Anterior Knee Pain

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Definition/Description

Knee - Side View

Anterior knee pain is pain that occurs in the front and central aspect of the knee. Its cause can be due to a number of conditions:

• Patellofemoral pain syndrome
• Chondromalacia Patellae
• Osgood-Schlatter’s disease
• Sinding Larsen Johansson syndrome
• Plica synovialis syndrome
• Knee bursitis/Hoffa’s disease
• Articular cartilage injury
• Bone tumors: Most patients will experience pain in the area of the tumor. Pain can become worse during physical activity and often awakens patients during the night. Bone mass around the tumor becomes weaker and the bone may fracture as a result.
• Osteochondritis dissecans
• Patellafemoral instability/subluxation
  

• Patellar stress fracture: A stress fracture in the patella is caused either by fatigue as a result of submaxiaml stress loads or insufficiency where the bone has been previously weakened due to physiological stress. It reduces shock absorption such that high repetitions of load may lead to a stress fracture.
  
• Patellar tendinitis
• Patellofemoral osteoarthritis
• Pes anserine bursitis: The anserine bursa is one of 13 bursae found around the knee, located just below the pes anserinus. Patients with pes anserine bursitis often complain of spontaneous knee pain with tenderness in the inferomedial aspect of the knee joint.  
• Quadriceps tendinopathy
• Prepatellar bursitis
• Iliotibial band syndrome 

Epidemiology /Etiology

The etiology of anterior knee pain is multifactorial and not well defined due to the variety of symptoms, pain location and pain level experienced by the patient. Underlying factors could be patella abnormalities or muscular imbalances or weakness leading to patella malalignment on flexion and extension. The causes include overuse injuries; tendinopathy, insertional tendinopathy, patellar instability, chondral and steochondral damage .

Characteristics/Clinical Presentation

Clinical classification of anterior knee pain.

There is no clear definition of anterior knee pain and patients can present with various symptoms.


Activities of Daily Living:
Pain often occurs or worsens when walking down stairs, squatting, depressing the clutch pedal in a car (in the case of left knee pain), wearing high-heeled shoes or sitting for long periods with the knees in a flexed position (‘‘movie sign’’). Patients also experience a certain degree of instability ‘‘in a straight line’’ especially going up and down stairs or ramps .

Individuals with overuse injuries may report a feeling of instability or giving way, although this may not a true giving way (usually associated with internal injury to the knee) but a neuromuscular inhibition as a result of the pain, muscle weakness, patellar or joint instability

Differential Diagnosis

• Refered pain from hip joint pathlogy such as capital femoral epiphysis

• Refered pain from the Saphenous nerve

Diagnostic Procedures

Evaluation of anterior pain is challenging as it can be non specific and differential diagnosis is extensive. It requires a thorough examination, symptom history, an indepth knowledge of the associated structures and typical injury patterns. In younger individuals an assessment of their general growth and development is essential to determine a diagnosis.

Hip and lumbar spine disorders can refer to the knee and need to be excluded.

Some key factors in obtaining an accurate diagnosis are; the pain characteristics, i.e. its location, character, onset, duration, change with activity or rest, aggravating and alleviating factors and any night pain; trauma (acute macrotrauma, repetitive microtrauma, recent/remote); mechanical symptoms (locking or extension block, instability, worse during or after activity); inflammatory symptoms such as morning stiffness, swelling; effects of previous treatments and the current level of function of the patient: if there is any history of gout, pseudogout, rheumatoid arthritis, or other degenerative joint disease. Selective use of appropriate imaging, such as Ultrasound and MRI are excellent tools for differential diagnosis and for ruling out sources of intra-articular derangements (14)(15)(17)

Diagnosing and thus selecting an individual specific, non-operative treatment protocol is vexing. The European Rehabilitation Panel have devised a guideline which should lead to a improved treatment choice and outcomes. They suggest the following assessment parameters:

1. Symptoms – Pain (location and type) or instability problems?

2. Alignment of the entire lower extremity – Squinting patella? – High q-angle? – Genu valgus? – Genu recurvatum? – Pronation of the subtalar joint?

3. Patellar position – Patella alta? – Patella baja? – Patellar glide? – Patellar tilt? – Patellar rotation?

4. Muscles and soft tissues – Hypotrophy of VMO? – Imbalance between VM and VL? – Weakness of knee extensors, hip flexors and/or hip abductors? – Tightness of the medial retinaculum? – Tightness of lateral muscle structures, hamstrings and/or rectus femoris?

5. Knee function (pain and/or maltracking of the patella) – During different dynamic activities, e.g. stair walking, step-up/step-down exercises and one-leg squat?

The 13 item screening Kujala Anterior Knee Pain Scale (AKPS) can also be used to identify patellofemoral pain in adolescents and young adults. Ittenbach et all suggest that is highly reliable but not without its limitations and further research is needed for its use outside of clinical environment and application to the general population. The AKPS has shown to have good test-retest reliability.

The Lower Extremity Functional Scale (LEFS) is a further self-report test, to assess difficulties that the patient has with activities. This questionnaire is less specific for anterior knee pain patient than the anterior knee pain scale. The LEFS also demonstrates a high test-retest reliability and its reliability and responsiveness is slightly higher than that of the AKPS

Outcome Measures

The Kujala anterior knee pain scale and the Lower extremity functional scale can be used for both an initial screening tool as well as to detect changes with treatment and as outcome measures.

Medical Management

Were there is bony abnormality or retinaculum dysfunction, non operative treatment may be less successful, but operative treatment should be reserved for those with correctable anatomical abnormalities that have failed conservative therapy

Physical Therapy Management

For long term non-operative results, any postural mal-alignment or altered movement patterns should be addressing initially before introducing a strengthening programme. When assessing functional abnormality and compensatory patterns the whole lower limb should be observed, not restricting assessment to the knee area. Any significant leg length discrepancy should be addressed as well any intrinsic imbalances in the foot where they are contributing factors. Eng et all suggest that orthotics alongside exercise can result in more effective outcomes for sufferers of anterior knee pain compared to exercise alone , but any exercise and/or stretching programme need to be individualised relative to the presenting symptoms and the movement dysfunction.

a non-specific Anterior Knee pain treatment we need first to focus on the symmetry between the knees before focusing on an operative measures.
Treatment aim is restoration of the symmetry between the 2 knees. To aim that you need to restore the Range of Motion (RoM) and the leg strength.
The first step for this treatment is restoration extension of the knee (also the hyperextension). After the fully recover extension the next step will be restoration of flexion. When the patient recover fully of his RoM then we can begin with strengthen the leg muscles (mostly the quadriceps).
Some exercise that can be use for improving Knee extension:
- Heel Prop (can also be use to train hyperextension)
- Towel extension
Some exercise that can be use for improving Knee flexion:
- Bicycle riding (can also be use to train extension of the knee)
- Wall slides with the heel (active as passive)
Some exercise that can be use for strengthen the knee (only when the RoM of the patient fully is recovered):
- Low Impact aerobic exercise on a stationary bike
- Stair stepping machine

Presentations

Case Study: Adolescent Anterior Knee Pain This presentation was created by Omolara Ajayi in collaboration with: EIM Clinical Excellence Network and Physical Therapy Central. View the presentation

Clinical Bottom Line

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References

1. ↑ Sala D, Silvestre A, Gomar-Sancho F. Intraosseous hyperpressure of the patella as a cause of anterior knee pain. Medscape Orth Sports Med. 1999;3:1–8.
2. ↑ http://orthoinfo.aaos.org/topic.cfm?topic=A00074
3. ↑ Livestrong. Patellofemoral Pain Syndrome Health Byte. Available from: http://www.youtube.com/watch?v=96nP8RaYQ6Y [last accessed 27/08/12]
4. ↑ Crowther MA, Mandal A, Sarangi PP. Propagation of stress fracture of the patella. Br J Sports Med. 2005;39(2):e6. Available at: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1725122/pdf/v039p000e6.pdf (accessed 29 Aug 2012)
5. ↑ Helfenstein M Jr, Kuromoto J. Anserine syndrome. Rev Bras Reumatol. 2010;50(3):313-327.
6. ↑ Dixit S, DiFiori JP, Burton M, Mines B. Management of patellofemoral pain syndrome. Am Fam Physician. 2007;75(2):194-202.fckLRAvailable at: http://www.drwilliamsilva.com.br/files/artigos/artigo08.pdf (accessed 29 Aug 2012)
7. Vincente Sanchis-Alfonso, Anterior Knee pain and Patellar Instability (second edition); Springer-Verlag London Limited 2011 ;pagina 66-68 ( = Level of evidence 2C)
8. Anterior knee pain scale; Australian journal of physiotherapy 2009 Vol. 55. Australian Physiotherapy association.
9. Cynthia j. Watson et al. ,Reliability and Responsiveness of the Lower Extremity Functional Scale and the Anterior Knee Pain Scale in Patients With Anterior Knee Pain. Journal of Orthopaedic and Sport Physical Therapy 2005. (Level of evidence 2B)
10. Vincente Sanchis-Alfonso, Holistic approach to understand anterior knee pain. Clinical implications, Knee Surg Sports Traumatol Artrosc (2014) 22:2257-2285 (Level of evidence 2C)

11. Suzanne Werner, Anterior knee pain: an update of physical therapy, Knee Surg Sports Traumatol Artrosc (2014) 22:2286-2294. (Level of evidence 2A)

12. Kim D. Barber Foss et al : Expected Prevalence From the Differential Diagnosis of Anterior Knee Pain in Adolescent Female Athletes During Preparticipation Screening ,Journal of Athletic Training, volume: 47, issue: 5, p. 519 ,2012 (level of evidence:2B)
13. Eva Llopis et al : Anterior knee pain, European journal of radiology , issue: April 21007 (level of evidence:2c)
15. William l. Davis et al : initial evaluation of the athlete with anterior knee pain ,vol 7 issue 2 april 9 pages 55-58(pubmed) (level of evidence:2a)
16. Toby O Smith et al: the contemporary management of anterior knee pain and patellofemoral instability,volume 20, pages s3-s15 ,sept. 2013(pubmed) (level of evidence:1a)

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