Anterior Knee Pain - Lecture 2 Flashcards
Patellofemoral Pain syndrome affects 9-25% of active sports participants
Things that can cause patellofemoral pain syndrome
* Overuse
* Biomechancial issues (think boney deformitites / brith defects)
* Joint mobility (hyper/hypo)
* Trauma
* Degeneration
Patellofemoral issues can br driven by extrinisc factors
* Acute Trauma
* Chronic Overuse
* Poor Mechanics
* Training Errors
Structures involved in patellofemoral issues
* Intrapatellar fat pad
* Ligaments
* Patellar tendon
* Retinaculum (tight)
* Subchondral bone, joint
* IT band
* Bursa
Dysfunctions that can cause patellofemoral issues
* Patella femora instability
* Patella femoral pain w/ malalignment or biomechanical dysfunction
* patella femoral pain w/o malalignment
* Tightness
* Weakness
* Muscular imbalance
* Neuromuscular factors (think proprioception / poor balance in the area causing overuse of muscles to provide external and internal stability)
These are examples of lateral problems w/ patallela
Patellofemoral knee instability are the pts that say they feel their kneecap roll off to the side or they have to kick their knee out a few times and can pop their patella back into place
* So the pts are often dislocators
Which way patella most likely to sublux?
Latearl subluxations
What 4 things can cause the patella to sublux latearlly?
Q angle, patella alta, tight latearl retinalcumum
Inadeqate medial stabilizers (not much stuff to pull patella back to the middle)
Trauma to stabilizers or shallow groove where their patella should be sitting
5 biomechanical issues that could be causing PF pain
1) Tight latearl retinaculum
2) Weak vastus medialis
3) Neuromuscular deficits in hip musculature
4) Joint hyper/hypomobility
5) Inappropriate firing of quads (arent having as much of an active stabilization component)
Feel all this when walking especially
Things that cause knee pain w/o malalignment:
* Soft tissue lesions to the area (i.e., trauma)
* Tight medial or lateral retinaculum (normally latearl)
* Osteochondritits dessecans of patella or femoral trochlea (where the patella is going to sit - where he was mentioning about ti being shallow)
* Traumatic patellar chondromalcica (trip or fall)
* PF OA
* Apophysitits
* Symptomatic bipartite patella
PF pain w/o malalignment soft tissue lesions
* Plica syndrome
* Fat pad syndrome
* Tendonitis
* IT band Friction syndrome
* Prepatellar Bursitits
What is Plica syndrome
* medial or lateral
* hyper or hypomobility
Synovial membrane that has invaginated in on itself - folded in and gotten pinched
Normally medial plica
because of abnormal loading there is tissue hypertrophy around the area and fibriotic scaring - CAUSING HYPOmibility
KNOW: Its tissue inflamamtion often initaed w/ trauma that results in synovitits
* so i think the synovial fluid swells and causes the irritation
This is showing where that medial plica syndrome is
We use the Plica Stutter test to test for plica syndrome
Plica syndrome hurts the most w/ activity. What movement hurts the most and why
Knee flexion - because thats where its goign to stretch it the most
KNOW: Plica is considered an inflammatory condition
What treatment do we do for plica?
- Massage
- Manage swelling
- Address muscle imbalances (usually strenghtneing quads and hamstrings and adressing tight structures in the area)
- Reduce compression on the anterior knee
- Arthroscopic excision if needed
Fat padsyndrome = Infrapaterllar syndrome = Hoffas syndrome
KNOW: The fat pads function is
* Synovial fluid secretion benefits (enclosis it?)
* Joint stability (keeps patella from tilting anterior / posterior)
* Neurovascular supply
* Occupiers of deadspace
Patella making contact and pinching down can create inflammation of that fat pad
Fat pad syndrome is normally caused by direct trauma
* It can also be caused by overuse
Often fat pad syndrome is caused by posterior tilt of inferior pole of patella - causing the fat pad to become irretated
Where will swelling and tinderness be present w/ fat pad syndrome
Pain inferior to pole of patella along w/ edema
What positions hurt w/ fat pad syndrome?
Knee extension pain (when its in the close packed position)
0-15 degrees or flexion where patella doesnt contact the trochlear groove
What to do for fat pad syndrome
* Rest
* Ice
* NSAIDS
* steriod injections
* Address cause through orthotic interventions such as heel lifts
* Tape (superior pole posterior, and superior)
* Surgical rescetion if necessary
what is jumpers knee
patellar tendinopathy
KNOW: pattellar tendinopathies are common in sports with sprinting and jumping and people whi are just taking up running
* caused by repetitive eccentric activities (hints jumping)
* Normally caused by some kinf of muscular imbalance
* Often in those weekend warriors that just took up running
Where is a patellar tendinopathiy
what makes it worse
anterior knee localized pain
Made worse by activity or prolonged flexion
also called movie theatre knee
If they dont have OA patellar tendinopathy would be one of my first thoughts
outcome measure for patellar tendinopathy:
* Victorian insttitute of sports assessment patellar tendinopathy or LEFS
Rule out hip / low back for patellar tendinopathy and other non-musculoskeletal causes
Which AROM is limited w/ patellar tendinpathy?
What about PROM
AROM = knee extension decreased w/ pain
PROM = knee flexion decreased (essentially stretching the joint)
w/ reissted provocaion w/ patellar tendinopathy what movement brings about pain?
Extension brings on pain (AROM)
* Note if it was passive flexion would bring on pain (stretching the joint)
What muscle might hurt w/ patellar tendinoapthy resisted?
Extension hurts to quads might be painful
Will be pain over tendin w/ patella tendinopathy (normally just over insertion points - superior/inferior pole)
What 3 interventions would we do for patellar tendinopathy
Pain contorl
EX
mobility and flexibility
Patellar tendinopathy treatment in acute phase
* Rest / activity modification
* Pain / inflammation management
* Stretch
* Eccentric strengthening
* Bracing, Taping
What position is worst for IT band?
Repetitive flexion / extension of knee w/ knee in adduction and IR
Essenitally the OBER position
What is the most comon cause of latearl knee pain in runners?
IT band
KNOW: IT band syndrome may be due to poor hip abduction and extension strength
May also be a fat layer compression and not a friction syndrome (its compressing the fat underneath causing the pain)
MOI: Overuse, tight ITB, forefoot varus, tight hip add, LLD, increase in running distance or speed (have you changed your distance or speed), genu varium, hip muscle imbalance, improper shoes, excessive rearfoot pronation leading to increased internal tibial rotation, adhesions of the ITB, tightness of TFL and / or Glute max, Hams, or Quads
May be releated to poor hip abduction and extension strength in atheletes
W/ IT band sundrome
* pain altearl leg that may radiate to lateral tibia; pain increases w/ continued activity
* ROM: Pain ~30 knee flexion (stretching it)
* MLT: Pain w/ ober
* Special test: Nobles compression
* Palpation: Tender lateral epicondyle, gerdy’s tubercle, latearl retinaculum
ITB Syndrome interventins
* Soft tissue mobilization
* Stretching associated impairments
* Address dysfunctions at hip and ankle
* Closed chain strengthening
Prepatellar bursitis = housemaids knee
What causes prepatellar bursitits
Prolonged kneeling
More prolonged causes of knee pain are actual chondromalacia of the patella. What is this?
Softning or wearing away of that cartilage
* OA of the patella
No clinical tests to confirm this outside of imaging
KNOW: Chondromalacia patella causes:
* Abornomal tracking of patella
* Muscle imbalances
* Structural issues
* Weak quads
* Direct trauma
* Repeated trauma (landing on knees over and over)
Chondromalacia pain is normlly hard for pt to explain. They might say “it feels like its coming from underneath the kneecap”
* if they say its not deep but feels like its underneath knee this is what im thinking
* primary complaint is pain
* note: might also be thinking pre-patellar bursitis (but remember - thats superficial to the kneecap - but is near the same area)
What 3 things clue us in to chondromalacia?
1) popping
2) pain
3) Under the kneecap but not deep
Under knee pain clues us in to
chondromalcia
Chondromalcia pain comes on slowly (its essentially kneecap OA) - unless direct trauma brings it on
* worse w/ climbing stairs, running, squatting, kneeling (really doing anything w/ knee
* also get a stiffness feeling
Why does chondromalacia get worse w/ long term sitting?
Essentially kneecap OA - decreases synovial fluid - stiffness feeling
Low impact activitises indicated for chondromalacia of patella - isometric or closed chain quadriceps strengthening EX at first
Who benefits the most form surgery for chondromalacia of patella? Suergeries?
Younger pts who have continued pain –> this is not normal for them and should be addressed
Surgery for this =
* Smoothing over undersurface of patella
* release lateral thigh muscles that are causing tracking issue
* worse case is replacement of patella
What is osgood schlatters disease?
* who does it happen the most to
AVN of the avolsed portion of the tibial tubercle
Avulsions normally happen when bone growth does not match the rate at which muscles are lengthening
* think someone growing to fast
* Most often in younger boys
* will resolve on its own at 18 or 19
Wht is this
* what position makes it painful
Osgood shlaters disease (AVN) - theres a bump over that tibial tuberosity because it has avolused there
theres going to be a lesion over the tibial tubercle and swelling
extension is painful because its pulling on that patellar tendin (right where the avulsion is)
KNOW: quad contraction hurts w/ osgood schlatters disease
What test would osgood shlatters disease pts have pain w/ - test question
Thomas test rec fem portion (because of the pulling on the avulsed tibial tuberosity)
* this is a good differentiatl diganosis
* note: this tibial tuberosity avulses but the quadrecepts tendin stays intact - so everytime they extend the avulsed area is pulled
Osgood schlatters normally resolves on its own
* PTs just strengthen those waek structures
Hip adduction / internal rotation cause knee pain. What most likely is it?
IT band at gerdys tubercle
For chonic patello femoral issues we want to strength hip extension / abductors
In open chain
at what degrees is patellar stress the greatest at ?
What about potellar compression
60
75
35
KNOW: Some proximal things that create knee pain:
* Increased hip adduction and internal rotation during certain activities = makes us think tight IT band = more stress at gerdys
KNOW: In PF treatment of subacute / chronic we want to do EX to the point of symptoms
For subacute / chronic PF treatment we would want to do some kind of total knee extension w/ light resistance
* We would eventually want to progress them to some kind of plyometric activity
what is the clinic presentattion for hamstring sprain?
Sharp pain in the back of the leg and “couldnt run”
What normally causes hamstring strain? (3)
* if its a proximal hamstring injury where is it painful
* what ranges of movement is in painful in
Quick stretch in a contracted position
Eccentric contraction
Muscular imbalance (quads to hamstring)
If it is a proximal hamstring tendinopathy it is usally going to be more painful in the sitting position (sit bone)
Hip flexion and knee extension (endrage - most stretched) are painful
KNOW: Hamstring strains take forever to heal
Does sterength retrun and pain relief mean hamstring pts are ready to go back to sport?
No! Hamstrings are very frequently reinjuried - as much as 30% - especially in the first 2 weeks - this is because they go back to sport way to quickly (they take forever to heal)
KNOW: Focus on aligity w/ trunk stabilization w/ hamstring strains (getting hamstrings back in that quickly lengthened contracted state)
where does the saphenous n innervate
Sensory innervation to the medial aspect of the knee and leg
* articular brnaches of the medial aspect of the kne ejoint as wayy
Saphenous n route
Passes posteriomedially from the femoral triangle to enter the subsatorial Hunters canal
Pases beneath sartourus, pierces fascia between sartorious and gracillis
Branches to side of knee, second branch along tibial side of leg, descends medial border down the leg
What 3 non traumatic things cause injury to the saphenous n
moderate thigh obesity
Genu Varum (stretch)
Internal Tibial rotatio
Pt reports pain at medial aspect of knee that may radiate doward to medial side of foot. Significant pain when doing stairs
Saphenous n issue
* Would have to make sure its not some kind of lumbar radiculopathy
* we would do a lumbar screen to rule this out
* may also get some numbness on the thigh?
what two muscle actions does the common fibular (peronlea) n do?
Supplies dorsiflexors of the ankle and evertors of the foot
Where does the common fibular n provide sensory innervation?
lateral Knee, ankle, small joints of the foot, distal lateral surface of the leg and dorsum of the foot
Where does common fib n get injuried? (3)
Becomes entrapped at the fibular neck
* any fracture the fibula can cause an issue here as well
* Also some kind of tight boot can cause issues
w/ common fib n issues we have:
* Pain in lateral aspect of leg and foot
* sensory alteration or muscle weakness
* Foot turning over into inversion w/ walking
Patient complains that their foot turns over into inversion w/ walking. What most likely is the issue?
Common fibular n pathology
What position causes the common fib n to have symptoms?
Foot plantar flexion and inversion - stretching this nerve
What kind of wedge do we use to bring down pain in people w/ fibular n pathologyies?
Lateral heel wedge
* Puts them into eversion and takes the nerve out of that stretched position
* also will give them NSAIDS
KNOW: ACL and PCL have lots of swelling even though their both intracapsular
Effusion = swelling
