ANTERIOR KNEE PAIN

The pain in the anterior surface of the knee is a common clinical entity that relates to athletes - jumper's knee, runner's knee - but also to people who are not engaged in a sport regularly or amateur.
The pain of knee referred internationally as' anterior knee pain'- or 'patellofemoral pain syndrome'  and the therapeutic approach should be multifactorial and including the involvement of the patient himself.
The patient reports mainly pain and stiffness in the knee prolonged immobility of joints (prolonged sitting position), or during activities that require bending of the knee such as raising and lowering the ladder, deep kneeling.


Pain during effecting deep seating knees -squating

The cause of patellofemoral pain is multifactorial implicated factors such as improper alignment of the patella, disturbances in the mechanical axis of the lower end (valgus knee, external rotation of the tibia, etc.), as well as sustained and persistent stress of said hinge sports or professional activities.

CAUSE

Overuse syndrome

In many cases, patellofemoral pain syndrome is due to prolonged and difficult physical activity which causes a particular stress in the joint such as jogging, lifting and lowering the ladder. It can also be due to a sudden change of physical activity such as starting a sport after prolonged abstinence from sports. It can also be due to variation in the frequency of physical activity or duration of fulfilling the example increased kilometers traveled by a runner. The sudden weight gain extra burden joint.
 

Patellar malalignment


The kneecap (patella), 'nests and smoothly slide within the femoral trochlea (femoral or trochlear groove), during flexion and extension of the knee


Radiographic view 'sunrise view', normal imaging of patella in the femoral trochlea


The forces exerted on the patella sometimes tend to shift from its normal position thereby causing damage of the articular cartilage which eventually causes pain.

The anterior knee pain may however be due to abnormal slipping patella in substrate the femoral trochlea. In this situation the patella is pushed away from its normal position during knee flexion. This causes increased pressure and wear between the articular surfaces of the patella and femoral trochlea stimulating round synovial bursa.

Factors that cause abnormal slipping patella include:

Anatomic factors.

1. The femoral trochlea, the substrate i.e. sliding patella is shallow and may not include the patella during flexion and extension motion. This results in the extrusion of the patella to the outside and simultaneously creating an increased pressure conditions between the articular cartilage and premature wear.
2. The high position of the patella -patella alta- with respect to the normal position creates conditions abnormal friction between the two bone pain resulting appearance.
3. valgus knee because the knee extrude outwardly
4. Women because of the wider pelvis than men tend to have problems with their knee pain of adolescence.
From the pelvis starts the quadriceps, the main tensile muscles of the knee and the vector that traction on the patella pushes outwards.
5. The outward shift tibias - externally rotated tibia -  people that walk with their open end feet, creating traction conditions out of patellar pain resulting appearance.
6. Stiff patella due to tight ligament structures around the joint.

The Q angle shows the force exerted by the quadriceps on the patella. The greater the Q angle both quadriceps tends to 'pull' the patella outwardly pulling it from the completely normal anatomical position. Women said open basin with respect to the man exhibit greater Q angle and hence greater sensitivity patellofemoral articulation


Comparison Q angle with respect to gender. Man (male), woman (female)


                    Female                                                         Male


Failure of the mechanical axis of the left lower limb due to old injuries creates conditions subluxation of the left patella and pain in the joint


Genu recurvatum causes severe disturbance in the sliding of the patella and pain in the joint
 
Muscle factors

The weakness of the quadriceps muscle is one of the most common causes of anterior knee pain. The quadriceps muscles helps the patella is maintained in the femoral trochlea creating painless joint motion conditions. The quadriceps muscles may lose much of its strength rapidly after an injury to the lower end, and therefore require a special reinforcement rehabilitation program to quickly return to its normal state.
'Tight hamstrings muscles'. The hamstring muscles inserts in the tibia and if it is inflexible through many times of great muscular power, creating increased pressure of the patella on the substrate resulting in severe pain.

CLINICAL EXAMINATION  X-Ray CT, MRI

Abnormal course of the patella during flexion and extension of the knee - bounce - because of abnormal anatomy in the patellofemoral joint in girl 12 years

Boy 8 years old with hemophilia. Disorder slipping patella in both knees.

The examination made by the Orthopaedic surgeon aims to clarify the cause of pain and not just suppress the pain with painkillers and anti-inflammatory drugs. The investigation and identification of the cause is the cornerstone of treatment of the problem.
This may have clinical evaluation of the knee more than once and conducting diagnostic work like simple radiological examinations MRI, CT scan, or CT scanogram for detailed imaging of bone and muscle joint structures and mechanical axis of the lower limb .


X-Ray knee bilaterally. The patellae are outside of their normal positions (upper and out of normal)


Knee Magnetic resonance imaging MRI- sagittal section, slightly elevated position of the patella causes significant damage to the articular cartilage thus causing pain.


Magnetic resonance imaging MRI, of the left knee showing the outward patella subluxation due to dysplasia of the femoral trochlea

ORTHOPEDIC DEVELOPMENTS: 

PRP PLATELET RICH PLASMA

INTRODUCTION

Autologous blood products have created a growing interest for use in a number of Orthopaedic therapies. The healing effects of plasma are supported by growth factors released by platelets . These growth factors induce a healing response.

INDICATIONS

CONSERVATIVE TREATMENT
THERAPY: 

The treatment plan for the treatment of the anterior knee pain due patellofemoral syndrome aims to relieve the patient, the muscle strength of the quadriceps muscle in a specific range of motion and a stretching program hamstring muscles.

The results of this effort can be seen after a long time for this reason you need patience and perseverance on the part of the patient and proper guidance from the Orthopaedic surgeon.

Conservative treatment includes:

  • Medication with non-steroidal anti-inflammatory drugs
  • Dietary supplements glucosamine and chondroitin sulfate, MSM, hyaluronic acid and oral intake
  • Intra-articular injections of autologous PRP growth factors
  • Intra-articular injections of autologous stem cells
  • Intra-articular injections of hyaluronic acid
  • Physiotherapy program from experienced physiotherapist
  • Rehabilitation program established by the treating orthopedic surgeon depending on the etiology of the problem of pain in the knee, which run daily by the patient at home. This program includes strength training and stretching exercises muscle groups.

The application of special soles in the shoes of the patient after special examination. The combinatorial approach to the problem with the above preservatives and after continuous reassessments of course pain in the patient's knee strikes and the solution of the problem
 
The hamstrings muscles crosses two joints and therefore directly affect the biomechanics of the knee


Regular stretching of the posterior thigh muscles is a very impotrant part of the conservative treatment program

OPERATIVE TREATMENT
THERAPY: 

Surgical treatment of the problem is the final solution after the failed attempt to tackle the problem with prolonged conservative treatment.

KNEE ARTHROSCOPY 
Arthroscopy of the knee is a modern and minimally invasive approach to the problem.

Mainly carried out:

  • alignment of the patella through the release of 'tight' anatomical structures - lateral retinaculum ligametn release- if this course is the cause of pain in the knee,
  • debridement- Purification of the articular cartilage of the patella and femoral trochlea of the wear elements.

OPEN SURGERY
Open surgical interventions are aimed anatomical alignment of the patella correcting anatomical deviations of the joint, such as:

  • the shallow trochlea with trochleoplasty,through transfer of the tibial tuberosity if the cause is the anatomical patella leads outwards,
  • or downward transfer of the tibial tuberosity in cases of high position of the patella - patella alta -
  • and finally carrying  osteotomies for correcting torsional deformations tibia or femur, in order to correct the anatomical and mechanical axis of the lower limb. The combination sometimes perform surgical revision surgery of soft and hard tissues is imperative for achieving a good effect.