dissection is continued down to the previously developed extracapsular plane. Under fluoroscopic guidance (Figure 3), 1 or 2 suture anchors are placed at Schöttle point, and horizontal mattress sutures are placed through the avulsed MPFL femoral origin.

MPFL Imbrication: Indications and Surgical Technique

MPFL reconstruction is the technique of choice in recurrent patellofemoral instability when no other procedures are required. When combined with distal realignment procedures, distal femoral osteotomy, open patellofemoral cartilage resurfacing procedures, or trochleoplasty, MPFL imbrication can be considered in place of MPFL reconstruction. Recurrent patellofemoral instability is influenced by various factors, including static soft-tissue restraints, dynamic muscle action, and bony anatomy, only one of which is directly addressed with MPFL imbrication. Relying on native tissues without a graft increases the risk for recurrent instability because of concern that the already attenuated native tissues will stretch out further, particularly in the presence of hyperlaxity. Although the significance of trochlear dysplasia in patellofemoral instability was first noted by Dejour and colleagues,³⁴ the presence of trochlear dysplasia has been shown to negatively influence outcomes of isolated MPFL imbrication.³⁵ Because of the relative frequency of trochlear dysplasia and axial or coronal plane malalignment in patients with chronic or recurrent patellar instability, MPFL imbrication typically is not performed on its own, and it is best used in conjunction with a distal realignment procedure or distal femoral osteotomy. MPFL reconstruction should be performed instead of MPFL imbrication in patients with severe trochlear dysplasia, in patients with hyperlaxity signs, and in young patients who participate in cutting or pivoting sports.

When distal realignment procedures are performed for axial alignment, or distal femoral osteotomy is performed for severe genu valgum, patellofemoral laxity is tested after the bony correction is completed. If the patella is still dislocatable, MPFL reconstruction provides the most predictable outcome. If laxity is increased, but the patella remains in the trochlea, typically MPFL imbrication is adequate.

Similar to MPFL repair, both open and arthroscopic techniques have been described in the literature.^36-38 As MPFL imbrication is most commonly performed in conjunction with large open procedures, this procedure can often be incorporated with other open incisions. In addition, open MPFL imbrication allows for precise control and tensioning of the medial retinacular structures, which is not always easily achieved by arthroscopic methods.

If a separate incision is required, a 4-cm to 5-cm longitudinal incision is made along the medial border of the patella, just as described for MPFL repair. The medial retinacular tissue, including the MPFL, is identified and isolated extracapsularly. Imbrication can be performed with sutures only (using a cuff of tissue along the medial border of the patella and placing pants-over-vest sutures in the adjacent tissue) or with sutures and anchors (more similar to MPFL repair described earlier). In either scenario, adequately tensioning the MPFL and associated medial retinaculum is essential in order to restore the checkrein function of the attenuated MPFL. Although typically described in the setting of MPFL reconstruction, the MPFL can easily be overtensioned during MPFL imbrication. This potential pitfall can be avoided by recognizing that forces over 2 N will overtension medial structures and thereby increase contact pressures at the medial patellar facet.³⁹ The complication can easily be prevented simply by placing the knee in 30° flexion and centering the patella in the trochlear groove while performing the MPFL imbrication.

Conclusion

Careful patient selection is the most important element for successful MPFL repair or imbrication. MPFL repair is most reliably used in patients with clear patella- or femoral-sided avulsions and in patients with a first-time patellar dislocation and a clear surgical indication, such as a large osteochondral fragment. Proximal realignment procedures, which include MPFL reefing, imbrication, and advancement, typically are not performed in isolation, as other osseous procedures are often needed concomitantly in order to preserve the checkrein effect provided by proximal realignment procedures. As is the case with MPFL reconstruction, understanding the relevant anatomy and avoiding overtensioning of the medial structures during MPFL repair or proximal realignment procedures are crucial.

Am J Orthop. 2017;46(2):87-91. Copyright Frontline Medical Communications Inc. 2017. All rights reserved.

Take-Home Points

• MPFL repair has the best results with isolated ligament avulsions in first-time dislocations. This can be demonstrated on MRI and verified at the time of arthroscopy.
• Recurrent dislocations, even if acute, have a higher failure rate with MPFL repair. In this setting, MPFL reconstruction provides more consistent outcomes.
• In cases of chronic lateral patellar dislocation, imbrication may be enough when other associated procedures have sufficiently stabilized the patella without the need for a strong soft-tissue checkrein.
• Femoral-sided repairs are more challenging due to the need to optimize the insertion point on the femur, as small changes in positioning can cause increased stress on the repaired tissue and lead to failure.
• If a repair is to have a chance to work, it must be performed at the site of the tear. Thus, preoperative planning and intraoperative inspection is important to precisely identify the site, which can involve intrasubstance and multifocal injuries as well as the femoral and patellar complex attachments.

The medial patellofemoral ligament (MPFL) is the primary soft-tissue restraint to lateral patellar translation.¹ In cases of first-time acute lateral patellar dislocation, injury to the MPFL is described as the essential lesion, occurring in almost 100% of cases.^2-4 Because of the relatively high frequency of recurrent instability after first-time acute lateral patellar dislocation,^5-7 much research has been focused on MPFL repair and reconstruction.^8-11 Although the clinical results of isolated MPFL repair are highly variable, this variability is likely secondary to relatively inconsistent clinical indications for repair, with repair described for patients with acute as well as chronic or recurrent instability.^10-13 From these early successes and failures, much has been learned about the appropriate indications for MPFL repair as well as medial retinacular “reefing” or imbrication in the chronic setting.

Relevant Anatomy

The MPFL is an extracapsular thickening of the medial retinacular structures and can be most consistently identified just distal to the vastus medialis obliquus, running within layer 2 of the medial side of the knee (using the often-referenced layer system popularized by Warren and Marshall¹⁴). The MPFL origin on the medial aspect of the femur falls within a well-defined saddle between the adductor tubercle and the medial epicondyle.¹⁵ From this relatively narrow origin, the MPFL broadens before attaching to the proximal one-third of the medial aspect of the patella.

Over the past 2 decades, the osseous anatomy surrounding the femoral origin of the MPFL has been of much interest in large part because of the increasing popularity of MPFL reconstruction. Although useful for MPFL reconstruction, the vast amount of literature and our improved understanding of this anatomical region can be extrapolated to MPFL repair. The radiographic landmarks described by Schöttle and colleagues¹⁶ have advanced our knowledge of the femoral origin of the MPFL, with fluoroscopic guidance allowing for more limited dissection and increased accuracy of repair for femoral-sided MPFL injuries.

Location of MPFL Injury

Understanding and appreciating the specific location of the MPFL injury are paramount to successful MPFL repair. Unfortunately, the location and pattern of MPFL injury cannot be consistently predicted. Although early surgical dissections described femoral-sided injuries as the most common injury site,⁴ more recent studies using magnetic resonance imaging (MRI) have described a more even distribution of MPFL injury patterns, which include patella-based ruptures, femoral-based ruptures, intrasubstance ruptures, and multifocal injuries.¹⁷ In addition, age and skeletal maturity likely play a role in the MPFL injury location, as skeletally immature patients more often have patella-based ruptures.^2,18,19 In acute MPFL repair, MRI appears to be the most accurate imaging modality for determining the patella- or femoral-based injuries most amenable to repair and for identifying clinically significant osteochondral lesions, which are not uncommon after first-time patellar dislocation.^20,21

Medial Reefing, Imbrication, and Advancement

Medial reefing, imbrication, and advancement, collectively referred to as proximal realignment procedures, describe a variety of techniques that essentially shorten or tighten the medial retinacular structures.^22-24 Although the terms cover a variety of similar surgical techniques and are often used interchangeably in the literature, imbrication, or overlapping of adjacent edges, is the single most accurate term used to define this spectrum of procedures. These procedures historically were performed in the setting of chronic or recurrent patellar instability, with the primary goal being to imbricate the attenuated medial retinaculum, which includes the MPFL. However, the procedure has had good clinical outcomes when performed in isolation for patients with normal bony anatomy.²⁵ Such anatomy is rare in chronic or recurrent dislocators, and these proximal soft-tissue procedures are often combined with other osseous realignment procedures, including distal realignment, trochleoplasty, and distal femoral osteotomy.²⁶

Discussion

MPFL Repair: Indications and Surgical Technique

Although optimal management of first-time patellar dislocation continues to be a topic for debate, the frequency of recurrent instability,^7,27 particularly in young patients, has led some to advocate early surgical management.^9,28 A clear indication for early operative intervention is the presence of a large osteochondral lesion that can undergo fixation or is causing persistent mechanical symptoms with recurrent effusion (Figures 1A, 1B).

Numerous open and arthroscopic MPFL repair techniques have been described.^10,30-33 Nevertheless, comparative studies are limited, and the greatest debate about MPFL repair continues to be appropriate indications. Arthroscopic MPFL repair can be technically demanding and can fully visualize only patella-based injuries. In addition, all-arthroscopic repair techniques may place suture material in the joint, which causes concern regarding suture irritation. As a result, the majority of MPFL repair techniques described in the literature use an open approach, which typically includes a 4-cm to 5-cm longitudinal incision along the medial aspect of the patella. Sharp dissection is carried down through the medial retinaculum to the underlying joint capsule. The plane between the medial retinaculum and the underlying joint capsule is bluntly developed posteriorly until the medial epicondyle and the adductor tubercle are palpated. For a patella-based rupture, the MPFL is defined within layer 2, and 2 suture anchors are placed within the superior third of the patella. Although there are other patellar fixation methods, suture anchors provide adequate fixation with minimal risk of iatrogenic patellar fracture. With anchors in place, horizontal mattress sutures are placed in the stump of the MPFL. For femoral-based ruptures, the same surgical exposure is used to identify the MPFL. However, depending on the size of the incision and the mobility of the tissue, a second incision can be made posterior and parallel to the first—best achieved using a spinal needle to fluoroscopically localize Schöttle’s point.¹⁶ An incision is made in line with the spinal needle, and dissection is continued down to the previously developed extracapsular plane. Under fluoroscopic guidance (Figure 3), 1 or 2 suture anchors are placed at Schöttle point, and horizontal mattress sutures are placed through the avulsed MPFL femoral origin.

MPFL Imbrication: Indications and Surgical Technique

MPFL reconstruction is the technique of choice in recurrent patellofemoral instability when no other procedures are required. When combined with distal realignment procedures, distal femoral osteotomy, open patellofemoral cartilage resurfacing procedures, or trochleoplasty, MPFL imbrication can be considered in place of MPFL reconstruction. Recurrent patellofemoral instability is influenced by various factors, including static soft-tissue restraints, dynamic muscle action, and bony anatomy, only one of which is directly addressed with MPFL imbrication. Relying on native tissues without a graft increases the risk for recurrent instability because of concern that the already attenuated native tissues will stretch out further, particularly in the presence of hyperlaxity. Although the significance of trochlear dysplasia in patellofemoral instability was first noted by Dejour and colleagues,³⁴ the presence of trochlear dysplasia has been shown to negatively influence outcomes of isolated MPFL imbrication.³⁵ Because of the relative frequency of trochlear dysplasia and axial or coronal plane malalignment in patients with chronic or recurrent patellar instability, MPFL imbrication typically is not performed on its own, and it is best used in conjunction with a distal realignment procedure or distal femoral osteotomy. MPFL reconstruction should be performed instead of MPFL imbrication in patients with severe trochlear dysplasia, in patients with hyperlaxity signs, and in young patients who participate in cutting or pivoting sports.

When distal realignment procedures are performed for axial alignment, or distal femoral osteotomy is performed for severe genu valgum, patellofemoral laxity is tested after the bony correction is completed. If the patella is still dislocatable, MPFL reconstruction provides the most predictable outcome. If laxity is increased, but the patella remains in the trochlea, typically MPFL imbrication is adequate.

Similar to MPFL repair, both open and arthroscopic techniques have been described in the literature.^36-38 As MPFL imbrication is most commonly performed in conjunction with large open procedures, this procedure can often be incorporated with other open incisions. In addition, open MPFL imbrication allows for precise control and tensioning of the medial retinacular structures, which is not always easily achieved by arthroscopic methods.

If a separate incision is required, a 4-cm to 5-cm longitudinal incision is made along the medial border of the patella, just as described for MPFL repair. The medial retinacular tissue, including the MPFL, is identified and isolated extracapsularly. Imbrication can be performed with sutures only (using a cuff of tissue along the medial border of the patella and placing pants-over-vest sutures in the adjacent tissue) or with sutures and anchors (more similar to MPFL repair described earlier). In either scenario, adequately tensioning the MPFL and associated medial retinaculum is essential in order to restore the checkrein function of the attenuated MPFL. Although typically described in the setting of MPFL reconstruction, the MPFL can easily be overtensioned during MPFL imbrication. This potential pitfall can be avoided by recognizing that forces over 2 N will overtension medial structures and thereby increase contact pressures at the medial patellar facet.³⁹ The complication can easily be prevented simply by placing the knee in 30° flexion and centering the patella in the trochlear groove while performing the MPFL imbrication.

Conclusion

Careful patient selection is the most important element for successful MPFL repair or imbrication. MPFL repair is most reliably used in patients with clear patella- or femoral-sided avulsions and in patients with a first-time patellar dislocation and a clear surgical indication, such as a large osteochondral fragment. Proximal realignment procedures, which include MPFL reefing, imbrication, and advancement, typically are not performed in isolation, as other osseous procedures are often needed concomitantly in order to preserve the checkrein effect provided by proximal realignment procedures. As is the case with MPFL reconstruction, understanding the relevant anatomy and avoiding overtensioning of the medial structures during MPFL repair or proximal realignment procedures are crucial.

Am J Orthop. 2017;46(2):87-91. Copyright Frontline Medical Communications Inc. 2017. All rights reserved.

Take-Home Points

• MPFL repair has the best results with isolated ligament avulsions in first-time dislocations. This can be demonstrated on MRI and verified at the time of arthroscopy.
• Recurrent dislocations, even if acute, have a higher failure rate with MPFL repair. In this setting, MPFL reconstruction provides more consistent outcomes.
• In cases of chronic lateral patellar dislocation, imbrication may be enough when other associated procedures have sufficiently stabilized the patella without the need for a strong soft-tissue checkrein.
• Femoral-sided repairs are more challenging due to the need to optimize the insertion point on the femur, as small changes in positioning can cause increased stress on the repaired tissue and lead to failure.
• If a repair is to have a chance to work, it must be performed at the site of the tear. Thus, preoperative planning and intraoperative inspection is important to precisely identify the site, which can involve intrasubstance and multifocal injuries as well as the femoral and patellar complex attachments.

The medial patellofemoral ligament (MPFL) is the primary soft-tissue restraint to lateral patellar translation.¹ In cases of first-time acute lateral patellar dislocation, injury to the MPFL is described as the essential lesion, occurring in almost 100% of cases.^2-4 Because of the relatively high frequency of recurrent instability after first-time acute lateral patellar dislocation,^5-7 much research has been focused on MPFL repair and reconstruction.^8-11 Although the clinical results of isolated MPFL repair are highly variable, this variability is likely secondary to relatively inconsistent clinical indications for repair, with repair described for patients with acute as well as chronic or recurrent instability.^10-13 From these early successes and failures, much has been learned about the appropriate indications for MPFL repair as well as medial retinacular “reefing” or imbrication in the chronic setting.

Relevant Anatomy

The MPFL is an extracapsular thickening of the medial retinacular structures and can be most consistently identified just distal to the vastus medialis obliquus, running within layer 2 of the medial side of the knee (using the often-referenced layer system popularized by Warren and Marshall¹⁴). The MPFL origin on the medial aspect of the femur falls within a well-defined saddle between the adductor tubercle and the medial epicondyle.¹⁵ From this relatively narrow origin, the MPFL broadens before attaching to the proximal one-third of the medial aspect of the patella.

Over the past 2 decades, the osseous anatomy surrounding the femoral origin of the MPFL has been of much interest in large part because of the increasing popularity of MPFL reconstruction. Although useful for MPFL reconstruction, the vast amount of literature and our improved understanding of this anatomical region can be extrapolated to MPFL repair. The radiographic landmarks described by Schöttle and colleagues¹⁶ have advanced our knowledge of the femoral origin of the MPFL, with fluoroscopic guidance allowing for more limited dissection and increased accuracy of repair for femoral-sided MPFL injuries.

Location of MPFL Injury

Understanding and appreciating the specific location of the MPFL injury are paramount to successful MPFL repair. Unfortunately, the location and pattern of MPFL injury cannot be consistently predicted. Although early surgical dissections described femoral-sided injuries as the most common injury site,⁴ more recent studies using magnetic resonance imaging (MRI) have described a more even distribution of MPFL injury patterns, which include patella-based ruptures, femoral-based ruptures, intrasubstance ruptures, and multifocal injuries.¹⁷ In addition, age and skeletal maturity likely play a role in the MPFL injury location, as skeletally immature patients more often have patella-based ruptures.^2,18,19 In acute MPFL repair, MRI appears to be the most accurate imaging modality for determining the patella- or femoral-based injuries most amenable to repair and for identifying clinically significant osteochondral lesions, which are not uncommon after first-time patellar dislocation.^20,21

Medial Reefing, Imbrication, and Advancement

Medial reefing, imbrication, and advancement, collectively referred to as proximal realignment procedures, describe a variety of techniques that essentially shorten or tighten the medial retinacular structures.^22-24 Although the terms cover a variety of similar surgical techniques and are often used interchangeably in the literature, imbrication, or overlapping of adjacent edges, is the single most accurate term used to define this spectrum of procedures. These procedures historically were performed in the setting of chronic or recurrent patellar instability, with the primary goal being to imbricate the attenuated medial retinaculum, which includes the MPFL. However, the procedure has had good clinical outcomes when performed in isolation for patients with normal bony anatomy.²⁵ Such anatomy is rare in chronic or recurrent dislocators, and these proximal soft-tissue procedures are often combined with other osseous realignment procedures, including distal realignment, trochleoplasty, and distal femoral osteotomy.²⁶

Discussion

MPFL Repair: Indications and Surgical Technique

Although optimal management of first-time patellar dislocation continues to be a topic for debate, the frequency of recurrent instability,^7,27 particularly in young patients, has led some to advocate early surgical management.^9,28 A clear indication for early operative intervention is the presence of a large osteochondral lesion that can undergo fixation or is causing persistent mechanical symptoms with recurrent effusion (Figures 1A, 1B).

Numerous open and arthroscopic MPFL repair techniques have been described.^10,30-33 Nevertheless, comparative studies are limited, and the greatest debate about MPFL repair continues to be appropriate indications. Arthroscopic MPFL repair can be technically demanding and can fully visualize only patella-based injuries. In addition, all-arthroscopic repair techniques may place suture material in the joint, which causes concern regarding suture irritation. As a result, the majority of MPFL repair techniques described in the literature use an open approach, which typically includes a 4-cm to 5-cm longitudinal incision along the medial aspect of the patella. Sharp dissection is carried down through the medial retinaculum to the underlying joint capsule. The plane between the medial retinaculum and the underlying joint capsule is bluntly developed posteriorly until the medial epicondyle and the adductor tubercle are palpated. For a patella-based rupture, the MPFL is defined within layer 2, and 2 suture anchors are placed within the superior third of the patella. Although there are other patellar fixation methods, suture anchors provide adequate fixation with minimal risk of iatrogenic patellar fracture. With anchors in place, horizontal mattress sutures are placed in the stump of the MPFL. For femoral-based ruptures, the same surgical exposure is used to identify the MPFL. However, depending on the size of the incision and the mobility of the tissue, a second incision can be made posterior and parallel to the first—best achieved using a spinal needle to fluoroscopically localize Schöttle’s point.¹⁶ An incision is made in line with the spinal needle, and dissection is continued down to the previously developed extracapsular plane. Under fluoroscopic guidance (Figure 3), 1 or 2 suture anchors are placed at Schöttle point, and horizontal mattress sutures are placed through the avulsed MPFL femoral origin.

MPFL Imbrication: Indications and Surgical Technique

MPFL reconstruction is the technique of choice in recurrent patellofemoral instability when no other procedures are required. When combined with distal realignment procedures, distal femoral osteotomy, open patellofemoral cartilage resurfacing procedures, or trochleoplasty, MPFL imbrication can be considered in place of MPFL reconstruction. Recurrent patellofemoral instability is influenced by various factors, including static soft-tissue restraints, dynamic muscle action, and bony anatomy, only one of which is directly addressed with MPFL imbrication. Relying on native tissues without a graft increases the risk for recurrent instability because of concern that the already attenuated native tissues will stretch out further, particularly in the presence of hyperlaxity. Although the significance of trochlear dysplasia in patellofemoral instability was first noted by Dejour and colleagues,³⁴ the presence of trochlear dysplasia has been shown to negatively influence outcomes of isolated MPFL imbrication.³⁵ Because of the relative frequency of trochlear dysplasia and axial or coronal plane malalignment in patients with chronic or recurrent patellar instability, MPFL imbrication typically is not performed on its own, and it is best used in conjunction with a distal realignment procedure or distal femoral osteotomy. MPFL reconstruction should be performed instead of MPFL imbrication in patients with severe trochlear dysplasia, in patients with hyperlaxity signs, and in young patients who participate in cutting or pivoting sports.

When distal realignment procedures are performed for axial alignment, or distal femoral osteotomy is performed for severe genu valgum, patellofemoral laxity is tested after the bony correction is completed. If the patella is still dislocatable, MPFL reconstruction provides the most predictable outcome. If laxity is increased, but the patella remains in the trochlea, typically MPFL imbrication is adequate.

Similar to MPFL repair, both open and arthroscopic techniques have been described in the literature.^36-38 As MPFL imbrication is most commonly performed in conjunction with large open procedures, this procedure can often be incorporated with other open incisions. In addition, open MPFL imbrication allows for precise control and tensioning of the medial retinacular structures, which is not always easily achieved by arthroscopic methods.

If a separate incision is required, a 4-cm to 5-cm longitudinal incision is made along the medial border of the patella, just as described for MPFL repair. The medial retinacular tissue, including the MPFL, is identified and isolated extracapsularly. Imbrication can be performed with sutures only (using a cuff of tissue along the medial border of the patella and placing pants-over-vest sutures in the adjacent tissue) or with sutures and anchors (more similar to MPFL repair described earlier). In either scenario, adequately tensioning the MPFL and associated medial retinaculum is essential in order to restore the checkrein function of the attenuated MPFL. Although typically described in the setting of MPFL reconstruction, the MPFL can easily be overtensioned during MPFL imbrication. This potential pitfall can be avoided by recognizing that forces over 2 N will overtension medial structures and thereby increase contact pressures at the medial patellar facet.³⁹ The complication can easily be prevented simply by placing the knee in 30° flexion and centering the patella in the trochlear groove while performing the MPFL imbrication.

Conclusion

Careful patient selection is the most important element for successful MPFL repair or imbrication. MPFL repair is most reliably used in patients with clear patella- or femoral-sided avulsions and in patients with a first-time patellar dislocation and a clear surgical indication, such as a large osteochondral fragment. Proximal realignment procedures, which include MPFL reefing, imbrication, and advancement, typically are not performed in isolation, as other osseous procedures are often needed concomitantly in order to preserve the checkrein effect provided by proximal realignment procedures. As is the case with MPFL reconstruction, understanding the relevant anatomy and avoiding overtensioning of the medial structures during MPFL repair or proximal realignment procedures are crucial.

Am J Orthop. 2017;46(2):87-91. Copyright Frontline Medical Communications Inc. 2017. All rights reserved.

Take-Home Points

• Loss of tissue homeostasis from overuse or injury produces pain.
• In patients with AKP, treatment should begin with activity modification with the envelope of function; pain-free rehabilitation; an anti-inflammatory program of cold, nonsteroidal anti-inflammatory drugs, and sometimes steroid injection.
• Physical therapy should be done without painful exercise, otherwise it could be counter-productive.
• Patellofemoral syndrome and chondromalacia are not valid clinical diagnoses. A more specific diagnosis based on careful clinical evaluation to determine anatomic origin of pain will better direct treatment.
• Even when lateral retinacular tightness is identified as the probable source of pain, surgery is seldom required.

Symptoms of patellofemoral pain (PFP) without a readily identifiable cause are perhaps the most common yet vexing clinical complaint heard by orthopedic surgeons worldwide. PFP typically occurs over the anterior knee, is often diffuse, and worsens with prolonged knee flexion and the use of stairs. Some prefer the term anterior knee pain (AKP) because we do not always know the pain is patellofemoral in anatomical origin; we know only that it is felt in the anterior knee. Pain is inherently and irreducibly a subjective phenomenon, a function of very discrete central nervous system activity within the sensory area of the contralateral cerebral cortex to the symptomatic knee. Pain is purely subjective and therefore by definition not objectively and consistently measurable between patients. Emotions play a role in pain as well, and somatization resulting in knee pain is a well-known phenomenon, particularly in adolescent women related to stress or even abuse. There is no imaging study that can be used to guide the rational treatment of pain. The best we can do is to ask patients to draw pain diagrams, which provide useful information proven to correlate with areas of tenderness.¹

Although many have referred to patients with PFP as having patellofemoral pain syndrome, we reject that term, as it implies a clearly defined syndrome—a consistent set of symptoms, signs, and test results—that does not exist. More complex AKP cases, such as those involving major trauma, complex regional pain syndrome, or multiple operative procedures, are beyond the scope of this article, though many of the principles discussed are applicable. Surprisingly, despite decades of research and clinical experience with a vast number of patients, there still is controversy regarding the underlying etiology of the symptoms and the best, safest treatment.

Primum non nocere. First, do no harm. Let us understand how to reach that noble goal.

Our Hypothesis: Loss of Homeostasis Causes Pain

Homeostasis is a natural process of maintaining relatively stable and asymptomatic physiologic conditions in all organ systems under fluctuating environmental conditions. We hypothesize that pain is the result when load applied to musculoskeletal tissues exceeds the ability to maintain homeostasis. As in other organ systems, in musculoskeletal tissues homeostasis is restored and maintained with appropriate treatment. To illustrate this hypothesis, Dr. Dye coined the term envelope of function (EOF). A combination of magnitude and frequency of load causes loss of homeostasis; with respect to the knee, activity or injury pushes it out of its acceptable EOF in which homeostasis is maintained (Figure 1).²

The therapeutic recommendations that follow from this new biocentric paradigm of joint function are quite different from those associated with hypotheses attributing AKP to chondromalacia and malalignment. This new “common sense” approach, which never encourages treatment that makes symptoms worse, recognizes healing as a complex, rate-limited biological phenomenon that can take time to achieve, especially within a harsh and unforgiving biomechanical environment such as the human patellofemoral joint.

Traditional Explanations and Treatment Strategies

In traditional teaching, 2 causes of AKP have been prominent: chondromalacia patella (CMP) (softening of the articular surface of the patella) and malalignment of the extensor mechanism. Ironically, many of the worst AKP cases are iatrogenic, resulting from surgery to “correct” CMP and/or patellofemoral malalignment or maltracking. Even exercises encouraged by ill-informed physical therapists—such as excessive squats and lunges—can easily worsen AKP symptoms. We think the clinical failure of these traditional methods reflects a profound misunderstanding of the most common cause of AKP.

Chondromalacia Patella—Not the Problem

If chondromalacia is the source of AKP, what is it about conservative treatment that “cures” or even improves structurally softened articular cartilage? How can mere activity modification and exercise result in symptom resolution secondary to improvement in cartilage structure? There is no evidence of this occurring. Nevertheless, patients with this “diagnosis” commonly respond to nonoperative treatment.

Dr. Dye has had personal experience in the possible genesis of AKP in CMP. When he was 46 years old, he allowed his asymptomatic knees to be arthroscopically inspected, without intra-articular anesthesia, so that a neurosensory map of their internal components could be drawn (Figure 2).³

Malalignment—Not Often the Problem

That brings us to the historically popular concept of patellofemoral “malalignment/maltracking” as a primary cause for AKP. Although this etiology appeals to many in the orthopedic and physical therapy community,^5,6 we and others^7-10 reject the notion that it is common. What objective malalignment changes occur when a patient becomes asymptomatic without operative treatment? Imaging measures of malalignment do not change significantly after effective treatment. In studying patients with AKP in the mid 1980’s, Dr. Dye found no difference between 104 adults with PFP and 79 age- and activity-matched controls with respect to 9 objective indicators of malalignment, including quadriceps (Q) angle, congruence angle, sulcus angle, and subchondral sclerosis of the lateral patellar facet.

The clinical success of McConnell taping, which often produces instant pain relief by using tape to apply loads to the patella and peripatellar soft tissues, is sometimes cited as evidence that maltracking or malalignment is the cause of the pain. We disagree with that conclusion. This pain relief more likely results from relieving pressure and tension on sensitive soft tissues, including synovial, fat-pad, and retinacular tissues—equivalent to, say, using a finger to pull inflamed and swollen bitten cheek tissues away from the teeth, which might repetitively traumatize them. In both cases, healing is not spontaneous; but relieving the sensitive tissue of the exacerbating load is the common principle. We think subtle changes in the tension and impingement of synovial and fat-pad tissues can have profound effects on AKP. Pain relief with McConnell taping no more proves that the source of the pain is malalignment or maltracking than a finger pulling away inflamed and swollen cheek tissues proves that cheek pain is caused by malocclusion.

Patellar Bone Overload—Part of the Problem

Patellar bone has been long assumed to be a source of AKP. To understand this better, Dr. Dye had one of his residents push a 15-gauge needle into the medial facet of his asymptomatic right patella to obtain real-time intraosseous pressure measurements as a control. This was done under local anesthesia, so no pain was felt as the needle entered the patella. However, when an arterial line was connected and flushed prior to pressure measurements, Dr. Dye experienced sharp lancinating pain. Patellar bone is richly innervated, and even mildly increased intraosseous pressure can produce severe symptoms. Dr. Dye’s patella was sore for about 7 months afterward.

Loss and restoration of osseous homeostasis occur often in AKP patients whose positive patellar bone scans (focal or diffuse) show resolution to normal (homeostasis) after symptom dissipation (Figures 9A, 9B).

The Mosaic of Anterior Knee Pain

The densely innervated synovial, fat-pad, and patellar bone tissues are nociceptive sources of AKP in the absence of homeostasis.

Clinical Applications of Homeostasis and Common Sense

Essential points to be covered in the history include overuse, injury, weight gain, systemic illness (which may produce weakness and deconditioning), prior treatment (especially physical therapy) and response to medications or injections. In the case of prior surgery, preoperative and postoperative identification of the patient’s exact symptoms can shed light on the underlying diagnosis and on any symptom changes resulting from treatment.

Sudden pain in the anterior knee can result in pain-mediated reflex quadriceps inhibition and the sensation that the knee is “giving way.” Typically, patients describe the knee collapsing into flexion and when asked if their knee is “unstable” after experiencing such episodes they will readily say yes. However, such a knee is not “unstable” in the sense that there is patholaxity that might require surgery. This is a critical distinction to avoid tragic-ally unnecessary surgery.

Careful evaluation for areas of tenderness may direct treatment to focal pathology, such as patellar or quadriceps tendinitis or tendinosis, pathologic medial parapatellar plica, or postoperative neuroma. Palpation and Tinel testing can uncover a neuroma or neuropathy of the infrapatellar branch of the saphenous nerve (Figure 11) that no other diagnostic tools can.

Treatment Options

Activity Modification

Avoid aggravating the problem. Consider this like a fire. If you are trying to put out a fire (AKP), would you throw sticks (increased activity/aggressive exercise) on it? Of course not. You would turn a hose on it (nonsteroidal anti-inflammatory drug [NSAID] regularly) or perhaps throw a bucket of water (steroid injection) on it. You would not throw gasoline (excessive exercise or activity) on it. Explaining to patients how to remain within their envelope by avoiding any activity that increases symptoms is crucial. No pain no gain is a lie from hell for patients with AKP. Don’t throw sticks on the fire.

We are frustrated that patients with PFP are still often told by well-meaning therapists to perform exercises that end up substantially increasing symptoms. Patients are admonished to push forward with “quad strengthening” by any means necessary, including painful lunges and squats, which can exacerbate synovial and fat-pad impingement and put excessive tension on muscle and tendon tissue, which is ill equipped to absorb the loads. Damaged tissues can usually return to pain-free biological homeostasis if given the opportunity and a reasonable mechanical environment.

Pain-free loading means that each of the hundreds of millions of sensory nerve endings is unperturbed, and is reporting, in effect, “I’m fine in my sector.” Minor discomfort is inevitable, but real pain during activity, and exacerbations after activity, is activity outside the EOF. Strive for patients to have “clinically quiet” knees during activity. This common sense approach is often rewarded with dramatic recovery, over time, even in patients with severe AKP. In long-standing cases, patients may take months or even years to recover, but slow and steady progress should be expected. Later, these may be among your most grateful patients.

Cold Therapy

Cold therapy relieves pain, decreases swelling, slows the metabolic rate, is simple, and has few complications. Many AKP-related tissues are superficial, and the application of cold is logical and effective. However, we should not overdo it, either. Cold applied for 20 minutes once or twice daily is sufficient in most cases, at least initially. If it does not help resolve symptoms, it may be abandoned. Likewise, if a patient does not tolerate cryotherapy, it should not be demanded. Some patients respond better to the application of warmth, which is allowed within reason.

Anti-Inflammatory Medication

Inflammation clearly plays a role in the production of pain and swelling in the soft tissues of the anterior knee (synovium, fat pad, patella and quadriceps tendons/peritenon, and retinacular tissues). Consistent use of oral NSAIDs in the absence of medical contraindications can be valuable, and there are benefits to using mild oral NSAIDs (eg, solubilized ibuprofen 400 mg 2 times daily). Prescription NSAIDs should be used short-term, if possible, to avoid complications; long-term use requires medical supervision and laboratory testing. Oral steroids can be used in similar fashion.

Intra-articular steroids (eg, triamcinolone or methylprednisolone 40 mg with a few cubic centimeters of local anesthetic) can be very helpful in quickly reducing inflammation within synovial and fat-pad tissues. In addition, an intra-articular steroid injection is diagnostic when the pain goes away, even if only for the duration of the local anesthetic; this change indicates the pain must be coming from a structure that is bathed by the intra-articular medication. Longer-term relief provides strong circumstantial evidence of causation related to intra-articular soft-tissue inflammation (loss of homeostasis) and not to chondromalacia or malalignment.

Physical Therapy

Therapy must be performed within the EOF as much as possible. Muscle soreness after a therapeutic workout is acceptable. There can easily be a lag time of 24 hours or more in the production of an activity-induced inflammatory enzyme spike. Therefore, when exercises are being done every other day, the rest days should also be kept well within the EOF. The patient must be essentially pain-free all the time, on exercise days and on rest days. Gentle stretching of tight muscles (especially quadriceps but also hips, hamstrings, and gastrocsoleus) and strengthening of hips and core are encouraged. Gentle stretching on rest days is encouraged as well.

The physical therapist must teach the principles of moderating activities of daily living (ADLs) within the EOF (eg, safe use of stairs, safely getting in and out of chairs and vehicles), for it is in these ADLs that many symptomatic patients experience recurrent overload. Total load in ADLs and in therapy must remain within the EOF to maximize the chance of return to homeostasis. Exercise-induced substantial patellofemoral soreness, effusion, or increased temperature in the knee is not acceptable.

Imaging

Advanced imaging in AKP can be a contentious subject. It is too easy to assume images hold the answers. A finding of CMP or alignment abnormality must be viewed with caution, as usually it is not an indication for patellofemoral surgery. You are treating a patient, not a picture. You must be responsible to integrate all available data (history, physical examination, imaging, response to treatment, etc) to make an accurate diagnosis. Always inspect all the imaging data yourself. Do not “push in the mental clutch” but rather do the challenging work of putting all the clinical pieces of the puzzle together to reach the right answer. Do not let the radiologist make the diagnosis!

Radiographs

It is imperative to obtain good-quality radiographs, including axial radiographs of the patella in early flexion, to check for evidence of arthrosis and other joint pathology that may be producing pain. Dr. Post always obtains bilateral knee radiographs to help understand the degree of any arthrosis or malalignment in the contralateral asymptomatic knee. The information in bilateral radiographs is also instructive for patients. Knowing that the contralateral knee shows the same radiographic changes, or even more, helps them understand that the structural factors as imaged do not dictate symptoms. More advanced or extensive imaging is not needed unless appropriate and patient therapy reaches a stalemate.

Bone Scans

In recalcitrant patients with persistent pain, a bone scan provides sensitive imaging of osseous metabolic activity and thereby clarifies the etiology of the pain. A negative scan rules out the bone as a significant cause, freeing the clinician to concentrate solely on the soft tissues. In a way that MRI can miss, a positive bone scan identifies specific regions that have lost osseous homeostasis and are being overloaded. Microscopically, these regions’ changes are very similar to the abnormal bone remodeling that occurs in early-stage stress fractures. Whether focal or diffuse, a positive bone scan means symptoms likely will take longer to reverse than is the case with a negative scan. Often, the stark findings of a positive bone scan can grab the patient’s attention and improve understanding and compliance. Focal inferior pole uptake is the most difficult pattern to reverse, perhaps because it may represent the most extreme biomechanical environment of the patellofemoral joint. In Dr. Dye’s experience, patients with this pattern may often require drilling of the inferior pole to achieve restoration of tissue homeostasis.

Magnetic Resonance Imaging

MRI can be useful, though scans are commonly read as normal. In some cases, MRI evidence of tendinopathy and other intra-articular pathology can direct both operative and nonoperative treatment of AKP. Carefully look for evidence of soft-tissue impingement—such as mild synovial swelling, low-grade effusion, and neovascularization of the fat pad—as in many cases it exists, and has been missed by the radiologist (Figures 12A, 12B).

When Surgery Is Needed: General Principles

Although the majority of patients with AKP do not need surgery, some do. Think of surgery as a tool used to create an environment in which homeostasis may be restored. Arthroscopy and meticulous débridement may be used to treat recalcitrant focal synovitis or fat-pad hypertrophy—or focal chondral pathology (eg, unstable flap of articular cartilage) that has produced mechanical symptoms with secondary inflammation. A well-localized area of patellar tendinosis may respond to either arthroscopic or open débridement. A true mechanical alignment abnormality may produce focal overload to such a degree that the most complete nonoperative programs cannot overcome the loss of homeostasis. In such a case, imaging studies that precisely document overloaded areas and associated malalignment must make sense given the clinical picture, and then must be used in developing a rational surgical plan for unloading bone and soft-tissue pathology to create a mechanical and biological environment for healing and return to homeostasis. At times, the articular damage may be so severe that patellofemoral arthroplasty is the best choice. The exact indications for these procedures are well described elsewhere.¹³

Surgery for Patients With PFP Caused by Recalcitrant Synovitis

As this type of surgery is not often covered in the literature, we offer some treatment pearls here. Arthroscopy for persistent focal synovitis should not be approached lightly; though the mechanics of removing abnormal inflamed synovial tissue may be straightforward, perioperative management and long-term postoperative management are not. The patient must be mentally prepared for the process; blood-thinning agents, fish oil, and turmeric must be discontinued; and hemostasis must be meticulous (Figures 13A-13C).

Conclusion

The history of medicine has included many misunderstandings of cause and effect. Trephination was used for headaches, leeches for fever, and, more recently, antacids for Helicobacter pylori caused duodenal ulcers. Stimulated by the enigma of AKP, we think our common sense way of thinking about tissue homeostasis in the musculoskeletal system represents an emerging orthopedic biological paradigm that is applicable to the entire body. We should let the remarkable capacity of vertebrate biology do the “heavy lifting” of healing. The traditional orthopedic emphasis on structure and alignment has a role, but we see it as complementary and secondary to the biological paradigm and find that the evidence presented herein supports our contention. The answer is seen only when one looks beyond the viewbox.

Primum non nocere. Your patients will be most grateful.

Am J Orthop. 2017;46(2):92-100. Copyright Frontline Medical Communications Inc. 2017. All rights reserved.

Take-Home Points

• Loss of tissue homeostasis from overuse or injury produces pain.
• In patients with AKP, treatment should begin with activity modification with the envelope of function; pain-free rehabilitation; an anti-inflammatory program of cold, nonsteroidal anti-inflammatory drugs, and sometimes steroid injection.
• Physical therapy should be done without painful exercise, otherwise it could be counter-productive.
• Patellofemoral syndrome and chondromalacia are not valid clinical diagnoses. A more specific diagnosis based on careful clinical evaluation to determine anatomic origin of pain will better direct treatment.
• Even when lateral retinacular tightness is identified as the probable source of pain, surgery is seldom required.

Symptoms of patellofemoral pain (PFP) without a readily identifiable cause are perhaps the most common yet vexing clinical complaint heard by orthopedic surgeons worldwide. PFP typically occurs over the anterior knee, is often diffuse, and worsens with prolonged knee flexion and the use of stairs. Some prefer the term anterior knee pain (AKP) because we do not always know the pain is patellofemoral in anatomical origin; we know only that it is felt in the anterior knee. Pain is inherently and irreducibly a subjective phenomenon, a function of very discrete central nervous system activity within the sensory area of the contralateral cerebral cortex to the symptomatic knee. Pain is purely subjective and therefore by definition not objectively and consistently measurable between patients. Emotions play a role in pain as well, and somatization resulting in knee pain is a well-known phenomenon, particularly in adolescent women related to stress or even abuse. There is no imaging study that can be used to guide the rational treatment of pain. The best we can do is to ask patients to draw pain diagrams, which provide useful information proven to correlate with areas of tenderness.¹

Although many have referred to patients with PFP as having patellofemoral pain syndrome, we reject that term, as it implies a clearly defined syndrome—a consistent set of symptoms, signs, and test results—that does not exist. More complex AKP cases, such as those involving major trauma, complex regional pain syndrome, or multiple operative procedures, are beyond the scope of this article, though many of the principles discussed are applicable. Surprisingly, despite decades of research and clinical experience with a vast number of patients, there still is controversy regarding the underlying etiology of the symptoms and the best, safest treatment.

Primum non nocere. First, do no harm. Let us understand how to reach that noble goal.

Our Hypothesis: Loss of Homeostasis Causes Pain

Homeostasis is a natural process of maintaining relatively stable and asymptomatic physiologic conditions in all organ systems under fluctuating environmental conditions. We hypothesize that pain is the result when load applied to musculoskeletal tissues exceeds the ability to maintain homeostasis. As in other organ systems, in musculoskeletal tissues homeostasis is restored and maintained with appropriate treatment. To illustrate this hypothesis, Dr. Dye coined the term envelope of function (EOF). A combination of magnitude and frequency of load causes loss of homeostasis; with respect to the knee, activity or injury pushes it out of its acceptable EOF in which homeostasis is maintained (Figure 1).²

The therapeutic recommendations that follow from this new biocentric paradigm of joint function are quite different from those associated with hypotheses attributing AKP to chondromalacia and malalignment. This new “common sense” approach, which never encourages treatment that makes symptoms worse, recognizes healing as a complex, rate-limited biological phenomenon that can take time to achieve, especially within a harsh and unforgiving biomechanical environment such as the human patellofemoral joint.

Traditional Explanations and Treatment Strategies

In traditional teaching, 2 causes of AKP have been prominent: chondromalacia patella (CMP) (softening of the articular surface of the patella) and malalignment of the extensor mechanism. Ironically, many of the worst AKP cases are iatrogenic, resulting from surgery to “correct” CMP and/or patellofemoral malalignment or maltracking. Even exercises encouraged by ill-informed physical therapists—such as excessive squats and lunges—can easily worsen AKP symptoms. We think the clinical failure of these traditional methods reflects a profound misunderstanding of the most common cause of AKP.

Chondromalacia Patella—Not the Problem

If chondromalacia is the source of AKP, what is it about conservative treatment that “cures” or even improves structurally softened articular cartilage? How can mere activity modification and exercise result in symptom resolution secondary to improvement in cartilage structure? There is no evidence of this occurring. Nevertheless, patients with this “diagnosis” commonly respond to nonoperative treatment.

Dr. Dye has had personal experience in the possible genesis of AKP in CMP. When he was 46 years old, he allowed his asymptomatic knees to be arthroscopically inspected, without intra-articular anesthesia, so that a neurosensory map of their internal components could be drawn (Figure 2).³

Malalignment—Not Often the Problem

That brings us to the historically popular concept of patellofemoral “malalignment/maltracking” as a primary cause for AKP. Although this etiology appeals to many in the orthopedic and physical therapy community,^5,6 we and others^7-10 reject the notion that it is common. What objective malalignment changes occur when a patient becomes asymptomatic without operative treatment? Imaging measures of malalignment do not change significantly after effective treatment. In studying patients with AKP in the mid 1980’s, Dr. Dye found no difference between 104 adults with PFP and 79 age- and activity-matched controls with respect to 9 objective indicators of malalignment, including quadriceps (Q) angle, congruence angle, sulcus angle, and subchondral sclerosis of the lateral patellar facet.

The clinical success of McConnell taping, which often produces instant pain relief by using tape to apply loads to the patella and peripatellar soft tissues, is sometimes cited as evidence that maltracking or malalignment is the cause of the pain. We disagree with that conclusion. This pain relief more likely results from relieving pressure and tension on sensitive soft tissues, including synovial, fat-pad, and retinacular tissues—equivalent to, say, using a finger to pull inflamed and swollen bitten cheek tissues away from the teeth, which might repetitively traumatize them. In both cases, healing is not spontaneous; but relieving the sensitive tissue of the exacerbating load is the common principle. We think subtle changes in the tension and impingement of synovial and fat-pad tissues can have profound effects on AKP. Pain relief with McConnell taping no more proves that the source of the pain is malalignment or maltracking than a finger pulling away inflamed and swollen cheek tissues proves that cheek pain is caused by malocclusion.

Patellar Bone Overload—Part of the Problem

Patellar bone has been long assumed to be a source of AKP. To understand this better, Dr. Dye had one of his residents push a 15-gauge needle into the medial facet of his asymptomatic right patella to obtain real-time intraosseous pressure measurements as a control. This was done under local anesthesia, so no pain was felt as the needle entered the patella. However, when an arterial line was connected and flushed prior to pressure measurements, Dr. Dye experienced sharp lancinating pain. Patellar bone is richly innervated, and even mildly increased intraosseous pressure can produce severe symptoms. Dr. Dye’s patella was sore for about 7 months afterward.

Loss and restoration of osseous homeostasis occur often in AKP patients whose positive patellar bone scans (focal or diffuse) show resolution to normal (homeostasis) after symptom dissipation (Figures 9A, 9B).

The Mosaic of Anterior Knee Pain

The densely innervated synovial, fat-pad, and patellar bone tissues are nociceptive sources of AKP in the absence of homeostasis.

Clinical Applications of Homeostasis and Common Sense

Essential points to be covered in the history include overuse, injury, weight gain, systemic illness (which may produce weakness and deconditioning), prior treatment (especially physical therapy) and response to medications or injections. In the case of prior surgery, preoperative and postoperative identification of the patient’s exact symptoms can shed light on the underlying diagnosis and on any symptom changes resulting from treatment.

Sudden pain in the anterior knee can result in pain-mediated reflex quadriceps inhibition and the sensation that the knee is “giving way.” Typically, patients describe the knee collapsing into flexion and when asked if their knee is “unstable” after experiencing such episodes they will readily say yes. However, such a knee is not “unstable” in the sense that there is patholaxity that might require surgery. This is a critical distinction to avoid tragic-ally unnecessary surgery.

Careful evaluation for areas of tenderness may direct treatment to focal pathology, such as patellar or quadriceps tendinitis or tendinosis, pathologic medial parapatellar plica, or postoperative neuroma. Palpation and Tinel testing can uncover a neuroma or neuropathy of the infrapatellar branch of the saphenous nerve (Figure 11) that no other diagnostic tools can.

Treatment Options

Activity Modification

Avoid aggravating the problem. Consider this like a fire. If you are trying to put out a fire (AKP), would you throw sticks (increased activity/aggressive exercise) on it? Of course not. You would turn a hose on it (nonsteroidal anti-inflammatory drug [NSAID] regularly) or perhaps throw a bucket of water (steroid injection) on it. You would not throw gasoline (excessive exercise or activity) on it. Explaining to patients how to remain within their envelope by avoiding any activity that increases symptoms is crucial. No pain no gain is a lie from hell for patients with AKP. Don’t throw sticks on the fire.

We are frustrated that patients with PFP are still often told by well-meaning therapists to perform exercises that end up substantially increasing symptoms. Patients are admonished to push forward with “quad strengthening” by any means necessary, including painful lunges and squats, which can exacerbate synovial and fat-pad impingement and put excessive tension on muscle and tendon tissue, which is ill equipped to absorb the loads. Damaged tissues can usually return to pain-free biological homeostasis if given the opportunity and a reasonable mechanical environment.

Pain-free loading means that each of the hundreds of millions of sensory nerve endings is unperturbed, and is reporting, in effect, “I’m fine in my sector.” Minor discomfort is inevitable, but real pain during activity, and exacerbations after activity, is activity outside the EOF. Strive for patients to have “clinically quiet” knees during activity. This common sense approach is often rewarded with dramatic recovery, over time, even in patients with severe AKP. In long-standing cases, patients may take months or even years to recover, but slow and steady progress should be expected. Later, these may be among your most grateful patients.

Cold Therapy

Cold therapy relieves pain, decreases swelling, slows the metabolic rate, is simple, and has few complications. Many AKP-related tissues are superficial, and the application of cold is logical and effective. However, we should not overdo it, either. Cold applied for 20 minutes once or twice daily is sufficient in most cases, at least initially. If it does not help resolve symptoms, it may be abandoned. Likewise, if a patient does not tolerate cryotherapy, it should not be demanded. Some patients respond better to the application of warmth, which is allowed within reason.

Anti-Inflammatory Medication

Inflammation clearly plays a role in the production of pain and swelling in the soft tissues of the anterior knee (synovium, fat pad, patella and quadriceps tendons/peritenon, and retinacular tissues). Consistent use of oral NSAIDs in the absence of medical contraindications can be valuable, and there are benefits to using mild oral NSAIDs (eg, solubilized ibuprofen 400 mg 2 times daily). Prescription NSAIDs should be used short-term, if possible, to avoid complications; long-term use requires medical supervision and laboratory testing. Oral steroids can be used in similar fashion.

Intra-articular steroids (eg, triamcinolone or methylprednisolone 40 mg with a few cubic centimeters of local anesthetic) can be very helpful in quickly reducing inflammation within synovial and fat-pad tissues. In addition, an intra-articular steroid injection is diagnostic when the pain goes away, even if only for the duration of the local anesthetic; this change indicates the pain must be coming from a structure that is bathed by the intra-articular medication. Longer-term relief provides strong circumstantial evidence of causation related to intra-articular soft-tissue inflammation (loss of homeostasis) and not to chondromalacia or malalignment.

Physical Therapy

Therapy must be performed within the EOF as much as possible. Muscle soreness after a therapeutic workout is acceptable. There can easily be a lag time of 24 hours or more in the production of an activity-induced inflammatory enzyme spike. Therefore, when exercises are being done every other day, the rest days should also be kept well within the EOF. The patient must be essentially pain-free all the time, on exercise days and on rest days. Gentle stretching of tight muscles (especially quadriceps but also hips, hamstrings, and gastrocsoleus) and strengthening of hips and core are encouraged. Gentle stretching on rest days is encouraged as well.

The physical therapist must teach the principles of moderating activities of daily living (ADLs) within the EOF (eg, safe use of stairs, safely getting in and out of chairs and vehicles), for it is in these ADLs that many symptomatic patients experience recurrent overload. Total load in ADLs and in therapy must remain within the EOF to maximize the chance of return to homeostasis. Exercise-induced substantial patellofemoral soreness, effusion, or increased temperature in the knee is not acceptable.

Imaging

Advanced imaging in AKP can be a contentious subject. It is too easy to assume images hold the answers. A finding of CMP or alignment abnormality must be viewed with caution, as usually it is not an indication for patellofemoral surgery. You are treating a patient, not a picture. You must be responsible to integrate all available data (history, physical examination, imaging, response to treatment, etc) to make an accurate diagnosis. Always inspect all the imaging data yourself. Do not “push in the mental clutch” but rather do the challenging work of putting all the clinical pieces of the puzzle together to reach the right answer. Do not let the radiologist make the diagnosis!

Radiographs

It is imperative to obtain good-quality radiographs, including axial radiographs of the patella in early flexion, to check for evidence of arthrosis and other joint pathology that may be producing pain. Dr. Post always obtains bilateral knee radiographs to help understand the degree of any arthrosis or malalignment in the contralateral asymptomatic knee. The information in bilateral radiographs is also instructive for patients. Knowing that the contralateral knee shows the same radiographic changes, or even more, helps them understand that the structural factors as imaged do not dictate symptoms. More advanced or extensive imaging is not needed unless appropriate and patient therapy reaches a stalemate.

Bone Scans

In recalcitrant patients with persistent pain, a bone scan provides sensitive imaging of osseous metabolic activity and thereby clarifies the etiology of the pain. A negative scan rules out the bone as a significant cause, freeing the clinician to concentrate solely on the soft tissues. In a way that MRI can miss, a positive bone scan identifies specific regions that have lost osseous homeostasis and are being overloaded. Microscopically, these regions’ changes are very similar to the abnormal bone remodeling that occurs in early-stage stress fractures. Whether focal or diffuse, a positive bone scan means symptoms likely will take longer to reverse than is the case with a negative scan. Often, the stark findings of a positive bone scan can grab the patient’s attention and improve understanding and compliance. Focal inferior pole uptake is the most difficult pattern to reverse, perhaps because it may represent the most extreme biomechanical environment of the patellofemoral joint. In Dr. Dye’s experience, patients with this pattern may often require drilling of the inferior pole to achieve restoration of tissue homeostasis.

Magnetic Resonance Imaging

MRI can be useful, though scans are commonly read as normal. In some cases, MRI evidence of tendinopathy and other intra-articular pathology can direct both operative and nonoperative treatment of AKP. Carefully look for evidence of soft-tissue impingement—such as mild synovial swelling, low-grade effusion, and neovascularization of the fat pad—as in many cases it exists, and has been missed by the radiologist (Figures 12A, 12B).

When Surgery Is Needed: General Principles

Although the majority of patients with AKP do not need surgery, some do. Think of surgery as a tool used to create an environment in which homeostasis may be restored. Arthroscopy and meticulous débridement may be used to treat recalcitrant focal synovitis or fat-pad hypertrophy—or focal chondral pathology (eg, unstable flap of articular cartilage) that has produced mechanical symptoms with secondary inflammation. A well-localized area of patellar tendinosis may respond to either arthroscopic or open débridement. A true mechanical alignment abnormality may produce focal overload to such a degree that the most complete nonoperative programs cannot overcome the loss of homeostasis. In such a case, imaging studies that precisely document overloaded areas and associated malalignment must make sense given the clinical picture, and then must be used in developing a rational surgical plan for unloading bone and soft-tissue pathology to create a mechanical and biological environment for healing and return to homeostasis. At times, the articular damage may be so severe that patellofemoral arthroplasty is the best choice. The exact indications for these procedures are well described elsewhere.¹³

Surgery for Patients With PFP Caused by Recalcitrant Synovitis

As this type of surgery is not often covered in the literature, we offer some treatment pearls here. Arthroscopy for persistent focal synovitis should not be approached lightly; though the mechanics of removing abnormal inflamed synovial tissue may be straightforward, perioperative management and long-term postoperative management are not. The patient must be mentally prepared for the process; blood-thinning agents, fish oil, and turmeric must be discontinued; and hemostasis must be meticulous (Figures 13A-13C).

Conclusion

The history of medicine has included many misunderstandings of cause and effect. Trephination was used for headaches, leeches for fever, and, more recently, antacids for Helicobacter pylori caused duodenal ulcers. Stimulated by the enigma of AKP, we think our common sense way of thinking about tissue homeostasis in the musculoskeletal system represents an emerging orthopedic biological paradigm that is applicable to the entire body. We should let the remarkable capacity of vertebrate biology do the “heavy lifting” of healing. The traditional orthopedic emphasis on structure and alignment has a role, but we see it as complementary and secondary to the biological paradigm and find that the evidence presented herein supports our contention. The answer is seen only when one looks beyond the viewbox.

Primum non nocere. Your patients will be most grateful.

Am J Orthop. 2017;46(2):92-100. Copyright Frontline Medical Communications Inc. 2017. All rights reserved.

Take-Home Points

• Loss of tissue homeostasis from overuse or injury produces pain.
• In patients with AKP, treatment should begin with activity modification with the envelope of function; pain-free rehabilitation; an anti-inflammatory program of cold, nonsteroidal anti-inflammatory drugs, and sometimes steroid injection.
• Physical therapy should be done without painful exercise, otherwise it could be counter-productive.
• Patellofemoral syndrome and chondromalacia are not valid clinical diagnoses. A more specific diagnosis based on careful clinical evaluation to determine anatomic origin of pain will better direct treatment.
• Even when lateral retinacular tightness is identified as the probable source of pain, surgery is seldom required.

Symptoms of patellofemoral pain (PFP) without a readily identifiable cause are perhaps the most common yet vexing clinical complaint heard by orthopedic surgeons worldwide. PFP typically occurs over the anterior knee, is often diffuse, and worsens with prolonged knee flexion and the use of stairs. Some prefer the term anterior knee pain (AKP) because we do not always know the pain is patellofemoral in anatomical origin; we know only that it is felt in the anterior knee. Pain is inherently and irreducibly a subjective phenomenon, a function of very discrete central nervous system activity within the sensory area of the contralateral cerebral cortex to the symptomatic knee. Pain is purely subjective and therefore by definition not objectively and consistently measurable between patients. Emotions play a role in pain as well, and somatization resulting in knee pain is a well-known phenomenon, particularly in adolescent women related to stress or even abuse. There is no imaging study that can be used to guide the rational treatment of pain. The best we can do is to ask patients to draw pain diagrams, which provide useful information proven to correlate with areas of tenderness.¹

Although many have referred to patients with PFP as having patellofemoral pain syndrome, we reject that term, as it implies a clearly defined syndrome—a consistent set of symptoms, signs, and test results—that does not exist. More complex AKP cases, such as those involving major trauma, complex regional pain syndrome, or multiple operative procedures, are beyond the scope of this article, though many of the principles discussed are applicable. Surprisingly, despite decades of research and clinical experience with a vast number of patients, there still is controversy regarding the underlying etiology of the symptoms and the best, safest treatment.

Primum non nocere. First, do no harm. Let us understand how to reach that noble goal.

Our Hypothesis: Loss of Homeostasis Causes Pain

Homeostasis is a natural process of maintaining relatively stable and asymptomatic physiologic conditions in all organ systems under fluctuating environmental conditions. We hypothesize that pain is the result when load applied to musculoskeletal tissues exceeds the ability to maintain homeostasis. As in other organ systems, in musculoskeletal tissues homeostasis is restored and maintained with appropriate treatment. To illustrate this hypothesis, Dr. Dye coined the term envelope of function (EOF). A combination of magnitude and frequency of load causes loss of homeostasis; with respect to the knee, activity or injury pushes it out of its acceptable EOF in which homeostasis is maintained (Figure 1).²

The therapeutic recommendations that follow from this new biocentric paradigm of joint function are quite different from those associated with hypotheses attributing AKP to chondromalacia and malalignment. This new “common sense” approach, which never encourages treatment that makes symptoms worse, recognizes healing as a complex, rate-limited biological phenomenon that can take time to achieve, especially within a harsh and unforgiving biomechanical environment such as the human patellofemoral joint.

Traditional Explanations and Treatment Strategies

In traditional teaching, 2 causes of AKP have been prominent: chondromalacia patella (CMP) (softening of the articular surface of the patella) and malalignment of the extensor mechanism. Ironically, many of the worst AKP cases are iatrogenic, resulting from surgery to “correct” CMP and/or patellofemoral malalignment or maltracking. Even exercises encouraged by ill-informed physical therapists—such as excessive squats and lunges—can easily worsen AKP symptoms. We think the clinical failure of these traditional methods reflects a profound misunderstanding of the most common cause of AKP.

Chondromalacia Patella—Not the Problem

If chondromalacia is the source of AKP, what is it about conservative treatment that “cures” or even improves structurally softened articular cartilage? How can mere activity modification and exercise result in symptom resolution secondary to improvement in cartilage structure? There is no evidence of this occurring. Nevertheless, patients with this “diagnosis” commonly respond to nonoperative treatment.

Dr. Dye has had personal experience in the possible genesis of AKP in CMP. When he was 46 years old, he allowed his asymptomatic knees to be arthroscopically inspected, without intra-articular anesthesia, so that a neurosensory map of their internal components could be drawn (Figure 2).³

Malalignment—Not Often the Problem

That brings us to the historically popular concept of patellofemoral “malalignment/maltracking” as a primary cause for AKP. Although this etiology appeals to many in the orthopedic and physical therapy community,^5,6 we and others^7-10 reject the notion that it is common. What objective malalignment changes occur when a patient becomes asymptomatic without operative treatment? Imaging measures of malalignment do not change significantly after effective treatment. In studying patients with AKP in the mid 1980’s, Dr. Dye found no difference between 104 adults with PFP and 79 age- and activity-matched controls with respect to 9 objective indicators of malalignment, including quadriceps (Q) angle, congruence angle, sulcus angle, and subchondral sclerosis of the lateral patellar facet.

The clinical success of McConnell taping, which often produces instant pain relief by using tape to apply loads to the patella and peripatellar soft tissues, is sometimes cited as evidence that maltracking or malalignment is the cause of the pain. We disagree with that conclusion. This pain relief more likely results from relieving pressure and tension on sensitive soft tissues, including synovial, fat-pad, and retinacular tissues—equivalent to, say, using a finger to pull inflamed and swollen bitten cheek tissues away from the teeth, which might repetitively traumatize them. In both cases, healing is not spontaneous; but relieving the sensitive tissue of the exacerbating load is the common principle. We think subtle changes in the tension and impingement of synovial and fat-pad tissues can have profound effects on AKP. Pain relief with McConnell taping no more proves that the source of the pain is malalignment or maltracking than a finger pulling away inflamed and swollen cheek tissues proves that cheek pain is caused by malocclusion.

Patellar Bone Overload—Part of the Problem

Patellar bone has been long assumed to be a source of AKP. To understand this better, Dr. Dye had one of his residents push a 15-gauge needle into the medial facet of his asymptomatic right patella to obtain real-time intraosseous pressure measurements as a control. This was done under local anesthesia, so no pain was felt as the needle entered the patella. However, when an arterial line was connected and flushed prior to pressure measurements, Dr. Dye experienced sharp lancinating pain. Patellar bone is richly innervated, and even mildly increased intraosseous pressure can produce severe symptoms. Dr. Dye’s patella was sore for about 7 months afterward.

Loss and restoration of osseous homeostasis occur often in AKP patients whose positive patellar bone scans (focal or diffuse) show resolution to normal (homeostasis) after symptom dissipation (Figures 9A, 9B).

The Mosaic of Anterior Knee Pain

The densely innervated synovial, fat-pad, and patellar bone tissues are nociceptive sources of AKP in the absence of homeostasis.

Clinical Applications of Homeostasis and Common Sense

Essential points to be covered in the history include overuse, injury, weight gain, systemic illness (which may produce weakness and deconditioning), prior treatment (especially physical therapy) and response to medications or injections. In the case of prior surgery, preoperative and postoperative identification of the patient’s exact symptoms can shed light on the underlying diagnosis and on any symptom changes resulting from treatment.

Sudden pain in the anterior knee can result in pain-mediated reflex quadriceps inhibition and the sensation that the knee is “giving way.” Typically, patients describe the knee collapsing into flexion and when asked if their knee is “unstable” after experiencing such episodes they will readily say yes. However, such a knee is not “unstable” in the sense that there is patholaxity that might require surgery. This is a critical distinction to avoid tragic-ally unnecessary surgery.

Careful evaluation for areas of tenderness may direct treatment to focal pathology, such as patellar or quadriceps tendinitis or tendinosis, pathologic medial parapatellar plica, or postoperative neuroma. Palpation and Tinel testing can uncover a neuroma or neuropathy of the infrapatellar branch of the saphenous nerve (Figure 11) that no other diagnostic tools can.

Treatment Options

Activity Modification

Avoid aggravating the problem. Consider this like a fire. If you are trying to put out a fire (AKP), would you throw sticks (increased activity/aggressive exercise) on it? Of course not. You would turn a hose on it (nonsteroidal anti-inflammatory drug [NSAID] regularly) or perhaps throw a bucket of water (steroid injection) on it. You would not throw gasoline (excessive exercise or activity) on it. Explaining to patients how to remain within their envelope by avoiding any activity that increases symptoms is crucial. No pain no gain is a lie from hell for patients with AKP. Don’t throw sticks on the fire.

We are frustrated that patients with PFP are still often told by well-meaning therapists to perform exercises that end up substantially increasing symptoms. Patients are admonished to push forward with “quad strengthening” by any means necessary, including painful lunges and squats, which can exacerbate synovial and fat-pad impingement and put excessive tension on muscle and tendon tissue, which is ill equipped to absorb the loads. Damaged tissues can usually return to pain-free biological homeostasis if given the opportunity and a reasonable mechanical environment.

Pain-free loading means that each of the hundreds of millions of sensory nerve endings is unperturbed, and is reporting, in effect, “I’m fine in my sector.” Minor discomfort is inevitable, but real pain during activity, and exacerbations after activity, is activity outside the EOF. Strive for patients to have “clinically quiet” knees during activity. This common sense approach is often rewarded with dramatic recovery, over time, even in patients with severe AKP. In long-standing cases, patients may take months or even years to recover, but slow and steady progress should be expected. Later, these may be among your most grateful patients.

Cold Therapy

Cold therapy relieves pain, decreases swelling, slows the metabolic rate, is simple, and has few complications. Many AKP-related tissues are superficial, and the application of cold is logical and effective. However, we should not overdo it, either. Cold applied for 20 minutes once or twice daily is sufficient in most cases, at least initially. If it does not help resolve symptoms, it may be abandoned. Likewise, if a patient does not tolerate cryotherapy, it should not be demanded. Some patients respond better to the application of warmth, which is allowed within reason.

Anti-Inflammatory Medication

Inflammation clearly plays a role in the production of pain and swelling in the soft tissues of the anterior knee (synovium, fat pad, patella and quadriceps tendons/peritenon, and retinacular tissues). Consistent use of oral NSAIDs in the absence of medical contraindications can be valuable, and there are benefits to using mild oral NSAIDs (eg, solubilized ibuprofen 400 mg 2 times daily). Prescription NSAIDs should be used short-term, if possible, to avoid complications; long-term use requires medical supervision and laboratory testing. Oral steroids can be used in similar fashion.

Intra-articular steroids (eg, triamcinolone or methylprednisolone 40 mg with a few cubic centimeters of local anesthetic) can be very helpful in quickly reducing inflammation within synovial and fat-pad tissues. In addition, an intra-articular steroid injection is diagnostic when the pain goes away, even if only for the duration of the local anesthetic; this change indicates the pain must be coming from a structure that is bathed by the intra-articular medication. Longer-term relief provides strong circumstantial evidence of causation related to intra-articular soft-tissue inflammation (loss of homeostasis) and not to chondromalacia or malalignment.

Physical Therapy

Therapy must be performed within the EOF as much as possible. Muscle soreness after a therapeutic workout is acceptable. There can easily be a lag time of 24 hours or more in the production of an activity-induced inflammatory enzyme spike. Therefore, when exercises are being done every other day, the rest days should also be kept well within the EOF. The patient must be essentially pain-free all the time, on exercise days and on rest days. Gentle stretching of tight muscles (especially quadriceps but also hips, hamstrings, and gastrocsoleus) and strengthening of hips and core are encouraged. Gentle stretching on rest days is encouraged as well.

The physical therapist must teach the principles of moderating activities of daily living (ADLs) within the EOF (eg, safe use of stairs, safely getting in and out of chairs and vehicles), for it is in these ADLs that many symptomatic patients experience recurrent overload. Total load in ADLs and in therapy must remain within the EOF to maximize the chance of return to homeostasis. Exercise-induced substantial patellofemoral soreness, effusion, or increased temperature in the knee is not acceptable.

Imaging

Advanced imaging in AKP can be a contentious subject. It is too easy to assume images hold the answers. A finding of CMP or alignment abnormality must be viewed with caution, as usually it is not an indication for patellofemoral surgery. You are treating a patient, not a picture. You must be responsible to integrate all available data (history, physical examination, imaging, response to treatment, etc) to make an accurate diagnosis. Always inspect all the imaging data yourself. Do not “push in the mental clutch” but rather do the challenging work of putting all the clinical pieces of the puzzle together to reach the right answer. Do not let the radiologist make the diagnosis!

Radiographs

It is imperative to obtain good-quality radiographs, including axial radiographs of the patella in early flexion, to check for evidence of arthrosis and other joint pathology that may be producing pain. Dr. Post always obtains bilateral knee radiographs to help understand the degree of any arthrosis or malalignment in the contralateral asymptomatic knee. The information in bilateral radiographs is also instructive for patients. Knowing that the contralateral knee shows the same radiographic changes, or even more, helps them understand that the structural factors as imaged do not dictate symptoms. More advanced or extensive imaging is not needed unless appropriate and patient therapy reaches a stalemate.

Bone Scans

In recalcitrant patients with persistent pain, a bone scan provides sensitive imaging of osseous metabolic activity and thereby clarifies the etiology of the pain. A negative scan rules out the bone as a significant cause, freeing the clinician to concentrate solely on the soft tissues. In a way that MRI can miss, a positive bone scan identifies specific regions that have lost osseous homeostasis and are being overloaded. Microscopically, these regions’ changes are very similar to the abnormal bone remodeling that occurs in early-stage stress fractures. Whether focal or diffuse, a positive bone scan means symptoms likely will take longer to reverse than is the case with a negative scan. Often, the stark findings of a positive bone scan can grab the patient’s attention and improve understanding and compliance. Focal inferior pole uptake is the most difficult pattern to reverse, perhaps because it may represent the most extreme biomechanical environment of the patellofemoral joint. In Dr. Dye’s experience, patients with this pattern may often require drilling of the inferior pole to achieve restoration of tissue homeostasis.

Magnetic Resonance Imaging

MRI can be useful, though scans are commonly read as normal. In some cases, MRI evidence of tendinopathy and other intra-articular pathology can direct both operative and nonoperative treatment of AKP. Carefully look for evidence of soft-tissue impingement—such as mild synovial swelling, low-grade effusion, and neovascularization of the fat pad—as in many cases it exists, and has been missed by the radiologist (Figures 12A, 12B).

When Surgery Is Needed: General Principles

Although the majority of patients with AKP do not need surgery, some do. Think of surgery as a tool used to create an environment in which homeostasis may be restored. Arthroscopy and meticulous débridement may be used to treat recalcitrant focal synovitis or fat-pad hypertrophy—or focal chondral pathology (eg, unstable flap of articular cartilage) that has produced mechanical symptoms with secondary inflammation. A well-localized area of patellar tendinosis may respond to either arthroscopic or open débridement. A true mechanical alignment abnormality may produce focal overload to such a degree that the most complete nonoperative programs cannot overcome the loss of homeostasis. In such a case, imaging studies that precisely document overloaded areas and associated malalignment must make sense given the clinical picture, and then must be used in developing a rational surgical plan for unloading bone and soft-tissue pathology to create a mechanical and biological environment for healing and return to homeostasis. At times, the articular damage may be so severe that patellofemoral arthroplasty is the best choice. The exact indications for these procedures are well described elsewhere.¹³

Surgery for Patients With PFP Caused by Recalcitrant Synovitis

As this type of surgery is not often covered in the literature, we offer some treatment pearls here. Arthroscopy for persistent focal synovitis should not be approached lightly; though the mechanics of removing abnormal inflamed synovial tissue may be straightforward, perioperative management and long-term postoperative management are not. The patient must be mentally prepared for the process; blood-thinning agents, fish oil, and turmeric must be discontinued; and hemostasis must be meticulous (Figures 13A-13C).

Conclusion

The history of medicine has included many misunderstandings of cause and effect. Trephination was used for headaches, leeches for fever, and, more recently, antacids for Helicobacter pylori caused duodenal ulcers. Stimulated by the enigma of AKP, we think our common sense way of thinking about tissue homeostasis in the musculoskeletal system represents an emerging orthopedic biological paradigm that is applicable to the entire body. We should let the remarkable capacity of vertebrate biology do the “heavy lifting” of healing. The traditional orthopedic emphasis on structure and alignment has a role, but we see it as complementary and secondary to the biological paradigm and find that the evidence presented herein supports our contention. The answer is seen only when one looks beyond the viewbox.

Primum non nocere. Your patients will be most grateful.

Am J Orthop. 2017;46(2):92-100. Copyright Frontline Medical Communications Inc. 2017. All rights reserved.