Patellofemoral Pain Syndrome

 

• Pain in and around patellofemoral joint that cannot be explained by a specific pathology
• Causes: 
  • Direct trauma
  • Overuse of the joint 
• Signs and Symptoms:
  • Dull to sharp pain, ranging from anterior to posterior, and all four of its borders
  • Symptoms occur during periods of inactivity (sitting), stair climbing, during, or after activity involving prolonged flexion of the knee
  • Often mimic symptoms of meniscal trauma
  • Mild swelling
• Evaluation:
  • Tightness of tissues surrounding the joint
  • Hyperlaxity of the tissues surrounding the joint
  • Assess patellar glide and tilt
  • Patellar Grind Test
  • Patellar Tilt Test
• Treatment:
  • Modify activity to avoid pain
  • NSAIDs
  • Ice after activity
  • Patella mobilization and passive stretching
  • Strengthening the hip and thigh muscles
  • Shoe orthotics
  • Patellar taping (used only in patients with patellar tracking problems)

 

Patellar Maltracking 

 

• Normal Patellar Tracking Dependent on:
  • Alignment of the femur on the tibia
  • The Q angle
  • Integrity of the patella's soft tissue
  • Foot and gait mechanics
  • Flexibility of the triceps surae, quads, hamstrings, and IT band
• The Q angle:
  • The relationship between the line of pull of the quadriceps and the patellar tendon
  • Performed once during extension, and once during flexion
  • Normal male values: extension = 13 degrees, flexion = 8 degrees
  • Normal female value: extension =18 degrees, flexion = 8 degrees
• Causes:
  • Mostly congenital
  • Injury to patella or knee causing change in one of the variables above
  • Increased laxity due to tearing of the medial restraints
  • Increased amount of lateral patellar glide
  • Increased body weight
  • Poor gait mechanics
  • Improper muscle length    

 

Patellar Subluxation and Dislocation

 

(http://www.nlm.nih.gov/medlineplus/ency/images/ency/fullsize/9721.jpg)

 

• Caused by increased lateral glide of the patella due to:
  • Acute, chronic, or congenital laxity of the medial patellar restraints                                      
  • Abnormal tightness of lateral retinaculum

• Contributing Factors:  
  • Hypomobile medial glide vs hypermobile lateral glide
    • tight lateral restraints, lax medial restraints
  • Flattened posterior articulating patellar surface
  • Increased Q angle causes patella to track laterally due to:
    • external tibial rotation
    • hyperpronated feet
  • Family history 
• Signs and Symptoms:
  • Obvious deformity
  • Effusion of the knee within 24 hours
• Risks:
  • Osteochondral fractures to lateral femoral condyle or posterior surface of the patella
  • Tearing of the medial collateral ligament
• Functional tests:
  • Active range of motion test produces pain during the first 30 degrees of flexion
  • Passive range of motion test produces pain as knee enters into flexion
  • Resisted range of motion test shows a decrease in strength during extension (between 0-30 degrees)
  • Patellar Apprehension Test: Pillow is placed under the knee to support it at a 15-20 degree angle. Use four fingers to draw the patella laterally. Pay close attention to the patient's face, he/she may show a positive sign of apprehension.

 

Patellar Tendinitis

 

(SmartImage)

 

• Sometimes refered to "Jumper's Knee"
• Causes:
  • Repeated stress involving resisted knee extension
  • Common among basketball and volleyball players due to high amounts of jumping and landing
  • Microtearing the fibers causes excess connective tissue and endothelial cells to form, increased vascularity, and alteration in structure
  • Blow to the tendon
  • Patellar maltracking
  • Overuse
• Symptoms:
  • Pain around the superior and inferior poles of the patella
  • Pain in middle of tendon, and at insertion point on tibial tuberosity
  • Swelling
  • Tightness of the quadriceps
• Functional Tests:
  • Active range of motion produces pain during knee extension
  • Passive range of motion produces pain during the end range of knee flexion
  • Resisted range of motion produces pain throughout knee extension
• Treatment:
  • Modify activity to avoid pain
  • NSAIDs
  • Ice after activity
  • Patella mobilization and passive stretching
  • Strengthening the hip and thigh muscles
  • Shoe orthotics
  • Surgery to debridge tendon

 

Patellar Tendon Rupture

 

• Causes:
  • Tension in the quadriceps overloads the tendon
  • Hyperflexion of the knee
  • Powerful knee extension
• Associations with:
  • Rheumatoid arthritis
  • Diabetes
  • Lupus
  • Chronic renal disease
  • Chronic inflammation of patellar tendon
  • Overuse of corticosteroids
• Signs and Symptoms:
  • Immediate gross deformity
  • Palpation shows exposed condyles
  • Rapid swelling
  • Inability of extend lower leg
  • Inability to perform a straight leg raise
• Treatment:
  • Immediate immobilization and hospitalization
  • Surgery to restore tendon
• Functional tests:
  • During active range of motion, unable to extend the knee against gravity
  • Passive range of motion produces an empty end-feel or soft end-feel during flexion
  • Resisted range of motion tests should not be performed 

 

 

Patellar Bursitis (suprapatellar bursa, prepatellar bursa, subcutaneous infrapatellar bursa, deep infrapatellar bursa) 

 

(SmartImage)

 

• Bursitis occurs as a result of inflamation due to local tissue damage from trauma or strain, overuse or infection
• Bursitis can be acute or chronic
• Chronic Bursitis often occurs with repeated trauma to the knees, in this case often there is a thickening of the walls of the bursa causing irritation
• Signs and Symptoms: Pain, swelling, warmth, tenderness and swelling of the knee and surrounding tissues
• Common Causes:
  • The mechanism of injury can be chemical, mechanical or septic
    • Chemical: Calcium or other deposits with in the bursa can activate an inflammatory response in the joint
    • Mechanical: Direct blow to an area, repeated rubbing of soft tissue on bone or poor biomechanics of a joint can lead to an inflammatory response
    • Septic: Viral or bacterial invasion of the bursa can often lead to an inflammatory response, this often happens via an open wound to the knee allowing foriegn pathogens to enter the bursa
  • Superficial prepatellar bursa & Subcutaneous infrapatellar bursa - commonly swelling of these bursae occurs as a result of direct injury to the joint
  • Suprapatellar bursa & Deep infrapatellar bursa - commonly these bursae become inflammed as a relult of overuse of the joint

•  Treatment:
  • Acute Bursitis - Ice, compression, rest, control of inflammation and elevation
  • Chronic Bursitis - Avoiding movements that irratate the bursa is important, knee pads may be helpful if kneeling must occur, anti-biotics are used in infected cases and severe cases fluid from the bursae may be removed

 

Synovial Plica Syndrome

 

 

(http://www.tri-countyortho.com/mmg/pated/knee_problems/plica/knee_plica.html)

 

• A fold in the membrane that surrounds and protects the joint
• These folds are formed during fetal devolpment and in majority of the population these folds remain throughout life
• These folds remain asymptomatic usually unless the area has undergone trauma
• Most commonly synovial plica syndrome involves the medial joint capsule
• When the plica becomes injured it loses its elastic properties consequently affecting the gliding mechanisms of the patella
• Signs and Symptoms:
  • Pain in anterior, medial or posterior region of the patella
  • Sharp pain when kneeling is often accompinied
  • Descriptions of pain may include - clicking, popping, locking or giving way in the knee
• Common Causes:
  • Plica rubbing across the femoral condyle resulting in friction as well as creation of resivors for synovial fluid
  • Repeatitive exercise such as running, biking or stair climbing in which the knee is extended and bent often are often common instigators
• Treatment:
  • Symptoms can be reduced by reducing activity, controlling inflammation through ice and NSAID's such as ibuprofen, and strenghting the oblique fibers of the vastus medialis
  • Usually the plica will heal with out surgey however treatment of Synovial Plica Syndrome can also be achieved through surgery by removing the plica

 

Osgood-Schlatter Disease

 

 

Figure 1: Osgood-Schlatter disease. Lateral radiograph of the knee demonstrating fragmentation of the tibial tubercle with overlying soft tissue swelling.

(http://www.childrensmemorial.org/cme/online/printableArticle.asp?articleID=101)

 

• Adolescent inflammatory condition affecting the tibial tuberosity growth plate at the site of patellar tendon attachment
• With repeated trauma to the tibial tuberosity and patellar tendon, new bone grows during the healing process leading to a more pronounced bump at the tibial tuberosity
• Signs and Symptoms:
  • Localized pain in the tibial tuberosity and distal portion of the patellar tendon, especially during or after exercise
  • Swelling of tibial tuberosity
  • Symptoms are similar to patellar tendinitis however can usually be distinguished from tendinitis because of the patients age and localization of pain at tibial tuberosity
• Common Causes:
  • Repeated avulsions of the patellar tendon from the tibial tuberosity
  • Avulsions usually due to rapid growth and/or increased strength of the quadriceps
• Treatment:
  • Can be managed by modifying activity to reduce the stresses on the tibial tuberosity, avoid exercise that elicits pain
  • Icing the area will help to aleve pain and inflammation
  • Controlling inflammation
  • If treatments fail and repeated avulsions continue surgery may be required

 

Sinding-Larsen-Johansson Disease

 

Figure 2: Sinding-Larsen-Johansson syndrome. Lateral radiograph of the knee demonstrating fragmentation of the apophysis at the inferior pole of the patella.

(http://www.childrensmemorial.org/cme/online/printableArticle.asp?articleID=101)

 

•  Injury occurs at the attachment of patellar tendon to the inferior pole of the patella or, less frequently, to the site at which the quadricep tendon attaches to the superior pole of the patella
• This pathology affects more males than females commonly
• The most common age group to see this is in adolesence ages 10-14
• Signs and Symptoms:
  • Pain and swelling at the site of the affected pole of the patella
  • Pain occuring with quadricep stretching
• Common Causes:
  • Stress fracture or avulsion of the tendon from the bone because of constant forces, usually associated with running or jumping
• Treatment:
  • Rest for 4-8 weeks
  • Immobilization of leg in a cast
  • Ice and anti-inflammatory medications
  • After pain and swelling have decreased a strength and stretching program is administered on the quadricep

 

Patellar Fracture

 

(SmartImage)

 

• Results from a severe or blunt trauma to the patella
• Often this injury is accompinied by the rupture and swelling of a patellar bursa
• Signs and Symptoms:
  • Active and passive knee extension produces severe pain if it is even possible for the patient to perform
  • Resistive knee extension cannot be performed
• Causes:
  • Blunt trauma to the patella
  • Risks of a Patellar Fracture are increased following an Anterior Cruciate Ligament reconstruction surgery
• Treatment:
  • Splinting or casting the leg in full extension is necessary to allow the patella to heal properly
  • As the fracture begins to heal the angle of leg extension can be decreased
  • Complete fracture of the patella requires surgical procedures to repair the damage
  • Rest, Rest, Rest!

 

 Bipartite and Triapartite Patella

 

Figure 3: Bipartite Patella. Anterior radiograph demonstrating unfused centers of patellar ossification.

http://www.mypacs.net/cases/BIPARTITE-PATELLA-A-NORMAL-VARIANT-802862.html

 

• Two (bipartite) or three (tripartite) pieces of patella instead of a single solid patella
• Results from abnormal coalesence of multiple ossification centers of patella between 3 and 6 years of age
• Almost always occurs bilaterally
• May be confused with patellar fracture if bilateral radiographs are not taken
• Signs and Symptoms:
  • Frequently asympotmatic  and only diagnosed after radiographs for active knee injury
  • Discomfort or pain while standing up or jumping
  • Continuous knee pain

• Causes:
  • Abnomal ossification of the patella
  • Blunt trauma to patella or activity aggrivating the abnormal patella
  • Blunt trauma associated with patella fracture separating fibrous connections between patella fragments

• Treatment:
  • If trauma has separated fragments splinting or casting  leg in full extension is necessary
  • Limit jumping activities
  • Rest

 

 

 

Sites Used:

Evaluation of Orthopedic and Athletic Injuries

www.sportsinjuryclinic.net

www.childrensmemorial.org

www.tri-countyortho.com

www.webmd.com

www.fpnotebook.com

www.dynomed.com

 

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