Pain in the Front of the Knee Causes and Treatments

Overview : Pain in the front of the knee is a very common complaint at all ages,especially in women. Evidence suggests the greater pelvic width and leg angulation ,differences in muscle function,and unique gender related issues such as estrogen in women may all play a role.However,anterior knee pain is not a diagnosis in itself anymore than all bellyache is appendicits. Most anterior knee pain is related to the patellofemoral joint ,it�s musculature,and ligament support. So called patellofemoral pain has become the most common knee symptom in the average orthopedic outpatient clinic ;depending on the exact cause , it is 2-7 times more prevalent in women. It is estimated that up to 10% of all aging knee pain is do to isolated patellofemoral arthritis. Because the exact source of pain can be difficult to isolate and is often multifactorial , patellofemoral pain syndrome requires careful diagnosis and proper management to avoid unnecessary,ineffective or potentially harmful treatment.

Key Points :

While the pain of inflammation or muscle soreness may be temporary,pain do to structural damage (eg. arthritis) can be made worse by ignoring symptoms of pain,swelling,catching,of stiffness.

An accurate,early diagnosis is critical to avoid irreparable damage from improper activity or training.

Non-operative solutions only work if accumulative joint damage is not too great.

Self diagnosis is rarely successful if pain is severe enough to cause a limp , change activity or work behavior.

Knee pain with climbing stairs and squatting are most often do to kneecap problems.

Common Causes of Patellofemoral Pain
Pain in the front of the knee can come from many sources including�weak or overused muscles,the kneecap (patella), inflammations and tendon injury ( bursitis,tendinits),loose ligaments with instability of the kneecap ,articular cartilage damage (chondromalacia patella), swelling due to fluid build up in the knee joint,and overload of the extensor mechanism of the knee with or without malalignment of the patella .

Basic Sources of Patellofemoral Pain :

Muscular : excessive muscle tightness (inflexibility), fatigue or tearing(strain) of quadriceps or hamstring muscles , muscular strength imbalances, overuse/disuse

Structuraldamage:chondromalacia(chondro=cartilage;malacia=softening) patella(kneecap), patella arthritis,stress fracture, direct traumatic injury

Congenital dysplasia : patella alta(high patella), facet or trochlear dysplasia

Malalignment : tilted patella, intoeing rotationof the legs(persistent femoral anteversion) knock knee (excessive valgus deformity)

Instability of the patella : maltracking with subluxation(partial) or complete dislocation of the knee cap ;damaged or stretched ligament support

Inflammatory : bursitis,tendinitis

Overuse of muscles : Bending overuse of the knee leads to high repetitive pressures between the kneecap and the femoral groove. The resulting overload, muscle fatigue and imbalances are the most common source of soreness and weakness around the knee. Patients that are too aggressive in starting a fitness program ( see discussion of overuse syndrome) ,young mothers or grandmothers who repeatedly squat to pick up little children, workers that must climb, runners and athletes that over train are all examples of people vulnerable to this problem. Younger patients need to be analyzed for inflexibility acquired from rapid teenage growth or poor conditioning. Inactivity can be as bad as too much. Just sitting with your knee bent can be painful when you get up (movie house sign) . Beginning a health fitness program too quickly is a common error;look out for these quick fix� solutions that are often marketed to midlife women . Most provide poor or no advice as the individual safety of their workouts. The client finds out too late that the knee can not take these abrupt demands.

Treatment : A quality physical therapy program prescribed by your orthopedic surgeon after proper evaluation is the best place to start. At our Center we teach improved exercise or work behavior combined with patellofemoral specific rehabilitation . Braces and orthotics may be helpful. The good news is that these conditions can respond well and do not need operative treatment. Beware of exploratory arthroscopic surgery or the suggestion that a lateral release may be helpful. Such approaches often lead to worse symptoms if not carefully planned.

Structural damage : Structural damage to the patella or the groove in which in travels(femoral trochlear groove )can occur from direct injury,eg.car accident-so called dash board knee. Such blows can kill the cells in the surface cartlilage layer and lead to softening or complete loss of tissue covering the bones .Either the kneecap or femoral surface or both can be affected. Noisy knees (crepitation) with crunchy sounds during knee bending,(eg stair climbing,squatting,working out with weights) are one of the first signs of articular damage(chondromalacia and degenerative arthritis).This stage is often missleadingly painless. Pain and swelling develop with time and further overactivity . Ignoring these signs is a mistake. Prevention of worse trouble and surgery depends upon early detection and proper adjustments in activity.Overweight is a big culprit in setting off these symptoms.This is often the case in women after pregnancy or menopause. Accumulative overuse(improper fitness or athletic training) combined with aging can lead to advanced arthritis(wear out of the joint surface) at a young age ,less than 40.

Treatment : When caught early, anti-arthritis measures such as weight loss,quad exercises,learning smarter activity habits like avoiding knee bends, switching to safer exercise(non impacting),combined with cautious use of medication or injection can help. If swelling and limp are severe despite these measures,then arthroscopic surgery may help. For complicated cases,patellofemoral realignment and conservative resurfacing either biological or prosthetic may be necessary.

How arthroscopy can help your problem :

1. Provide a more accurate diagnosis

2. Relieve some of the pain of inflammation by washing out the knee

3. Quiet down the aggravation of rough joint surfaces and reduce mechanical irritations

4. Combine with other surgical measures to realign or stabilize the kneecap

5. Remove a painful plica

Congenital dysplasia : Some people are born with miss shaped kneecaps or the groove in which the patella must travel is too shallow.This can lead to abnormal wear or instability. Such conditions may present in youth or not be noticed until adulthood when aging or excessive activity aggravates the knee.

Treatment : Exercises and avoidance of aggravating exercise can help,but if symptoms are disabiling,operative treatments are used to correct the forces on the kneecap. Such operations require the surgeon to acquire special experience and training .

Malalignment /Patella Instabiity : Malalignments can involve the whole leg or just the kneecap joint(patellofemoral) portion of the knee. Persistent intoeing from birth is often do to internal rotation of the femur bone and contributes to a mal-adaptation growth pattern known as the malicious mal-alignment syndrome�. This is characteristically seen in young girls and persists into adult life. It is an inherited characteristic between mother and daughter. The resulting knock knee shape to the leg puts extra stress on the kneecap and favors dislocation. At the least, patients complain of aching pain with exercise or sports. Other times,the kneecap is tilted or out of position. This can lead to pain from excessive lateral(outer side of knee) patella pressure. In advanced cases the patella begins to wear and deform causing mechanical symptoms of sharp pain or catching. Sometimes, the knee just gives way and falls occur. Such instability can be a pseudo phenomenum of pain induced muscle weakness in the leg; other times,the kneecap actually jumps out of place,true patellofemoral instability. Recurrent patella dislocation either partial or complete is do to loose ligaments,patellofemoral dyplasia ,or both.

Treatment : Most overuse/overload patellofemoral pain responds initially to nonoperative treatment. In younger patients,treatment always begins with methods such as icing,arch supports,physical therapy,patella support braces,and moderate short term anti-inflammatory medication. A taping and rehabilitative program (McConnell) should be tried. True patella dislocations can be managed nonoperatively,with arthroscopic surgery,or with more complicated ligament and/or extensor realignment surgery. If arthritis or severe chondromalacia develops and other efforts fail,then patella replacement can be very helpful in the older patient or the younger patient when all else has been tried.

Inflammation : Patella tendinitis results from excessive overload or overuse of the extensor mechanism of the knee. Known as jumper�s knee� , this injury occurs not only with the strain of jumping,but also during landing after a jump, excessive weight lifting, or kicking. The injury is a true tearing and degeneration of the tendon at the microscopic level with failure to heal (tendinosis). .Basketball,soccer,Tai-Bo,step aerobics, volleyball- all can produce this injury. Ignoring pain may lead to sudden rupture of the patella tendon and emergency surgical repair.

Treatment : Proper diagnosis followed by an eccentric tendon therapy program,bracing,and modified activity. In difficult cases our Center has pioneered leading approaches to stimulating the healing of injured tendon.Percutaneous methods in the office as well as outpatient arthroscopic and surgical tenotomy are very successful.

Prepatella bursitis : inflammation of the small lubricating sac under the skin in front of the knee cap. Normally this sac is flat with only a film of fluid to allow the skin over the patella to slide and be protected when kneeling. Excessive kneeling (eg. wrestling,scrubbing floors,laying carpet) or direct trauma (blunt force,eg. car accident or fall) cause increased fluid or bleeding in this sac resulting in a bump (water on the knee�),pain and redness.Infection can follow.

Treatment : Anti-inflammatory medication,removal of fluid and steroid injection . In persistant cases,the sac may to be removed with minor surgery.

Additional sources of pain :

Synovial plica : A plica is a normal fold of tissue within the knee that can cause patellofemoral pain symptoms if aggravated by injury of overuse.It is diagnosed by a distinct presence of tenderness along the inside of the kneecap.There is often a popping or catching sensation on bending the knee.

Treatment : Physical therapy,local icing,injection and relative rest most often help; arthroscopic excision of this functionless structure can be a practical and simple remedy for persistant cases.

Click this link for further discussion and illustration of kneecap anatomy:

www.kneepaininfo.com or www.JointHealing.com