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Approach to anterior knee pain.pptx
1. Approach to anterior knee
pain
Dr. Nishchal Rijal
Fellow, Arthroscopy and Sports injuries
AKB Education Foundation
2. Introduction
• one of the most common conditions to
bring active young patients to a sports
injury clinic
• Incidence variable – 22.7 % in general
population
• F>M
• Challenging to treat
• 60-70% recurrent or chronic pain
Smith et al. Incidence and prevalence of patellofemoral pain:
a systematic review and meta-analysis. PLoS ONE. 2018;13: e0190892
3. Anterior knee pain
Instability Chondropathy OA
Osseous/ cartilage overload
Retinacular overload
PF imbalance
Lower limb structural abnormalities Lower limb lack of dynamic control
Mechanical stimulation of patellar/ trochlear intraosseous nerves
Increment intraosseous pressure Increment subchondral bone stress
Loss of vascular homeostasis
Focal supraphysiological loading of anatomical normal
knee components and soft tissue homeostasis
Ischemia Overuse
Decrease envelope of function
Osseous hypertension
Sanchis-Alfonso V. Holistic approach to understanding anterior knee pain. Clinical implications. Knee Surgery, Sports Traumatology, Arthroscopy. 2014 Oct;22(10):2275-85.
4. History - Pain
• Insidious onset, gradually
progressive
• Hx of trauma is uncommon
• two patterns: retro-patellar or
peripatellar
• Localization of pain
• tibial tuberosity - OSD
• inferior pole of patella - SLJ
D’Ambrosi R, Meena A, Raj A, Ursino N, Hewett TE. Anterior knee pain: state of the art. Sports Medicine-Open. 2022 Dec;8(1):98.
5. History - Pain
• Aggravated on
• climbing up or down stairs
• squatting and kneeling
• prolonged flexion of the knee joint
• Movie theater sign
• May be a/w hyperalgesia,
allodynia and other psychological
factors
Sanchis-Alfonso V, McConnell J, Monllau JC, Fulkerson JP. Diagnosis and treatment of anterior knee pain. Journal of ISAKOS.
2016 May 1;1(3):161-73.
6. History
• Swelling
• Instability – giving way
• functional impairment
• Sometimes, crepitus and limitation of extension may be present
Sanchis-Alfonso V, McConnell J, Monllau JC, Fulkerson JP. Diagnosis and treatment of anterior knee pain. Journal of ISAKOS.
2016 May 1;1(3):161-73.
7. History
• Aggravation of symptoms on
• overuse of knee
• new activity
• increased performance of an accustomed activity
• Psychiatric issues
• depression and catastrophization
• kinesiophobia
• any previous surgery on the symptomatic knee
Sanchis-Alfonso V, McConnell J, Monllau JC, Fulkerson JP. Diagnosis and treatment of anterior knee pain. Journal of ISAKOS.
2016 May 1;1(3):161-73.
8. Clinical examination
• Evaluation of lower limb alignment
• genu valgum
• excessive femoral anteversion
• tibial external rotation
Neal BS, Lack SD, Lankhorst NE, Raye A, Morrissey D, van Middelkoop M. Risk factors for patellofemoral pain: a systematic review
and metaanalysis. Br J Sports Med. 2019;53:270–81
Genu Valgum
Excessive
femoral
anteversion
External tibial
torsion
9. Q angle
• Represents vector of quadriceps
pull
• Normal
• 8-10 degrees in male
• 10-20 degrees in females
• Increased Q angle – increased risk
of PF instability
D’Ambrosi R, Meena A, Raj A, Ursino N, Hewett TE. Anterior knee pain: state of the art. Sports Medicine-Open. 2022 Dec;8(1):98.
10. Clinical examination
• Localization of pain
• Patellar tendinopathy (Jumper’s knee)
• Tenderness of the medial-distal patellar tip
• Hoffa impingement syndrome
• Tenderness of the lateral–distal patellar tip
• Osgood Schlatter disease
• Tenderness in tibial tuberosity
D’Ambrosi R, Meena A, Raj A, Ursino N, Hewett TE. Anterior knee pain: state of the art. Sports Medicine-Open. 2022 Dec;8(1):98.
11. Hoffa’s test
• To test impingement of
Hoffa’s fat pad
• Frequently a/w Patella
alta
Dragoo JL, Johnson C, McConnell J. Evaluation and treatment of disorders of the infrapatellar fat pad. Sports Med 2012;42:51–67.
12. • + Patellar facet
tenderness
• To evaluate PF
chondropathy
Clark’s test/ Patellar grind test
D’Ambrosi R, Meena A, Raj A, Ursino N, Hewett TE. Anterior knee pain: state of the art. Sports Medicine-Open. 2022 Dec;8(1):98.
13. Tests for PF instability
• Patellar glide test
• Patellar tilt test
• Patellar apprehension test and J sign
• Tenderness at insertion MPFL
• Beighton score for GLL
14. Clinical examination
• Restricted ROM of knee
• Hip examination- Hip pain radiating to anterior knee
• Muscle weakness
• Hip abduction, extension and external rotation
• core muscles
Sanchis-Alfonso V, McConnell J, Monllau JC, Fulkerson JP. Diagnosis and treatment of anterior knee pain. Journal of ISAKOS.
2016 May 1;1(3):161-73.
15. Investigation
• X ray
• 1st line investigation
• Weight bearing AP, True lateral and Axial views
• CT
• Bone morphology, TT-TG, torsional anomalies of lower limb
• MRI
• Cartilage lesion, plica, soft tissue impingement
16. MRI – Patellar tendinitis
• focal thickening of the proximal one-
third of the tendon
• AP diameter greater than 7 mm
• focal T2 hyperintensity within the
proximal tendon (eps medial third)
• an indistinct posterior tendon border
• edema in the adjacent Hoffa’s fat pad
Samim M, Smitaman E, Lawrence D, Moukaddam H. MRI of anterior knee pain. Skeletal Radiol. 2014;43:875–93.
17. MRI - OSD
• enlarged patellar tendon with T1 and
T2 hyperintensity at its insertion on
TT
• Edema of the deep infrapatellar bursa
with surrounding soft tissue edema
• marrow edema in TT
Samim M, Smitaman E, Lawrence D, Moukaddam H. MRI of anterior knee pain. Skeletal Radiol. 2014;43:875–93.
18. MRI - SLJ
• Bony avulsion injury at proximal
patellar tendon insertion
• No injury to cartilage
• Patellar sleeve avulsion
• Avulsion of inferior pole cartilage
Samim M, Smitaman E, Lawrence D, Moukaddam H. MRI of anterior knee pain. Skeletal Radiol. 2014;43:875–93.
19. MRI – medial plica
• Hyperintense on T2 sequence
when symptomatic
MRI – Hoffa’s disease
• T2 hyperintensity at inferolateral
aspect of the patellofemoral joint
and the lateral portion of the
Hoffa’s fat pad
Samim M, Smitaman E, Lawrence D, Moukaddam H. MRI of anterior knee pain. Skeletal Radiol. 2014;43:875–93.
20. Treatment
• Usually conservative, according
to cause
• Multimodal physio
• Operative indications
• PF instability
• PF cartilage injury
• Symptomatic plica
• Advanced PF arthritis
Adapted from Dye SF. The pathophysiology of patellofemoral pain:
a tissue homeostasis perspective. Clin Orthop Relat Res
2005;436:100–10.
21. Anterior knee pain
Classical peripatellar or
retropatellar pain
History
1
Pain not localized to a specific
landmark
3
Pain localized to a specific landmark
2
Adapted from D’Ambrosi R, Meena A, Raj A, Ursino N, Hewett TE. Anterior knee pain: state of the art. Sports Medicine-Open. 2022
Dec;8(1):98.
22. Classical peripatellar or
retropatellar pain
1
Giving way while climbing or
descending stairs or uneven
surfaces
Giving way while turning or
pivoting
Consider PF instability
Consider ACL insufficiency
Abnormal limb alignment
Trochlea dysplasia
Soft tissue problem (Patella
alta, MPFL insufficiency)
PF chondral lesion Surgery if conservative fails
Treat accordingly
‘a la carte’
Adapted from D’Ambrosi R, Meena A, Raj A, Ursino N, Hewett TE. Anterior knee pain: state of the art. Sports Medicine-Open. 2022
Dec;8(1):98.
23. Pain localized to a specific landmark
2
Tenderness localized to a specific landmark
Confirmation by X ray and/or MRI
Plica syndrome OSD or SLJ
Patellar tendinopathy
Arthroscopic
resection
Rest, activity
modification and
physical therapy
Taping and physical
therapy
Rest, activity
modification and
physical therapy
Adapted from D’Ambrosi R, Meena A, Raj A, Ursino N, Hewett TE. Anterior knee pain: state of the art. Sports Medicine-Open. 2022
Dec;8(1):98.
Fat pad syndrome
24. Pain not localized to a specific
landmark
3
Strengthening exercises and
physical therapy
Assess hip abduction, extension,
external rotation and core strength
Adapted from D’Ambrosi R, Meena A, Raj A, Ursino N, Hewett TE. Anterior knee pain: state of the art. Sports Medicine-Open. 2022
Dec;8(1):98.
25. Take home message
• Anterior knee pain has diverse etiology
• Meticulous history is crucial for management
• Diagnosis is essentially clinical with focus on identifying cause
• Investigations aim to support clinical findings
• Treatment is mainly nonoperative with surgery for selective
indications
• Patient education and counselling are crucial to success of treatment
Dey et al. reported the annual prevalence of patellofemoral pain (PFP) in the general population as 22.7%
Patellofemoral imbalance arising from a disorder of the retinacular structures;
loss of vascular homoeostasis secondary to patellofemoral imbalance or direct trauma
overuse (Dye’s theory of envelope of load acceptance)
Thorough and meticulous history-taking is the foundation of an accurate diagnosis
A history of trauma is uncommon, except in cases which may present post-traumatic patellar instability where we need to investigate for recurrent patellar instability
Pain usually occurs in response to activities that burden the patellofemoral joint, such as climbing up or down stairs, squatting, kneeling, and prolonged flexion of the knee joint
The so-called movie theater sign is observed when the patient experiences knee pain upon sitting with their knees flexed for a continuous period, such as while watching a movie in the theater or long car drives. The pain may improve on knee extension. This points to a pathology of the extensor mechanism and not the ftibiofemoral joint joint.
Swelling -Post-traumatic cases will offer a history of painful knee swelling after the antecedent trauma. Other patients may provide a history of knee swelling that was resolved after a period of avoiding pain-provoking activity. There may be multiple episodes of knee joint swelling.
Instability - sensation of their knee joint “giving way” while walking, which is related to reflex inhibition and/or atrophy of quadriceps. The patient is apprehensive about walking up or down stairs or on uneven surfaces
Commonly, the appearance or worsening of the symptoms is related to the overuse of the knee
The pain might also be brought on by a new activity that the patient is not used to performing or increased performance of an accustomed activity
patients with more severe symptoms have been found to suffer from depression and catastrophization
May be apprehensive about clinical examination maneuvers, that is, kinesiophobia (the fear that a manoeuvre will cause more injury or a reinjury and pain)
catastrophising (the belief that pain will worsen and cannot be relieved)
A genu valgum, excessive femoral anteversion, and consecutive tibial external rotation are independent risk factors for patellar instability
Craig’s test - Performed with the patient prone with knees flexed to 90°. The examiner palpates the greater trochanter and rotates the hip internally and externally until the greater trochanter lies at the lateral-most aspect of the hip (parallel to the examination table or bed), thereby projecting the femoral head into the center of the acetabulum. Interpretation: (1) Normal: At birth, the mean anteversion angle is 30°; it decreases to 8–15° in adults (angle of internal rotation). (2) Angle > 15°: Increased anteversion leads to squinting patellae and pigeon-toed walking (in-toeing), which is twice as common in girls. (3) Angle < 8°: Retroversion
Q-angle (quadriceps angle) is the angle between the quadriceps tendon and the patellar tendon. It provides useful information about the knee joint’s alignment. The Q-angle is formed
in the frontal plane by two line segments—one drawn from the anterior superior iliac spine (ASIS) to the center of the patella, and the other drawn from the center of the patella to the tibial tubercle. An increased Q-angle is a risk factor for patellar subluxation
The next step is to localize the painful area to identify the injured or pathological structure, followed by palpation of the important patellofemoral and tibiofemoral landmarks.
In patients with impingement of the Hoffa fat pad, pain is dramatically exacerbated by quadriceps contraction (B) or passive knee extension (C), while applying pressure of the fat pad with the fingers (A,B,C), because this movement causes a small posterior tilt of the inferior pole of the patella, which impinges on an inflamed and sensitised infrapatellar fat pad.
Restricted range of motion of the knee due to any postoperative stiffness tends to increase the patellofemoral contact pressure and cause AKP
Hip abduction, hip extension, and hip external rotation weakness can be associated with AKP, as can core muscle weakness
These patients with AKP tend to activate their quadriceps less, leading to a quadriceps avoidance gait pattern
The diagnosis of AKP is essentially a clinical one. Imaging plays a role in complementing the clinical examination by confirming the diagnosis and estimates the pathology quantitatively and qualitatively, ruling out others.
When no significant abnormality is detected, or the patient’s symptoms are refractory, more detailed studies of the knee such as computed tomography (CT) and magnetic resonance imaging (MRI) are obtained
On MRI, the normal plica has low signal on both T1- and T2-weighted images and is easily identified with some degree of joint distention
The clinician needs to decrease the strain of excessively loaded and painful soft tissues around the PFJ, improving the seating of the patella in the trochlea, as well as to optimise the lower limb mechanics, which should decrease the patient’s symptoms and, if maintained, will minimise any recurrences of symptoms.
To maintain the envelope of function and remain symptom free the patient must keep the intensity and frequency of the load below the threshold.
