Treatment For Anterior Knee Pain

Patella Femoral Solutions

Patella Femoral Solutions is a complete program that will walk you step by step through 21 exercises proven to eliminate knee pain caused by patella femoral syndrome. It contains the best exercises to treat patella femoral syndrome. Each exercise has been tested and proven on hundreds of patients just like you. Patella Femoral Solutions is divided into 4 levels, with each level building upon the previous as your body gets stronger. These are the same exercises I use with my own patients and I know they work. The entire program requires very little equipment, so you don't have to make any huge investments or gym memberships. That also means you can do it in the comfort of your own home, saving time and gas driving to a rehabilitation clinic or gym. Best of all, patella femoral solutions will give you back your life and the freedom to do the things you love. No more sitting on the sidelines because it hurts to run. No more waking up in the middle of the night from aching knees. More here...

Patella Femoral Solutions Summary


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Imaging of Anterior Knee Pain

Anterior knee pain (AKP) is a common complaint in primary care and orthopedic clinics. In fact, in the sports medicine clinic, up to 25 of patients with knee complaints have symptoms of anterior knee pain 1 . Adolescent females and other young individuals are at particular risk for AKP. In these individuals, symptoms are usually related to increased use, frequently because of increased sports participation 2 . AKP among school-age students has been reported to be 3.3 in the 10- to 19-year age group, and the incidence was 10 among 15 year olds 3 . Symptomatic individuals are more likely to be involved in competitive sports than age-matched controls 4 . Another group with a higher incidence of AKP is older females, and their major risk factors are lack of conditioning, previous trauma, and degenerative changes 5 . The anatomy of the patellofemoral joint is complex. The patella is the largest sesamoid bone in the body and its articular surface is covered by thick cartilage. The length of...

Patellofemoral Pain Syndrome

Patellofemoral pain syndrome has been suggested as a diagnosis of exclusion reserved for patients with anterior knee pain without one of the conditions described above. Causes of this variety of anterior knee pain are somewhat controversial. Fulkerson points out that there are six main tissues to consider when looking for the etiology of patellofemoral pain. These include subchondral bone, synovium, retinaculum, skin, muscle, and nerve. He believes that the most common causes of pain from an orthopedic standpoint are overuse, patel-lofemoral malalignment, and trauma 36 .

Patellofemoral pain

Injuries to the patellofemoral joint are more common in women. Patellofemoral pain is often thought to be secondary to a variation in limb alignment ( miserable malalignment syndrome) consisting of a combination of increased anteversion of the femoral head, internal rotation of the femur, external rotation of the tibia, and foot pronation. Other anatomic features often blamed for patellofemoral pain include an increased quadriceps angle and hypermobility of the patella. 2. Patellofemoral pain should be differentiated according to whether the patella is hypermobile or tight (lateral patella compression syndrome). This distinction is important because treatment varies depending on whether the patella needs to be restrained (in the case of hypermobility) or loosened (in the case of tight lateral structures causing lateral compressive pain). In the case of the hypermobile patella, strengthening of the medial quadriceps (vastus medialis obliquus) aids in restraining the patella. In the...

Instrumentation in Total Knee Arthroplasty

Femoral Sulcus Anatomy

The femoral valgus angle can be referenced with respect to the femoral shaft. The anterior to posterior position and the external rotation can be verified with respect to the posterior condylar axis, the anterior cortex of the shaft of the femur, the intramedullary canal, the epicondyles, and the flexion gap. Each of the references has an individual variability. The posterior femoral condyles are easily defined. However, as the varus or valgus deformity of the knee increases the posterior aspect of the medial condyle (in varus) and the lateral condyle (in valgus) can become deficient. With this atrophy, the anterior to posterior thickness will be underestimated and the femoral cuts will be internally rotated in the valgus deformity and externally rotated in the varus deformity if the posterior condylar axis is the primary reference (Fig. 2.2). The anterior cortex of the femur is readily available for referencing.5 Because the lateral femoral condyle rises higher than the medial...

Differential diagnosis

Patellofemoral subluxation or dislocation will often present as acute knee pain. Inherent abnormalities of the patellofemoral mechanism usually result in most patellofemoral injuries. These patients will complain of patellar apprehension and usually respond to physical therapy. However, surgical realignment of the extensor mechanism may be necessary in recurrent cases.

Diseases Of Hoffas Fat

Patellar Plica

Acute or repetitive trauma to Hoffa's fat pad can result in edema and hemorrhage. The resultant changes of enlargement put the fat pad at risk for impingement between the femur and tibia. Fibrosis and anterior knee pain can result 27 . This is called Hoffa's disease or syndrome. Acutely, there is high T2 signal and mass effect with the fat pad. Chronically, fibrosis appears dark on both T1- and T2-weighted images 27 . Patellar tendon lateral femoral condyle friction syndrome, so named by Chung and colleagues 33 , is related to the clinical disease known as fat pad impindge-ment syndrome. Patients present with anterior knee pain, more pronounced at the inferior aspect of the patella. Abnormal increased T2 signal is seen in the in-ferolateral aspect of the patellofemoral joint and with possible involvement of the lateral fat pad. Cystic changes in the fat pad and enhancement may occur.

Malalignment Evaluationtraditional Indices

Lateral Patellofemoral Angle

Several measurements obtained from the axial, or sunrise, view have traditionally been used to evaluate for malalignment. There are three main radiographic patterns of malalignment (described with CT). These include subluxation of the patella with and without tilt, and tilt without subluxation 37 . Conditions that lead to malalignment and influence patellofemoral stability, such as depth of the trochlea, can be measured with imaging. The most common indices described in the literature are the lateral patellofemoral angle (tilt), the congruence angle, and lateral patellar displacement 38-40 . Other measurements that have been shown to potentially have merit are the Q angle and the trochlear-tubercle distance 41,42 . Fig. 11. Lateral patellofemoral angle. The angle of the lateral patellar facet compared with a line drawn across the femoral condyles. Angle A is the lateral patellofemoral angle. Fig. 11. Lateral patellofemoral angle. The angle of the lateral patellar facet compared with a...

Lateral Radiographs Of The Knee

Maldague Knee

Recently, several studies have described the limitations of the axial view for patellar alignment evaluation. Walker and colleagues 44 questioned the value of the axial view and compared the axial view with CT of the patellofemoral joint. They found that these two modalities often give conflicting results and concluded the axial view to be of limited value due to lack of sensitivity, as ''even florid examples of maltracking must be missed.'' Many researchers now advocate using the lateral view of the knee, in various degrees of flexion, to evaluate for alignment at the patellofemoral joint. The basis of this argument rests on the fact that in most knees, the patella is fully engaged in the trochlea by 30 degrees of flexion. Many patients with mild subluxation or tilt are not diagnosed on axial images as their abnormally aligned patellae have corrected at the angle the axial images are obtained. It is not possible to obtain an axial image at less than 20 degrees of flexion special...

Human immunodeficiency virusassociated painful articular syndromes

Typically, this syndrome has a gradual onset during a period of a few weeks. It too has a predilection for knees and ankles. At times, it appears as a classic patellofemoral syndrome and may be accompanied by some degree of quadriceps femoris atrophy. Often, direct palpation in the area of complaint will elicit diffuse tenderness of muscle, tendons, and bone, suggesting myositis, enthesitis, or periostitis. Most cases gradually resolve during weeks or months and require minimal intervention. Some are progressive and lead to significant debility.

Giles R Scuderi and Henry D Clarke

Following the removal of the infected components, cement spacers are placed between the femoral-tibial and patellofemoral articulations. The use of antibioticimpregnated cement beads or spacer blocks allows local delivery of high concentrations of antibiotics. While the larger surface area of multiple beads theoretically provides greater allusion of local antibiotics than from a single spacer block, no definite clinical advantage has been proven. However, the spacer block has definite mechanical advantages over the beads. Spacer blocks facilitate ambulation prior to the reimplantation and also allow easier exposure at the time of the later surgery.5 In most cases a spacer block is fashioned using two to three 40 g batches of polymethylmethacrylate cement mixed with high doses of antibiotics. We typically use 2.4g of tobramycin and 1 g of vancomycin per pack of cement. When mixing the antibiotics, the lumps in the crystalline vancomycin should not be crushed. Once the cement has...

Radiographic findings

Tangential view of the patella (Merchant view) may demonstrate lateral displacement or tilt of the patella. Narrowing of the joint space is suggestive of patellofemoral arthritis. b. Lateral view of the knee may demonstrate a high-riding patella (patella alta), which has been associated with patellofemoral pain. Patella alta is defined as a ratio of the length of the patellar tendon to the length of the patella greater than 1.2 1.0.

Restoration of Anatomy

Anatomy Knee Bony

The level of the trochlear groove on the femur is anatomically restored by a stepped anterior chamfer cut that allows the bone to be resected and replaced with a deeply grooved femoral component. As a result, patellofemoral joint stability is achieved, making lateral release infrequent and, when required, less extensive. Increased patellofemoral compressive forces are avoided by main taining the patellofemoral joint line, which reduces wear and patellar breakage and failure.


The standard radiographic evaluation of the knee includes frontal, lateral, and axial (sunrise) views of the knee. The axial view is usually obtained in 30 degrees of flexion. Computed tomography (CT) and MRI are also commonly used to evaluate anterior knee pain, especially in complex or refractory cases. Both of these modalities can be performed using standard protocols. CT is useful for osseous evaluation, such as in trauma or in some cases of possible ma-lalignment. MRI is a more powerful modality, as it can diagnose cartilage and soft tissue abnormalities to greater effect than CT or radiography. Both CT and MRI can be used in dynamic modes, which can be useful for tracking abnormalities of the patella. Nuclear scinitigraphy is somewhat limited in its usefulness for anterior knee pain, however it can have a role, especially in cases of occult fracture and tumors.

Diagnostic tests

Radiography should be performed while the patient is standing (anteroposterior and lateral views) to demonstrate joint space narrowing. Tangential patellar views (Merchant views) are obtained to assess the patellofemoral compartment. A tunnel view is obtained to assess the contour of the intercondylar notch.

Convalescent phase

Quadriceps and hamstring exercises are frequently used for many knee disorders. Straight leg raising without weights is helpful in arthritis patients because it minimizes patellofemoral stress. Exercises with weights are more effective in rehabilitation after athletic injuries.

Etiology of injury

Patients with increased ligamentous laxity may be susceptible to sprains while running. The abnormal distribution of stresses on the feet of runners with flat feet or high arches makes them prone to particular problems. The likelihood of patellar problems is increased in a person with congenital abnormalities of the patellofemoral joint. The Q angle of the female hip may also predispose women to certain overuse running injuries.


With patellofemoral OA, the patella loses side-to-side mobility, which results in a loss of about 10 of extension and flexion. Pain and tenderness are most marked anteriorly. Pain may be elicited if the patella is held firmly against the femur and the quadriceps is isometrically contracted. Patellofemoral disease may occur alone without medial or lateral compartment disease.

Knee Patterns

Avm Vastus Lateralis

The term dashboard injury reflects the common mechanism of injury in which the flexed knee of a front seat passenger strikes against the dashboard in a head-on motor vehicle collision. When the force is applied to the superior tibia, this can produce posterior translation of the tibia, leading to disruption of the posterior cruciate ligament (PCL) and posterior joint capsule. Blunt trauma applied more superiorly to the patella of a flexed knee may result in osteochon-dral fractures of the patellofemoral joint 109 . Lower velocity loading of the patellofemoral joint, such as that from a fall on a flexed knee, can produce acute chondral injuries of the patella and trochlea in a ''kissing'' pattern reflecting the contact points at the time of injury (see Fig. 8). Patellar chondral injuries are generally best seen on axial views, and consist of fissures often associated with high signal in the deep radial zone of cartilage. Delamination injuries are also encountered with this mechanism,...


There are some surgeons who prefer to approach the valgus knee from the lateral side in order to maintain the integrity of the extensor mechanism and theoretically improve patellar tracking. Keblish, in a review of 53 knees in 46 patients with preoperative valgus deformity averaging 22 degrees, utilized the lateral ap-proach.10 There was some variability in his implant selection. The low-contact stress (LCS) mobile-bearing knee system was used in 50 knees, and the kinematic rotating hinge was used in three. Of the LCS cases, 39 were meniscal-bearing cruciate-sparing (ACL and or PCL) knees and 11 were rotating platform. Cementless porocoat LCS components were used in 41 knees. Because of the associated bony deficiencies, 48 of the 53 knees required bone grafting to the lateral side. He reported 94 good or excellent results based on the New Jersey Orthopaedic Hospital scoring system at an average follow-up of 2.9 years. There was one transient sensory and one transient motor peroneal...

Grade I Lesions

Grade Meniscus Tear

Cartilage blister 3.0 T fat-suppressed, PD-weighted FSE MRI image in 18-year-old male with anterior knee pain. Focally elevated, T2-weighted signal consistent with altered organization of the collagen matrix is observed in the deep radial zone of cartilage (arrow), with a smooth contour elevation of the overlying chondral surface. Fig. 4. Cartilage blister 3.0 T fat-suppressed, PD-weighted FSE MRI image in 18-year-old male with anterior knee pain. Focally elevated, T2-weighted signal consistent with altered organization of the collagen matrix is observed in the deep radial zone of cartilage (arrow), with a smooth contour elevation of the overlying chondral surface.

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