Knee Pain

Anterior knee pain

As the title implies this anterior knee pain is pain in front of the knee and it is caused by variety of different conditions. One of the common cause for anterior knee pain is patellofemoral joint related abnormalities. There are so many other causes for anterior knee pain which 

Patello-femoral Pain Syndrome (PFPS): 

  • PFPS is defined as pain behind or around the patella(knee cap), caused by abnormal or excessive stress to the patellofemoral joint. It is very common in young and athlectic population, especially girls. Although PFPS most often presents in adolescents and young adults, it can occur at any age. Over half of the people suffer PFPS on both sides of the knee.
  • PFPS seems to be multifactorial, resulting from a complex interaction between intrinsic anatomy and external training factors. Pain and dysfunction often result from either abnormal forces or prolonged repetitive compressive or shearing forces between the patella and the femur.
  • Symptoms such as anterior knee pain, clicking or grinding are usually provoked by climbing stairs, squatting and sitting with bent knees for long periods of time.
  • Mostly PFPS is associated with biomechanical abonormalities of the knee joint related to structural abnormalities, decrease muscle and joint flexibility or decreased muscle strength or coordination. Sudden increase in activity level with inadequate preparation is also a cause for PFPS. This doesnot denote anatomical abnormality and physical damage of knee joint.

In many cases, the true cause for patellofemoral pain may not be clear. It may be due to one of more reasons to get anterior knee pain.

  • Weakness of muscles around the knee joint causing imbalance (quadriceps, hamstringns and calf).
  • Poor flexibility of quadriceps, hemstrings and calf muscles.
  • Problems with alignment of the legs between the hips and the ankles.
  • Using improper sports training techniques or equipment.
  • Overuse of the knee or sudden increase in activity level for example gardening in early spring, participating in charity runs.
  • Minor problems in the alignment of the knee either due to hip (Coxa vara, valga) or foot anatomical abnormalities (Calcaneal valgus, varus).
  • Foot problems such as decreased or increased arch can have an effect on the knee biomechanics.
  • Joint hypermobility affecting the knee.

Patellar tendinopathy (Jumper's knee):

  • Patellar tendinopathy is a condition affects the tendon which connects the knee cap and bony prominence at the front of your shin bone.
  • Jumper's knee can be seen in any age group.
  • This tendon is crucial in jumping creating the force. Hence if you over do jumping related exercises or sports you may cause over use injury to this tendon.
  • The main symptom is pain beloe the knee cap along the tendon and swelling or thickening of tendon.
  • Similar to PFPS, Patellar tendon problems also related to abnormal anatomical and biomechanical factors.

Patellar tendinopathy (Osgood-Schlatter disease): 

  • This is inflammation of the patellar tendon below the kneecap where it attaches to the shin bone.
  • This is a overuse injury commonly seen in growing adolescents involved in certain sports such as football, gymnastics, basketball, and distance running.
  • This presents with anterior knee pain, tendon swelling near the shin bone and tenderness over the tendon attachment.

Sinding-Larsen-Johansson disease:  

  • This is similar to Osgood-Schlatter disease but occurs at the lower pole of the patella.
  • Unlike Jumper's knee this is commonly seen in active adolescents between the age of 10-14 years old.
  • Clinically it presents with pointed tenderness over the inferior pole of patella and local swelling.

Chondromalacia patella: 

  • This is roughening and softening of the articular cartilage of the patella.
  • There is a poor correlation between the degree of anterior knee pain and cartilage damage.
  • This is commonly associated with muscle weakness, leg malalignment, patella maltracking and cartilage lesions
  • Generally causes diffuse knee pain around your knee cap
  • Pain increases with stairs climbing and sitting long period of time (theatre sign)

Bipartite patella:

  • This means your knee cap has two bony fragments and this is commonly from birth due to lack of bony bridging.
  • Upto 2% of general population may have this problem but rarely cause pain and tenderness.
  • Sevre symptomatic cases may require surgical treatment.

Recurrent patella dislocation or subluxation:

  • This means your knee cap is repeatedly slips out of its grove on your thigh bone.
  • Alignment of your leg or foot, higher position of patella on your thigh and decreased angle of the grove plays a major role.
  • This is often accompanied by damage to the chondral surface of the patellofemoral joint.
  • More commonly seen in girls.
  • Exercises will help to improve this condition if your problem is due to muscle weakness.
  • Surgery may be necessary in sevre cases if your symptoms fail to improve with physiotherapy.

Hypermobility:

  • This means your joint has unusually large range of movement.
  • In knee this particularly causes hyperextension and hyperflexion of the knee.
  • This increased movement can cause your knee cap to pinge the soft tissues at the front of your knee joint.

Patellar bursitis

  • Bursa is a sac like tissue folding and commonly seen around tendons near joint to reduce friction.
  • A bursa can become inflammed and filled with fluid due to injury, repetitive strain, infection or due an inflammatory disease.
  • Housemaid's knee, also known as pre-patellar bursitis seen on top of your knee cap. 
  • Parson's knee is known as deep pre-patellar bursitis.
  • This is more commonly seen in people who kneel regularly for their job.

Patellofemoral joint osteoarthritis:

  • This is wear and tear of the cartilage on grove on your thigh bone and knee cap.
  • This is a common form of knee osteoarthritis seen in middle and older age causing anterior knee pain.
  • Most commonly this responds well to physiotherapy and severe case may require patella resurfacing.

What are the treatments available?

Conservative management: Non-surgical treatment such as ice, rest, exercises are often helpful during eearly stage of patello femoral pain. If you symptoms are not improving you could try simple anti-inflammatory medications such as ibuprofen. 

  1. Paracetamol and ibuprofen: These medications helps to control the pain and inflammation. You may require to take this medication for several days during the early stage. These medications must be taken after food in order to avoid the potential stomach problems. If you have any oother medical problems please consult your pharmacist or doctor before taking these medications.
  2. Ice: This helps to relieve swelling and inflammation, apply ice wrapped in a towel to your sore knee a few times each day.
  3. Rest: Stopping, reducing or changing your activity levewls will help to control or ease the pain. Avoiding high impact activities such as running or sports will reduce further irritation of the tissue causing your pain. This means probably changing your training routine by discussin with your trainer. Losing weight will also significantly help to reduce the pressure on your knee.
  4. Knee Retraining: The mainstay of treatment is formulating a specific exercise programme to retrain your knee. Plesae follow watch the exercises video for appropriate exercises. If your symptoms fail to improve you may need to see your physiotherapist for further advice and guidance. Your physiotherapist may also consider other treatment options such as patellar taping, specific stretching, joint and soft tissue manipulation and acupuncture. Generally a balance must be achieved on appropriate rest and specific retraining exercises to improve flexibility and strength to your lower limb muscles including quadriceps, hamstrings, calf, gluteals, ITB etc.
  5. Foot wear: Appropriate footwear is important reduce, improve and prevent anterior knee pain. Foot orthoses are often considered to decrease rotational forces in the tibia that affect tracking of the patella during locomotion. Your physiothrapist may refer your to a podiatrist if you need a specialised for of orthotics and biomechanics assessment.
  6. Prevention: If your knee pain behind is severe and persists despite all the above self-management measures, it is important to see your doctor. If your pain has gone away but you have concerns about it returning, you may be able to prevent recurrences through the following
  • Wear shoes appropriate to your activities.
  • Warm up with stretching exercises before physical activity.
  • Stop or reduce any activity that causes or increases you knee pain.
  • Limit the total number of miles you run in training and competition.

Surgical Management: Most people do not need surgery for anterior knee pain. However, if conservative measures fail, there are a number of possible surgical procedures depending on the underlying diagnosis. Simply removing the damaged cartilage is not enough. The biomechanical problem of foot and knee needs addressing and there are various procedures to aid re-alignment. Surgical intervention usually involves arthroscopic evaluation followed by release of the lateral attachments of the patella.

  1. Shaving or debridement: If you have early degenerative changes, one of the option is to shave the damaged cartilage to smoothen the patella gliding surface. The success of the treatment depends on the severity of the cartilage damage.
  2. Tightening of the medial capsule: If your knee cap malalignment is due to soft tissue (joint capsule) laxity on the inside of your knee joint, it can be tightened surgically to pull your knee cap back into the correct alignment.
  3. Medial shift of the tibial tubercle: This procvedure involves moving the insertion of the patellar tendon towards the inside of the leg at the tibial tubercle (bony prominence on your shin bone). This allows your thigh muscle to pull the knee cap under normal alignment and decreases the amount of wear on the underside of the patella.
  4. Rarely other surgical techniques such as partial or complete removal of the patella, or replacement of damaged cartilage by a polyethylene cap prosthesis (patella resurfacing) is considered.

 

 

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