The McConnell medial taping technique; effects on patellar alignment and pain for patellofemoral pain syndrome by Alicia Canning A thesis submitted in partial fulfilment of the requirements for the degree of Master of Science in Interdisciplinary Health (MSc INDH) The Faculty of Graduate Studies Laurentian University Sudbury, Ontario, Canada Alicia Canning, 2017 © THESIS DEFENCE COMMITTEE/COMITÉ DE SOUTENANCE DE THÈSE Laurentian Université/Université Laurentienne Faculty of Graduate Studies/Faculté des études supérieures Title of Thesis Titre de la thèse The McConnell medial taping technique; effects on patellar alignment and pain for patellofemoral pain syndrome Name of Candidate Nom du candidat Canning, Alicia Degree Diplôme Master of Science Department/Program Date of Defence Département/Programme Interdisciplinary Health Date de la soutenance August 21, 2017 APPROVED/APPROUVÉ Thesis Examiners/Examinateurs de thèse: Dr. Sylvain Grenier (Supervisor/Directeur(trice) de thèse) Dr. Céline Larivière (Committee member/Membre du comité) Dr. Brent Lievers (Committee member/Membre du comité) Approved for the Faculty of Graduate Studies Approuvé pour la Faculté des études supérieures Dr. David Lesbarrères Monsieur David Lesbarrères Dr. Monica Maly Dean, Faculty of Graduate Studies (External Examiner/Examinateur externe) Doyen, Faculté des études supérieures ACCESSIBILITY CLAUSE AND PERMISSION TO USE I, Alicia Canning, hereby grant to Laurentian University and/or its agents the non-exclusive license to archive and make accessible my thesis, dissertation, or project report in whole or in part in all forms of media, now or for the duration of my copyright ownership. I retain all other ownership rights to the copyright of the thesis, dissertation or project report. I also reserve the right to use in future works (such as articles or books) all or part of this thesis, dissertation, or project report. I further agree that permission for copying of this thesis in any manner, in whole or in part, for scholarly purposes may be granted by the professor or professors who supervised my thesis work or, in their absence, by the Head of the Department in which my thesis work was done. It is understood that any copying or publication or use of this thesis or parts thereof for financial gain shall not be allowed without my written permission. It is also understood that this copy is being made available in this form by the authority of the copyright owner solely for the purpose of private study and research and may not be copied or reproduced except as permitted by the copyright laws without written authority from the copyright owner. ii ABSTRACT The effect of the McConnell medial taping technique on patellar alignment and perceived knee pain in patients with patellofemoral pain syndrome (PFPS) between the ages of 20- 50 years old was examined in this study. Clinical patellar alignment was assessed with the McConnell and Herrington manual patellar measuring technique while pain measures were assessed using a visual analogue scale (VAS). These measures were collected at three-times during a 4-week treatment protocol: prior to treatment, mid-way treatment and 24 hours after treatment. This study included two therapy groups: one received a standard 4-week therapeutic exercise program for PFPS and the other underwent the same standard 4-week exercise program with the inclusion of McConnell’s taping technique. No statistically significant differences were found before and after treatment for pain or patellar alignment in either group. Nonetheless, upon plotting the results a trending decrease in pain for all patients irrespective of group was noted, which raises the question of possible underlying effects influencing pain such as the patellofemoral contact area. Although it appears that the McConnell taping technique had no added benefit when combined with the standard exercise program, this study reaffirms that exercise therapy continues to have a positive effect on PFPS. In conclusion, we speculate that changes in patellofemoral joint (PFJ) contact area may be the primary reason that pain decreases for PFPS patients. Keywords: Patellofemoral Pain Syndrome, Patellar Alignment, McConnell Taping, Osteoarthritis. iii ACKNOWLEDGEMENTS I am extremely thankful and appreciative to those who have assisted me throughout this thesis journey. To my supervisor, Dr. Sylvain Grenier, thank you for your guidance and mentorship, and all your time and expertise in bettering the study. To my committee members, Dr. Brent Lievers and Dr. Céline Larivière, thank you for your time and assistance throughout the process and providing me with excellent feedback. I would like to thank Physiotherapist Sulabh Singh, who graciously agreed to provide his expertise for this research. I truly appreciate all the time you’ve committed throughout the therapeutic treatment. I would also like to thank the participants who have devoted ample time and efforts to the exercise program. Without you, this study would not have been possible. Finally, I would like to thank my friends and family for being there and supporting me throughout my entire graduate degree. iv TABLE OF CONTENTS ABSTRACT ...................................................................................................................... iii ACKNOWLEDGEMENTS ............................................................................................ iv TABLE OF CONTENTS ................................................................................................. v LIST OF TABLES ......................................................................................................... viii LIST OF FIGURES ......................................................................................................... ix LIST OF APPENDICES .................................................................................................. x LIST OF ABRIVIATIONS ............................................................................................. xi CHAPTER I ...................................................................................................................... 1 1.0 Introduction ............................................................................................................... 2 CHAPTER II ..................................................................................................................... 7 REVIEW OF LITERATURE ......................................................................................... 7 2.0 Knee Pain and Patellofemoral Pain Syndrome (PFPS) ............................................. 8 2.1 Overweight ................................................................................................................ 9 2.2 Injuries .................................................................................................................... 13 2.3 Knee Mechanics ...................................................................................................... 15 2.3.1 Q-angle ............................................................................................................. 17 2.3.2 Muscle Strength ............................................................................................... 20 2.3.3 Muscle Tightness ............................................................................................. 23 2.4 PFPS Left Untreated ............................................................................................... 25 2.5 Treatment Methods ................................................................................................. 26 2.6 Purpose .................................................................................................................... 32 2.7 Research Questions ................................................................................................. 33 v 2.8 Hypotheses .............................................................................................................. 33 CHAPTER III ................................................................................................................. 35 METHODOLOGY ....................................................................................................... 35 3.0 Study Design ........................................................................................................... 36 3.1 Sample Size Calculation ......................................................................................... 36 3.2 Recruitment Strategy and Changes ......................................................................... 36 3.3 Statistical and Non-Statistical Design ..................................................................... 36 3.4 Inclusion and Exclusion Criteria ............................................................................. 37 3.5 Participant Demographics ....................................................................................... 39 3.6 Data Collection ....................................................................................................... 39 3.7 Procedure ................................................................................................................ 40 3.8 Variables ................................................................................................................. 42 3.9 Instruments .............................................................................................................. 42 CHAPTER IV .................................................................................................................. 47 RESULTS ..................................................................................................................... 47 4.0 Participant Demographics ....................................................................................... 48 4.1 SPSS Non-parametric tests ..................................................................................... 49 4.1.1 Patella Measurement Results ........................................................................... 49 4.1.2 Perceived Pain Results ..................................................................................... 50 4.2 Individual results ..................................................................................................... 51 4.2.1 Patella Measurement Case Results .................................................................. 52 4.2.2 Perceived Pain Score Case Results .................................................................. 54 CHAPTER V ................................................................................................................... 57 DISCUSSION ............................................................................................................... 57 vi 5.0 Study overview: purpose, hypotheses and findings ................................................ 58 5.1 Patellar Alignment .................................................................................................. 59 5.1.1 Asymptomatic Alignment ................................................................................ 60 5.1.2 Symptomatic Alignment .................................................................................. 61 5.2 Manual patella alignment assessment ..................................................................... 62 5.3 Pain Measurement ................................................................................................... 63 5.4 Patellofemoral Joint Area ....................................................................................... 65 5.5 Limitations .............................................................................................................. 67 5.6 Future Directions .................................................................................................... 70 CHAPTER VI .................................................................................................................. 72 CONCLUSION ............................................................................................................. 72 6.0 Conclusions ............................................................................................................. 73 REFERENCE LIST ........................................................................................................ 74 APPENDICES ............................................................................................................... 110 vii LIST OF TABLES Table 1: Demographic features of both the Taped (n=4) and Non-Taped (n=4) group ... 39 Table 2: Demographic participant features of the taped and non-taped treatment groups49 Table 3: Lateral patellar displacement (%) of the total knee length before and after treatment for taped group .................................................................................................. 53 Table 4: Medial-lateral patellar difference (mm) and percentage change (%) before and after treatment for taped group ......................................................................................... 53 Table 5: Lateral patellar displacement (%) of the total knee length before and after treatment for non-taped group .......................................................................................... 54 Table 6: Medial-lateral patellar difference (mm) and percentage change (%) before and after treatment for non-taped group .................................................................................. 54 Table 7: Comparison of perceived pain percentage scores before and after 4-week treatment, and the pain percentage change for taped group .............................................. 55 Table 8: Comparison of perceived pain percentage scores before and after 4-week treatment, and the pain percentage change for non-taped group ...................................... 56 viii LIST OF FIGURES Figure 1: Left image displaying the patella as it normally rests in the trochlear groove (patella alignment). Right image representing the patellar glide within the groove as the knee flexes and extends (patella tracking) (Hettrich & Liechti, 2015). ............................ 16 Figure 2: Q-angle (Marra, 2013). ..................................................................................... 18 Figure 3: Quadriceps muscles including the Vastus medialis musle (VMO) and the Vastus lateralis muscle (VL) (Richards, 2016). ................................................................ 23 Figure 4: 20° Knee flexion............................................................................................... 44 Figure 5: Medial and lateral femoral condyle landmarks (Chai, 2005). .......................... 44 Figure 6: Example of patella measurement taken from the midpoint of the patella to the lateral femoral condyle. .................................................................................................... 44 Figure 7: Flow chart diagram of the progression of participants through the treatment . 48 Figure 8: The number of occurrences within each group: taped and non-taped. Pain improvement (blue), no change (red) and pain deterioration (green). .............................. 52 ix LIST OF APPENDICES Appendix A: Recruitment Poster ................................................................................ 111 Appendix B: Participant Information and Consent Form ........................................ 112 Appendix C: Measures ................................................................................................. 115 Appendix D: Exercises .................................................................................................. 116 Appendix E: Individual Pain Scores ........................................................................... 117 Appendix F: Research Ethics Board Approval .......................................................... 119 x