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Approach to the Active Patient with Chronic Anterior Knee Pain

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Approach to the Active Patient with Chronic Anterior Knee Pain No part of The Physician and Sportsmedicine may be reproduced or transmitted in any form without written permission from the publisher. All permission requests to reproduce or adapt published material must be directed to the journal office in Berwyn, PA, no other persons or offices are authorized to act on our behalf. CLINICAL FOCUS: ORTHOPEDICS AND SPORTS INJURIES Approach to the Active Patient with Chronic Anterior Knee Pain DOI: 10.3810/psm.2012.02.1950 Alfred Atanda Jr, MD1 Abstract: The diagnosis and management of chronic anterior knee pain in the active individual Devin Ruiz, BSc2 can be frustrating for both the patient and physician. Pain may be a result of a single traumatic event Christopher C. Dodson, or, more commonly, repetitive overuse. “Anterior knee pain,” “patellofemoral pain syndrome,” and MD2 “chondromalacia” are terms that are often used interchangeably to describe multiple conditions that Robert W. Frederick, MD2 occur in the same anatomic region but that can have significantly different etiologies. Potential pain sources include connective or soft tissue irritation, intra-articular cartilage damage, mechanical 1Department of Orthopaedic irritation, nerve-mediated abnormalities, systemic conditions, or psychosocial issues. Patients with Surgery, Nemours/Alfred I. duPont Hospital for Children, Wilmington, anterior knee pain often report pain during weightbearing activities that involve significant knee DE; 2Thomas Jefferson University flexion, such as squatting, running, jumping, and walking up stairs. A detailed history and thorough Hospital, Jefferson Medical College, Philadelphia, PA physical examination can improve the differential diagnosis. Plain radiographs (anteroposterior, anteroposterior flexion, lateral, and axial views) can be ordered in severe or recalcitrant cases. Treat- ment is typically nonoperative and includes activity modification, nonsteroidal anti-inflammatory drugs, supervised physical therapy, orthotics, and footwear adjustment. Patients should be informed that it may take several months for symptoms to resolve. It is important for patients to be aware of and avoid aggravating activities that can cause symptom recurrence. Patients who are unresponsive to conservative treatment, or those who have an underlying systemic condition, should be referred to an orthopedic surgeon or an appropriate medical specialist. Keywords: patellofemoral pain syndrome; physical therapy; differential diagnosis Introduction “Anterior knee pain,” “patellofemoral pain syndrome” (PFPS), and “chondromalacia” are terms often used interchangeably to describe conditions that occur in the same ana- tomic region but that can have significantly different etiologies. Potential pain sources include connective or soft tissue irritation (quadriceps/patellar tendonitis), intra-articular cartilage damage, mechanical obstructions (loose bodies, unstable cartilage flaps), nerve- mediated abnormalities (referred pain from hip or spine pathology, complex regional pain syndrome), systemic conditions (inflammatory arthritis), or psychosocial issues. Although the differential diagnosis is broad, a detailed history and physical examination Correspondence: Alfred Atanda Jr, MD, Pediatric Orthopedic Surgeon, can narrow the diagnosis (Table 1). Appropriate treatment can begin only after correct Surgical Director, diagnosis. The primary care sports medicine physician can manage most conditions that Sports Medicine Program, Nemours/Alfred I. duPont Hospital cause anterior knee pain in the active individual. However, there are occasions when the for Children, patient should be referred to an appropriate specialist (Table 2). Department of Orthopaedic Surgery, 1600 Rockland Rd., Wilmington, DE 19803. History Tel: 302-651-6521 Although the exact etiology of chronic anterior knee pain may not be obvious, there are Fax: 302-651-5951 E-mail: [email protected] several key historical components that can help in formulating the differential diagnosis. © The Physician and Sportsmedicine, Volume 40, Issue 1, February 2012, ISSN – 0091-3847 41 ResearchShareTM: http://www.research-share.com/GetIt • Copyright Clearance Center: http://www.copyright.com Atanda et al It is important to determine whether the pain began abruptly In these cases, it may help to have the patient point to one with a specific event or if the pain occurred gradually and area that bothers him or her most. had no particular inciting event. If the pain began acutely, as The patient should be asked to characterize the pain in with trauma or a fall, it is important for the patient to report simple terms. Constant, dull pain can be a sign of referred the circumstances of the event (eg, knee buckling, twist- or sympathetic-mediated pain.1 Referred pain from the ing, or popping) to the physician. Using the center of the hip may be suspected if there is decreased hip range of patella as a reference point, the anterior region of the knee motion (ROM) and difficulty performing tasks such as can be divided into 5 locations for purposes of defining the putting on and taking off one’s shoes. Referred pain from source of the pain (Figure 1). The bony patella itself, the the lumbar spine should be suspected if there is back pain underlying cartilage, and the overlying skin comprise the that radiates into the buttocks/posterior thigh region or is first region. The superior structures, such as the superior accompanied by lower-extremity numbness or weakness. pole of the patella and the quadriceps tendon, form the Sharp, intermittent pain may be due to loose bodies or car- second region. The inferior structures, such as the inferior tilage flaps in the joint, which can also be associated with pole of the patella, patellar tendon, and tibial tubercle, locking and catching. Locking episodes may be associated form the third. The medial structures, including the medial with swelling and severe pain; however, patients may be retinaculum, plica band, pes anserinus (hamstring tendon entirely asymptomatic between episodes.2 These episodes insertion), and medial patellofemoral ligament, comprise are frequently unpredictable and are not caused by any the fourth. Lastly, the lateral structures, such as the lateral specific activity. Activity-related pain is usually caused by retinaculum, lateral patellar facet, and iliotibial band, form soft tissue/bone overload that is exacerbated with increased the fifth region. When asked to localize the pain, patients activity. Pain caused specifically by kneeling, crawling, will often place their entire hand over the front of the knee. going up and down stairs, and prolonged knee flexion can Table 1. Summary of Etiology, Diagnosis, and Treatment of Anterior Knee Pain Pain Source Diagnosis Signs and Symptoms Diagnostic Tool Treatment Connective Soft tissue irritation (quadriceps/ Reproducible pain over the MRI to evaluate soft Physical therapy/activity tissue patellar tendonitis, plica syndrome, involved structure, pain with tissues, CT scan to modification; possible fat pad syndrome, ITB tendonitis), resisted motion evaluate for possible surgery for tendinopathy, patellar stress fracture malalignment, bone plica band, or stress scan evaluating for fracture bony uptake Cartilage Articular cartilage irritation (DJD, Swelling, crepitus with flexion/ Axial/sunrise patellar Physical therapy, posttraumatic, chondromalacia) extension, pain with direct radiograph, MRI arthroscopy for cartilage compression resurfacing, patellar realignment to unload cartilage Mechanical Loose bodies, unstable Swelling, locking, catching Radiographs, MRI Arthroscopic loose cartilage flaps body removal, cartilage resurfacing Nerve Referred pain Abnormalities of lumbar Radiographs, MRI, Dependent on underlying spine or hip bone scan pathology Complex regional Findings consistent with Clinical diagnosis Pain management referral pain syndrome abnormal sympathetic function Postoperative neuroma Sensitivity and pain in the Clinical diagnosis, Neuroma excision proximity of scars diagnostic local anesthetic injection Systemic Inflammatory arthritis Other joint involvement, morning Laboratory work-up Nonsteroidal anti- condition stiffness, systemic symptoms inflammatory drugs Medical condition causing weakness, Past medical history and condition- Treat underlying condition muscle atrophy, laxity (cancer, specific physical examination endocrinopathies, pregnancy) findings Psychologic Malingering/symptom exaggeration Psychosocial issues Psychiatric assessment Therapy/counseling for secondary gain Abbreviations: CT, computed tomography; DJD, degenerative joint disease; ITB, iliotibial band syndrome; MRI, magnetic resonance imaging. 42 © The Physician and Sportsmedicine, Volume 40, Issue 1, February 2012, ISSN – 0091-3847 ResearchShareTM: http://www.research-share.com/GetIt • Copyright Clearance Center: http://www.copyright.com Chronic Anterior Knee Pain Table 2. Summary of Specific Anterior Knee Pain Disorders Disorder Clinical Radiographic Initial Specialist Presentation Findings Treatment Referral Patellofemoral Anterior or retropatellar pain Often normal PF joint load restriction, Orthopedic surgeon pain syndrome with running, jumping, squatting, VMO strengthening, hamstring after 3–6 months of and stair climbing21–24 stretching, NSAIDs, McConnell conservative treatment taping, orthotics10–12,20,25,31–33,40–43 Patellar tendinopathy Pain at proximal patellar MRI findings of Activity modification, quadriceps Orthopedic surgeon tendon/bone interface45,46 increased signal strengthening, NSAIDs, shoe
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