髌股关节疼痛综合征

治疗计划需注重相对休息及改变活动方式（即低水平活动，特别是会产生压力的活动）。

急性期可用冰敷或其他方式冷敷以缓解症状，一次10-15分钟，每日2-3次。通常不建议热敷。[23]Dixit S, DiFiori JP, Burton M, et al. Management of patellofemoral pain syndrome. Am Fam Physician. 2007;75:194-202.http://www.aafp.org/afp/2007/0115/p194.htmlhttp://www.ncbi.nlm.nih.gov/pubmed/17263214?tool=bestpractice.com

针对经选择患者组全部患者的治疗推荐

目前支持NSAID短期内可缓解疼痛的证据仍有限。证据 C疼痛缓解：目前有低质量的证据支持在缓解髌股关节疼痛方面萘普生比安慰剂更有效。然而有研究发现NSAID与安慰剂在缓解疼痛方面无显著差异。[50]Suter E, Herzog W, De Souza K, et al. Inhibition of the quadriceps muscles in patients with anterior knee pain. J Appl Biomech. 1998;14:360-373.[51]Bentley G, Leslie IJ, Fischer D. Effect of aspirin treatment on chondromalacia patellae. Ann Rheum Dis. 1981;40:37-41.http://ard.bmj.com/content/40/1/37.longhttp://www.ncbi.nlm.nih.gov/pubmed/7008711?tool=bestpractice.com[52]Marchese A, Cherubini M, Forte R. Laser therapy versus pharmacological in anterior knee pain. La Riabilitazione. 1998;31:189-198.低质量的观察性（队列）研究或者受试者＜200名且方法学存在缺陷的随机对照临床试验（RCT）。

尽管目前关于髌骨带临床有效性的临床试验证据不足，且质量偏低，但髌骨带可以减轻症状，增加股四头肌活动，允许膝关节应力增加，仍须行进一步临床试验确定其长期疗效。[54]Callaghan MJ, Selfe J. Patellar taping for patellofemoral pain syndrome in adults. Cochrane Database Syst Rev. 2012;(4):CD006717.http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD006717.pub2/fullhttp://www.ncbi.nlm.nih.gov/pubmed/22513943?tool=bestpractice.com[55]Powers CM. Rehabilitation of patellofemoral joint disorders: a critical review. J Ortho Sports Phys Ther. 1998;28:345-354.http://www.ncbi.nlm.nih.gov/pubmed/9809282?tool=bestpractice.com[56]Aminaka N, Gribble PA. A systematic review of the effects of therapeutic taping on patellofemoral pain syndrome. J Athl Train. 2005;40:341-351.http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1323297/http://www.ncbi.nlm.nih.gov/pubmed/16404457?tool=bestpractice.com

若佩戴适宜的动力髌骨稳定支具，患者或可减轻疼痛。

股四头肌的强度、功能及运动模式可通过开链或闭链运动来增强。证据 B疼痛缓解：中等质量的证据证实锻炼比不进行锻炼可减轻髌股关节疼痛。[63]Timm KE. Randomized controlled trial of Protonics on patellar pain, position, and function. Med Sci Sports Exerc. 1998;30:665-670.http://www.ncbi.nlm.nih.gov/pubmed/9588606?tool=bestpractice.com[60]Clark DI, Downing N, Mitchell J, et al. Physiotherapy for anterior knee pain: a randomised controlled trial. Ann Rheum Dis. 2000;59:700-704.http://ard.bmj.com/content/59/9/700.longhttp://www.ncbi.nlm.nih.gov/pubmed/10976083?tool=bestpractice.com[81]McMullen W, Roncarati A, Koval P. Static and isokinetic treatments of chondromalacia patella: a comparative investigation. J Orthop Sports Phys Ther. 1990;12:256-266.http://www.jospt.org/doi/pdf/10.2519/jospt.1990.12.6.256http://www.ncbi.nlm.nih.gov/pubmed/18796869?tool=bestpractice.com受试者＜200名的随机对照临床试验（RCT）、受试者＞200名且方法学存在缺陷的随机对照临床试验（RCT）、方法学存在缺陷的系统评价或者高质量的观察性（队列）研究。目前机制未明，可能的原因为股四头肌肌力增强改变了髌骨的轨迹，也可用接触位置的精细改变及压力分布变化来解释观察到的获益。[82]Besier TF, Fredericson M, Gold GE, et al. Knee muscle forces during walking and running in patellofemoral pain patients and pain-free controls. J Biomech. 2009;42:898-905.http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2671570/http://www.ncbi.nlm.nih.gov/pubmed/19268945?tool=bestpractice.com

开链运动包括膝关节伸直练习，闭链运动包括弓箭步、划墙练习及腿部推蹬机练习。闭链运动更受青睐，因为其更好地复制了运动员的运动需求，需要多肌群的同时收缩，且关节应力更接近功能位。[67]Irish SE, Millward AJ, Wride J, et al. The effect of closed-kinetic chain exercises and open-kinetic chain exercise on the muscle activity of vastus medialis oblique and vastus lateralis. J Strength Cond Res. 2010;24:1256-1262.http://www.ncbi.nlm.nih.gov/pubmed/20386128?tool=bestpractice.com[68]Bennell K, Duncan M, Cowan S, et al. Effects of vastus medialis oblique retraining versus general quadriceps strengthening on vasti onset. Med Sci Sports Exerc. 2010;42:856-864.http://www.ncbi.nlm.nih.gov/pubmed/19997004?tool=bestpractice.com

有良好的证据证实开链和闭链运动同样有效。证据 A疼痛缓解：良好质量的证据证实开链和闭链运动在减轻疼痛方面同样有效。[67]Irish SE, Millward AJ, Wride J, et al. The effect of closed-kinetic chain exercises and open-kinetic chain exercise on the muscle activity of vastus medialis oblique and vastus lateralis. J Strength Cond Res. 2010;24:1256-1262.http://www.ncbi.nlm.nih.gov/pubmed/20386128?tool=bestpractice.com[68]Bennell K, Duncan M, Cowan S, et al. Effects of vastus medialis oblique retraining versus general quadriceps strengthening on vasti onset. Med Sci Sports Exerc. 2010;42:856-864.http://www.ncbi.nlm.nih.gov/pubmed/19997004?tool=bestpractice.com[69]Stiene HA, Brosky T, Reinking MF, et al. A comparison of closed kinetic chain and isokinetic joint isolation exercise in patients with patellofemoral dysfunction. J Orthop Sports Phys Ther. 1996;24:136-141.http://www.ncbi.nlm.nih.gov/pubmed/8866272?tool=bestpractice.com[70]Witvrouw E, Lysens R, Bellemans J, et al. Open versus closed kinetic chain exercises for patellofemoral pain: a prospective, randomized study. Am J Sports Med. 2000;28:687-694.http://www.ncbi.nlm.nih.gov/pubmed/11032226?tool=bestpractice.com[71]Wijnen LC, Lenssen AF, Kuys-Wouters YM, et al. McConnell therapy versus Coumans bandage for patellofemoral pain: a randomised pilot study. Ned Tijdschr Fysiother. 1996;(special issue):12-17.[72]Gaffney K, Fricker P, Dwyer T, et al. Patellofemoral joint pain: a comparison of two treatment programmes. Excel. 1992;8:179-189.[73]Smith TO, Bowyer D, Dixon J, et al. Can vastus medialis oblique be preferentially activated? A systematic review of electromyographic studies. Physiother Theory Pract. 2009;25:69-98.http://www.ncbi.nlm.nih.gov/pubmed/19212898?tool=bestpractice.com系统评价或者受试者＞200名的随机对照临床试验（RCT）。

无论采取何种类型的锻炼，增强肌肉耐力及强度，对于耐力型运动员非常重要。高剂量高重复性的锻炼比低剂量低重复性的锻炼更有效。[83]Østerås B, Østerås H, Torstensen TA, et al. Dose-response effects of medical exercise therapy in patients with patellofemoral pain syndrome: a randomised controlled clinical trial. Physiotherapy. 2013;99:126-131.http://www.ncbi.nlm.nih.gov/pubmed/23219636?tool=bestpractice.com高剂量高重复性的训练可提供良好的长期疗效，尤其对髌股关节疼痛综合征的疼痛缓解和提高功能更为有效。[84]Østerås B, Østerås H, Torstensen TA. Long-term effects of medical exercise therapy in patients with patellofemoral pain syndrome: results from a single-blinded randomized controlled trial with 12 months follow-up. Physiotherapy. 2013;99:311-316.http://www.ncbi.nlm.nih.gov/pubmed/23764516?tool=bestpractice.com

对于因疼痛无法进行肌力训练的患者，用McConnell带技术矫正异常髌骨姿势可以恢复髌骨与滑车的对位对线（或某种程度上减少髌股关节的接触压力）。[53]Derasari A, Brindle TJ, Alter KE, Sheehan FT. McConnell taping shifts the patella inferiorly in patients with patellofemoral pain: a dynamic magnetic resonance imaging study. Phys Ther. 2010;90:411-419.https://academic.oup.com/ptj/article-lookup/doi/10.2522/ptj.20080365http://www.ncbi.nlm.nih.gov/pubmed/20110340?tool=bestpractice.com尽管目前关于髌骨带临床有效性的临床试验证据不足，且质量偏低，但髌骨带可以减轻症状，增加股四头肌活动，允许膝关节应力增加，仍须行进一步临床试验确定其长期疗效。[54]Callaghan MJ, Selfe J. Patellar taping for patellofemoral pain syndrome in adults. Cochrane Database Syst Rev. 2012;(4):CD006717.http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD006717.pub2/fullhttp://www.ncbi.nlm.nih.gov/pubmed/22513943?tool=bestpractice.com[55]Powers CM. Rehabilitation of patellofemoral joint disorders: a critical review. J Ortho Sports Phys Ther. 1998;28:345-354.http://www.ncbi.nlm.nih.gov/pubmed/9809282?tool=bestpractice.com[56]Aminaka N, Gribble PA. A systematic review of the effects of therapeutic taping on patellofemoral pain syndrome. J Athl Train. 2005;40:341-351.http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1323297/http://www.ncbi.nlm.nih.gov/pubmed/16404457?tool=bestpractice.com除单独应用物理治疗以外，结合使用髌骨带是否为有效的治疗方式，目前尚无足够质量的证据确定这一点。[57]Collins NJ, Bisset LM, Crossley KM, et al. Efficacy of nonsurgical interventions for anterior knee pain: systematic review and meta-analysis of randomized trials. Sports Med. 2012;42:31-49.http://www.ncbi.nlm.nih.gov/pubmed/22149696?tool=bestpractice.com证据 C疼痛缓解：有低质量的证据证明髌骨带结合锻炼比单独锻炼更有效。然而有研究认为两者无差别。[58]Whittingham M, Palmer S, Macmillan F. Effects of taping on pain and function in patellofemoral pain syndrome: a randomized controlled trial. J Orthop Sports Phys Ther. 2004;34:504-510.http://www.ncbi.nlm.nih.gov/pubmed/15493518?tool=bestpractice.com[59]Kowall MG, Kolk G, Nuber GW, et al. Patellar taping in the treatment of patellofemoral pain: a prospective randomized study. Am J Sports Med. 1996;24:61-66.http://www.ncbi.nlm.nih.gov/pubmed/8638755?tool=bestpractice.com[60]Clark DI, Downing N, Mitchell J, et al. Physiotherapy for anterior knee pain: a randomised controlled trial. Ann Rheum Dis. 2000;59:700-704.http://ard.bmj.com/content/59/9/700.longhttp://www.ncbi.nlm.nih.gov/pubmed/10976083?tool=bestpractice.com低质量的观察性（队列）研究或者受试者＜200名且方法学存在缺陷的随机对照临床试验（RCT）。

若佩戴适宜的动力髌骨稳定支具，患者或可减轻疼痛。运动影像学研究显示膝关节支具可在减轻髌骨轨迹异常方面起到机械性作用。[61]Draper CE, Besier TF, Santos JM, et al. Using real-time MRI to quantify altered joint kinematics in subjects with patellofemoral pain and to evaluate the effects of a patellar brace or sleeve on joint motion. J Orthop Res. 2009;27:571-577.http://onlinelibrary.wiley.com/doi/10.1002/jor.20790/pdfhttp://www.ncbi.nlm.nih.gov/pubmed/18985690?tool=bestpractice.com症状改善可能是因为接触面积增加（通过挤压）、通过更大的面积分散关节反作用力以及减轻关节应力。[62]Powers CM, Shellock FG, Beering TV, et al. Effect of bracing on patellar kinematics in patients with patellofemoral joint pain. Med Sci Sports Exerc. 1999;31:1714-1720.http://www.ncbi.nlm.nih.gov/pubmed/10613420?tool=bestpractice.com髌股支具的有效性目前仍存争议。但支具可作为长期的治疗方式使用。一小部分患者，如髌股显著移位的患者，对支具治疗的反应良好。[63]Timm KE. Randomized controlled trial of Protonics on patellar pain, position, and function. Med Sci Sports Exerc. 1998;30:665-670.http://www.ncbi.nlm.nih.gov/pubmed/9588606?tool=bestpractice.com[64]Miller MD, Hinkin DT, Wisnowski JW. The efficacy of orthotics for anterior knee pain in military trainees: a preliminary report. Am J Knee Surg. 1997;10:10-13.http://www.ncbi.nlm.nih.gov/pubmed/9051172?tool=bestpractice.com[65]Lun VM, Wiley JP, Meeuwisse WH, et al. Effectiveness of patellar bracing for treatment of patellofemoral pain syndrome. Clin J Sport Med. 2005;15:235-240.http://www.ncbi.nlm.nih.gov/pubmed/16003037?tool=bestpractice.com[66]Swart NM, van Linschoten R, Bierma-Zeinstra SM, et al. The additional effect of orthotic devices on exercise therapy for patients with patellofemoral pain syndrome: a systematic review. Br J Sports Med. 2012;46:570-577.http://www.ncbi.nlm.nih.gov/pubmed/21402565?tool=bestpractice.com证据 B疼痛缓解及关节功能：有中等质量的证据认为髌骨带有助于缓解疼痛，提高关节功能。然而亦有研究认为两者无差别。[63]Timm KE. Randomized controlled trial of Protonics on patellar pain, position, and function. Med Sci Sports Exerc. 1998;30:665-670.http://www.ncbi.nlm.nih.gov/pubmed/9588606?tool=bestpractice.com[64]Miller MD, Hinkin DT, Wisnowski JW. The efficacy of orthotics for anterior knee pain in military trainees: a preliminary report. Am J Knee Surg. 1997;10:10-13.http://www.ncbi.nlm.nih.gov/pubmed/9051172?tool=bestpractice.com[65]Lun VM, Wiley JP, Meeuwisse WH, et al. Effectiveness of patellar bracing for treatment of patellofemoral pain syndrome. Clin J Sport Med. 2005;15:235-240.http://www.ncbi.nlm.nih.gov/pubmed/16003037?tool=bestpractice.com受试者＜200名的随机对照临床试验（RCT）、受试者＞200名且方法学存在缺陷的随机对照临床试验（RCT）、方法学存在缺陷的系统评价或者高质量的观察性（队列）研究。

软组织结构紧张包括髂胫束或外侧支持带紧张。

可通过深方纵向按摩减少髂胫束及其上覆筋膜的粘连。

可通过保持髌骨向内侧滑动来被动拉伸髌骨外侧结构。

髌股关节疼痛患者伴臀中肌及腰方肌肌筋膜“扳机点”的比例更高。治疗时对上述区域需进行针对性的深层组织肌筋膜松解。一旦近端髋关节外展肌充分活动，这些扳机点发生几率会减少。[85]Roach S, Sorenson E, Headley B, et al. Prevalence of myofascial trigger points in the hip in patellofemoral pain. Arch Phys Med Rehabil. 2013;94:522-526.http://www.archives-pmr.org/article/S0003-9993(12)01079-9/fulltexthttp://www.ncbi.nlm.nih.gov/pubmed/23127304?tool=bestpractice.com

髌骨过度活动的患者可以从活动技术中获益。

使用这些技术时需小心，防止髌股关节压力过高。

为了更好地活动髌骨，膝关节需处于伸直位或轻度屈曲位（不超过20°）。

若膝关节屈曲超过20°，则髌骨坐于滑车沟中，被动紧张股四头肌将限制髌骨活动。[5]Fredericson M, Powers CM. Practical management of patellofemoral pain. Clin J Sport Med. 2002;12:36-38.http://www.ncbi.nlm.nih.gov/pubmed/11854587?tool=bestpractice.com

矫形器具可用来减少动力性Q角，控制下肢旋转。证据 B疼痛缓解：中等质量的证据证实矫形支具可改善疼痛症状。[75]Johnston LB, Gross MT. Effects of foot orthoses on quality of life for individuals with patellofemoral pain syndrome. J Orthop Sports Phys Ther. 2004;34:440-448.http://www.ncbi.nlm.nih.gov/pubmed/15373007?tool=bestpractice.com[76]Eng JJ, Pierrynowski MR. Evaluation of soft foot orthotics in the treatment of patellofemoral pain syndrome. Phys Ther. 1993;73:62-68.http://www.ncbi.nlm.nih.gov/pubmed/8421719?tool=bestpractice.com[77]Hossain M, Alexander P, Burls A,et al. Foot orthoses for patellofemoral pain in adults. Cochrane Database Syst Rev. 2011;(1):CD008402.http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD008402.pub2/fullhttp://www.ncbi.nlm.nih.gov/pubmed/21249707?tool=bestpractice.com[78]Barton CJ, Munteanu SE, Menz HB, et al. The efficacy of foot orthoses in the treatment of individuals with patellofemoral pain syndrome: a systematic review. Sports Med. 2010;40:377-395.http://www.ncbi.nlm.nih.gov/pubmed/20433211?tool=bestpractice.com受试者＜200名的随机对照临床试验（RCT）、受试者＞200名且方法学存在缺陷的随机对照临床试验（RCT）、方法学存在缺陷的系统评价或者高质量的观察性（队列）研究。

若放松站立位与距下关节中立位Q角变化不超过5°，则矫形器具并不能显著改变下肢对位对线。

前足的稳定性对后足的稳定性至关重要，主要原因在于前足的不稳定会在脚趾离开地面时造成后足的不稳定。[86]Eng JJ, Pierrynowski MR. The effect of soft foot orthotics on three-dimensional lower-limb kinematics during walking and running. Phys Ther. 1994;74:836-844.http://www.ncbi.nlm.nih.gov/pubmed/8066110?tool=bestpractice.com因此，矫形器具的长度需包括趾蹼的部分，以控制前足的不稳定性。[87]Watson CJ, Propps M, Galt W, et al. Reliability of McConnell's classification of patellar orientation in symptomatic and asymptomatic subjects. J Orthop Sports Phys Ther. 1999;29:378-385.http://www.ncbi.nlm.nih.gov/pubmed/10416177?tool=bestpractice.com

在这些患者中，观察报道显示股骨在步态过程中向内旋转，且该动作起源自骨盆（相对胫骨旋转的影响来说）。股骨内旋的功能性影响主要在于滑车沟可于髌骨下进行旋转，将髌骨置于一个相对靠外的位置。[88]Powers CM, Ward SR, Fredericson M, et al. Patellar kinematics during weight-bearing and non-weight bearing knee extension in persons with lateral subluxation of the patella: a preliminary study. J Orthop Sports Phys Ther. 2003;33:677-685.http://www.ncbi.nlm.nih.gov/pubmed/14669963?tool=bestpractice.com[89]Peters JS, Tyson NL. Proximal exercises are effective in treating patellofemoral pain syndrome: a systematic review. Int J Sports Phys Ther. 2013;8:689-700.http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3811739/http://www.ncbi.nlm.nih.gov/pubmed/24175148?tool=bestpractice.com

患者可自负重练习中受益，这些练习强调通过锻炼髋外展肌及外旋肌以控制股骨旋转。

与年龄匹配的无症状女性相比，髌股关节疼痛的年轻女性更易出现髋关节外旋及外展无力。[48]Ireland ML, Willson JD, Ballantyne BT, et al. Hip strength in females with and without patellofemoral pain. J Orthop Sports Phys Ther. 2003;33:671-676.http://www.ncbi.nlm.nih.gov/pubmed/14669962?tool=bestpractice.com[79]Cichanowski HR, Schmitt JS, Johnson RJ, et al. Hip strength in collegiate female athletes with patellofemoral pain. Med Sci Sports Exerc. 2007;39:1227-1232.http://www.ncbi.nlm.nih.gov/pubmed/17762354?tool=bestpractice.com患髌股关节疼痛综合征且日常久坐的女性中，膝关节拉伸、力量训练结合髋关节后外侧肌肉力量训练，在改善长期功能及减轻疼痛方面，比单纯膝关节锻炼更为有效。[90]Fukuda TY, Melo WP, Zaffalon BM, et al. Hip posterolateral musculature strengthening in sedentary women with patellofemoral pain syndrome: a randomized controlled clinical trial with 1-year follow-up. J Orthop Sports Phys Ther. 2012;42:823-830.http://www.jospt.org/doi/full/10.2519/jospt.2012.4184#.U-BD9uOSxgkhttp://www.ncbi.nlm.nih.gov/pubmed/22951491?tool=bestpractice.com

恢复正常步态功能对总体治疗计划非常关键。

跑步机上运动的实时视频反馈是一项非常有效地工具。[91]Davis I. Gait retraining in runners. Orthop Pract. 2005;17:8-13.

通过减少站立时过度髋关节内收及内旋的错误，患者可改善下肢对位对线并减少疼痛。

由于过度使用造成的髌股关节疼痛综合征患者（如运动员）需对其训练计划进行评估，找到其中明显的错误，如过快地增加运动强度，恢复时间不足，过多登山运动等。[5]Fredericson M, Powers CM. Practical management of patellofemoral pain. Clin J Sport Med. 2002;12:36-38.http://www.ncbi.nlm.nih.gov/pubmed/11854587?tool=bestpractice.com

跑步者需要减少训练量至不会引发疼痛（跑步当日或次日无痛）的程度。

替代运动包括骑车、游泳或使用椭圆机，可在治疗期间仍保证健康。[23]Dixit S, DiFiori JP, Burton M, et al. Management of patellofemoral pain syndrome. Am Fam Physician. 2007;75:194-202.http://www.aafp.org/afp/2007/0115/p194.htmlhttp://www.ncbi.nlm.nih.gov/pubmed/17263214?tool=bestpractice.com

在完成初始期及复能期治疗后，需给予所有患者综合性且个体化的练习计划。

大多数患者在接受保守治疗及综合性的康复治疗后能成功缓解。

当康复停止或恢复原有运动水平时，有些患者会出现症状复发的显现，尤其在髌骨活动性增高的运动员中更为明显。[1]Devereaux MD, Lachmann SM. Patello-femoral arthralgia in athletes attending a sports injury clinic. Br J Sports Med. 1984;18:18-21.http://bjsm.bmj.com/content/18/1/18.longhttp://www.ncbi.nlm.nih.gov/pubmed/6722419?tool=bestpractice.com[92]Blond L, Hansen L. Patellofemoral pain syndrome in athletes: a 5.7 year retrospective follow-up study of 250 athletes. Acta Orthop Belg. 1998;64:393-400.http://www.ncbi.nlm.nih.gov/pubmed/9922542?tool=bestpractice.com

手术治疗髌股关节疼痛综合征的指征为：康复治疗后症状仍持续的患者，存在结构性异常可能通过手术纠正的患者，尤其是那些X线显示存在慢性半脱位或脱位的患者。[7]Earl JE, Vetter CS. Patellofemoral pain. Phys Med Rehabil Clin N Am. 2007;18:439-458,viii.http://www.ncbi.nlm.nih.gov/pubmed/17678761?tool=bestpractice.com