TIS
Chapter 14
Anterior Knee Pain
- Introduction
- other causes of anterior knee pain, besides primary PF pain
- differential diagnosis may be more difficult than anticipated owing to interrelationships
- realize that more than one problem may exist concurrently
- a small acute injury may stir up an underlying mechanical
anomaly that had previously been painfree; daily activity with a
malalignment may be enough to perpetuate symptoms
- Plica
- embryologically the knee is formed by the fusion of three
synovial compartments and the intervening synovial tissues resorbed.
The plicae are synovial remnants of these synovial tissues
- intrapatellar plica (ligamentus mucosum) most common and runs
parallel to the ACL; it has no clincial significance
- suprapatellar second most common: acts as a tethering band in
the superior portion of the quadriceps bursa and may separate it into
two separate segments
- medial plica least common, but probably produces the most
symptoms; runs distally along the medial aspect of the knee from the
level of the superior pole of the patella to insert into the medial fat pad
- incidence of medial plica ranges from 9.1-50%
- as knee is passively flexed form 30-60°, this plica can be seen
to slide over the MFC beneath the patella; ER of tibia causes wedging
of the plica between the medial facet and the MFC
- generally tender one fingerbreadth proximal to the distal pole of the patella, medially
- symptoms increased with repetitive activities
Treatment:
- NSAID's
- painfree stretching
- LE strengthening, avoiding repetitive activities
- work in painfree range
- occasional injection and/or surgical resection
- Prepatellar bursitis
- common in wrestlers
- cause: either acute trauma from a single blow or chronic irritation
- if acute, often the result of small blood vessel rupture, resulting in aspiration of blood
- if chronic, likely the result of chronic inflammation, and aspiration will not contain blood
- in wrestlers, probably a combination of chronic and acute onset
- chronic bursitis much more difficult to treat; has a high
recurrance rate; surgery reveals a thickened bursal wall
- high incidence of septic bursitis (>95% in Myshnyk's series);
staphylococcus aureus most common cause
- repeated aspiration of chronic bursitis discouraaed owing to the high rate of infected bursae
- swelling is superficial to patella
- blood workup not particularly helpful in making diagnosis of septic bursitis
Treatment:
- RICE
- NSAIDs
- cortisone injection not helpful in most cases
- aspiration (limited)
- consider HVPC
- maintain CV, ROM
- maintain quad strength without increasing swelling
- consider pool therapy
- kneepad when returning to kneeling activity
- Iliotibial band friction syndrome
- commonly seen in runners, bikers
- symptoms can be seen at hip, knee or both
- hip pain generally over the greater trochanter, and involves both the TFL and gluts
- knee pain is over LFC
- at 0°, ITB is anterior to LFC; as the knee passes 30° of
flexion, it passes across the LFC to become posterior
- diagnosis is made on history, palpation and special test at knee
- must assess alignment and treat underlying cause; varus or
valgus knee alignment, and pronation can predispose to symptoms at knee
- tight ITB (+ Ober test) and tight hamstrings are diagnostic and form basis for treatment program
- assess patella for related problems
Treatment:
- ice
- activity modification
- treat malalignment
- flexibility
- NSAIDs
- strength, posture, predisposing habits (running surface)
- surgery used for chronic cases unresponsive to conservative
management; consist of making a "window" in ITB in area of irritation
- Fat pad impingement
- rare problem, generally not painful
- may be related to patellar malalignment (AP tilt)
- correct underlying cause
- tender medial and/or lateral to patellar tendon on fat pad
- quad setting (screw home mechanism) hurts
- thickening of fat pad produces additional irritation as problem progesses
- can be chronic or acute
Treatment:
- NSAIDs
- correction of underlying cause
- ice
- HVPC, ionto/phonophoresis
- cortisone injection (NOT into the tendon)
- surgical resection
- Osgood-Schlatter's disease
- originally described by Osgood & Schlatter in 1903
- tibial tuberosity apophysitis - result of tensile forces
- self-limiting problem with pain & enlargement of the tibial tuberosity
- incidence for those in sports = 21%, those uninvolved = 4.5% for an overall incidence of 12.9%
- Males:females = 1.5:1 to 4:1 (depending upon who you ask)
- common in athletes with a past history of Sever's disease
- average age of onset = 13.1
- bilateral in 56%
- etiology is likely the result of avulsion of a portion of the
developing ossification center and overlying hyaline cartilage
- inflammatory changes occur seconday to micro-avulsion fractures of the tuberosity
- S&S: dull ache increased with running and jumping; local redness and point tenderness
- x-ray may demonstrate soft tissue swelling anterior to tibial tuberosity
Treatment:
- symptomatic
- ice
- stretching, strengthening
- activity modification
- rarely immobilize
- NSAIDs
Complication: tibial tuberosity fracture; rare, requires surgical fixation
- Sinding-Larsen-Johansson disease
- similar to Osgood-Schlatter, but symptoms present at the inferior pole of the patella
- age 10-13
- no history of trauma
- hypothesize that etiology is avulsion of the periosteum at
inferior pole of the patella with resultant ossification
- seen with repetitive traction at the patellar tendon attachment site
- knee pain exacerbated by running, stairs and kneeling
- may have concomitant Osgood-Schlatter
- tender over inferior pole
- x-rays demonstrate irregular calcification at inferior pole
Treatment:
- similar to Osgood-Schlatter
- Patellar tendinitis
- Blazina referred to patellar tendinitis and quadriceps
tendinitis as "jumper's knee" in a classic 1973 article; this same
paper described the "Blazina scale" of pain and functional impairment
- focus here on patellar tendinitis as quadriceps tendinitis is rare (usually over age 40)
- very difficult problem to treat; patients often wait until
problem is advanced before seeking treatment
- specific point tenderness at distal pole of patella (must tip patella to get at distal pole)
Blazina's phases:
Phase I: Pain after activity only. No undue functional impairment.
Phase II: Pain during and after activity. Still able to perform at a satisfactory level.
Phase III: Pain during and after activity and more prolonged. Patient
has progressively increasing difficulty in perfoming at a satisfactory level.
Stages of healing:
- cell mobilization
- ground substance proliferation
- collagen protein synthesis
- final organization
Treatment:
- controlled activity
- modalities
- medications
- exercise
Principles of eccentric exercise program:
- muscle length
- intensity
- load
- speed of contraction
Optimal loading:
- must try to mimick demands of their activity
** ALWAYS plug into functional progression and set specific criteria
for return to play!!!
From: Curwin & Stanish: Tendinitis: Its etiology and treatment