Patella Pain

History

The presenting symptom in patients with patellofemoral joint syndrome is knee pain.

  • The quality of the knee pain varies from dull and achy to sharp and shooting; occasionally, there is a burning sensation.
  • The location of the pain may also vary. The pain may be described as anterior knee pain, retropatellar knee pain, peripatellar knee pain, global knee pain, posterior knee pain, joint line pain, or a combination of these.
  • Patients may complain of painful or painless retropatellar crepitation. Symptoms may also include a painful catching sensation and a painful giving way of the knee.
  • The pain may have an obvious etiology. Pain is often related to overuse or a change in exercise intensity.
    • Some activities that frequently trigger symptomatology are stair climbing, uphill running, hiking, deep knee bends, and squatting. The pain is often not noted until completion of the activity. The patient may also complain of pain with prolonged sitting in which the knees are in flexion.
    • Pain may be related to trauma, most frequently from falls onto the anterior knee or from the impact of the knees on the dashboard in motor vehicle accidents. Most commonly though, an inciting event cannot be determined.
    • A family history of anterior knee pain may be positive.
    • Genetics may predispose a person to develop patellofemoral joint syndrome. Genetic factors that are commonly associated with this condition include the following:
      • Hyperlaxity of the knee (genu recurvatum) or patellofemoral joint
      • Genu varus or genu valgus
      • Femoral anteversion or tibial torsion
      • Wide pelvic girdle
      • Pes planus or pronation of the foot
      • Muscle tightness, which itself may have a genetic component
      • Abnormal concentration of forces over a smaller articular surface of the patellofemoral joint.
    • This condition may either be caused or aggravated by overuse or a change in activity level. Repetitive knee flexion, especially on a weighted joint (eg, stair climbing, hiking, uphill running, kneeling, squatting, prolonged sitting with knee flexion) can cause symptomatology.
    • Trauma can be the underlying cause.
    • A forceful compression of the patellofemoral joint (eg, a fall onto the anterior knees, impact of the knees on a dashboard during a motor vehicle accident) may precipitate this condition.
      • Patellofemoral syndrome may occur after a patella subluxation or dislocation.
      • Patients may develop this condition after having ACL reconstruction with a bone-patellar tendon-bone technique. One year postoperatively, one third of these patients may have patellofemoral symptoms secondary to a weak quadriceps from patellar irritability or flexion contracture.
    • Osgood-Schlatter disease may be a predisposing factor to the development of patellofemoral pain later in life.
      • These patients continue to have the predisposing factors, such as muscle imbalance, that caused the Osgood-Schlatter disease.

      Conservative treatment is successful in 80% of cases of patellofemoral joint syndromes. The goal of treatment is to control the symptoms. Underlying strength and flexibility deficits need to be addressed. 

    • Start by having the patient modify his/her activity level. Decrease activities that increase patellofemoral pressure (eg, jumping, squatting, kneeling). Gentle eccentric loading activities may be initiated.
    • Apply ice for 10-15 minutes, 4-6 times per day, especially after activity.
    • Increase muscle strength, especially of the VMO, with short-arc quadriceps sets, knee presses, isometric quadriceps sets, and straight-leg raises with the leg externally rotated. Biofeedback may aid in teaching recruitment of the VMO.
    • Improve flexibility of the hamstrings, vastus lateralis, and iliotibial band. Stretch tight retinacular structures.
    • Initiate proprioceptive exercises.
    • Ultrasound or phonophoresis may decrease pain symptoms.
    • A patellofemoral brace with a patella cutout and lateral stabilizer or McConnell taping/Kinesio Taping may improve neuromotor control of the patellofemoral joint by affecting the osseoligamentous structures through alteration of patellar tracking, improving proprioception, or a combination of these factors.

    Surgery may be useful for patients who have been compliant and in whom a 12-month trial of conservative therapy was unsuccessful. Surgery may completely resolve the patient's symptomatology, partially resolve the symptomatology, or may not change the symptomatology; rarely is the symptomatology exacerbated iatrogenically. Surgery is more successful when a specific diagnosis has been established and when clear surgical goals can be defined.

    Surgical intervention includes arthroscopy for articular cartilage shaving, with or without lateral release of the retinaculum. Surgery may also include proximal or distal realignment. Open surgical procedures include patellar tendon transfer, or rarely, patellectomy.


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