ANTERIOR KNEE PAIN

18 Oct ANTERIOR KNEE PAIN

Lateral patella compression syndrome

• Maltracking of patella due to tight lateral retinaculum
• Excessive lateral patellar tilt
• Treatment is usually physiotherapy and stretching exercises

Causes

• Mechanical
  • Tight lateral retinaculum leading to excessive lateral patellar tilt and mobility.
• Increased femoral anti-version
• Genu valgum
• External tibial torsion/ Pronated foot

Clinical features

• Pain on climbing stairs
• Theatre sign( pain on prolonged sitting)
• Pain on compression of patella
• Lateral facet tenderness
• Inability to evert the lateral facet of patella
• Lateral patella-femoral angle on merchants x-ray view

Treatment

• Anti-inflammatory and physiotherapy
  • for most of the cases and done for a prolonged period of time
  • closed chain exercises of Vastus medialis obliues(VMO) , Vastus medialis and quadriceps exercises.
• Arthroscopic lateral release for patients without instability with decreased medial patellar glide less than 1 quadrant
• Patellar realignment surgery
  • maquets( Anteriorization of tibial tubercle)
  • Medialization od tibial tuberosity ( Elmslie-Trillat procedure)
  • Fulkersons osteotomy( Anteriorization and medicalisation of tibial tuberosity)

Osgood-schlatters disease

• Its a tractional apophysitis of tibial tubercle
• tibial tubercle is clinically enlarged
• treatment is usually non-operative

Demographics

• More common in boys
  • Male 12-15 years
  • Female 8-12years
  • 20-3-% B/L
  • Common in athletes involved in jumping and sprinting

Clinical features

• Anterior knee pain
• Enlarged tibial tubercle
• tenderness over the tibial tuberosity
• pain on resisted knee extension

Investigation

• fragmentation and irregular tibial tuberosity on a lateral view knee x-ray
• MRI
• D/D- Sinding larsen Johansson syndrome, osteochondroma of proximal tibia, tibial tubercle fracture and jumpers knee

Treatment

• Non-operative
  • Cast immobilisation for 6 weeks
  • NSAIDS
  • Physiotherapy
  • Quadriceps exercises
• Operative
  • excision

Plica syndrome

• Embriological remnant synovial fold which causes anterior knee pain
• There is painful restriction of knee movement with thick and inflamed synovial folds.

Pathophysiology

• Trauma in 50% of cases
• Most common plicas
  • ligamentum mucosum
  • supra-patellar plica
  • Medial plica

Clinical features

• Snapping
• Buckling
• knee pain on sitting
• Tender and palpable in the medial parapatellar region
• Resisted flexion of knee causes pain over anterior knee

Management

• Investigation
  • MRI
• Treatment
  • NSAID, activity modification and physiotherapy
  • Arthroscopic resection.

Quadriceps tendinosis

• Inflammation of supra patellar tendon
• usually diagnosis is made clinically by palpating tenderness over the quadriceps
• treatment is conservative mostly.
• Also seen along with patella hyper mobility

Epidemiology and pathophysiology

• Male to female 8:1
• common in athletes involved in jumping
• occurs due to repetitive contraction of extensor mechanism leading to micro tear at bone and tendon interface
• associated with jumpers knee

Clinical feature

• Athletes with jumping history or recent trauma complaining of pain over superior border of patella.
• Pain with resisted knee extension
• Hyper mobility of patella
• Blazina classification
  • phase 1 pain after activity
  • phase 2 pain during and after activity
  • phase 3 persistent pain with or without activity

Investigation

• X-ray in AP, lateral and merchants view
• USG
• MRI most sensitive test

Treatment

• Nonoperative
  • physio open chain and stretching exercises. taping reduces pain
  • Ultrasonic therapy
  • Extracorporial shock wave therapy
  • corticosteroids injection is contraindicated due to quadriceps tendon rupture.
  • PRP injection improves pain
• operative
  • mucoid degenerative tissue resection
  • bone abrasion at tendon insertion.

Chondromalacia patellae

• May be associated with miserable alignment syndrome
• Idiopathic in nature
• Treatment is usually conservative

Etiology( Causes)

• women more than men
• occurs in adolescents and young
• multifactorial
  • limb malalignment
  • muscle weakness
  • chondral lesion
  • maltracking patella
  • increased femoral antiversion
  • increase external tibial torsion
  • Genu valgum

Classification

• Outer bridge classification
  • 0 normal cartilage
  • 1 softening
  • 2 fissuring and fragmentation
  • 3 partial thickness changes (crab meat changes)
  • 4 exposed subchondral bone

Presentation and imaging

• peripatellar or retropatellar pain aggravated by climbing stairs, squatting and kneeling
• Atrophy of quadriceps muscles
• Patellar maltracking
• pain on compression of patella
• MRI best imaging modality

Treatment

• Nonoperative
  • NSAIDS
  • Rest
  • Physiotherapy
  • Activity modification
• operative
  • Arthroscopic debridement
  • if malt racking then patellar realignment surgery