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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
- 26. Thank you
Editor's Notes
- 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.