Patellofemoral pain syndrome

Patellofemoral pain syndrome (PFPS; not to be confused with jumper's knee) is knee pain as a result of problems between the kneecap and the femur. The pain is generally in the front of the knee and comes on gradually. Pain may worsen with sitting, excessive use, or climbing and descending stairs.
While the exact cause is unclear, it is believed to be due to overuse. Risk factors include trauma, increased training, and a weak quadriceps muscle. It is particularly common among runners. The diagnosis is generally based on the symptoms and examination. If pushing the kneecap into the femur increases the pain, the diagnosis is more likely.
Treatment typically involves rest and physical therapy. Runners may need to switch to activities such as cycling or swimming. Insoles may help some people. Symptoms may last for years despite treatment. Patellofemoral pain syndrome is the most common cause of knee pain, affecting more than 20% of young adults. It occurs about 2.5 times more often in females than males.
Signs and symptoms.
The onset of the condition is usually gradual, although some cases may appear suddenly following trauma. The most common symptom is diffuse vague pain around the kneecap (peripatellar) and localized pain focused behind the kneecap (retropatellar). Affected individuals typically have difficulty describing the location of the pain. They may place their hands over the anterior patella or describe a circle around the patella. This is often called the "circle sign". Pain is usually initiated when weight is put on the knee extensor mechanism, such as when ascending or descending stairs or slopes, squatting, kneeling, cycling, or running. Pain during prolonged sitting is sometimes termed the "movie sign" or "theatre sign" because individuals might experience pain while sitting to watch a film or similar activity. The pain is typically aching and occasionally sharp. Pain may be exacerbated by activities. The knee joint may exhibit noises such as clicking. However, this has no relation to pain and function. Giving-way of the knee may be reported. Reduced knee flexion may be experienced during activities.
Causes.
In most patients with PFPS an examination of their history will highlight a precipitating event that caused the injury. Changes in activity patterns such as excessive increases in running mileage, repetitions such as running up steps and the addition of strength exercises that affect the patellofemoral joint are commonly associated with symptom onset. Excessively worn or poorly fitted footwear may be a contributing factor. To prevent recurrence the causal behaviour should be identified and managed correctly.
The medical cause of PFPS is thought to be increased pressure on the patellofemoral joint. There are several theorized mechanisms relating to how this increased pressure occurs:
Causes can also be a result of excessive genu valgum and the above-mentioned repetitive motions leading to abnormal lateral patellar tracking. Individuals with genu valgum have larger than normal Q-angles causing the weight-bearing line to fall lateral to the centre of the knee causing overstretching of the MCL and stressing the lateral meniscus and cartilages.
The cause of pain and dysfunction often results from either abnormal forces (e.g. increased pull of the lateral quadriceps retinaculum with acute or chronic lateral PF subluxation/dislocation) or prolonged repetitive compressive or shearing forces (running or jumping) on the PF joint. The result is synovial irritation and inflammation and subchondral bony changes in the distal femur or patella known as "bone bruises". Secondary causes of PF Syndrome are fractures, internal knee derangement, osteoarthritis of the knee and bony tumors in or around the knee.
Diagnosis.
Examination.
People can be observed standing and walking to determine patellar alignment. The Q-angle, lateral hypermobility, and J-sign are commonly used determined to determine patellar maltracking. The patellofemoral glide, tilt, and grind tests (Clarke's sign), when performed, can provide strong evidence for PFPS. Lastly, lateral instability can be assessed via the patellar apprehension test, which is deemed positive when there is pain or discomfort associated with lateral translation of the patella. Various clinical tests have been investigated for diagnostic accuracy. The Active Instability Test, knee pain during stair climbing, Clarke's test, pain with prolonged sitting, patellar inferior pole tilt, and pain during squatting have demonstrated the best accuracy. However, careful consideration is still needed when using these tests to make a differential diagnosis of PFPS.
Individuals with PFP may be exhibit higher pain level and lower function.
Magnetic resonance imaging rarely can give useful information for managing patellofemoral pain syndrome and treatment should focus on an appropriate rehabilitation program including correcting strength and flexibility concerns. In the uncommon cases where a patient has mechanical symptoms like a locked knee, knee effusion, or failure to improve following physical therapy, then an MRI may give more insight into diagnosis and treatment.
Classification.
PFPS is one of a handful of conditions sometimes referred to as runner's knee; the other conditions being chondromalacia patellae, iliotibial band syndrome, and plica syndrome.
Chondromalacia patellae is a term sometimes used synonymously with PFPS. However, there is general consensus that PFPS applies only to individuals without cartilage damage, thereby distinguishing it from chondromalacia patellae, a condition with softening of the patellar articular cartilage. Despite this distinction, the diagnosis of PFPS is typically made based only on the history and physical examination rather than on the results of any medical imaging. Therefore, it is unknown whether most persons with a diagnosis of PFPS have cartilage damage or not, making the difference between PFPS and chondromalacia theoretical rather than practical. It is thought that only some individuals with anterior knee pain will have true chondromalacia patellae.
Differential diagnosis.
The diagnosis of patellofemoral pain syndrome is made by ruling out patellar tendinitis, prepatellar bursitis, plica syndrome, Sinding-Larsen and Johansson syndrome, and Osgood–Schlatter disease. Currently, there is not a gold standard assessment to diagnose PFPS.
Treatment.
A variety of treatments for patellofemoral pain syndrome are available. Most people respond well to conservative therapy.
Exercises.
Patellofemoral pain syndrome may also result from overuse or overload of the PF joint. For this reason, knee activity should be reduced until the pain is resolved.
There is consistent but low quality evidence that exercise therapy for PFPS reduces pain, improves function and aids long-term recovery. However, there is insufficient evidence to compare the effectiveness of different types of exercises with each other, and exercises with other forms of treatment.
Exercise therapy is the recommended first line treatment of PFPS. Various exercises have been studied and recommended. Exercises are described according to 3 parameters:
The majority of exercise programs intended to treat PFPS are designed to strengthen the quadriceps muscles. Quadriceps strengthening is considered to be the "gold" standard treatment for PFPS. Quadriceps strengthening is commonly suggested because the quadriceps muscles help to stabilize the patella. Quadriceps weakness and muscle imbalance may contribute to abnormal patellar tracking.
If the strength of the vastus medialis muscle is inadequate, the usually larger and stronger vastus lateralis muscle will pull sideways (laterally) on the kneecap. Strengthening the vastus medialis to prevent or counter the lateral force of the vastus lateralis is one way of relieving PFPS. However, there is growing evidence that shows proximal factors play a much larger role than vastus medialis (VMO) strength deficits or quadriceps imbalance. Hip abductor, extensor, and external rotator strengthening may help.
Emphasis during exercise may be placed on coordinated contraction of the medial and lateral parts of the quadriceps as well as of the hip adductor, hip abductor and gluteal muscles. Many exercise programs include stretches designed to improve lower limb flexibility. Electromyographic biofeedback allows visualization of specific muscle contractions and may help individuals performing the exercises to target the intended muscles during the exercise. Neuromuscular electrical stimulation to strengthen quadracep muscles is sometimes suggested, however the effectiveness of this treatment is not certain.
Inflexibility has often been cited as a source of patellofemoral pain syndrome. Stretching of the lateral knee has been suggested to help.
Knee and lumbar joint mobilization are not recommended as primary interventions for PFPS. It can be used as combination intervention, but as we continue to promote use of active and physical interventions for PFPS, passive interventions such as joint mobilizations are not recommended.
Medication.
Non-steroidal anti-inflammatory drugs (NSAIDs) are widely used to treat PFPS; however, there is only very limited evidence that they are effective. NSAIDs may reduce pain in the short term; overall, however, after three months pain is not improved. There is no evidence that one type of NSAID is superior to another in PFPS, and therefore some authors have recommended that the NSAID with fewest side effects and which is cheapest should be used.
Glycosaminoglycan polysulfate (GAGPS) inhibits proteolytic enzymes and increases synthesis and degree of polymerization of hyaluronic acid in synovial fluid. There is contradictory evidence that it is effective in PFPS.
Braces and taping.
There is no difference in pain symptoms between taping and non-taping in individuals with PFPS. Although taping alone is not shown to reduce pain, studies show that taping in conjunction with therapeutic exercise can have a significant effect on pain reduction.
Knee braces are ineffective in treating PFPS. The technique of McConnell taping involves pulling the patella medially with tape (medial glide). Findings from some studies suggest that there is limited benefit with patella taping or bracing when compared to quadriceps exercises alone. There is a lack of evidence to show that knee braces, sleeves, or straps are effective.
Insoles.
Low arches can cause overpronation or the feet to roll inward too much increasing load on the patellofemoral joint. Poor lower extremity biomechanics may cause stress on the knees and can be related to the development of patellofemoral pain syndrome, although the exact mechanism linking joint loading to the development of the condition is not clear. Foot orthoses can help to improve lower extremity biomechanics and may be used as a component of overall treatment. Foot orthoses may be useful for reducing knee pain in the short term, and may be combined with exercise programs or physical therapy. However, there is no evidence supporting use of combined exercise with foot orthoses as intervention beyond 12 months for adults. Evidence for long term use of foot orthoses for adolescents is uncertain. No evidence supports use of custom made foot orthoses.
Surgery.
The scientific consensus is that surgery should be avoided except in very severe cases in which conservative treatments fail. The majority of individuals with PFPS receive nonsurgical treatment.
Alternative medicine.
The use of electrophysical agents and therapeutic modalities are not recommended as passive treatments should not be the focus of the plan of care. There is no evidence to support the use of acupuncture or low-level laser therapy. Most studies claiming benefits of alternative therapies for PFPS were conducted with flawed experimental design, and therefore did not produce reliable results.
Prognosis.
Patellarfemoral pain syndrome can become a chronic injury, with an estimated 50% of people reporting persistent patellar-femoral pain after a year. Risk factors for a prolonged recovery (or persistent condition) include age (older athletes), females, increased body weight, a reduction in muscle strength, time to seek care, and in those who experience symptoms for more than two months.
Epidemiology.
Patellofemoral pain syndrome is the most common cause of anterior knee pain in the outpatient. Specific populations at high risk of primary PFPS include runners, bicyclists, basketball players, young athletes and females.
BMI did not significantly increase risk of developing PFPS in adolescents. However, adults with PFPS have higher BMI than those without. It is suggested that higher BMI is associated with limited physical activity in people with PFPS as physical activity levels decrease as a result of pain associated with the condition. However, no longitudinal studies are able to show that BMI can be a predictor of development or progression of the condition.


Maritime and Commercial Court (Denmark)

Maritime and Commercial Court (Danish: Sø- og Handelsretten) is a specialized Danish court with jurisdiction over cases involving commercial law and maritime law. It was founded in 1861.


Lepiota brunneolilacea

Lepiota brunneolilacea, also known as the star dapperling, is a gilled mushroom of the genus "Lepiota" in the order Agaricales. It is known to contain deadly amounts of alpha-Amanitin, and was responsible for a fatal poisoning.


Manila Reception and Action Center

The Manila Reception and Action Center (RAC) is a government-run shelter for street children in Manila, Philippines. The facility is located on Arroceros Street in the central district of Ermita. In October 2014 it was the subject of news reports alleging that children were being subjected to horrendous conditions tantamount to criminal abuse. Reports focused on one particular child of unknown identity, given the name Federico, who, seven months after admission to the center was photographed lying naked on the concrete floor. The child's gravely malnourished state, with protruding ribs, the shape of his bones severely outlining his buttocks and knee caps larger than his emaciated thighs lead to wide "viral" circulation of these reports.
The center was again the subject of reports during the January 2015 visit to the Philippines by Pope Francis when it was reported that street children were being forcefully taken from the streets and housed in the center, while the government maintained it was for their protection.


Urban Search and Rescue Virginia Task Force 2

Urban Search and Rescue Virginia Task Force 2 (VA-TF2) is one of the 28 FEMA Urban Search and Rescue Task Forces. Based in Virginia Beach, VA-TF2 is sponsored by the Virginia Beach Fire Department.
The department has two heavy rescue apparatus fitted with specialized equipment designed for technical rescue incidents. The primary technical rescue squad, Fire Rescue 2, has additional equipment including high angle rope rescue equipment, extrication tools, concrete and wood cutting tools, torches and other cutting implements, retrieval systems and confined space equipment. The VBFD Technical Rescue Team is trained to meet NFPA 1670 Technician Level standards.
Deployments.
 VA-TF2 has taken part in the following deployments:


Social planner

In welfare economics, a social planner is a decision-maker who attempts to achieve the best result for all parties involved. In neo-classical welfare economics, this means the maximization of a social welfare function. In modern welfare economics, there is a greater emphasis on Pareto optimality, in which no one's economic status can be improved without worsening someone else's. Pareto-optimal solutions are not unique, and according to the Second Fundamental Theorem of Welfare Economics, a social planner can achieve any Pareto-optimal outcome by an appropriate redistribution of wealth by means of competitive market.
In practice, the social planner role is generally played by a government entity. However, real governments have multiple goals in addition to, or instead of the benefit of their people. This problem is studied in public choice economics.
Social planning problem and welfare theorem.
 The close connection that exists between the social planning problem and the competitive equilibrium."The first welfare theorem" tells us that if an allocation and a set of prices constitute a competitive equilibrium, then the allocation ·will be Pareto efficient . This tells us that the competitive equilibrium is efficient; the only option we have is to redistribute endowments in order to achieve a different point on the contract curve, but there is nothing more we can do. "The second welfare theorem", tells us that any social planning problem can be decentralized as a competitive equilibrium.
The welfare theorems establish a connection between the competitive equilibrium and the social planning problem. The welfare theorems also have practical implications.
Benevolent social planner.
 Instead of looking at a decentralized exchange process, let the economy assume the existence of a benevolent social planner who makes all the decisions in the economy. The social planner is benevolent because he only cares about the welfare of the consumer. Therefore, instead of having prices to guide the economy to equilibrium, it is allowed the social planner to decide how the consumer's time will be allocated between leisure and labor. The only constraints the planner faces are the consumer's time endowment and the state of technology. Obviously, the social planning problem gives us the highest possible utility level for the consumer. It is assumed, in particular, that information is costless and readily available to the social planner.
The benevolent social planner solves:
"max u(c,R) s.t. c = f(l)"
"l + R = T"
We can observe the absence of the planning problem. The planning problem is an assignment or allocation problem that arises because the consumer faces a tradeoff in the way he allocates his time. It is important to notice that  time,  in the form of leisure gives direct utility, but that consumption of leisure leaves less time for labor and, therefore, reduces the agent's consumption opportunities. In other words, the opportunity cost of leisure is foregone consumption. The planner looks for the best way to allocate the consumer's time endowment by balancing labor and leisure. Best means that the planner maximizes the consumer's utility function. In this problem, best is unambiguous. However, when there are more that two agents the planners allocation will depend on what the welfare function that is used.
 The benevolent social planner is an all-knowing, all-powerful, well-intentioned dictator. The planner wants to maximize the economic well-being of everyone in society. What should this planner do? Should he just leave buyers and sellers at the equilibrium that they reach naturally on their own? Or can he increase economic well-being by altering the market outcome in some way?"
To answer this question, the planner must first decide how to measure the economic well-being of a society. One possible measure is the sum of consumer and producer surplus, which is called total surplus. Consumer surplus is the benefit that buyers receive from participating in a market, and producer surplus is the benefit that sellers receive. It is therefore natural to use total surplus as a measure of society's economic well-being.
Social planner example as a real job.
 This is professional planning work in the areas of social services planning and/or city-wide recreation planning in a multidisciplinary team environment. Employees of this class are responsible for providing community based agencies with social consultative and monitoring services as it relates to the development and administration of preventive social services programs or low income and social housing, and/or conducting socioeconomic evaluations, planning and developing innovative strategies for city-wide social and.
Working as social planner has an emphasis on the development of social policy documents and the management of preventive social service funding programs based on the results of community needs assessments and evaluation studies. Work involves collaboration and partnership with diverse community groups. Employees work with considerable independence and initiative in the funding, consultation and implementation of service initiatives consistent with municipal priorities and/or provincial requirements.
Work involves the effective long-range planning and co-ordination of programs and projects to meet the social needs and aspirations of community services provided throughout the city. Incumbents may be required to act as a Project/Team Leader or Contract Manager and provide advice and direction to consultants or other professional staff. Work can be performed under strategic guidance; results can be evaluated through consultation with a superior for conformance with municipal policy and procedures, and through the implementation of reports and recommendations.


Western Products

Western Products is an American brand name for snow plows and other professional snow removing equipment manufactured by Western Welding and Manufacturing. The company also manufactures a variety of truck-mounted sand and salt spreaders, snowplow replacement parts and snow removal accessories.
Western Products employs approximately 250 people at its manufacturing facility in Milwaukee, Wisconsin. Headquartered in Milwaukee, Wisconsin, the company is a division of Douglas Dynamics group (NYSE:PLOW), which also owns the Blizzard and Fisher Engineering brand names.
History.
On September 5, 1950, Douglas Seaman purchased Western Welding & Manufacturing, a small machine shop in Milwaukee that was founded in 1943. Western mainly handled small, one-off welding jobs for large manufacturers. A friend suggested to Seaman that he should start manufacturing snowplows as a way to diversify his business, which he did. In 1952, Western Welding introduced its first snowplow at a time when the U.S. population was shifting toward suburb settings, which increased the market for light trucks. This increased the demand for snowplows.
Growth.
Suburban areas continued to thrive through the 1950s, and the light-truck market continued to grow. The demand for snowplows continued rising, allowing Western Products' sales to double between 1961 and 1968. The 1970s also proved to be a profitable time for the company, as its share of the national market for the type of snowplows mounted on light trucks rose from 33 percent in 1968 to 40 percent a decade later. In 1977 Douglas Seaman incorporated as Douglas Dynamics Incorporated, which he placed as the parent company for Western Welding & Manufacturing. In 1984, Douglas Dynamics expanded, purchasing Fisher Engineering, a well respected competitor in the snow plow business.
Expansion.
In November 2005 Douglas Dynamics purchased Blizzard Corporation, including their complete line of snowplows and snowplow patents. Among the patents was a patent for an "adjustable-wing snowplow" that allowed the blade to extend from 8 feet out to 10 feet. Douglas Dynamics incorporated that technology into both its existing snowplow brands.
In the 3rd Quarter of 2012, Douglas Dynamics' profits declined considerably due to a record low snowfall.
References.
Notes


Generational imbalance

Generational imbalance is the economic and political tension which characterizes a state which has a reduced birth rate and increased health resulting in an increasing aging population compared to its younger working population; cost and generosity of welfare systems also plays a role.


National Round Table on the Environment and the Economy

The National Round Table on the Environment and the Economy was a Canadian advisory agency founded in response to the 1987 United Nations document Our Common Future by the Progressive Conservative Party of Canada. The NRTEE focused on sustaining Canada’s prosperity without borrowing resources from future generations or compromising their ability to live securely. The Conservative government of Stephen Harper ended funding to NRTEE, which ceased to exist on March 31, 2013.
Overview.
The National Round Table was an independent policy advisory agency to the Government of Canada. Its mandate was to raise awareness among Canadians and their governments about the challenges of sustainable development.
Over 25-year it released dozens of reports on priority issues – forests, brownfields, infrastructure, energy, water, air, climate change, and more. It offered advice to governments on how best to reconcile and integrate the often divergent challenges of economic prosperity and environmental conservation.
It brought together hundreds of leaders and experts with first-hand knowledge in a diversity of areas. Its Members, appointed by the Federal government, were active in businesses, universities, environmentalism, labour, public policy, and community life from across Canada.
Defunding and Disbandment.
On March 31, 2013, the Conservative government of Stephen Harper eliminated the budget for the NRTEE, effectively ending it. Then-Environment Minister Peter Kent initially offered the rationale that the funding was unnecessary, because Canadians could by that time access climate change research through the Internet, universities, and think tanks. However, in response to a question in the House of Commons, then-Foreign Affairs Minister John Baird said that the government should not be funding the Roudtable because it had issued a series of reports advocating a form of carbon pricing, which he said "the people of Canada have repeatedly rejected ... It should agree with Canadians. It should agree with the government." The Roundtable had released several reports that had concluded that the federal government would have to act more aggressively if it were to reach its Kyoto Protocol target of a 17% reduction in greenhouse gas emissions from 2005 levels by 2020.
On March 26, 2013, Kent issued a directive preventing the Roundtable from transferring its research and the contents of its website to Sustainable Prosperity, a national research network based at the University of Ottawa. Instead, he said that Environment Canada would lay claim to all previous work, which Kent promised would remain accessible to the public. However, the move appeared to leave the fate of two unpublished documents on the history, role, and relationship of the Roundtable to the government uncertain. One of these, entitled "Reflections of Past Leaders of the NRTEE," was subsequently leaked and posted to the internet.


Bay of Mali Ston

Bay of Mali Ston () is a bay in the Adriatic Sea, enclosed by the Pelješac peninsula and the mainland. The name primarily refers to the innermost, eastern part of the bay, while the name Channel of Mali Ston () is used for the channel between Klek (peninsula) and Pelješac, in the west. The two bodies of water are located in Croatia's and partly in Bosnia and Herzegovina's territorial waters.
The bay is named after the village of Mali Ston (near Ston). Its southernmost point is at the isthmus of the Pelješac peninsula, while its mouth is located roughly north of Hodilje. The Channel, in turn, extends from there to the line
between Cape Blaca on Pelješac and Cape Međed on the shore, located south of Komarna. The sea to the west of the Mali Ston Channel, near the Neretva Delta, is called the "Malo more", and further west is the Neretva Channel.
The bay is long and has a maximum breadth of and the depth is between . On account of its clean waters, the bay of Mali Ston was declared a Special Natural Reserve in 1983. An area of 4821 ha is covered, from the line Sreser-Duba eastwards. The Croatian Ministry of Agriculture considers this larger body of water as the total area of the bay for the purposes of regulating mariculture, with a length of , a maximum breadth of , and the depth largely between meters.
The part of the bay that is in Bosnia and Herzegovina is a section in the northwest of the bay near Neum, and it also constitutes said country's only coastline. The maritime boundary between the two is, according to the common standards for territorial waters, an equidistant line between the Pelješac peninsula of Croatia in the southwest and the Klek peninsula in Bosnia and Herzegovina in the northeast.
The location of the planned Pelješac Bridge is in the far west of the channel.
The climate of the area is Mediterranean, characterized by mild winters and dry summers, with three times more rain in the rainier than in the drier months, during which the mean precipitation do not exceed 40 mm (1.57 in).