Well over a year now, back into the mists of a pre pandemic world, I interviewed Claire Robertson to get a flavour of her approach and what was on the menu in the upcoming PFP course (now rescheduled for the 18th Sept 2021) in Exeter.
BW: Claire thanks for your time and agreeing to come down to teach in Exeter. With a twitter handle like @clairepatella there are no prizes for guessing your specialist subject. What gave you the bug to research and specialise in the treatment of patellofemoral pain?
CR: Well the real turning point was my MSc. I was already a lower limb MSK physio but my dissertation was my first piece of research and I looked at PFP after THR which I had observed on many occasions. I was dreading my dissertation but actually really loved taking a real-life problem and investigating it. I was excited to then publish this work and when the university asked me to stay on after my MSc as a part-time lecturer and continue researching, I couldn’t resist! At that point my local referrers had been informally sending me all their patients with PFP as they knew I was interested by it so Wimbledon Clinics turned round and asked if I would like to do a pure second opinion PFP service. That was 12 years ago so you can imagine how many patellae I’ve seen since then!
BW: That’s a considerable number of poorly patellae! Speaking of which, one of the first in-service training sessions I attended as a rotational physiotherapist was on serious and sinister pathology around the knee. Our knee ESP presented a case of osteosarcoma in the distal femur. Do you incorporate teaching of screening for sinister pathology on the course?
CR: Absolutely. If you don’t have these other pathologies on your radar you won’t spot it. They are not all sinister, but a wrong diagnosis is hugely unhelpful. Over the years I have seen slipped femoral epiphysis, FAI, PCL rupture and many other pathologies masquerade as PFP.
BW: Great, we will have to get our differential diagnosis thinking caps on then. Given that you must see a lot of cases who have passed through various physiotherapy approaches in the past, do you recognise any common pit falls in the management of PFP that we should be awake to?
CR: Yes it is interesting when pretty much all your patients have had failed physio. Without a doubt the number one thing I see is too many exercises being given out. Reams of exercises so that the poor patient has no buy in to what they are trying to achieve, and is overwhelmed by the thought of the exercises.
The other most common thing is the patient has been given painful squats as rehab. It makes them worse, loses their confidence in the physio and they don’t get stronger due to pain inhibition.
BW: My perception of your approach is that you don’t seem to be afraid of utilising symptom modification as a means of taking patients forward, in particular your use of ice in practice sounds interesting.
CR: Well it’s very variable. I would never use a passive therapy in isolation. But often the ice, and particularly tape lessen the pain which gives a window of opportunity to do effective exercise.
BW: On the topic of tricky persistent cases, I must admit I usually get a feeling a dread when I hear the words PFP and surgery in the same sentence. Especially the group with pain in that fiddly area just inferior to the patella. Am I right to be allergic or should I be keeping an open mind?
CR: There are some scenarios where surgery works really well, but patient selection is key. So, for example a grossly unstable patella or an unstable osteochondral defect can respond well. Sadly the bigger group of post-surgical patients I see are patients that have had something like an ACL or meniscectomy and have post-surgical PFP. They are probably about 15% of my entire case load.
BW: Claire, thank you for this introduction. I’m very much looking forward to catching up properly over the duration of the course and picking your brain on all things PFP.
CR: I’m so excited about coming to Exeter. I’d like to finish saying that my course is all about confidence and I do tailor it during the day to each person’s needs. So, if I have a paeds physio I will talk to them more about the adolescent knee, and an ESP will have advanced clinical reasoning. All in all though it should make every delegate really excited about seeing their next patient with PFP!!
For those who are keen to familiarise themselves with Claire’s previous work I would direct you to her website.
I hope you will join us for this course which has now been rearranged for 18th September at Heavitree Hospital Physiotherapy outpatient department.