20 Oct 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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