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3 Patellofemoral Syndrome
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Patellofemoral syndrome is among the most common causes of knee complaints in primary care medicine, particularly among adolescent and young adult patients The syndrome frequently gives rise to the chief complaint of anterior knee pain A variety of injuries or anatomic abnormalities predispose patients to irregular patellar movements, leading to the patellofemoral syndrome Such predisposing conditions include imbalance of quadriceps strength, patella alta, recur-
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rent patellar subluxation, direct trauma to the patella, and meniscal injuries For most of these causes, the therapeutic approach is similar
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Clinical Findings
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Symptoms resulting from all of these conditions worsen as the patient continues to run and often require cessation of the activity Anserine bursitis results in pain medial and inferior to the knee joint over the medial tibia The iliotibial band syndrome and popliteal tenosynovitis may be difficult to differentiate, because the popliteus tendon inserts into the lateral femoral condyle underneath the iliotibial band Both conditions result in pain on the lateral side of the knee Patellar tendinitis, a cause of anterior knee discomfort, typically occurs at the tendon s insertion into the patella rather than at its more inferior insertion All of these diagnoses are confirmed by palpation at the relevant sites around the knee None is associated with joint effusions or other signs of synovitis
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Clinical Findings
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Patients frequently have difficulty localizing the source of their complaint but generally confirm that the pain is in the front of the knee, around or underneath the patella Questions regarding specific precipitants of the pain may be useful in establishing the diagnosis For example, because of the flexion load, patients have difficulty going up or down staircases (down is usually associated with greater symptoms) Another characteristic symptom is the positive theater sign: after remaining seated for a prolonged period, patients describe extreme discomfort with their first few steps after rising The symptoms improve with further walking Finally, patients with patellofemoral syndrome often complain of crepitus, joint locking, or sensations of joint instability, all of which lack readily confirmed anatomic explanations The physical examination is less useful than the history in establishing the diagnosis, but a significant number of patients have characteristic physical findings In particular, when the knee is held in slight flexion, gentle pressure against the patella as the patient contracts the quadriceps muscles may reproduce the symptoms In some cases, with the knee extended and the quadriceps relaxed, the typical pain may be reproduced by digital pressure under the medial or lateral border of the patella, with side-to-side movement of the bone Inflammatory findings on examination are incompatible with the diagnosis of patellofemoral syndrome and suggest other disorders
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Rest and abstention from the associated physical activities for a period of days to weeks are essential Once pain has subsided, a program of gentle stretching (particularly prior to resuming exercise) may prevent recurrence Corticosteroid injections with lidocaine may be useful when intense discomfort is present, but caution must be used when injecting corticosteroids into the region of a tendon to avoid rupture
5 Medial Meniscus Injuries
Tears of the medial meniscus are the most common knee injuries encountered in primary care Because the medial meniscus is tethered firmly to the underlying tibia, injuries to the medial meniscus occur ten times more commonly than injuries to the lateral meniscus Both result from a twisting action exerted on the knee joint while the foot is in a weight-bearing position
Treatment
Therapy includes avoidance of flexion loads and strengthening of the quadriceps Referral to a physical therapist is helpful in educating the patient about home exercises Many patients learn that the most effective therapy is bicycling, with the seat high enough to permit nearly full knee extension with each cycle Although most cases respond to these interventions and even resolve altogether, some persist for years Even in the latter, conservative therapy remains the rule; operation is rarely indicated There is only limited evidence for the effectiveness of NSAIDs in short-term pain reduction associated with the patellofemoral pain syndrome The evidence supporting the use of glycosaminoglycan polysulfate is conflicting Bracing is no more effective than a home exercise program
Fredericson M et al Physical examination and patellofemoral pain syndrome Am J Phys Med Rehabil 2006 Mar;85(3): 234 43 [PMID: 16505640]
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