Anterior Knee Pain Syndrome

Anterior Knee Pain

• Anterior knee pain (AKP) is one of the most fre-
quent reasons for consultation in the context of
knee conditions in adolescent and young adult
patients.
• Gender is a significant predictor for the
development of AKP, with females having an
incidence that is 2.23 times higher than that of
males
• From US Naval Academy: 15% in females, 12% in
males
 Definition
• By definition anterior knee pain is a symptom and not a
diagnosis
• Other names for this condition: anterior knee pain
syndrome (AKPS), patellofemoral pain syndrome (PFPS)
• The predominant symptom is peripatellar or
retropatellar pain which is often activity-related:
-ascending/ descending stairs
-squatting or sitting for prolonged periods of time
• Other associated manifestations described include
functional deficit, crepitus and instability.
 Etiology
Nonspesific AKP has varying etiologies and thus
varying pain mechanism
• Apophysis
• Inflammatory reaction .
• Nociceptive stimuli
• Direct trauma and indirect
• Cold
• Tissue homeostasis
• During the evaluation of anterior knee pain,
patellar height is often evaluated because
many conditions are often associated with an
abnormal patellofemoral relationship
• The most accepted and widespread method is
the Insall-Salvati ratio
 Anatomy of the Knee
• The Joint
Compartments
• The patella
• The joint line
• The meniscus
• Anterior and Posterior
Cruciate Ligaments
• Medial and Lateral
Collateral Ligaments
• Iliotibial band
Anatomy of the Knee
• Anterior, posterior, and
superior view surface of
the patella
The Insall Salvati Ratio
The Insall-Salvati Ratio
 Insall-Salvati Ratio
A high riding patella (patella alta) ratio > 1,2
recurrent lateral dislocation or subluxation of patella
• chondro-malacia of patella
• Sinding-Larsen-Johansson disease
• Patellar and quadriceps tendonitis
• Osgood-Schlatter disease
A low-riding patella (patella baja) ratio < 0,8
• Quadriceps tendon rupture
• Neuromuscular disorders
• Achondroplasia
 DIAGNOSIS
History
The main symptom: retropatellar or peripatellar pain
• The location of the pain?
• Whether the pain appears or is aggravated by
activites?
• Quality (dull and sharp)
• Experience anxiety, depression, kinesiophobia and
catastrophising
• Uni or Bilateral (50% bilateral)
• Other symptoms: a giving-way sensation walking
 Physical Examination
• General observation
 Bony malformation
 Abnormal alignment
 Quadriceps atrophy
 Retinacular tightness
 Elevated quadriceps angle
• Pinpoint the painful area
• Tenderness over the lateral retinaculum (frequent
finding)
Physical Examination
In patients with impingement
of the Hoffa fat pad, pain is
dramatically exacerbated by
quadriceps contraction (B) or
passive knee extension (C),
while applying pressure of the
fat pad with the fingers
(A,B,C), because this
movement causes a small
posterior tilt of the inferior
pole of the patella, which
impinges on an inflamed and
sensitised infrapatellar fat pad
 Physical Examination

Assessment of the flexibility of the anterior hip

structures.
 Physical Examination

Both internal femoral rotation and external tibial

rotation increase pressure on the lateral side of the
patellofemoral joint.
 Physical Examination

Lateralisation of the tibial tubercle • Functional or dynamic knee

correlates with anterior knee pain valgus visualised by a one-
legged squat
 Imaging
• The standing anteroposterior view, a true
lateral view, and axial X-rays should be
obtained for all patients with AKP (first steps
for imaging)
• In cases refractory to conservative treatment,
CT and MRI should be considered
 Imaging

Axial MRI. Impingement of a peripatellar

synovitis (arrow).
 Recurrent Lateral Dislocation or
Subluxation of Patella
• This can occur as a result of direct trauma to the knee, or
just as frequently by indirect trauma (for example, a
pivoting mechanism without a direct blow to the knee).
• The patients who present with an indi-rect trauma history
may have predisposing mechanical factors, such as a
hypermobile patella, patella alta (high riding patella), a
shallow trochlear groove, or a systemic collagen tissue
disorder (eg, Marfan syndrome).
• A patient will present complaining of anterior knee pain
and may report hearing a pop or snap at the time of injury;
the patient may describe feeling as if the knee itself dis-
located.
 Chondro-malacia of patella

• Chondromalacia is a softening of the

patellofemoral cartilage, and may be a
precursor to degenerative joint disease in this
compartment of the knee.
• Leslie and Bentley found retro patellar
crepitus, effusion, and quadriceps wasting
greater than 2 cm as the most important
findings for detection of chondromalacia of
the patella.
Sinding-Larsen-Johansson Disease
• Sinding-Larsen-Johannson syndrome is a traction apophysitis of the
inferior pole of the patella.
• It is typically seen in boys 10 to 13 years of age; however, active
girls also may present with this.
• It is caused by repetitive stress on the patella at the prox-imal
insertion of the patellar tendon. The pain can range from mild to
severe and the duration of these symptoms can be from 3 to 18
months. Patients will usually be involved in sports or exercise that
requires a fair amount of running or jumping.
• Patients will usually present pain with any activity that increases the
patellofemoral joint load (eg, running, jumping, climbing, stairs,
squatting/kneeling). On physical examination, there is focal
tenderness at the patella’s inferior pole; there also may be localized
soft tissue swelling.
 Patellar and Quadriceps Tendonitis
• Quadriceps and patellar tendinopathy (also known as
Jumper’s Knee) are common conditions seen in sports
medicine offices, and were first described by Blazina
and colleagues. These conditions are most often a
result of overuse: repetitive stresses on the tendon
overwhelm the tissue’s ability to heal itself, resulting in
symptoms and dysfunction.
• These patients will typically complain of an aching pain
in the anterior portion of the knee, and may be able to
localize the source as below or above the patella.Ask
the patient if he or she can put a finger on the location
of the anterior knee pain.
 Osgood-schlatter disease
• Osgood-Schlatter disease is a common cause of
anterior knee pain in the adolescent. It is an
apophysitis of the tibial tubercle, thus found only in the
skeletally immature in acute cases. Patients usually
present at the beginning of their growth spurt with this
pain. In boys, this tends to be 10 to 15 years of age and
in girls, 8 to 13 years of age. Boys also seem to be more
affected than girls. Most adolescents are patients who
are active in sports with running and cutting involved,
such as soccer, basketball, and lacrosse. With the tibial
apophyses undergoing repetitive stress from the
patellar tendon constantly pulling on it, this can lead to
the condition and presentation of the patient.
 TREATMENT
• Non-surgical intervention
– Lifestyle and exercise modification
– Rehabilitation
– Icing pad
– NSAIDS
– Steroid injection
– Dry needling
– Patellar taping
– Proper footwear
– Foot orthotic
– Soft knee braces

• Collins N, Crossley K, Beller E, Darnell R, McPoil T, Vicenzino B. Foot orthoses and physiotherapy in the treatment of patellofemoral pain
syndrome: randomised clinical trial. BMJ. 2008 Oct 24. 337:a1735.

• Miller DM, Thompson SR (2016). Miller's Review of Orthopaedics Seventh edition. Elsevier, Inc
 • Surgical intervention
– Arthoscopic and debridement
– Acute repair of medial patellofemoral ligament
– Lateral retinacular release
– Proximal realignment procedures
– Femoral attachment
– Distal realignment/tibial tubercle osteotomy
procedures

• Miller DM, Thompson SR (2016). Miller's Review of Orthopaedics Seventh edition. Elsevier, Inc

• Potter PJ MD, et al. (2017). Patellofemoral syndrome. https://emedicine.medscape.com/article/308471-overview . Cited at 29th July 2018

• Vora M, et al (2017). Patellofemoral Pain Syndrome In Female Athletes: A Review Of Diagnoses, Etiology And Treatment Options. Orthopaedic
Reviews 2017; volume 9:7281
 Schottle’s point for radiographically identifying the femoral attachment of the MPFL.This occurs 1 mm anterior to the
posterior cortex extension line (Line 1), 2.5 mm distal to the posterior origin of the medial femoral condyle and proximal to
the level of the posterior point of the Blumensaat line on a lateral radiograph with both posterior condyles projected in the
sameplane. To identify this radiographically, two perpendiculars to Line 1 are drawn, intersecting the contact point of the
medial condyle and the posterior cortex (Point 1, Line 2) and intersecting the most posterior point of the Blumensaat line
(Point 2, Line 3).

• Miller DM, Thompson SR (2016). Miller's Review of Orthopaedics Seventh edition. Elsevier, Inc