Knee pain syndromes (iliotibial band, patellofemoral syndrome) Flashcards
Define iliotibial band syndrome.
Syndrome from repetitive friction of the iliotibial band sliding over the lateral femoral epicondyle, moving anterior to the epicondyle as the knee extends and posterior as the knee flexes, remaining tense in both positions.
What is the most common cause of lateral knee pain in runners and cyclists?
ITBS - more experienced runners are less likely to develop this
What underlying problems are often found in ITBS?
Weak hip abductor muscles (he gluteus medius, gluteus minimus, and tensor fasciae latae, the piriformis, sartorius, and superior fibers of the gluteus maximus)
What is proximal ITB syndrome and its main features?
Involves stress to the iliotibial band origin at the iliac crest.
Reported uniquely in women runners, influenced by increasing age and weight.
What does the ITB consist of?
Continuation of the tendinous portion of the tensor fascia lata muscle with significant contributions from the gluteus maximus
What are the clinical features of ITBS?
- Sharp or burning pain 2cm superior to the lateral joint line
- Pain begins after a reproducible time or distance and subsides quickly upon cessation of activities
- With increased severity normal walking or sitting with knee in flexion becomes painful
Other:
- Positive Noble’s test
- Positive Ober’s tert
- Positive modified Thomas’s test
- Reduced hip abductor muscle strength
- Genu varum
- Hind-foot and fore-foot varum
- Pes cavus
- Prominent lateral femoral epicondyle, tight iliotibial tract and tensor fascia lata
- Weak gluteus medius, gluteus maximus, and tensor fascia lata - other muscles like ITB compensate to stabilise pelvis
- Tightness and weakness in the quadriceps, iliotibial tract, and lateral retinaculum
What is a positive Noble’s test?
Pressure applied over the lateral femoral epicondyle while extending the knee from 90° of flexion –> pain when knee is flexed around 30° = ITBS
What is a positive Ober’s test?
Test for tightness - leg cannot be passively adducted to horizontal
Normal tightness is when the leg can be passively stretched to a position horizontal but not completely adducted to a table. Moderate tightness is when the leg can be passively adducted to horizontal at best. If the leg cannot be passively adducted to horizontal, this is maximal tightness
What is a positive modified Thomas’s test?
The patient sits on the end of an examining table, rolls back to a supine position, and holds both knees to the chest. The patient holds the knee on the asymptomatic side close to the chest, keeping the hips on the table, and avoiding excessive posterior tilt. The examiner then slowly lowers the affected limb towards the floor.
The test is positive if the angle of the femur is below horizontal or if flattening causes curvature of the lumbar spine.
What is the management of ITBS acutely and long-term?
Acute:
- NSAIDs
- Actvity modification - replace aggrevating activity with other e.g. swimming with arms only
- Ice
- +/- Local anaesthetic and corticosteroid injection
Once resolved:
- Stretches - with legs crossed
- Foam roll mobilisation
- Hip abductor strengthening
Rarely surgery is needed to decrease impingemnet of theB is removed.
What is the prognosis with ITBS?
Chronic illness which typically follows a fluctuating course
Define patellofemoral pain syndrome.
Knee pain resulting from mechanical and biochemical changes to the patellofemoral joint.
How common is patellofemoral pain syndrome?
Accounts for ~25% of knee injuries seen in the sports medicine clinic
What is the aetiology of patellofemoral syndrome?
Exact aetiology is unknown, but it is likely to be multi-factorial with contributing factors including:
- Abnormal patellofemoral joint mechanics e.g. bone, tightness, mobility issues or quad issues
- Altered leg alignment or motion
- Overuse i.e. training errors
What are the clinical features of patellofemoral syndrome?
- Ill-defined ache or anterior knee behind patella - aggrevated by compression
- e.g. going up and down stairs or prolonged sitting with knee flexed
- Q angle - greater than 15 degrees means greater tendency to move laterally
- Pain on palpation of patellar retinaculum
Other:
- Patellar tilt test
- Mediolateral glide test
- Patellar mobility test
- Patellar apprehension test
- Patellar maltracking test - ‘J sign’ - suddeen deviation of the patella laterally instead of moving superiorly with knee extension
- Decreased muscle flexibility
- Quads, hamstrings, iliotibial band
- Muscle weakness - quads, hip abductors or external rotator muscle weakness often seen
What is the Q angle?
Angle between:
- Line connecting ASIS to centre of patella
- Line connecting center of patella to middle of anterior tibial tuberosity
Most practitioners accept 10° to 15° as normal; the greater the angle the more tendency of the patella to move laterally.
