Anterior knee pain is a common symptom with many potential underlying causes that can be related to muscles, ligaments, tendons, meniscus or bone. It is diagnosed through a thorough history and physical exam to determine potential patellar abnormalities, muscular imbalances or other causes. Treatment involves physical therapy focusing on exercises to improve strength, flexibility, and mechanics, as well as bracing, with surgery reserved for more severe cases. Proper rehabilitation after surgery aims to regain quadriceps strength and knee flexibility.

2. Anterior Knee pain
 Anterior knee pain is pain that occurs in the anterior and central aspect of the knee.
 ‘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 is a common complaint caused by a wide range of muscle, ligament, tendon, meniscus or bone
related condition or injury.
 Anterior knee pain is a symptom, not a diagnosis. Any diagnosis for the pain is, essentially, via
exclusion due to the numerous possible conditions, where patella abnormality or muscular imbalances
are important factors, determined by a thorough history and patient examination. There is also a high
correlation between AKP and faulty hip mechanics, so any assessment needs to involve the entire
kinetic chain.

3. Anterior knee pain could be as a result of
 Patellofemoral pain syndrome
 Chondromalacia Patellae
 Osgood-Schlatter’s disease
 Sinding Larsen Johansson syndrome
 Plica synovialis syndrome
 Knee bursitis/Hoffa’s disease
 Articular cartilage injury
 Bone tumours
 Osteochondritis dissecans
 Patellafemoral instability/subluxation
 Patellar stress fracture
 Patellar tendinitis
 Patellofemoral osteoarthritis
 Quadriceps tendinopathy
 Prepatellar bursitis
 Iliotibial band syndrome

4. Etiology
The etiology of anterior knee pain is multifactorial and not well defined due to the variety of symptoms, pain location
and pain level experienced by the patient. Underlying factors could be patella abnormalities, muscular imbalances or
weakness leading to patella malalignment on flexion and extension. This can cause include overuse injuries such
as; tendinopathy, insertional tendinopathy, patellar instability, chondral and osteochondral damage

5. Clinical presentation
 There is no clear definition of anterior knee pain as patients can present with various symptoms.
 There may be functional deficit, crepitus and/or instability.
 With activities of daily living pain often occurs or get worse when walking downstairs, squatting, depressing the clutch pedal in
a car, wearing high-heeled shoes, or sitting for long periods with the knees in a flexed position, known as 'movie sign'.
 Patients can also experience a degree of instability, especially on walking up and down stairs or over ramps.
 Individuals with overuse injuries may report a feeling of instability or giving way, although this may not be a true giving way
(which is associated with internal injury to the knee), but a neuromuscular inhibition as a result of pain, muscle weakness,
patellar or joint instability.

6. Diagnostic Procedures
Diagnosis requires a thorough examination, symptom history, in-depth knowledge of the associated structures and typical injury
patterns.
Some key factors in obtaining an accurate diagnosis are; the pain characteristics, i.e. its location, character, onset, duration, change
with activity or rest, aggravating and alleviating factors and any night pain; trauma (acute macrotrauma, repetitive microtrauma,
recent/remote); mechanical symptoms (locking or extension block, instability, worse during or after activity); inflammatory
symptoms such as morning stiffness, swelling; effects of previous treatments and the current level of function of the patient:
The European Rehabilitation Panel have devised a guideline which should lead to improved treatment choice and outcomes. They
suggest the following assessment parameters:
 Symptoms: Pain (location and type) or instability problems
 Alignment of the entire lower extremity: Squinting patella, High Q-angle? Genu valgus? Genu recurvatum? Pronation of the
subtalar joint?
 Patellar position: Patella alta? Patella baja? Patellar glide? Patellar tilt? Patellar rotation?
 Muscles and soft tissues: Hypotrophy of VMO? An imbalance between VM and VL? Weakness of knee extensors, hip flexors
and/or hip abductors? Tightness of the medial retinaculum? Tightness of lateral muscle structures, hamstrings and/or rectus
femoris?
 Knee function (pain and/or maltracking of the patella): During different dynamic activities, e.g. stair walking, step-up/step-down
exercises and one-leg squat?

7. OUTCOME MEASURES
The Kujala anterior knee pain scale and the Lower extremity functional scale can be used for both an initial screening
tool as well as to detect changes with treatment and as outcome measures.
The 13 item screening Kujala Anterior Knee Pain Scale (AKPS) is used to identify patellofemoral pain in adolescents
and young adults. Ittenbach et al. suggest that is highly reliable, but not without its limitations and further research is
needed for its use outside of a clinical environment and application to the general population. The AKPS has shown
to have good test-retest reliability.
The Lower Extremity Functional Scale (LEFS) is a further self-report test, to assess difficulties that the patient has
with activities. This questionnaire is less specific for anterior knee pain patient than the anterior knee pain scale. The
LEFS also demonstrates a high test-retest reliability and its reliability and responsiveness is slightly higher than that
of the AKPS.
The single leg squat is also used to assess anterior knee pain.

8. SURGICAL MANAGEMENT OFANTERIOR KNEE PAIN
 Arthroscopic patellar debridement (shaving)
 Arthroscopic lateral release
 Medial tibial tubercle
 Transfer
 Proximal quadriceps plasty
 Medial patellofemoral ligament reconstruction
 Anteromedial tibial tubercle plasty (fulkerson)
 Anteriorization (Maquet)
 Patellectomy
 Total patellofemoral arthroplasty

9. PHYSICAL THERAPY MANAGEMENT
Rehabilitation program includes
 Patient education
 Pain modalities: RICE, NSAIDS, Ultrasound, TENS (Transcutaneous electrical nerve stimulation)
 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
 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

10. PHYSICAL THERAPY MANAGEMENT
Post-op rehabilitation has two main goals
1. Regaining quadriceps strengths
2. 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

11. Stationary cycling
Short arch extensions
Isometric quadriceps
Straight leg raising

12. Patellar straps Patellar braces