Sports Medicine and Exercise Information  

Dr. Allan Mishra | Knee Pain Diagnosis



Diagnosis 

PATELLOFEMORAL PAIN SYNDROME


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Definition Patellofemoral pain syndrome describes a variety of possible disorders that cause pain in the joint between the kneecap (Patella) and the thigh bone (Femur).

Model and X-ray of a Normal Knee
Details Patellofemoral pain syndrome is known by other names such as: Patellar Chondromalacia, Excessive Lateral Pressure Syndrome and simply Anterior Knee Pain. It is a very common problem especially in women.

The pain associated with this disorder may worsen with descending stairs climbing or deep squating. Sitting with your knees flexed for a long period of time in a car or movie theatre may also aggravate the symptoms.
Causes A variety of underlying anatomic abnormalities may result in patellofemoral pain syndrome. It can be caused by softening or cracking of the articular cartilage under the kneecap. This is known as chondromalacia. A malalignment of the kneecap or tight tissue around the kneecap can also create tension that may lead to patellofemoral pain syndrome.

Usually, this disorder arises without a history of significant trauma. Occasionally, the pain may begin after a blow to the knee or a minor injury.

Arthroscopic pictures of a normal kneecap and one with chondromalacia
Diagnosis Patellofemoral pain syndrome patients complain of pain in the front of the knee. This pain may be localized but more often is diffuse. The pain may be made worse by descending stairs or sitting with a flexed knee for an extended period of time. The patient may also complain of occasionally giving way or a grinding sensation behind the kneecap.

The physical exam is critical to confirming the diagnosis. On inspection of the knee, an assessment of the alignment of the kneecap is done. The kneecap should fall in the center of the thigh. If it is riding on the outside portion of the knee or appears to tilt with knee bending, the patient is at higher risk for patellofemoral pain syndrome. Evaluation of the quadriceps muscle strength (especially its inside portion, the vastus medialis obliqus or VMO) is essential. Palpation of the kneecap and finding the area of maximal tenderness is done next. Assessing the kneecap for restricted movement and possible instability are other important components of the physical exam. Checking the knee for fluid (an effusion in medical terms) should also be done. Finally, it critical to evaluate the patient's quadriceps (thigh muscle) flexibility. This can be done by having the patient lie on their stomach and attempt to pull their heel toward their buttock. Comparison to the opposite side will help in this assessment.

X-rays, CT Scans and or MRI Scans may be used to confirm the diagnosis.
Treatment Nonoperative
Phase I Control of pain and inflammation with Rest, Icing, Stretching, Anti-inflammatory medication (RICE)
Phase II Restore strength and function with continued stretching and a strengthening program.
Phase III Return to sports or work via a customized program of exercises designed to maintain flexibility, coordination and endurance
These phases may be directed by your physician or may be done under the supervision of a physical therapist. The exercise program should be designed to improve quadriceps and hamstring flexibility and emphasize VMO strengthening. Taping of the kneecap by a therapist may also provide some relief of the symptoms.

It may also be important to evaluate the patient's feet for orthotics if excessive pronation is present or consider bracing for the kneecap if it is unstable.


Operative

If nonoperative measures fail, surgery may be required to smooth the articular cartilage or release tight structures around the kneecap. The operation may take the form of minimally invasive arthroscopic surgery or may require an open kneecap realignment procedure. Any surgery for this disorder should be individualized to the patient and is best discussed with the surgeon of your choice.

Arthroscopic Surgery--smoothing of the knee cap cartilage
Prevention

Avoid training error such as overuse and knee extension exercises.
Maintain strong and flexible quadriceps and hamstring muscles.
Always warm up before playing or training.


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