Anterior knee pain
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Transcript of Anterior knee pain
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Presenter : Dr. Sushil Paudel
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Introduction
Common clinical problem
Refers to pain in anterior region of knee
It is a symptom not a diagnosis
Mid 1970’s - Sports medicine
Patellofemoral components are subjected to the highest loads within the knee
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Definition
‘A syndrome characterized by dysfunction and pain expressed in the anterior region of the knee. Signs and symptoms are variable and multiple tissue sources and etiologies exist’.
It has been referred as
Patellofemoral pain syndrome / chondromalacia patellae / recalcitrant anterior knee pain / patellae femoral stress syndrome / femoropatellar pain syndrome / patellofemoral arthralgia or patellagia
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Patellofemoral Anatomy
Femur
Trochlear groove between Med and Lat femoral condyles
Lat wall is more prominent
Abnormalities of groove - lateral tracking
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Patella Acts as a lever arm -
increase function of quadriceps
Decrease functional load and abrasions on the anterior soft tissues
Thickest articular cartilage of any human joint
Central ridge ◦ Longer lateral facet -
Superior, interior and middle
◦ Shorter medial facet ‘Odd’ facet - medially
non-load bearing except in extreme flexion
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Articulation0°-No contact
20°-Inferior facet - upper trochlear groove
45°-Middle facet - mid portion of trochlear
90°-Superior facet - lower trochlear articular cartilage
135°-Lateral medial and odd facet
Along with undersurface of quadriceps
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Quadriceps and other soft tissues
Rectus femoris tendon - superior pole
Vastus medialis obliqus (VMO)◦ Superomedial border◦ Primary stabilizer of patella
medially against VL Vastus lateralis
◦ Superolateral border◦ Lateral retinaculum◦ Lateral patellofemoral lig
Medial PF lig is weaker than lat
Medial and lateral retinaculum
Iliotibial band
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Biomechanics Often termed ‘Extensor mechanism’ Resultant force of both quadriceps
and patellar tendon vectors - ‘Patellofemoral joint reaction force’ (PFJR) force
Directly related to quadriceps force generation (M1\M2)
Increase as the angle of flexion increases
Load decrease - straight leg raising and swimming
Increase in - Flexion activities like - climbing up and down stains, squatting, jumping, running and tennis, soccer etc.
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Quadriceps ‘Q’ angle
‘Angle between line of application of quadriceps force and direction of patellar tendon in coronal plane’
Normal ◦ Males 10 - 12°
◦ Females 15 - 18°
- Greater pelvic width
- Short femoral length
Normally has a valgus patellofemoral vector
Greatest at full extension - External rotation of tibia
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Factors resisting the normal lateral vector
of patella
Deeper PF trochlea
Large lateral femoral condyle
VMO - inserted more distally and horizontally than VL
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Factors predispose subluxation
Deficiency of intercondylar sulcus
Deficiency of VMO Increase in ‘Q’ angle
◦ Internal femoral torsion◦ External tibial torsion◦ Genu valgum
Patella alta Patella baja Excessive pronation of
foot Tight lateral
retinaculum
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ClassificationInsall - based on amount and extent of articular
cartilage damage Presence of cartilage damage
◦ Chondromalacia patellae◦ Osteoarthritis◦ Direct trauma◦ Osteochondral fractures◦ Osteochondritis dissecans
Variable cartilage damage◦ Subluxation◦ Dislocation◦ Tilt◦ Plicae
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Usually normal cartilage◦ Patellar tendinitis (Jumper’s Knee)
◦ Traction apophysitis Patella - Sinding - Larsen Johansson disease
Tibial tubercle - osgood - Schlatter disease
◦ Prepatellar bursitis (Housemaid’s knee)
◦ Hoffa’s (infrapatellar fat pad) syndrome
◦ Patellar anomalies
◦ Reflex sympathetic dystrophy
◦ Iliotibial band friction syndrome
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Other causes Referred pain from hip
◦ Perthes disease
◦ Slipped capital femoral epiphysis
Tumor
Gaint cell tumour , others
Post operative causes
◦ Interlocking nailing of tibia
◦ Arthroscopic ACL reconstruction
◦ Total knee replacement
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History
Pain
◦ Dull aching, retro patellar, often bilateral
◦ Aggravate - going up and down stairs, squatting, kneeling and sitting with knee flexed (Movie Sign or Theatre ache)
Giving way - subluxation and dislocation
Grating sound on movement of patella, flexion and extension of knee
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Mechanisms of PF painOverloading of the subchondral bone
Synovial sourceRetinacular sourceCartilage is aneuric and cannot be source of pain
It has limited power of repair or regenaration once fibrillation or ulceration has occurred
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Physical Examination Contralateral “Normal” knee
should also be examined Patient standing - limb
alignment G-varum / G-valgum, femoral or tibial rotation◦ “Squinting” patellae - point
medially Foot-excess pronation Deficient VMO - 30° flexion
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Patellar position in sitting◦ Patella alta
Grasshopper eye Camelback sign
Tracking of patella◦ Shape of Hockey Stick ‘J’ Sign
Tenderness Crepitus Q-angle - > 20° abnormal Tubercle sulcus angle > 10°
abnormal Patellar mobility
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Tubercle sulcus angleApprehension test Patellar tilt test
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Apprehension sign of Fairbanks
Patellar tilt test - retinacular contracture or laxity
Passive and Active lateral glide test
Generalised laxity of other joints
Examination of hip – tenderness, ROM
Examination spine - Straight leg raising
Ober’s test - Iliotibial band contracture, lateral knee pain
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◦ Pt stands facing examiner with one leg on stool, other on floor
◦ Hold pt for balance only◦ Pt lifts toes off the floor and
shifts weight to that on stool gradually
◦ He lowers the opp leg to floor trying not to drop last inches
◦ Requires good control of PF extensor mechanism
◦ It applies lot of stress on ant compartment
◦ If pathology –elicits pain and\weakness
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IMAGING Anterioposterior
view in full weight bearing on one leg
Posteroanterior view in 45° flexion weight bearing view of Rosenberg - for assessment of articular cartilage loss in posterior compartment
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Lateral view◦ Best assessment of
patellar height - Patella alta or baja
◦ Black borne - peel ratio - 1:1 (± 20%)
◦ Insall - salvati ratio - 1:1 (± 20%)
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Axial view◦ X-ray beam
perpendicular to film
◦ Knee flexed 30° to 45°
◦ Both knees together
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Sulcus angle◦ Between condyles and
sulcus◦ Mean 138° ± 6°◦ Correlates with instability
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Congruence angle◦ Zero reference line bisects sulcus
angle◦ Mean 6° ± 6°◦ Measures subluxation
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Lateral patellofemoral angle◦ Between intercondylar line
and lateral facet◦ Should open laterally◦ Tilt with subluxation
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Patellofemoral index◦ M - closest distance between articular
ridge and medial condyle◦ L - closest distance between lateral facet
and condyleIndicates - Tilt with subluxation
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Patellar tilt◦ Angle between transverse plane of patella and a
horizontal line parallel with x-ray table◦ Normal 5° or less◦ Tilt can occur without subluxation◦ Indicates tight lateral retinaculum
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Longstanding lateral patellar compression syndrome◦ Pain increases on
flexion of knee◦ Sclerosis of lateral
patellar facet◦ Trabeculae
perpendicular to lateral facet
◦ Lateral traction spur
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CT Scan ◦ To evaluate patellar
position and lateral tilt in too obese patient
◦ CT Scan classification of malalignment Type 1 – lateral
subluxation
Type 2 – lateral subluxation with tilt
Type 3 – lateral tilt without subluxation
Type 4 – radiographically normal alignment
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MRI
◦Suspected tumour
◦Medial patellofemoral ligament tear
◦No diagnosis can be established Bone scan
◦Reflex sympathetic dystrophy
◦To document progress during treatment
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Non-operative treatment of patellofemoral pain
Will be successful in about 90% of cases Rehabilitation program includes
◦ Patient education
◦ Pain modalities RICE
NSAIDS
Ultrasound
TENS Transcutaneous electrical nerve stimulation (Gate
theory)
TREATMENT
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◦ Stretching Stretching of tight muscles -
ITB, hamstrings, gastrocnemius and quadriceps
Increasing patellar mobility
Slow sustained, five times on each side for 10 secs.
◦ Strengthening Isometric quadriceps exercises
- VMO strengthening, cycling
Hip adductors and abductors
Never use knee extensors against resistance
Mc Connell - closed chain kinetic exercises and taping of knee
Short arch extensions
Isometric quadriceps
Straight leg raising
Stationary cycling
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◦ Extrinsic support - Bracing
Patellar strap - patellar tendinitis
Patellar brace with full ring support with lateral buttress pad - resist lateral vectors
Longitudinal arch supports - medial correction for pronated foot
They effect changes in patellar tracking
Patellar straps
Patellar braces
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Surgical Techniques - Needed in 10%
casesArthroscopic patellar
debridement (shaving)
Without a leg holder Minimal portals Conservative -
remove only unstable cartilage
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Arthroscopic lateral release Indication - Tight lateral
retinaculum, producing symptoms, not responding to conservative treatment
Proximal Superomedial portal Coagulate lateral superior
geniculate artery Avoid injury to lat meniscus Release until muscle fibers of
Vastus lateralis complication– haemarthrosis, Residual band, post op
scarring Medial subluxation
Patellofemoral malalignment with or without articular degenaration
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Medial tibial tubercle transfer
Indicated in large ‘Q’ angle causing symptoms - not responding to non-operative treatment
Combined with arthroscopic lateral release
Cut osteotomy and move proximal end medially correcting ‘Q’ angle
Avoid overcorrection Three screw, bicortical,
lag fixation Avoid injury to anterior
recurrent tibial artery
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Proximal quadriceps plasty Indication ‘Q’ angle is normal or has been corrected but patella remain subluxated laterally causing symptom or that recurrently dislocated
Used for moderate alignment Release lower third or half of vastus lateralis and perform derotation quadriceps plasty
Tubulization of extensor tendon
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Medial patellofemoral ligament reconstruction
Chronic dislocation of patella Recurrent dislocation in which ligament is absent
or irrepairable Use central area of quadriceps tendon Sutured medial edge of patella Staple over medial epicondyle of femur
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Anteromedial tibial tubercle plasty (fulkerson)
Increases the tibial linear arm of extensor mechanism
Reduces patellofemoral joint reaction time
Indicated in Gr III or IV chondromalacia
Anterior transfer is indicated only when the extensor mechanism is already well aligned e.g. in trauma
Articular degeneration in a normally aligned patellofemoral joint
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Flat ledge on medial side of tibia
Rotate the tibial tubercle with bone block medially and anteriorly with distal end attached
15-18 mm anterior elevation can obtained
Three screw bicortical lag fixation
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Anteriorization (Maquet)◦Bandi and Maquet◦ Increases the efficiency of
quadriceps by increasing the lever arm
◦Decreases the PF joint reaction force
◦Modified Maquet procedure Lateral release Anterior elevation of atLeast 2cm Medialization by appx 1 cm
◦Notched iliac crest graft◦No internal fixation◦Complications
Skin necrosis over tubercle Acute or stress #s DVT Arthrofibrosis Compartment syndrome
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Patellectomy Salvage procedure Best done for comminuted
patellar fracture with a normal trochlea
Realign the extensor mechanism
Soto-Hall technique - lateral release and transposition and repair
Vastus medialis advancement
Can do with anteromedial transfer of tubercle
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Total patellofemoral
arthroplasty Indications
◦ Isolated patellofemoral arthritis
◦ Trochear chondrosis is present
Extensor mechanism should be aligned
Chrome - Cobalt molybdenum trochlear implant
Modified Mckeever-type prosthesis
Geometry of trochlear implant should be identical with that of femoral component from TKR system by same manufacturer
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Rehabilitation
Post-op - 2 main goals Regaining quadriceps strengths Restoring knee flexibility
◦ Extension knee splint (knee immobilizer) for 6 wks◦ Weight bearing with splint - immediately◦ Gradual flexion - Active and passive heel slides◦ Quadriceps exercise - immediately after surgery◦ Assisted straight leg raising - 3 weeks◦ Full straight leg raising - 6 weeks
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Complications
Reflex sympathetic dystrophy
Infrapatellar contraction syndrome
Compartment syndromes
Iatrogenic medial subluxation of patella
Loss of correction
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plica◦Remnants of Synovial
tissue◦MC – Infrapatellar
(ligamentus mucosum) no clinical significance
◦Next is Suprapatellar – act as tethering band
◦ Medial plica least common – produces most symptom
◦ Incidence 9.1%-50%◦Tenderness one finger
breadth prox to distal pole of patella medially
◦Treatment – NSAIDS, stretching, strengthing,
injection, surgical resection
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Prepatellar bursitis◦ Common in wrestlers◦ Cause – acute –trauma
(rupture of vessels) chronic – irritation
(inflammation)◦ High recurrance rate◦ Swelling superficial to
patella◦ High incidence of septic
arthritis (staph aureus)◦ Surgery – thickened bursal
wall◦ Treatment – RICE, NSAIDS,
aspiration, cortisone injection
quadriceps, knee cap pad.
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Iliotibial band friction syndrome◦ Common in runners, bikers◦ Symtoms can be at hip, knee or both◦ Pain at - hip – greater trocanter - knee – lat femoral condyle◦ Tight ITB (Obers test) and tight
hamstrings are diagnostic◦ Asses alignment and treat
underlying cause◦ Treatment – ICE, NSAIDS, activity
modification, treat malalignment, flexibility
◦ Surgery – chronic unresponsive cases ‘window’ in ITB in area of irritation
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Fat pad syndrome◦ Rare problem , not painful in many
◦ Can be acute or chronic
◦ May be related to malalignment
◦ Squat sitting is painful
◦ Tenderness medial and\or lateral to patellar tendon on fat pad
◦ Treatment – NSAIDS, RICE, cortisone injection, correction of cause, surgical resection
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Osgood schlatters disease◦ Tibial tuberosity apophysitis –
result of tensile force◦ Self limiting problem with pain and
enlargement of tibial tuberosity◦ Incidence with sports -20%,
uninvolved -4.5% overall – 12.9%
◦ male:female – 1.5:1 to 4:1◦ Bilateral in 51% average age of
onset 13 years◦ Dull ache increases with running
and jumping with local tenderness
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Osgood schlatters disease◦ Etiology - avulsion of
portion of ossification centre
Inflammatory changes sec to micro avulsion fractures of tuberosity
◦ X-ray soft tissue swelling ant to tuberosity
◦ Treatment –ice, NSAIDS, stretching, strengthing, activity modification, rarely immobilize
◦ Complication – tibial tuberosity # (rare) requres surgical resection
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Sinding-Larsen-Johansson disease◦ Similar to Osgood’s disease but
symtoms at inferior pole of
patella (with tenderness)◦ Age 10-13 years, no h\o trauma◦ Etiology avulsion of periosteum
at inf pole of patella with ossification or repetitive traction at patellar tendon attachment
◦ X –ray show irregular calcification
◦ Treatment same as Osgood’s disease
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Patellar tendinitis and quadriceps tendinitis◦ Blazina referred these as “jumper’s knee”◦ Usually over 40 years◦ Difficult to treat, usually present very late◦ Point tenderness over distal pole of patella◦ Blazina’s phases
Phase 1 – pain after activity only, no functional impairment Phase 2 – pain during and after activity, still able to perform at
a satisfactory level Phase 3 – pain during and after and more prolonged
progressively increases not able to perform satisfactorily◦ Treatment – controlled activites, medications, excersies
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Chondromalacia patellae (Runner’s knee)◦ Definition: “it is softening or wearing away and
cracking of the articular cartilage under the patella, resulting in pain and inflammation.”
◦ Acute – direct trauma◦ Chronic – inflammation , repetitive rubbing◦ Resultant force – retro patellar compression
force◦ Increase in ‘Q’ angle – malalignment of patella◦ symptoms-
Ant knee pain while walking, running, squatting, climbing stairs
Recurrent effusion Crepitation or grating on flexion and extension of
knee
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Chondromalacia patellae◦ Clinical signs
Crepitation on passive movement of patella
Pain on compression of patella ‘Q’ angle usually>15° Tenderness – along borders and
underside of patella G . Valgum ,external tibial rotation Femoral anteversion combined with
external tibial torsion ( miserable malalignment syndrome )
◦ X ray Patella alta Shallow femoral groove Shallow patellar angle Tilting or gliding of patella
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◦ Eisele (1991) grading of cartilage damage Grade 1 - articular cartilage only shows
softening or blistering Grade 2 - fissures appear in cartilage Grade 3 - fibrillation of cartilage occurs,
causing 'crabmeat' appearance Grade 4 - full cartilage defects are present
and subchondral bone is exposed◦Treatment◦ Conservative
modification of activities Patellar tapping Quadriceps strengthing – most important NSAIDS and rest Orthotics and braces
Chondromalacia patellaeChondromalacia patellae
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Surgical treatment◦ Shaving◦ Drilling◦ Realignment procedure
Tightening of the medial capsule Lateral releaseMedial shift of tibial tubercle
◦ Chondrectomy◦ Partial\full patellectomy◦ Maquet procedure◦ Patellar prosthesis◦ Future directions – autologous chondrocyte transplantation
for femoral articular surfaces
Chondromalacia patellaeChondromalacia patellae
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Conclusion◦ Common problem in this era of sports medicine◦ Can be diagnostic and therapeutic challenge◦ Evalution needs careful history, physical examination and
radiography◦ No single cause or successful solution has been identified◦ Conservative treatment is the cornerstone in
management (90%)◦ Surgery in minority cases (10%)◦ Currently arthroscopic procedures
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