An Athletes Guide To Chronic 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 .
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.
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.
Stress fractures of the femur in runners may occur in the femoral neck, trochan-teric and subtrochanteric region, and femoral shaft. These injuries are often not considered in the initial presentation, and a high index of suspicion must be maintained. Patients commonly present with hip, groin, gluteal, thigh, or knee pain, depending on the location of the injury 18,72,73 . In general, stress fractures of the femoral neck may occur along the medial or lateral margin of the neck (Fig. 11A, B). Distraction or tension stress fractures tend to occur along the lateral femoral neck in older patients, whereas compression stress fractures occur along the medial femoral neck, and tend to occur in younger, active patients. Patients typically present with activity related pain, and pain is often reproduced with passive range of motion, particularly internal rotation 74 . Patients commonly present with hip, groin, gluteal, thigh, or knee pain 72,74 . A high clinical suspicion is required in...
In a separate study, O'Donnell and colleagues 57 compared tracking patterns in 50 patients with anterior knee pain to 50 asymptomatic controls using the protocol described by McNally and coworkers. They demonstrated that increasing degrees of patellar lateralization relate to increasing severity of symptoms in patients. They also showed that many normal controls show mild lateralization near full extension, and thus conclude that this phenomenon is likely a normal variant rather than pathologic. Dye 58 has challenged the idea that malalignment (without subluxation) by itself causes patellofemoral pain, and has questioned some of the measurements that have been traditionally used to evaluate patients with anterior knee pain. In his study there was no statistical difference in Qangle and congruence angle in patients with patellofemoral pain and asymptomatic controls. He also concluded that osseous landmarks on radiography often do not match the contour of the underlying cartilage, which...
A 70-year-old male with two previous knee arthroplasties in two consecutive years. Patient began complaining of significant medial knee pain and sudden increasing deformity. (A) Preoperative radiograph demonstrating varus positioning of the tibial component with subsidence and fracturing of the medial tibial plateau. Figure 15.3. A 70-year-old male with two previous knee arthroplasties in two consecutive years. Patient began complaining of significant medial knee pain and sudden increasing deformity. (A) Preoperative radiograph demonstrating varus positioning of the tibial component with subsidence and fracturing of the medial tibial plateau.
Friedman L, Finlay K, Popovich T, et al. Sonographic findings in patients with anterior knee pain. J Clin Ultrasound 2003 31 85-97. Davies SG, Baudouin CJ, King JB, etal. Ultrasound, computed tomography and magnetic resonance imaging in patellar tendinitis. Clin Radiol 1991 43 52-6.
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 .
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.
Numerous conditions, including gout, rheumatoid arthritis (RA), neoplasm, peripheral vascular disease, diabetes mellitus, congenital deformity, and neurologic conditions, can all contribute to foot or ankle dysfunction. Similarly, the altered gait pattern related to foot and ankle dysfunction can contribute to other musculoskeletal complaints, such as low back pain and medial knee pain.
Stress fractures of the fibula may occur in runners, presenting as local pain and tenderness over the fibula. The incidence of stress fractures in the fibula in running has been quoted between 7 and 12 , and is most common in the distal fibula 6,8,66 . Proximal fibular stress fractures may also rarely occur, but are more common in jumpers. A high clinical suspicion is particularly important in making both of these diagnoses. Fractures may present as pain and tenderness over the lateral proximal fibula or as knee pain, requiring a high clinical awareness to make the correct diagnosis 67,68 . Imaging findings are similar to findings in the tibia.
4 FairbankJC, Pynsent PB, van PoortvlietJA, etal. Mechanical factors in the incidence of knee pain in adolescents and young adults. J Bone Joint Surg Br 1984 66(5) 685-93. 5 Fulkerson JP, Arendt EA. The female knee anterior knee pain. Conn Med 1999 63(11) 661-4. 12 Peers KH, Lysens RJ. Patellar tendinopathy in athletes current diagnostic and therapeutic recommendations. Sports Med 2005 35(1) 71-87. 41 McNally EG. Imaging assessment of anterior knee pain and patellar maltracking. Skeletal Radiol 2001 30 484-95.
Although often referred to as patellar tendonitis, a more accurate description of ''Jumper's knee,'' based on histologic studies, is of overuse tendinopathy. This is the most common tendinopathy in skeletally mature athletes, occurring in up to 20 of jumping athletes. Jumper's knee primarily affects the proximal posterior fibers of the patellar tendon and is a cause of significant functional disability in professional and recreational athletes 12 . Biomechanically, to squat and land softly from a jump, the quadriceps muscle lengthens in eccentric contraction and creates high tension on the patellar tendon. Patellar tendinopathy occurs secondary to repetitive microtrauma caused by tendon overload without adequate repair. This overuse can lead to pain, tenderness, swelling, and decreased performance. Most commonly, an athlete will present with anterior knee pain of insidious onset that is aggravated by activity (jumping, squatting, kneeling, and going down stairs). Symptoms can range...
Heterogeneous T2 elevation 29-year-old male with chronic knee pain and history of skiing injury 1 6 years earlier. (A) Diffuse T2 elevation is present in cartilage of the lateral patella facet on this fat-suppressed, PD-weighted FSE image. (B) More superiorly, there is a flap tear extending to bone (Grade III lesion) associated with abnormal marrow hyperintensity in subchondral bone. Note the decreased signal intensity of cartilage adjacent to the flap tear. This is frequently seen in subacute or chronic cartilage injuries. 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. Fig. 4. Cartilage blister 3.0 T fat-suppressed, PD-weighted FSE MRI image in 18-year-old male with anterior knee pain....
Flap tear 40-year-old male runner with 3-month history of persistent knee pain and intermittent locking. Coronal fat-suppressed, PD-weighted FSE image demonstrates a partial-thickness flap tear of the medial femoral condyle (arrow). A linear zone of T2 hypointensity present in the deep margin of the flap tear can be seen in the setting of chronic cartilage injury. Fig. 6. Flap tear 40-year-old male runner with 3-month history of persistent knee pain and intermittent locking. Coronal fat-suppressed, PD-weighted FSE image demonstrates a partial-thickness flap tear of the medial femoral condyle (arrow). A linear zone of T2 hypointensity present in the deep margin of the flap tear can be seen in the setting of chronic cartilage injury.
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