Anterior Knee Pain - Lecture 2

Question 1

Patellofemoral Pain syndrome affects 9-25% of active sports participants

Question 2

Things that can cause patellofemoral pain syndrome
* Overuse
* Biomechancial issues (think boney deformitites / brith defects)
* Joint mobility (hyper/hypo)
* Trauma
* Degeneration

Question 3

Patellofemoral issues can br driven by extrinisc factors
* Acute Trauma
* Chronic Overuse
* Poor Mechanics
* Training Errors

Question 4

Structures involved in patellofemoral issues
* Intrapatellar fat pad
* Ligaments
* Patellar tendon
* Retinaculum (tight)
* Subchondral bone, joint
* IT band
* Bursa

Question 5

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)

Question 6

These are examples of lateral problems w/ patallela

Question 7

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

Question 8

Which way patella most likely to sublux?

Answer 8

Latearl subluxations

Question 9

What 4 things can cause the patella to sublux latearlly?

Answer 9

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

Question 10

5 biomechanical issues that could be causing PF pain

Answer 10

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

Question 11

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

Question 12

PF pain w/o malalignment soft tissue lesions
* Plica syndrome
* Fat pad syndrome
* Tendonitis
* IT band Friction syndrome
* Prepatellar Bursitits

Question 13

What is Plica syndrome
* medial or lateral
* hyper or hypomobility

Answer 13

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

Question 14

This is showing where that medial plica syndrome is

Question 15

We use the Plica Stutter test to test for plica syndrome

Question 16

Plica syndrome hurts the most w/ activity. What movement hurts the most and why

Answer 16

Knee flexion - because thats where its goign to stretch it the most

KNOW: Plica is considered an inflammatory condition

Question 17

What treatment do we do for plica?

Answer 17

• 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

Question 18

Fat padsyndrome = Infrapaterllar syndrome = Hoffas syndrome

Question 19

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

Question 20

Patella making contact and pinching down can create inflammation of that fat pad

Question 21

Fat pad syndrome is normally caused by direct trauma
* It can also be caused by overuse

Question 22

Often fat pad syndrome is caused by posterior tilt of inferior pole of patella - causing the fat pad to become irretated

Question 23

Where will swelling and tinderness be present w/ fat pad syndrome

Answer 23

Pain inferior to pole of patella along w/ edema

Question 24

What positions hurt w/ fat pad syndrome?

Answer 24

Knee extension pain (when its in the close packed position)

0-15 degrees or flexion where patella doesnt contact the trochlear groove

Question 25

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

Question 26

what is jumpers knee

Answer 26

patellar tendinopathy

Question 27

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

Question 28

Where is a patellar tendinopathiy what makes it worse

Answer 28

anterior knee localized pain Made worse by activity or prolonged flexion also called movie theatre knee

Question 29

If they dont have OA patellar tendinopathy would be one of my first thoughts

Question 30

outcome measure for patellar tendinopathy: * Victorian insttitute of sports assessment patellar tendinopathy or LEFS

Question 31

Rule out hip / low back for patellar tendinopathy and other non-musculoskeletal causes

Question 32

Which AROM is limited w/ patellar tendinpathy? What about PROM

Answer 32

AROM = knee extension decreased w/ pain PROM = knee flexion decreased (essentially stretching the joint)

Question 33

w/ reissted provocaion w/ patellar tendinopathy what movement brings about pain?

Answer 33

Extension brings on pain (AROM) * Note if it was passive flexion would bring on pain (stretching the joint)

Question 34

What muscle might hurt w/ patellar tendinoapthy resisted?

Answer 34

Extension hurts to quads might be painful

Question 35

Will be pain over tendin w/ patella tendinopathy (normally just over insertion points - superior/inferior pole)

Question 36

What 3 interventions would we do for patellar tendinopathy

Answer 36

Pain contorl EX mobility and flexibility

Question 37

Patellar tendinopathy treatment in acute phase * Rest / activity modification * Pain / inflammation management * Stretch * Eccentric strengthening * Bracing, Taping

Question 38

What position is worst for IT band?

Answer 38

Repetitive flexion / extension of knee w/ knee in adduction and IR Essenitally the OBER position

Question 39

What is the most comon cause of latearl knee pain in runners?

Answer 39

IT band

Question 39

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

Question 40

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

Question 41

ITB Syndrome interventins * Soft tissue mobilization * Stretching associated impairments * Address dysfunctions at hip and ankle * Closed chain strengthening

Question 42

Prepatellar bursitis = housemaids knee

Question 43

What causes prepatellar bursitits

Answer 43

Prolonged kneeling

Question 44

More prolonged causes of knee pain are actual chondromalacia of the patella. What is this?

Answer 44

Softning or wearing away of that cartilage * OA of the patella No clinical tests to confirm this outside of imaging

Question 45

KNOW: Chondromalacia patella causes: * Abornomal tracking of patella * Muscle imbalances * Structural issues * Weak quads * Direct trauma * Repeated trauma (landing on knees over and over)

Question 46

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)

Question 47

What 3 things clue us in to chondromalacia?

Answer 47

1) popping 2) pain 3) Under the kneecap but not deep

Question 48

Under knee pain clues us in to

Answer 48

chondromalcia

Question 49

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

Question 50

Why does chondromalacia get worse w/ long term sitting?

Answer 50

Essentially kneecap OA - decreases synovial fluid - stiffness feeling

Question 51

Low impact activitises indicated for chondromalacia of patella - isometric or closed chain quadriceps strengthening EX at first

Question 52

Who benefits the most form surgery for chondromalacia of patella? Suergeries?

Answer 52

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

Question 53

What is osgood schlatters disease? * who does it happen the most to

Answer 53

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

Question 54

Wht is this * what position makes it painful

Answer 54

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)

Question 55

KNOW: quad contraction hurts w/ osgood schlatters disease

Question 56

**What test would osgood shlatters disease pts have pain w/** - test question

Answer 56

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

Question 57

Osgood schlatters normally resolves on its own * PTs just strengthen those waek structures

Question 58

Hip adduction / internal rotation cause knee pain. What most likely is it?

Answer 58

IT band at gerdys tubercle

Question 59

For chonic patello femoral issues we want to strength hip extension / abductors

Question 60

In open chain at what degrees is patellar stress the greatest at ? What about potellar compression

Answer 60

60 75

Question 61

35

Question 62

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

Question 63

KNOW: In PF treatment of subacute / chronic we want to do EX to the point of symptoms

Question 64

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

Question 65

what is the clinic presentattion for hamstring sprain?

Answer 65

Sharp pain in the back of the leg and "couldnt run"

Question 66

What normally causes hamstring strain? (3) * if its a proximal hamstring injury where is it painful * what ranges of movement is in painful in

Answer 66

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

Question 67

KNOW: Hamstring strains take forever to heal

Question 68

Does sterength retrun and pain relief mean hamstring pts are ready to go back to sport?

Answer 68

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)

Question 69

KNOW: Focus on aligity w/ trunk stabilization w/ hamstring strains (getting hamstrings back in that quickly lengthened contracted state)

Question 70

where does the saphenous n innervate

Answer 70

Sensory innervation to the medial aspect of the knee and leg * articular brnaches of the medial aspect of the kne ejoint as wayy

Question 73

Saphenous n route

Answer 73

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

Question 74

What 3 non traumatic things cause injury to the saphenous n

Answer 74

moderate thigh obesity Genu Varum (stretch) Internal Tibial rotatio

Question 75

Pt reports pain at medial aspect of knee that may radiate doward to medial side of foot. Significant pain when doing stairs

Answer 75

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?

Question 76

what two muscle actions does the common fibular (peronlea) n do?

Answer 76

Supplies dorsiflexors of the ankle and evertors of the foot

Question 77

Where does the common fibular n provide sensory innervation?

Answer 77

lateral Knee, ankle, small joints of the foot, distal lateral surface of the leg and dorsum of the foot

Question 78

Where does common fib n get injuried? (3)

Answer 78

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

Question 79

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

Question 80

Patient complains that their foot turns over into inversion w/ walking. What most likely is the issue?

Answer 80

Common fibular n pathology

Question 81

What position causes the common fib n to have symptoms?

Answer 81

Foot plantar flexion and inversion - stretching this nerve

Question 82

What kind of wedge do we use to bring down pain in people w/ fibular n pathologyies?

Answer 82

Lateral heel wedge * Puts them into eversion and takes the nerve out of that stretched position * also will give them NSAIDS

Question 83

KNOW: ACL and PCL have lots of swelling even though their both intracapsular

Question 84

Effusion = swelling