‘Bone Joint and Nerve Clinic’ was started in the year 2018 by one of the Best Orthopaedic Surgeons in Patna, Dr. Neeraj kumar.

To establish the centre of excellence in Orthopaedics Dr. Neeraj kumar focused on its specialities by providing a safe & secure environment and performed the duties with utmost competency through utilising effective and innovative clinical practices with profound academic research.

ANTERIOR KNEE PAIN (CONTINUE)

ANTERIOR KNEE PAIN (CONTINUE)

Causes of anterior knee pain

  • Lateral patella compression
  • Osgood schlatters disease
  • Plica syndrome
  • Patella tendinosis
  • Sinding Larsen Johansson syndrome
  • Shin splints
  • Semimembranosus tendinitis
  • ITB friction syndrome
  • Chronic compartment syndrome
  • Popliteal artery entrapment syndrome
  • Hoffa syndrome( fat pad impingement)
  • Referred pain
  • Bipartite patella

Chronic exertion compartment syndrome

  • exercise induced leg pain characterized by reversible ischeamia of muscles in the particular compartment.
  • 2nd most common cause of leg pain.
  • Pain and parenthesis in the leg following the exercise.
  • No symptom at rest
  • Male more than female
  • 3rd decade of life
  • Most common in anterior leg compartment

Pathophysiology and symptoms

  • Accumulation of metabolites locally and spasm leading to clearance of metabolic waste
  • Aching and burning pain
  • parenthesis over foot
  • symptomless at rest
  • X-rays to rule out any stress fracture
  • MRI not very helpful
  • compartment pressure measurement
    • resting
    • 1min post exercise
    • 15 min post exercise
  • criteria
    • rersting pressure more than 15 mm of hg
    • immediate pressure ( 1 min) > 30 mm of hg
    • post exercise (15 min) pressure > 15 mm of hg

Treatment

  • Nonoperative
    • Activity modification
    • NSAIDS
  • Operative
    • If after 3 months of treatment there is no symptomatic improvement
    • Fasciotomy, successful in > 30% patients
    • recurrence 20% at a mean of 2 years due to fibrosis

ITB friction syndrome

  • Friction of ITB over lateral femoral condyle as it move from anterior to posterior during initial knee movement from extension.
  • Painful squatting and active single raise test
  • 2-15% of all the over use injuries
  • Mostly seen in runners and cyclist
  • limb length discrepancy, Genu varum or valgum, weak abductors and tight iliotibial band

Pathophysiology and symptoms

  • During initial 30 degree of knee flexion ITB rubs over lateral femoral condyle causing inflammation.
  • Irritation of underlying tissue
  • May result in cyst or bursitis
  • Associated with patellofemoral arthritis, medial compartment arthritis of knee and greater trochanter bursitis
  • Pain over lateral femoral condyle
  • Pain increases on running and relieved on rest
  • Mal-alignment of knee
  • Obers test positive
  • X-RAY AP, Lateral and skyline view may show osteoarthritis of knee or malalignment
  • MRI to rule out internal derangement of knee

Treatment

  • Nonoperative
    • rest
    • NSAIDS
    • Corticosteroid injection
    • Physiotherapy and activity modification
      • Stretching of ITB, lateral fascia and gluteal muscles
      • hip abductor strengthening
  • Operative
    • excision of cyst or bursa
    • Z-plasty of ITB
  • 50 TO 90 IMPROVE WITH CONSERVATIVE MANAGEMENT

Popliteal artery entrapment syndrome

  • There is constriction of popliteal artery by surrounding tissues
  • most commonly by medial head of gastrocnemius
  • There is diminished pulses with active plantar flexion of foot and passive dorsiflexion of foot
  • MALE TO FEMALE 4:1
  • Seen in 25 to 40 years of age

Pathophysiology, symptoms and imaging

  • Decreased blood flow below the popliteal artery
  • Classification
    • Medial head of gastrocnemius normal, popliteal artery aberrant
    • medial head of gastrocnemius laterally, popliteal artery normal
    • fibrous band from medial head of gastrocnemius constricting the popliteal artery
    • Popliteus muscle entrapping the artery
    • popliteal vein and artery entrapped by polliteus
  • there is swelling, parenthesis and cramps in the calf, foot and leg
  • on palpation there is reduced pulses
  • extremities can be cold
  • X-rays are normal
  • Arteriogram 100% sensitive
  • doppler useful when done during activity

Treatment

  • Nonoperative
    • activity modification
  • operative
    • Vascular bypass with vein graft
  • 30% chances of re entrapment
  • DVT 10%

Tibial stress syndrome( Shin splints)

  • Caused by traction periostitis
  • seen in runners without enough shock absorption
  • Overuse injury causing leg pain
  • Diagnosis is usually clinical
  • most common medial tibial stress syndrome

Pathophysiology, symptoms and imaging

  • Anteromedial periostitis due to tibialis anterior muscle
  • posteromedial periostitis due to tibialis posterior muscle
  • associated with tibial stress fracture
  • diffuse pain along middle and distal tibia which improves on running in early stages
  • tenderness along posteromedial border of tibia
  • xray to exclude stress fracture
  • Bone scan
  • MRI to rule out any other soft tissue injury

Treatment

  • Nonoperative
    • shoe modification
    • ask the patient to stop running or stop sports activity
    • strengenthen evertors and inverters
    • corticosteroid injection deos help.
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