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ANTERIOR KNEE PAIN

by loading of the PFJ, particularly in semi-flexed positions with eccentric knee extensor activity ie. walking downstairs or deceler- ating, often being more painful than concentric activity ie. walk- ing upstairs or pushing off. The patient may also complain of pain during prolonged sitting (‘movie goers knee’) and locking and giv- ing way of the knee Assessment: The patient will present with poorly controlled lower limb rotation during a variety of functional activities (stair ascent and descent, walking and running), either excessive/late prona- tion or excessive hip internal rotation/lateral pelvic displacement. Poorly controlled activities are frequently painful and correction of alignment often relieves the pain immediately. The patient may have pain on resisted quadriceps contraction, but will always have inhibition and decreased strength of the quadriceps. Short tight muscles (hamstrings, rectus femoris, iliotibial band, gastrocne- mius/soleus) and features of biomechanical mal-alignment are always present. Patella mobility, particularly medially and caudal- ly (towards the feet) is often limited

Patella mobility is often normal in knee extension, where it is not engaged in the trochlear groove. A better test of patella mobility as it affects tracking, is to test patella mobility in 20-30 degrees of knee flexion as it enters the groove.

Treatment/rehabilitation: Correcting the biomechanical mal- alignment is of primary importance (refer to shaded box). Strengthening of the quadriceps is essential, but should be done with exercises that do not over stress the PFJ ie. closed kinetic chain quadriceps exercises in the range of 30-60 degrees of flex- ion. Stretching of the shortened muscles must be carried out along with mobilising of the patella. Patella taping can bring about a significant reduction in pain allowing much greater func- tion and higher levels of muscle training to be achieved

2. PATELLA TENDONITIS Definition: An inflammatory condition affecting the patella ten- don

Cause: It is usually caused from some form of overload. The over- load comes from either: a) eccentric quadriceps activity, for instance with an unaccus- tomed amount or intensity of plyometric exercise b) repetitive micro-trauma, most often related to extensor mech- anism mal-alignment Presentation: Most patients present with a gradual onset of pain localised to the inferior pole of the patella or proximal patella tendon. The pain experienced can be divided into four activity related stages: Stage 1: Pain after activity only, with no functional impairment Stage 2: Pain at the beginning of activity that disappears after warm up

Stage 3: Pain during and after activity limiting performance Stage 4: Significant functional impairment due to pain Assessment: Localised tenderness at the inferior pole of the patella or proximal patella tendon. There is normally minimal swelling, though in long standing chronic situations the tendon may be hypertrophied/thickened. Pain will be aggravated by resisted quadriceps contraction (often there is associated weak- ness and inhibition); mid to full squat; going downstairs; end range knee flexion; running and jumping (especially landing). However, the patient can often be pain free at slow running

speeds during the early stages of the condition. Biomechanical lower limb alignment faults will often be present. Ultrasound scan may reveal a hypoechoic or black space in the tendon especially in the chronic situation where tendon degeneration may be pre- sent. MRI scan may similarly reveal tendon degeneration and effu- sion Treatment/rehabilitation: Electrotherapeutic modalities and ice can be used to decrease any swelling and provide some pain relief. Manual therapy in terms of both patella mobilisation and specific soft tissue mobilisations (1) will improve local tissue mobility. Stretching of rectus femoris will aid in improving range of move- ment. However, the key to treatment success is to improve the tendon’s ability to withstand tensile loading and correct any bio- mechanical alignment faults exacerbating stresses on the tendon (refer to the ‘Lower limb alignment’ shaded box). A programme of exercises developed by Curwin and Standish (2) is very useful for applying progressively increasing loads on the tendon, and is highly recommended. But the patient must be cautioned that it may take considerable time to take affect because the laying down of new collagen within a tendon is a slow process

3. PLICA SYNDROME Definition: Inflammation and scarring of the medial plica. A plica is a fold in the synovium of the knee that performs no known function and is a remnant from embryonic development of the knee

Cause: It is usually caused by micro-trauma resulting from a bio- mechanical alignment abnormality Presentation: There is a gradual onset of pain, often described as a localised ache medial to the patella. It is aggravated by repet- itive flexion/extension activities of the knee and is often associ- ated with a popping or snapping noise. It is usually unilateral, rarely is any swelling present and it is only infrequently associat- ed with prolonged sitting. Medial glide patella taping may aggra- vate the condition considerably

60% of all knees have a plica present, the large majority being asymptomatic. A plica should only be considered significant if appropriate PFPS rehabilitation has failed.

Assessment: A biomechanical mal-alignment is usually present, along with a palpable thickened band medial to the patella. Resisted isometric knee extension is not normally painful, but passive knee flexion is. A useful test is the mediopatellar plica test, this is performed with the patient in the supine position with the knee flexed to 30 degrees, the examiner displaces the patella medially, the test is positive if translation reproduces pain Treatment/rehabilitation: Correcting the biomechanical mal- alignment is of primary importance. Electrotherapeutic modalities may help to decrease the inflammation. Deep transverse frictions and local massage tend to cause increased irritation of the plica. Arthroscopic resection to remove the problem plica may be required. Recovery and rehabilitation from this operation is always slow and frequently accompanied by synovitis (gross swelling) of the knee

4. FAT PAD SYNDROME Definition: Inflammation of the infra-patella fat pad Cause: Either direct trauma in the form of a direct blow or arthro- scopic incision, or repetitive micro-trauma resulting from repeat-

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