Understanding Red Flags in Patellofemoral Pain: Difference between revisions

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<div class="editorbox"> '''Original Editor '''- [[User:Carin Hunter|Carin Hunter]] based on the course by [https://members.physio-pedia.com/course_tutor/claire-robertson// Claire Robertson]<br>'''Top Contributors''' - {{Special:Contributors/{{FULLPAGENAME}}}}</div>
<div class="editorbox"> '''Original Editor '''- [[User:Carin Hunter|Carin Hunter]] based on the course by [https://members.physio-pedia.com/course_tutor/claire-robertson// Claire Robertson]<br>'''Top Contributors''' - {{Special:Contributors/{{FULLPAGENAME}}}}</div>
== Introduction ==
== Introduction ==
Why do we need to know red flags?
Screening for red flags is an important part of the assessment process, but it is often overlooked in patients with knee pain. It is important to have a good understanding of red flags for patient safety and to ensure appropriate and timely referrals are made when necessary. If there has been any trauma to the knee, it is necessary to make sure that all relevant investigations have been carried out. For more information on red flags, please see this page: [[An Introduction to Red Flags in Serious Pathology]].
 
Safety
 
Directing patients to the right place
 
If there has been trauma to the knee - always make sure the correct imaging/investigations have been done.


== Non-Traumatic Masquerading Conditions ==
== Non-Traumatic Masquerading Conditions ==
There are certain conditions that can have similar pain patterns as patellofemoral pain, and these should be considered in a differential diagnosis. The following non-traumatic conditions occur in the adolescent population (i.e. pre-teen and teen).<ref name=":6">Robertson C. Understanding Red Flags in Patellofemoral Pain Course. Plus. 2022.</ref>


==== Young people ====
==== Osgood-Schlatter Disease (OSD) ====
 
[[File:Osgood_Schlatters.jpg|alt=|right|frameless|400x400px|link=https://www.physio-pedia.com/File:Osgood_Schlatters.jpg]]'''<u>Signs and Symptoms:</u>'''
==== Osgood Schlatters ====
* This condition is common in adolescents aged 11-15 years old<ref name=":0">Neuhaus C, Appenzeller-Herzog C, Faude O. [https://www.sciencedirect.com/science/article/pii/S1466853X2100047X A systematic review on conservative treatment options for OSGOOD-Schlatter disease.] Physical Therapy in Sport. 2021 May 1;49:178-87.</ref>
11-15 years olds
* It is prevalent in children participating in quadriceps dominant sports, i.e. running, kicking and jumping<ref name=":0" />
 
* Patients present with an obvious bump at the tibial tubercle<ref name=":1">Corbi F, Matas S, Álvarez-Herms J, Sitko S, Baiget E, Reverter-Masia J, López-Laval I. [https://www.mdpi.com/2227-9032/10/6/1011 Osgood-Schlatter Disease: Appearance, Diagnosis and Treatment: A Narrative Review.] InHealthcare 2022 May 30 (Vol. 10, No. 6, p. 1011). MDPI.</ref>
prevalent in kids that do lots of quads dominant sports, so running, and kicking and jumping
* Pain is specific to the tibial tubercle
 
* Inflammation and elevation of the growth plates are present in the tibial tuberosity
obvious bump at the tibial tubercle
* An MRI to show the level of inflammation can be used as confirmation, but this will not change the treatment plan
* Pain can progress to a level that prevents any participation in sport if left untreated
'''<u>Treatment:</u>'''
* Education
* Activity modification:<ref name=":6" /><ref name=":0" /><ref name=":1" />
** Try to eliminate the patient's least favourite sport, or
** Change their playing position to a less active position to decrease load
* NSAIDS (non-steroidal anti-inflammatories)
* Ice massage - this will provide symptomatic relief
* Address overload:
** Extrinsic factors
*** Load management of sport<ref name=":0" />
*** Footwear<ref>O’Sullivan IC, Crossley KM, Kamper SJ, van Middelkoop M, Vicenzino B, Franettovich Smith MM, Menz HB, Smith AJ, Tucker K, O’Leary KT, Costa N. HAPPi Kneecaps! [https://onlinelibrary.wiley.com/doi/abs/10.1002/tsm2.252 A double-blind, randomised, parallel group superiority trial investigating the effects of sHoe inserts for adolescents with patellofemoral PaIn]: phase II feasibility study. Journal of Foot and Ankle Research. 2021 Dec;14(1):1-1.</ref>
*** Landing technique<ref>Gaulrapp H, Nührenbörger C. [https://link.springer.com/article/10.1007/s00264-021-05178-z The Osgood-Schlatter disease: A large clinical series with evaluation of risk factors, natural course, and outcomes.] International Orthopaedics. 2022 Feb;46(2):197-204.</ref>
** Intrinsic factors
*** Muscle length<ref name=":0" />
*** Muscle strength<ref name=":0" />
For more information, please see [[Osgood-Schlatter Disease]].


Pain specific to tibial tubercle
==== Sinding Larsen Johansson Syndrome ====
[[File:Adapted_Sinding-Larsen-Johansson_Syndrome_-_Shutterstock_Image_-_ID_633281234.jpg|alt=|right|frameless|link=https://www.physio-pedia.com/File:Adapted_Sinding-Larsen-Johansson_Syndrome_-_Shutterstock_Image_-_ID_633281234.jpg]]Sinding Larsen Johansson Syndrome (SLJS) is a juvenile osteochondrosis and traction epiphysitis. It affects the extensor mechanism of the knee, which disturbs the patella tendon attachment to the inferior pole of the [[patella]]. There is tenderness of the inferior pole of the patella. This is usually accompanied by x-ray evidence of splintering of that pole. Most patients with SLJS also have calcification at the inferior pole of the patella.<ref>Medlar RC, Lyne ED. [https://journals.sagepub.com/doi/abs/10.1177/2325967121S00503 Sinding-Larsen-Johansson disease. Its etiology and natural history.] The Journal of Bone and Joint surgery. American Volume. 1978 Dec 1;60(8):1113-6.</ref>


inflammation and elevation of the growth plates in the tibial tuberosity, so the proximal tibia
The syndrome usually appears in adolescence, during a growth spurt. It is associated with localised pain which is worsened by exercise. Usually localised tenderness and soft tissue swelling are observed. The surrounding muscles may also be tight, particularly the [[Rectus Femoris|quadriceps]], [[hamstrings]] and [[gastrocnemius]]. This tightness usually results in inflexibility at the [[Knee|knee joint]], which alters the stress applied through the [[Patellofemoral Joint|patellofemoral joint]].<ref>Houghton, K. M., [https://ped-rheum.biomedcentral.com/articles/10.1186/1546-0096-5-8 ‘Review for the generalist: evaluation of anterior knee pain]’, Paediatric Rheumatology, (2007), vol. 5, p. 4-10.</ref>


Can be confirmed on MRI to show level of inflammation
'''<u>Signs and Symptoms:</u>'''
* Inflammation at the growth plate of the distal pole of the patella<ref>Fischer AN. [https://link.springer.com/chapter/10.1007/978-3-030-55870-3_8 Sinding-Larsen-Johansson Syndrome.] InCommon Pediatric Knee Injuries 2021 (pp. 63-68). Springer, Cham.</ref>
* This condition is most likely to be seen during growth spurts
* Primary treatment focuses on tracking growth for activity modification during a growth spurt<ref>McCormick KL, Tedesco LJ, Bixby EC, Swindell HW, Popkin CA, Redler LH. [https://journals.sagepub.com/doi/abs/10.1177/2325967121S00503 Sinding-Larsen-Johansson Disease: Analysis of the Associated Factors in the Largest Cohort to Date.] Orthopaedic Journal of Sports Medicine. 2022 May 31;10(5_suppl2):2325967121S00503.</ref>
* Pain can progress to a level that prevents any participation in sport
'''<u>Treatment:</u>'''


Pain worsen to a point that it can prevent any participation in sport
* Education
* Activity modification:<ref name=":6" />
** Try to eliminate the patient's least favourite sport, or
** Change their playing position to a less active position to decrease load
* NSAIDS (non-steroidal anti-inflammatories)
* Ice massage - to provide symptomatic relief
* Address overload:
** Extrinsic factors
*** Load management of sport
*** Footwear
*** Landing technique
** Intrinsic factors
*** Muscle length
*** Muscle strength


Treatment:Education
For more information, please see [[Sinding Larsen Johansson Syndrome|Sinding-Larsen-Johansson Syndrome]].
 
Activity modification - eliminate least fav sport, change playing position to a less active one to decrease load
 
NSAIDS
 
Ice Massage(Symptomatic relief)
 
Address overload
 
extrinsic
 
load management of sport
 
footwear
 
landing technique
 
intrinsic factors
 
muscle length
 
muscle strength
[[File:Osgood Schlatters.jpg|thumb|alt=|none]]
 
==== Sinding-Larsen-Johansson Disease ====
[[File:Adapted Sinding-Larsen-Johansson Syndrome - Shutterstock Image - ID 633281234.jpg|thumb|alt=|none]]
inflammation at the growth plate of the distal pole of the patella
 
most likely to be seen at times of aggressive growth/growth spurts
 
treatment tactics that I ask parents to do is to track growth because they're more likely to manage it well at times of aggressive growth with their activity modification.
 
Pain worsen to a point that it can prevent any participation in sport
 
Treatment:activity modification


==== Knee Effusion ====
==== Knee Effusion ====
A child should not have a knee effusion
[[File:Osteochondritis Dissecans.jpg|alt=|right|frameless|link=https://www.physio-pedia.com/File:Osteochondritis_Dissecans.jpg]]There are no instances where a child should have a knee effusion without a cause. Thus, any effusion in the absence of trauma should always be investigated. A knee effusion can often lead to patellofemoral pain.
 
Effusion very often leads to patellofemoral pain
 
A knee effusion in a child should always be investigated
 
Possible Causes:
 
systemic autoimmune disease, juvenile arthritis
 
infective arthritis
 
Osteochondritis Dissecans
[[File:Osteochondritis Dissecans.jpg|none|thumb]]


'''<u>Possible Effusion Causes:</u>'''
* Systemic autoimmune disease (eg. [[Juvenile Rheumatoid Arthritis|juvenile arthritis]])
* [[Septic (Infectious) Arthritis|Infective arthritis]]
* Osteochondritis dissecans
'''<u>Autoimmune Disease Red Flags:</u>'''
* Multiple joint involvement
* Joint is stiff on waking
* Fatigue
'''<u>Infective Arthritis Red Flags:</u>'''
* Temperature
* Recent illness
==== Osteochondritis Dissecans/Osteochondral Defect ====
==== Osteochondritis Dissecans/Osteochondral Defect ====
cartilage and some of the subchondral bone can break off and float in the joint, which irritates the synovium, which in turn causes the effusion
[[File:OD.jpg|alt=|right|frameless|link=https://www.physio-pedia.com/File:OD.jpg]][[Osteochondritis Dissecans of the Knee|Osteochondritis dissecans]] (OCD) is defined as an inflammatory pathology of bone and cartilage. This can result in localised necrosis and fragmentation of bone and cartilage.<ref>[[Osteochondritis Dissecans of the Elbow]]</ref> Cartilage and subchondral bone can break off and float in the joint. This irritates the synovium, which causes an effusion.


Autoimmune disease red flags:
'''<u>Osteochondritis Dissecans Treatment:</u>'''
* Manage conservatively for stable lesions<ref>Chau MM, Klimstra MA, Wise KL, Ellermann JM, Tóth F, Carlson CS, Nelson BJ, Tompkins MA. [https://journals.lww.com/jbjsjournal/Abstract/2021/06160/Osteochondritis_Dissecans__Current_Understanding.11.aspx Osteochondritis dissecans: current understanding of epidemiology, etiology, management, and outcomes.] JBJS. 2021 Jun 16;103(12):1132-51.</ref>
* Possible debridement / knee wash out
* Possible surgical resection (resect back to a stable margin)
* Review the osteochondral defects with an MRI<ref>Detterline AJ, Goldstein JL, Rue JP, Bach BR. [https://pubmed.ncbi.nlm.nih.gov/18500061/ Evaluation and treatment of osteochondritis dissecans lesions of the knee.] Journal of Knee Surgery. 2008;21(02):106-15. </ref> - check for stability of the margins of the osteochondral defect and if the location is a weight-bearing zone
* Monitor bone oedema around a defect - the oedema should decrease when serially monitored
* Physiotherapy advice: load management
** When there is a trochlear osteochondral defect in the patellofemoral joint, remember to avoid excessive deep loaded flexion
For more information, please see [[Osteochondritis Dissecans]] and [[Osteochondritis Dissecans of the Knee]].


Multiple joint involvement
==== Slipped Capital Femoral Epiphysis ====
 
[[File:SCFE.jpg|alt=|right|frameless|link=https://www.physio-pedia.com/File:SCFE.jpg]]Slipped capital femoral epiphysis is not common. However, it needs to be considered as a differential diagnosis<ref name=":2">Purcell M, Reeves R, Mayfield M. [https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0269745 Examining delays in diagnosis for slipped capital femoral epiphysis from a health disparities perspective.] Plos one. 2022 Jun 24;17(6):e0269745.</ref> as it is can refer pain to the anteromedial knee. A mild condition diagnosed early has a better outcome as the condition will progress until the epiphysis is fused.<ref name=":2" />
Joint was stiff on waking
 
Fatigue
 
Infective arthritis red flags:
 
Temperature
 
Recent Illness
 
Osteochondritis Dissecans Treatment:


Possible debridement/knee washed out
For more information, please see [[Slipped Capital Femoral Epiphysis]].
 
Review, ideally, the OCDs, the osteochondral defects, with MRI. And what they're looking for there is how stable are the margins of the osteochondral defect and where are they? Are they in a very weight-bearing zone or not? And with respect to the stability, the margins, I think about it a bit like a divot on a golf course. So, sometimes you might have a really clean bit of grass, the soil has been removed, and it's not all crumbling in. So, that's a stable situation. And then we might have a divot on a golf course where the grass and soil has been removed and the soil is just crumbling in, and that would be an unstable OCD and there
 
Possible surgical resection ly they might need to resect back to a stable margin.
 
Monitor bone oedema around these defects, which over time, serially scanned, you're looking for those to decrease. So, from a
 
physiotherapy point of view, we're looking at load management. Understanding, for example, in the patellofemoral joint if we've got a trochlear OCD, then we're not going to be wanting to do lots of deep loaded flexion, for example. So, message there without a doubt, do not sit on a child with an effused knee
 
Always refer a child with a knee effusion for further investigations to establish an underlying cause
[[File:OD.jpg|none|thumb]]
 
==== Slipped Capital Femoral Epiphysis ====
Okay, let's keep going with the teenagers. So, the next one is not common in terms of referring pain to the knee, but I have seen it, so I want to have it on my list and that is slipped epiphysis. So, now right up to the proximal femur, and we know that that area can refer to anteromedial knee. And the patient that I recall came to me with anteromedial knee pain, no hip pain but the position of the limb, the rotation of the limb, it was shortened, was all completely wrong. And I couldn't have immediately said it slipped epiphysis, but I knew that there was something going on at the hip and had an urgent review with one of my surgical colleagues. So, be on your guard for that.
[[File:SCFE.jpg|none|thumb]]


==== Others ====
==== Others ====
Less common but more serious:Systemic Auto-Immune Disease
Less common but more serious:
* Systemic auto-immune disease
* Slipped epiphysis
* [[Femoroacetabular Impingement|Femoroacetabular impingement (FAI)]]
* Leukaemia
* Metastatic [[neuroblastoma]]
* Primary bone tumour
* Red flags
** Night pain
** Weight loss
** Malaise


Slipped Epiphysis
== Conditions That Can Occur in the Adult Population ==
The following conditions should be considered in the differential diagnosis of adults presenting with patellofemoral pain symptoms.


FAI
=== Posterior Cruciate Ligament Rupture ===
[[File:PCL Rupture.jpg|alt=|right|frameless|400x400px|link=https://www.physio-pedia.com/File:PCL_Rupture.jpg]]A rupture of the posterior cruciate ligament (PCL) can be caused by a blow to the front of the knee.<ref name=":3">Perelli S, Masferrer-Pino Á, Morales-Ávalos R, Fernández DB, Ruiz AE, Gallego JT, Idiart R, Fabregat ÁA, Alcaraz10 NU. [https://fondoscience.com/sites/default/files/articles/pdf/reacae.28373.fs2101003-current-management-posterior-cruciate.pdf Current management of posterior cruciate ligament rupture. A narrative review.] Rev Esp Artrosc Cir Articul. 2021;28(3):180-91.</ref> For some patients, their only reported symptom is patellofemoral joint pain. It is, therefore, advisable to assess all ligaments to see if surgery is necessary.<ref name=":3" /> Physiotherapy for an injury to the PCL will often focus on quadriceps rehabilitation.


Leukaemia
For more information, please see this page: [[PCL Reconstruction]].


Metastatic Neuroblastoma
=== Synovial Plica ===
[[File:Synovial Plica.jpg|alt=|right|frameless|link=https://www.physio-pedia.com/File:Synovial_Plica.jpg]]A plica is a fold in the synovial membrane. They are common and are normally asymptomatic. A plica can often be palpated anteromedially, next to the superior half of the patella. Occasionally, they can get trapped in the patellofemoral joint, and become impinged or inflamed and sore.<ref name=":4">Casadei K, Kiel J. [https://www.ncbi.nlm.nih.gov/books/NBK535362/ Plica syndrome]. StatPearls [Internet]. 2021 Jul 25.</ref>


Primary Bone Tumour
'''<u>Diagnosis</u>:'''


Red Flags
* Inject with local anaesthetic for symptomatic relief. If this is successful, it strongly indicates an inflamed synovial plica.


Night pain
'''<u>Treatment</u>:'''


Weight loss
* Steroid injections to decrease inflammation
* Plica resection
* Rehabilitation<ref name=":4" />


Malaise
=== Patellar Tendinopathy ===
[[File:Patella Tendinopathy.jpg|alt=|right|frameless|350x350px|link=https://www.physio-pedia.com/File:Patella_Tendinopathy.jpg]]Tendinopathy is a failed healing response of the tendon, with haphazard proliferation of tenocytes, intracellular abnormalities in tenocytes, disruption of [[collagen]] fibres, and a subsequent increase in non-collagenous matrix.<ref>Maffulli N, Longo UG, Franceschi F, Rabitti C, Denaro V. [https://link.springer.com/article/10.1007/s11999-008-0261-0 Movin and Bonar scores assess the same characteristics of tendon histology.] Clinical orthopaedics and related research. 2008 Jul;466(7):1605-11.</ref><ref>Maffulli N, Longo UG, Maffulli GD, Rabitti C, Khanna A, Denaro V. [https://link.springer.com/article/10.1007/s00167-010-1193-2 Marked pathological changes proximal and distal to the site of rupture in acute Achilles tendon ruptures.] Knee Surgery, Sports Traumatology, Arthroscopy. 2011 Apr;19(4):680-7.</ref><ref>Alexander L, Shim J, Harrison I, Moss R, Greig L, Pavlova A, Parkinson E, Maclean C, Morrissey D, Swinton P, Brandie D. [https://rgu-repository.worktribe.com/output/1674382/exercise-therapy-for-tendinopathy-a-scoping-review-mapping-interventions-and-outcomes Exercise therapy for tendinopathy: a scoping review mapping interventions and outcomes.]</ref>  The term tendinopathy is a generic descriptor of the clinical conditions (both pain and pathological characteristics) associated with overuse in and around [[Tendon Anatomy|tendons]].<ref>Maffulli N. [https://www.sciencedirect.com/science/article/abs/pii/S0749806398700210 Overuse tendon conditions: time to change a confusing terminology.] Arthroscopy: The Journal of Arthroscopic & Related Surgery. 1998 Nov 1;14(8):840-3.</ref>


== PCL Rupture  ==
'''<u>Treatment:</u>'''
Can be caused by a blow to the front of the knee


can present with PFJ pain only
* Heavy resistance loading
 
* Eccentric<ref>Challoumas D, Pedret C, Biddle M, Ng NY, Kirwan P, Cooper B, Nicholas P, Wilson S, Clifford C, Millar NL. [https://bmjopensem.bmj.com/content/7/4/e001110.abstract Management of patellar tendinopathy: a systematic review and network meta-analysis of randomised studies.] BMJ open sport & exercise medicine. 2021 Nov 1;7(4):e001110.</ref> decline loading
Assess all ligaments to see if surgery is necessary
 
Quadriceps rehabilitation
[[File:PCL Rupture.jpg|none|thumb]]
 
== Synovial Plica ==
a plica is a fold in the synovial membrane
 
common
 
normally asymptomatic
 
Can be palpated anteromedially, perhaps next to the superior half of the patella, you can feel a little ridge and you can even sort of flick over them, palpate them. But the key thing is, is it painful? And is it their pain if you flick over it and it's painful? And also, occasionally, they can get trapped into the patellofemoral joint,  
 
Can become impinged or inflamed and sore.
 
Use of a local anaesthetic diagnostically , and if they're injected with local anaesthetic and their pain goes off, well, we've got our answer that the plica is relevant. We can then potentially bathe their plica in steroid, which can decrease the inflammation, the thickening enough, hopefully to break the cycle and then with good quality rehab that they're nice and strong and their patella is sitting well, hopefully they will see the back of it. If they have the local anaesthetic, maybe the
 
steroid, and the diagnosis is made and confirmed, but it comes back, then they might be one of the few candidates that needs the plica resected. And I certainly, fairly recently, had an ultramarathon runner who was performing at national level and the surgeon laughed with me and said, "Oh, you know, normally I wouldn't touch a plica and particularly in an elite athlete, but I really do think, actually, it might be relevant, and can you have a look?" And I agreed. And she had the surgery, and she was great. So, there are cases where it's relevant, but it is few and far between.
 
Rehabilitation
 
Plica resection if necessary
[[File:Synovial Plica.jpg|none|thumb]]
 
== Patella Tendonopathy ==
{| class="wikitable"
{| class="wikitable"
|+
|+
Treated with heavy resistance loading or eccentric decline loading[[File:Patella Tendinopathy.jpg|none|thumb]]
 
!
!
!Patella Tendinopathy
!Patellar Tendinopathy
!Patellofemoral Pain
!Patellofemoral Pain
|-
|-
|Aggravating Factors
|Aggravating Factors
|Being still
|Being still<ref name=":5">Rosen AB, Wellsandt E, Nicola M, Tao MA. [https://watermark.silverchair.com/10.4085_1062-6050-0049.21.pdf?token=AQECAHi208BE49Ooan9kkhW_Ercy7Dm3ZL_9Cf3qfKAc485ysgAAAvwwggL4BgkqhkiG9w0BBwagggLpMIIC5QIBADCCAt4GCSqGSIb3DQEHATAeBglghkgBZQMEAS4wEQQM5YViQASunIW7VgEhAgEQgIICr1LhRKQo5y9XATjyg0AJCRRCpV6XhW3BQj_x9kmRVgTG8Y4P5XPnww5uP2De-NzJz5PJxMbdJC_QLOc-yMiM11JwOfrjL7xWb5KmcvhnL8bBrElYGiEl4gLaUFupMCeDMi2NY1oRm6LDuQ5brwz-c6_hBb2uC3vFQPZZhvr_6ECKo86A2CYDkgMbANaV4-Wu2-EM78r4EeETNg16V4sJ72rVak9C2QHoIi84gYvznLtxE_fJJz7jsahWVi0gSWNA7QK46JzijB1TVlTaUhL07l2vhNnSTJMar0fcEqyJtNC1PXZ-xJ-TqGEcTPzDN03r5pUkkKLLxTIPapbN2h_gb5zBxsjOxwQlB6Mc5UlUh7o4sglt1IQRThQswro5WEFQFXgeGKeZ6MZRA4kU-V-mpeeAuwhxVBsR1hNg5yf8UAFAvSg3gFGPrStnRSpdFphzHuApRlhR-Eq2rPgEH8k5MkMvUQXfWq-eBhJwaagvujDpH_La4tFqfZR4C2xOBqLy1UkiTFaXpkKpvqkmivUgWe6Psw05r07ATRpXJlcVDK8RFYwlwZtAe1_sJfNOuZfpy0_XC7zhh61iocKzjmY-B4FgVsXSmWjE4hMTohghUXgAkuM2OZ_t7w15NE4Ib-dIYDzL35vhWWm35fWERXgq7gQH-W9HCMI-K6t2yJdC6bOoj4lK1bbKPoNSP7Sd5mU7DMQFOFUPT4Cmwo_LRO_nAPBZ4k9D0jiK3LwNYJzbkXjNPwoIIsmUOR9wRUQ7k5zytbYeAUeCV8WWc3MVLnJS1qW04GXBa8tV5m87abDRhuL3VX0HOPuUNCbLj6GM1q-KHcS9QbcOdh4YDaFhAOZKefkVl3OlX2-nyHHHMTsxmJE8WfV2-lDakNxmbklCJIj9C2UxXdbLRFTk1GInCinblg Current clinical concepts: clinical management of patellar tendinopathy]. Journal of Athletic Training. 2021 Oct 1.</ref>
Early morning
Early morning
|Being still if knee at end of range flexion
|Being still if knee at end of range flexion
|-
|-
|Description of Pain
|Description of Pain
|Pinpoint to proximal tendon
|Pinpoint to proximal tendon<ref name=":5" />
|Vague
|Vague
|-
|-
|Effect of Excercise
|Effect of Excercise
|Pain decreases as tendon warms up
|Pain decreases as tendon warms up<ref name=":5" />
|Worsens with repetitive load
|Worsens with repetitive load
|}
|}
For more information, please see [[Patellar Tendinopathy]].


== FAI ==
=== Femoroacetabular Impingement ===
Has been known to refer pain to the anteromedial knee
[[File:Femoral AI.jpg|alt=|right|frameless|link=https://www.physio-pedia.com/File:Femoral_AI.jpg]]While femeroacetabular impingement (FAI) is not common, it can refer pain to the anteromedial knee. This referred pain could be confused with patellofemoral pain. One of the most commonly recognised clinical signs for FAI is pain with hip flexion, adduction, and internal rotation,<ref>Hale RF, Melugin HP, Zhou J, LaPrade MD, Bernard C, Leland D, Levy BA, Krych AJ. [https://journals.sagepub.com/doi/full/10.1177/0363546520970914 Incidence of femoroacetabular impingement and surgical management trends over time.] The American journal of sports medicine. 2021 Jan;49(1):35-41.</ref> so it can be useful to perform the [[Hip Quadrant Test|Quadrant Test]]. In relation to patellofemoral pain, you will be looking to see if the patient's ''knee'' pain is reproduced on testing. 


looking at their pain response, particularly with the quadrant - flexion, adduction, internal rotation - those kinds of movements. Does it reproduce their knee pain?
For more information, please see [[Femoroacetabular Impingement]].
[[File:Femoral AI.jpg|none|thumb]]


== Assessment Tools ==
== Assessment Tools ==
Load Assessment Table for Growth Tracking - Track volume of exercise in a week
When encouraging an individual to modify their activity levels, it can be helpful to print out / provide a table for them to accurately track their volume of exercise in a week (see figure below). Be sure to encourage your client to fill out the form accurately as this will ensure you can offer the most relevant advice. It is also advisable to correctly record the length of time spent on each activity and the intensity of the activity.[[File:Load Assessment Table.jpg|alt=|center|550x550px|link=https://www.physio-pedia.com/File:Load_Assessment_Table.jpg|thumb|Load Assessment Table for Growth Tracking.]]
[[File:Load Assessment Table.jpg|none|thumb]]
 
== References ==
== References ==
[[Category:Course Pages]]
[[Category:Course Pages]]
[[Category:Physioplus Content]]
[[Category:Plus Content]]
[[Category:Knee]]
[[Category:Knee]]
[[Category:Joints]]
[[Category:Joints]]
[[Category:Knee - Conditions]]
[[Category:Knee - Conditions]]

Latest revision as of 02:24, 2 September 2022

Original Editor - Carin Hunter based on the course by Claire Robertson
Top Contributors - Carin Hunter, Jess Bell and Kim Jackson

Introduction[edit | edit source]

Screening for red flags is an important part of the assessment process, but it is often overlooked in patients with knee pain. It is important to have a good understanding of red flags for patient safety and to ensure appropriate and timely referrals are made when necessary. If there has been any trauma to the knee, it is necessary to make sure that all relevant investigations have been carried out. For more information on red flags, please see this page: An Introduction to Red Flags in Serious Pathology.

Non-Traumatic Masquerading Conditions[edit | edit source]

There are certain conditions that can have similar pain patterns as patellofemoral pain, and these should be considered in a differential diagnosis. The following non-traumatic conditions occur in the adolescent population (i.e. pre-teen and teen).[1]

Osgood-Schlatter Disease (OSD)[edit | edit source]

Signs and Symptoms:

  • This condition is common in adolescents aged 11-15 years old[2]
  • It is prevalent in children participating in quadriceps dominant sports, i.e. running, kicking and jumping[2]
  • Patients present with an obvious bump at the tibial tubercle[3]
  • Pain is specific to the tibial tubercle
  • Inflammation and elevation of the growth plates are present in the tibial tuberosity
  • An MRI to show the level of inflammation can be used as confirmation, but this will not change the treatment plan
  • Pain can progress to a level that prevents any participation in sport if left untreated

Treatment:

  • Education
  • Activity modification:[1][2][3]
    • Try to eliminate the patient's least favourite sport, or
    • Change their playing position to a less active position to decrease load
  • NSAIDS (non-steroidal anti-inflammatories)
  • Ice massage - this will provide symptomatic relief
  • Address overload:
    • Extrinsic factors
      • Load management of sport[2]
      • Footwear[4]
      • Landing technique[5]
    • Intrinsic factors
      • Muscle length[2]
      • Muscle strength[2]

For more information, please see Osgood-Schlatter Disease.

Sinding Larsen Johansson Syndrome[edit | edit source]

Sinding Larsen Johansson Syndrome (SLJS) is a juvenile osteochondrosis and traction epiphysitis. It affects the extensor mechanism of the knee, which disturbs the patella tendon attachment to the inferior pole of the patella. There is tenderness of the inferior pole of the patella. This is usually accompanied by x-ray evidence of splintering of that pole. Most patients with SLJS also have calcification at the inferior pole of the patella.[6]

The syndrome usually appears in adolescence, during a growth spurt. It is associated with localised pain which is worsened by exercise. Usually localised tenderness and soft tissue swelling are observed. The surrounding muscles may also be tight, particularly the quadriceps, hamstrings and gastrocnemius. This tightness usually results in inflexibility at the knee joint, which alters the stress applied through the patellofemoral joint.[7]

Signs and Symptoms:

  • Inflammation at the growth plate of the distal pole of the patella[8]
  • This condition is most likely to be seen during growth spurts
  • Primary treatment focuses on tracking growth for activity modification during a growth spurt[9]
  • Pain can progress to a level that prevents any participation in sport

Treatment:

  • Education
  • Activity modification:[1]
    • Try to eliminate the patient's least favourite sport, or
    • Change their playing position to a less active position to decrease load
  • NSAIDS (non-steroidal anti-inflammatories)
  • Ice massage - to provide symptomatic relief
  • Address overload:
    • Extrinsic factors
      • Load management of sport
      • Footwear
      • Landing technique
    • Intrinsic factors
      • Muscle length
      • Muscle strength

For more information, please see Sinding-Larsen-Johansson Syndrome.

Knee Effusion[edit | edit source]

There are no instances where a child should have a knee effusion without a cause. Thus, any effusion in the absence of trauma should always be investigated. A knee effusion can often lead to patellofemoral pain.

Possible Effusion Causes:

Autoimmune Disease Red Flags:

  • Multiple joint involvement
  • Joint is stiff on waking
  • Fatigue

Infective Arthritis Red Flags:

  • Temperature
  • Recent illness

Osteochondritis Dissecans/Osteochondral Defect[edit | edit source]

Osteochondritis dissecans (OCD) is defined as an inflammatory pathology of bone and cartilage. This can result in localised necrosis and fragmentation of bone and cartilage.[10] Cartilage and subchondral bone can break off and float in the joint. This irritates the synovium, which causes an effusion.

Osteochondritis Dissecans Treatment:

  • Manage conservatively for stable lesions[11]
  • Possible debridement / knee wash out
  • Possible surgical resection (resect back to a stable margin)
  • Review the osteochondral defects with an MRI[12] - check for stability of the margins of the osteochondral defect and if the location is a weight-bearing zone
  • Monitor bone oedema around a defect - the oedema should decrease when serially monitored
  • Physiotherapy advice: load management
    • When there is a trochlear osteochondral defect in the patellofemoral joint, remember to avoid excessive deep loaded flexion

For more information, please see Osteochondritis Dissecans and Osteochondritis Dissecans of the Knee.

Slipped Capital Femoral Epiphysis[edit | edit source]

Slipped capital femoral epiphysis is not common. However, it needs to be considered as a differential diagnosis[13] as it is can refer pain to the anteromedial knee. A mild condition diagnosed early has a better outcome as the condition will progress until the epiphysis is fused.[13]

For more information, please see Slipped Capital Femoral Epiphysis.

Others[edit | edit source]

Less common but more serious:

Conditions That Can Occur in the Adult Population[edit | edit source]

The following conditions should be considered in the differential diagnosis of adults presenting with patellofemoral pain symptoms.

Posterior Cruciate Ligament Rupture[edit | edit source]

A rupture of the posterior cruciate ligament (PCL) can be caused by a blow to the front of the knee.[14] For some patients, their only reported symptom is patellofemoral joint pain. It is, therefore, advisable to assess all ligaments to see if surgery is necessary.[14] Physiotherapy for an injury to the PCL will often focus on quadriceps rehabilitation.

For more information, please see this page: PCL Reconstruction.

Synovial Plica[edit | edit source]

A plica is a fold in the synovial membrane. They are common and are normally asymptomatic. A plica can often be palpated anteromedially, next to the superior half of the patella. Occasionally, they can get trapped in the patellofemoral joint, and become impinged or inflamed and sore.[15]

Diagnosis:

  • Inject with local anaesthetic for symptomatic relief. If this is successful, it strongly indicates an inflamed synovial plica.

Treatment:

  • Steroid injections to decrease inflammation
  • Plica resection
  • Rehabilitation[15]

Patellar Tendinopathy[edit | edit source]

Tendinopathy is a failed healing response of the tendon, with haphazard proliferation of tenocytes, intracellular abnormalities in tenocytes, disruption of collagen fibres, and a subsequent increase in non-collagenous matrix.[16][17][18]  The term tendinopathy is a generic descriptor of the clinical conditions (both pain and pathological characteristics) associated with overuse in and around tendons.[19]

Treatment:

  • Heavy resistance loading
  • Eccentric[20] decline loading
Patellar Tendinopathy Patellofemoral Pain
Aggravating Factors Being still[21]

Early morning

Being still if knee at end of range flexion
Description of Pain Pinpoint to proximal tendon[21] Vague
Effect of Excercise Pain decreases as tendon warms up[21] Worsens with repetitive load

For more information, please see Patellar Tendinopathy.

Femoroacetabular Impingement[edit | edit source]

While femeroacetabular impingement (FAI) is not common, it can refer pain to the anteromedial knee. This referred pain could be confused with patellofemoral pain. One of the most commonly recognised clinical signs for FAI is pain with hip flexion, adduction, and internal rotation,[22] so it can be useful to perform the Quadrant Test. In relation to patellofemoral pain, you will be looking to see if the patient's knee pain is reproduced on testing.

For more information, please see Femoroacetabular Impingement.

Assessment Tools[edit | edit source]

When encouraging an individual to modify their activity levels, it can be helpful to print out / provide a table for them to accurately track their volume of exercise in a week (see figure below). Be sure to encourage your client to fill out the form accurately as this will ensure you can offer the most relevant advice. It is also advisable to correctly record the length of time spent on each activity and the intensity of the activity.

Load Assessment Table for Growth Tracking.

References[edit | edit source]

  1. ↑ 1.0 1.1 1.2 Robertson C. Understanding Red Flags in Patellofemoral Pain Course. Plus. 2022.
  2. ↑ 2.0 2.1 2.2 2.3 2.4 2.5 Neuhaus C, Appenzeller-Herzog C, Faude O. A systematic review on conservative treatment options for OSGOOD-Schlatter disease. Physical Therapy in Sport. 2021 May 1;49:178-87.
  3. ↑ 3.0 3.1 Corbi F, Matas S, Álvarez-Herms J, Sitko S, Baiget E, Reverter-Masia J, López-Laval I. Osgood-Schlatter Disease: Appearance, Diagnosis and Treatment: A Narrative Review. InHealthcare 2022 May 30 (Vol. 10, No. 6, p. 1011). MDPI.
  4. ↑ O’Sullivan IC, Crossley KM, Kamper SJ, van Middelkoop M, Vicenzino B, Franettovich Smith MM, Menz HB, Smith AJ, Tucker K, O’Leary KT, Costa N. HAPPi Kneecaps! A double-blind, randomised, parallel group superiority trial investigating the effects of sHoe inserts for adolescents with patellofemoral PaIn: phase II feasibility study. Journal of Foot and Ankle Research. 2021 Dec;14(1):1-1.
  5. ↑ Gaulrapp H, Nührenbörger C. The Osgood-Schlatter disease: A large clinical series with evaluation of risk factors, natural course, and outcomes. International Orthopaedics. 2022 Feb;46(2):197-204.
  6. ↑ Medlar RC, Lyne ED. Sinding-Larsen-Johansson disease. Its etiology and natural history. The Journal of Bone and Joint surgery. American Volume. 1978 Dec 1;60(8):1113-6.
  7. ↑ Houghton, K. M., ‘Review for the generalist: evaluation of anterior knee pain’, Paediatric Rheumatology, (2007), vol. 5, p. 4-10.
  8. ↑ Fischer AN. Sinding-Larsen-Johansson Syndrome. InCommon Pediatric Knee Injuries 2021 (pp. 63-68). Springer, Cham.
  9. ↑ McCormick KL, Tedesco LJ, Bixby EC, Swindell HW, Popkin CA, Redler LH. Sinding-Larsen-Johansson Disease: Analysis of the Associated Factors in the Largest Cohort to Date. Orthopaedic Journal of Sports Medicine. 2022 May 31;10(5_suppl2):2325967121S00503.
  10. ↑ Osteochondritis Dissecans of the Elbow
  11. ↑ Chau MM, Klimstra MA, Wise KL, Ellermann JM, Tóth F, Carlson CS, Nelson BJ, Tompkins MA. Osteochondritis dissecans: current understanding of epidemiology, etiology, management, and outcomes. JBJS. 2021 Jun 16;103(12):1132-51.
  12. ↑ Detterline AJ, Goldstein JL, Rue JP, Bach BR. Evaluation and treatment of osteochondritis dissecans lesions of the knee. Journal of Knee Surgery. 2008;21(02):106-15.
  13. ↑ 13.0 13.1 Purcell M, Reeves R, Mayfield M. Examining delays in diagnosis for slipped capital femoral epiphysis from a health disparities perspective. Plos one. 2022 Jun 24;17(6):e0269745.
  14. ↑ 14.0 14.1 Perelli S, Masferrer-Pino Á, Morales-Ávalos R, Fernández DB, Ruiz AE, Gallego JT, Idiart R, Fabregat ÁA, Alcaraz10 NU. Current management of posterior cruciate ligament rupture. A narrative review. Rev Esp Artrosc Cir Articul. 2021;28(3):180-91.
  15. ↑ 15.0 15.1 Casadei K, Kiel J. Plica syndrome. StatPearls [Internet]. 2021 Jul 25.
  16. ↑ Maffulli N, Longo UG, Franceschi F, Rabitti C, Denaro V. Movin and Bonar scores assess the same characteristics of tendon histology. Clinical orthopaedics and related research. 2008 Jul;466(7):1605-11.
  17. ↑ Maffulli N, Longo UG, Maffulli GD, Rabitti C, Khanna A, Denaro V. Marked pathological changes proximal and distal to the site of rupture in acute Achilles tendon ruptures. Knee Surgery, Sports Traumatology, Arthroscopy. 2011 Apr;19(4):680-7.
  18. ↑ Alexander L, Shim J, Harrison I, Moss R, Greig L, Pavlova A, Parkinson E, Maclean C, Morrissey D, Swinton P, Brandie D. Exercise therapy for tendinopathy: a scoping review mapping interventions and outcomes.
  19. ↑ Maffulli N. Overuse tendon conditions: time to change a confusing terminology. Arthroscopy: The Journal of Arthroscopic & Related Surgery. 1998 Nov 1;14(8):840-3.
  20. ↑ Challoumas D, Pedret C, Biddle M, Ng NY, Kirwan P, Cooper B, Nicholas P, Wilson S, Clifford C, Millar NL. Management of patellar tendinopathy: a systematic review and network meta-analysis of randomised studies. BMJ open sport & exercise medicine. 2021 Nov 1;7(4):e001110.
  21. ↑ 21.0 21.1 21.2 Rosen AB, Wellsandt E, Nicola M, Tao MA. Current clinical concepts: clinical management of patellar tendinopathy. Journal of Athletic Training. 2021 Oct 1.
  22. ↑ Hale RF, Melugin HP, Zhou J, LaPrade MD, Bernard C, Leland D, Levy BA, Krych AJ. Incidence of femoroacetabular impingement and surgical management trends over time. The American journal of sports medicine. 2021 Jan;49(1):35-41.
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