44 Musculoskeletal Disorders FAMILY P RACTICE N EWS • November 15, 2006 Clinical Pearls for Managing Atraumatic Knee Pain

BY HEIDI SPLETE lacia patella, and patellofemoral Treatment and rehab strate- Senior Writer arthralgia. Evidence suggests gies include anti-inflammato- that there is a 20% prevalence ries; stretches for the quadri- WASHINGTON — Atraumatic knee of PFPS among individuals ceps, hamstrings, and calf pain, especially on the outside of the knee, aged 12-20 years, and that this muscles (gastrocnemius and is a common complaint in primary care of- type of knee pain accounts for soleus); and exercises for the fices, and although its mechanisms are up to 30% of visits in some adductor muscles of the hip. poorly understood, the pain is real, even sports injury clinics. Patients can usually ride a bike in those lacking clinical symptoms such as With any type of atraumatic to help maintain fitness during redness or swelling. knee pain, Dr. Flinn said to be recovery. Often, atraumatic knee pain is related to sure to ask patients about a his- the cartilage behind the kneecap, Dr. Scott tory of trauma; feelings that the Prepatellar Bursitis Flinn said at the annual meeting of the knee is catching, popping, lock- Also known as housemaid’s REAVES

American Academy of Family Physicians. ing, or giving way; and a histo- G knee, prepatellar bursitis is usu- “The retropatellar cartilage behind the ry of swelling in or around the ally caused by repeated micro- RED

knee is the thickest in the body—5 mm— knee joint. ©F trauma associated with kneel- and when the patella is extended, the car- Other symptoms include pa- Dr. Flinn, performing a Q-angle test, noted that the greater the ing, but it can in rare tilage causes pressure across the knee,” tient reports of anterior knee angle, the more likely a patient is to have patellofemoral pain. circumstances be caused by an said Dr. Flinn, a family physician, Special- pain while sitting for a long time infection. Ask patients who pre- ty Leader for Sports Medicine to the Sur- (known as the “theater sign”); pain when oblique). Also, consider foot orthotics for sent with atraumatic anterior knee pain ac- geon General, and Force Surgeon for walking down stairs, which is more com- patients who need to correct excessive companied by swelling and redness Commander Naval Surface Forces in San mon than pain walking up stairs; and pain pronation and imbalance. whether they spend much time scrubbing Diego, Calif. when squatting, running, or jumping. floors, gardening, laying carpet, or per- Dr. Flinn presented diagnostic pearls, On physical examination, check for the Patellar Tendinitis forming other activities that involve exces- treatment strategies, and rehabilitation quadriceps angle, or Q-angle, which is the Patellar tendinitis is a misnomer because sive kneeling or wearing hard knee pads. tips for getting patients with the following angle created between a line drawn from the condition is actually more of a tendi- A patient with an infected prepatellar common causes of anterior atraumatic the center of the anterior superior iliac nosis than tendinitis, Dr. Flinn said. De- bursa may present with fever, chills, and knee pain back to strength without spine on the pelvis to the center of the patel- spite an initial inflammation, histology sweatiness. On physical exam, the area surgery: la and a second line from the center of the tends to show few inflammatory cells. Pa- will be warm and tender to the touch, but patella to the middle of the tibial tubercle. tients with “jumper’s knee” usually hurt that isn’t enough to confirm or rule out Patellofemoral Pain Syndrome The greater the Q-angle the more like- themselves by overusing the knee in an ac- sepsis. Get a cell count and gram stain to Patellofemoral pain syndrome (PFPS) is ly a patient is to have PFPS, according to tivity such as basketball or volleyball. rule out infection. White blood cell counts also known as runner’s knee, chondroma- some studies. Patients who overpronate Patients present with almost no swelling, are usually greater than 10,000 cells/mcL are more likely to have PFPS than are but they report anterior knee pain that in septic patients but less than 1,000 those whose stride is even. On palpation, worsens with activities such as running, cells/mcL in nonseptic patients. A Twist on RICE clinicians may feel a tight lateral retinacu- jumping, using stairs, and squatting. Patel- As for treatment, Dr. Flinn recommends lum. There may be a trace effusion, and lar tendinitis can occur in conjunction with treating for gram-positive Staphylococcus For Management patients with PFPS do not usually com- PFPS, but the patient with patellar ten- aureus, which is the cause of 80% of these plain of instability or joint tenderness. dinitis alone usually does not experience infections. Methicillin-resistant S. aureus n all cases of atraumatic knee Rehab for PFPS includes improving flex- the fullness in the knee that can accompa- (MRSA), Mycobacterium tuberculosis, and Ipain, remember the principles of ibility in the hamstrings, iliotibial band, and ny PFPS, nor do these patients tend to re- M. marinum are rare causes. Treatment PRICEMM (an extension of the old lateral retinaculum. In particular, tightness port feelings of locking, catching, or giv- should be based on cultures, whenever standby RICE): in the lateral retinaculum (one of the fi- ing way in the knee. Foot orthotics or possible. Ǡ Protect the injury from additional brous bands that hold the patella in align- new shoes may correct overpronation. Prescribe ice packs and NSAIDs for non- harm (with bracing, for example) ment) could contribute to the pain by caus- Some patients with jumper’s knee will septic patients, and recommend a knee Ǡ Relative rest (maintain cardiovas- ing the patella to ride laterally, which may find pain relief by using a patellar tendon pad for protection in nonacute cases. Re- cular and strength training activities contribute to the retropatellar pain of PFPS. strap, such as the Chopat strap—a rubber hab for nonseptic patients is similar to in other ways) Many atraumatic injuries of the knee strap designed to change the forces across strategies for other atraumatic anterior Ǡ Ice are caused by incorrect training or poor the patellar tendon and relieve the pain— knee injuries and is based on the Ǡ Compression biomechanics, or a combination of the which is available from most sporting PRICEMM principles (see box). Focus on Ǡ Elevation two. Consequently, the best treatment for goods stores, catalogs, and Web sites. “The stretching and strengthening the quadri- Ǡ Medications (NSAIDs for pain) PFPS includes physical therapy, with a fo- patellar tendon strap tricks the body into ceps, hamstrings, and iliotibial band, and Ǡ Modalities for rehab (stretching, cus on strengthening exercises for the out- thinking that forces are distributed differ- recommend the use of a cushioned knee physical therapy) side of the quadriceps muscle (with an at- ently around the knee,” Dr. Flinn ex- pad, perhaps with a hard exterior shell, tempted focus on the vastus medialis plained. when the patient resumes activity. ■ Surgery Relieves Pain From Degenerative Lumbar Scoliosis

BY BRUCE K. DIXON life were all significantly improved, and those who were ready to proceed with misplaced pedicle screws in two others Chicago Bureau 80% of patients felt their preoperative ex- elective surgery underwent decompres- had to be adjusted, he said. “Excluding pectations had been met or exceeded,” sion and fusion with pedicle screw instru- those who had immediate postoperative S EATTLE — A majority of adults with said Dr. Furey, of the department of or- mentation and iliac crest graft. treatment for infections, there was a 21% degenerative lumbar scoliosis experienced thopedic surgery at Case Western Reserve All levels with spinal stenosis were de- reoperation rate, which is high.” pain relief after undergoing posterior de- University in Cleveland. compressed, including bilateral foramino- Dr. Furey and his coauthor, Dr. Sanford compression and fusion, according to a 42- This type of repair is a major under- tomies. All levels decompressed were Emery of West Virginia University, patient study presented at the annual meet- taking, he said. “Adults with degenerative fused, as were any levels with lateral lis- Charleston, said that because the proce- ing of the North American Spine Society. lumbar scoliosis frequently have signifi- thesis greater than 6 mm. The proximal dure potentially can cause significant At an average follow-up of just over 4 cant medical issues—including osteopenia extent of the fusion was at the lowest neu- complications in older patients, it should years, 95% of patients reported excellent and osteoporosis—that make them more tral vertebra in the upper lumbar or low- be reserved for those who have failed con- or good relief of leg pain, and nearly 90% of a challenge. These are lengthy surgeries er thoracic spine. Fusion was extended to servative management and who are suit- had the same response when asked about with the potential for significant blood loss the sacrum only if an L5-S1 spondylolis- able medical candidates. “These patients back pain. In addition, 86% felt there was and long hospital stay, and complications thesis was present, but otherwise was deserve respect, and optimizing medical is- improvement in their lifestyle postopera- are common,” Dr. Furey explained. stopped at L5, Dr. Furey said. sues—including good intraoperative anes- tively, said Dr. Christopher Furey. All patients in this retrospective analysis Two patients developed deep infections thesia support and postoperative obser- “Pain, function, image, and quality of were first treated conservatively, and only that required surgical debridement, and vation—is critical,” Dr. Furey said. ■