Anterior knee pain

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Anterior knee pain

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Anterior knee pain

  1. 1. Presenter : Dr. Sushil Paudel
  2. 2. 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
  3. 3. 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
  4. 4. Patellofemoral Anatomy Femur  Trochlear groove between Med and Lat femoral condyles  Lat wall is more prominent  Abnormalities of groove lateral tracking
  5. 5. 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 nonload bearing except in extreme flexion
  6. 6. Articulation 0°-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
  7. 7. Quadriceps and other soft tissues  Rectus femoris tendon - superior pole  Vastus medialis obliqus (VMO) ◦ ◦    patella Vastus lateralis ◦ ◦ ◦  Superomedial border Primary stabilizer of medially against VL Superolateral border Lateral retinaculum Lateral patellofemoral lig Medial PF lig is weaker than lat Medial and lateral retinaculum Iliotibial band
  8. 8. 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 (M1M2) 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.
  9. 9. 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 patellofemoral vector valgus  Greatest at full extension External rotation of tibia
  10. 10. Factors resisting the normal lateral vector of patella  Deeper PF trochlea  Large lateral condyle  VMO - inserted more distally and horizontally than VL femoral
  11. 11. 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 
  12. 12. Classification Insall - 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
  13. 13.  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
  14. 14. 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
  15. 15. 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
  16. 16. Mechanisms of PF pain  Overloading of the subchondral bone  Synovial source  Retinacular source Cartilage is aneuric and cannot be source of pain It has limited power of repair or regenaration once fibrillation or ulceration has occurred
  17. 17. Physical Examination  Contralateral “Normal” knee should also be examined  Patient standing limb alignment G-varum / Gvalgum, femoral or tibial rotation ◦ “Squinting” medially patellae - Foot-excess pronation  Deficient VMO - 30° flexion  point
  18. 18.  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 
  19. 19. Tubercle sulcus angle Apprehension test Patellar tilt test
  20. 20.  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
  21. 21. ◦ 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 andweakness
  22. 22. 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
  23. 23.  Lateral view ◦ Best assessment of patellar height Patella alta or baja ◦ Black borne - peel ratio - 1:1 (± 20%) ◦ Insall - salvati ratio - 1:1 (± 20%)
  24. 24.  Axial view ◦ X-ray beam perpendicular to film ◦ Knee flexed 30° to 45° ◦ Both knees together
  25. 25.  Sulcus angle ◦ Between condyles and sulcus ◦ Mean 138° ± 6° ◦ Correlates with instability
  26. 26.  Congruence angle ◦ Zero reference line bisects sulcus angle ◦ Mean 6° ± 6° ◦ Measures subluxation
  27. 27.  Lateral angle patellofemoral ◦ Between intercondylar and lateral facet ◦ Should open laterally ◦ Tilt with subluxation line
  28. 28.  Patellofemoral index ◦ ◦ M - closest distance between articular ridge and medial condyle L - closest distance between lateral facet and condyle Indicates - Tilt with subluxation
  29. 29.  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
  30. 30.  Longstanding lateral patellar compression syndrome ◦ Pain increases on flexion of knee ◦ Sclerosis of lateral patellar facet ◦ Trabeculae perpendicular to lateral facet ◦ Lateral traction
  31. 31.  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
  32. 32.  MRI ◦ Suspected tumour ◦ Medial patellofemoral ligament tear ◦ No diagnosis can be established  Bone scan ◦ Reflex sympathetic dystrophy ◦ To document progress during treatment
  33. 33. TREATMENT 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)
  34. 34. ◦ Stretching  Stretching of tight muscles ITB, hamstrings, gastrocnemius and quadriceps Short arch extensions  Increasing patellar mobility  Slow sustained, five times on each side for 10 secs. ◦ Strengthening Straight leg raising  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 Isometric quadriceps Stationary cycling
  35. 35. ◦ Extrinsic support - Bracing  Patellar strap - patellar tendinitis  Patellar brace with full ring support with lateral buttress pad - resist lateral vectors Patellar straps  Longitudinal arch supports medial correction for pronated foot  They effect changes in patellar tracking Patellar braces
  36. 36. Surgical Techniques - Needed in 10% cases Arthroscopic patellar debridement (shaving)  Without a leg holder  Minimal portals  Conservative - remove only unstable cartilage
  37. 37. Patellofemoral malalignment with or without articular degenaration 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
  38. 38. 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
  39. 39. 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
  40. 40. 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
  41. 41. Articular degeneration in a normally aligned patellofemoral joint Anteromedial tubercle (fulkerson) tibial plasty  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
  42. 42.  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
  43. 43. 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 at Least 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
  44. 44. 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
  45. 45. 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
  46. 46. 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
  47. 47. Complications  Reflex sympathetic dystrophy  Infrapatellar contraction syndrome  Compartment syndromes  Iatrogenic medial subluxation of patella  Loss of correction
  48. 48. 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
  49. 49. 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
  50. 50. 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
  51. 51. 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 andor lateral to patellar tendon on fat pad ◦ Treatment – NSAIDS, RICE, cortisone injection, correction of cause, surgical resection
  52. 52. 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
  53. 53. 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
  54. 54. Sinding-LarsenJohansson disease ◦ Similar to Osgood’s disease but symtoms at inferior pole of ◦ ◦ ◦ ◦ patella (with tenderness) Age 10-13 years, no ho 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
  55. 55. ◦ ◦ ◦ ◦ ◦ 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
  56. 56. 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
  57. 57. 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
  58. 58. Chondromalacia patellae ◦ 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
  59. 59. Chondromalacia patellae  Surgical treatment ◦ Shaving ◦ Drilling ◦ Realignment procedure  Tightening of the medial capsule  Lateral releaseMedial shift of tibial tubercle ◦ ◦ ◦ ◦ ◦ Chondrectomy Partialfull patellectomy Maquet procedure Patellar prosthesis Future directions – autologous chondrocyte transplantation for femoral articular surfaces
  60. 60. 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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