Treatment For Anterior Knee Pain

Patella Femoral Solutions

Patella Femoral Solutions is a complete program that will walk you step by step through 21 exercises proven to eliminate knee pain caused by patella femoral syndrome. It contains the best exercises to treat patella femoral syndrome. Each exercise has been tested and proven on hundreds of patients just like you. Patella Femoral Solutions is divided into 4 levels, with each level building upon the previous as your body gets stronger. These are the same exercises I use with my own patients and I know they work. The entire program requires very little equipment, so you don't have to make any huge investments or gym memberships. That also means you can do it in the comfort of your own home, saving time and gas driving to a rehabilitation clinic or gym. Best of all, patella femoral solutions will give you back your life and the freedom to do the things you love. No more sitting on the sidelines because it hurts to run. No more waking up in the middle of the night from aching knees. Continue reading...

Patella Femoral Solutions Summary


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Patellofemoral Syndrome

Anterior knee pain has been variously termed patellofemo-ral syndrome and chondromalacia patellae. When treating anterior knee pain, the physician should identify the specific pathology to initiate targeted treatment. Chondromala-cia patellae, or degenerative changes on the undersurface of the patella, is more common in young females. Pain complaints related to chondromalacia are exacerbated by sitting for an extended period with a flexed knee, doing deep squats, or going up and down stairs. Each of these activities increases the posteriorly directly forces of the patella, directing increased pressure onto the chondral surfaces. Treatment of these early arthritic changes is typically rehabilitation. Surgical intervention, such as cartilage scraping and debridement, has not been shown to provide long-term relief or benefit. In rare patients who have associated tight lateral retinacular structures and patellar tilt, surgical release of the lateral retinaculum can provide benefit....

Patellofemoral pain syndrome PFPSanterior knee pain

The diagnosis of PFPS is made if the patient has three of the symptoms listed in Table 6.2.7. The diagnosis is clinical a radiograph, CT scan or MRI will not give further information. The diagnosis of chondromala-cia during an arthroscopic procedure is inconclusive. Many patients without any symptoms from the patellofemoral joint may have chondromalacia on their patella and patients with major patellofemoral pain may have normal cartilage under arthroscopic examination. Table 6.2.7 Overview of typical history of patients with patellofemoral (PF) pain syndrome. Table 6.2.7 Overview of typical history of patients with patellofemoral (PF) pain syndrome. The basic rehabilitation principles for the patellofemoral joint are to restore the normal balance between the quadriceps and hamstring muscle groups. This must be done in balance with how the joint responds to a particular exercise program. One of the first basic principles in addressing rehabilitation for the quadriceps mechanism is to...

Patellofemoral patients

The application of this process has been described previously with a more specific listing of diagnostic classifications.6 The categorization into four rehabilitation patterns is somewhat arbitrary and designed to illustrate the special concepts for patellofemoral patients. However, Table 63-4 (compression rehabilitation concepts) is quite reflective of the approach to patients with arthritis or articular injury. Table 63-5 presents approaches to these patients in a nonoperative situation.

The anatomy of the patellofemoral joint

The patellofemoral joint is difficult to examine because it functions as a dynamic joint and static loading thus provides limited information. However, a thorough knowledge of the anatomy and the different dynamic interactions that occurs in this joint, is necessary to understand its complexity. The patellofemoral joint has a rather unique anatomy because it relies on a combination of both static and dynamic stabilizers to have normal function. Imbalances in any of these can lead to patellofemoral dysfunction and pain. This can include the lack of dynamic stability due to muscle weakness or hamstring tightness or a lack of static stabilizers due to injury or to intrinsic anatomic bony abnormalities. It is important to understand the anatomy of both the dynamic and the static portions of the patellofemoral joint in order to understand both its function and how to treat its dysfunction. Dynamic stability of the patellofemoral joint is provided by the quadriceps muscles consisting of the...

Anterior Knee Pain

Fig. 92 Area affected by anterior knee pain Fig. 92 Area affected by anterior knee pain SYMPTOMS Gradual onset of diffuse or localised exercise-induced pain around the anterior part of the knee. Prolonged sitting or squatting often trigger the symptoms (positive 'movie sign' - so named because you are in the same position for a long period when watching a movie at the cinema) as can walking down stairs. AETIOLOGY Anterior knee pain is not a diagnosis but a symptom that can be caused by a number of underlying pathologies. The correct diagnosis must be made before treatment can be successful. This condition often occurs as a result of sudden changes in training habits, such as increase in intensity or amount of impact. PROGNOSIS Because many cases never reach an absolute diagnosis and correct treatment, anterior knee pain ends the career of many young athletes.

Physical activity and osteoarthritis

Found a prevalence of tibiofemoral knee OA of 29 in soccer players, and patellofemoral OA in 31 of weight-lifters. No premature knee OA in runners or shooters was found in that study 43 . Female soccer is a more recent sport and long-term follow-up studies are thus lacking. In a Swedish study 66 retired female soccer players with a mean age of 43 years were radiographically examined 49 . The exposure to soccer was on average 13 years. The prevalence of hip OA was comparable to age- and gender-matched controls. In contrast, knee OA was present in 17 of the female players, compared to 2 of the age-matched male soccer ex-players and 0 of the age-matched female controls. The females were recruited from all levels of competitive soccer and no differences according to level of soccer playing could be detected, which contrasts with the findings among male explayers. Spector et al. 50 studied the risk of knee OA defined as the presence of osteophytes in female ex-athletes and similarly...

Extensor Mechanism Problems

The extensor mechanism comprises the quadriceps muscle, quadriceps tendon, patella, and patellar tendon. Differential diagnosis of problems in the extensor mechanism is broad, including muscle or tendon rupture, patellar fracture, patellar tendinopathy, patellofemoral syndrome, patellar instability, Osgood-Schlatter's disease, and symptomatic medial plica. Examination of patients with anterior knee pain or extensor mechanism problems should always include a careful evaluation of the lumbar spine and hip to rule out referred pain, as well as assessment of the antagonist hamstring muscles posteriorly. Hamstring tightness can exacerbate problems of tendinosis, patellofemoral syndrome, and instability.

Surgical Complications And Outcomes

The most common intraoperative complications concern neu-rovascular injury, particularly involving the popliteal artery. Techniques to reduce this are discussed in the preceding section and are especially important during procedures using a transtibial approach. Hematoma formation and drainage from a posterior arthrotomy may occur as a result of gravity drainage or bleeding from inferior geniculate vessels. Because of this, some authors recommend routine ligation of the inferior medial genic-ulate vessels.16 Postoperatively, residual laxity, loss of motion or arthrofibrosis, infection, painful hardware, and anterior knee pain are the most common complications. Reconstructed PCL knees may be slow to regain full flexion this may be worsened by poor tunnel placement.6 As importantly, patient age, severity of trauma, and ability to actively rehabilitate are important factors often beyond the surgeon's control. It is important to note, however, that PCL reconstruction may not consistently...

Communication with the surgeon and a consistent message to the patient are essential

It is important to recognize that patellofemoral conditions are multifactorial and the assessment provides the information that allows the proper grouping of the patient into a treatment or rehabilitation protocol. Four patient groups are outlined in Figure 63-3 as a rehabilitation classification of patellofemoral patients. This process is built on assessment (allowing classification) and then the application of a specific rehabilitation protocol. The four areas are ligamentous instability, tension, friction, and compression with specific rehabilitation pearls to assist with each classification. It is important that clinicians recognize that their level of successful outcomes should be greater than 80 generally in patellofemoral patients, but not necessarily within each individual class. The factors that we control include range of motion (ROM) of contact (patellofemoral and tibiofemoral), length of time (and) level of pressure applied to the surface, activation type,

Infrapatellar Tendonitis

Patients complain of an insidious onset of anterior knee pain usually localized to the inferior pole of the patella. Often the pain is described as aching and made worse with activity. Some patients may report a reduction in pain during the course of activity. Severe cases usually involve pain at rest. Initial treatment involves RICE, NSAIDs, and the use of analgesics for pain control. Patients with mild to moderate disability are treated with activity modification and physical therapy. The goals of physical therapy are to restore pain-free ROM, strength, and flexibility. Some patients benefit from functional bracing. The most widely used brace is a patellofemoral brace with a patellar cutout and lateral stabilizer.

Functional instability

Inferior Humeral Head Osteophyte

The investigations into the relationship between mechanical and functional aspects of ankle taping are paralleled over the years by those on patellar taping. It is well known that McConnell (1986) originally described patellar taping as part of an overall treatment programme for patellofemoral pain syndrome (PFPS) and theorized that this technique could alter patellar position, enhance contraction of the vastus medialis oblique (VMO) muscle, and hence decrease pain. It is becoming clear from recent literature reviews on this subject (Callaghan 1997, Crossley et al 2000) that studies thus far on patients with PFPS have been inconclusive regarding patellar taping enhancement of VMO contractions and taping realignment of patellar position. Nevertheless, there are several studies assessing taping's effect on chronic patellofemoral pain, summarized in a systematic review and meta-analysis (Warden et al 2007). Combined analysis of 13 eligible trials showed that medially directed taping...

Bilateral Stance On Unstable Surface

Single Leg Stance Foam

Witvrouw et al42 prospectively studied the risk factors for the development of anterior knee pain in the athletic population over a 2-year period. A significant difference was noted in the flexibility of the quadriceps and gastrocnemius muscles between the group of subjects who developed patellofemoral pain and the control group, suggesting that athletes exhibiting tightness of specific muscles may be at risk of the development of patellofemoral disorders. 33. Witvrouw E, Lysens R, Bellemans J, et al Open versus closed kinetic chain exercises for patellofemoral pain. Am J Sports Med 2000 28 687-694. 42. Witvrouw EE, Lysens R, Bellemans J, et al Intrinsic risk factors for the development of anterior knee pain in an athletic population. Am J Sports Med 2000 28 480-489.

Knee pain in adolescents

Knee pain in adolescents has many etiologies and the clinician must also rule out rare entities (e.g. tumor, referred pain) to establish a thorough diagnosis. Although meniscal injuries are less common in children than in adults, several recent reports indicate an increasing incidence of meniscal lesions in children and adolescents, especially those in competitive sports. De Inocencio i0i investigated the distribution of mus-culoskeletal pain in children. The knee was the most affected joint (33 ), followed by other joints (e.g. ankle, wrist, elbow, in 28 ), soft tissue pain (i8 ), heel pain (8 ), hip pain (6 ) and back pain (6 ). Symptoms were caused by trauma in 30 overuse syndromes in 28 (e.g. chondromalacia patellae, mechanical plantar fasciitis, overuse muscle pain) and normal skeletal growth variants (e.g. Osgood-Schlat-ter syndrome, hypermobility, Sever's disease) in i8 of patients. Sources of chronic pain about the knee may include tendinitis, apophysitis, patellofemoral...

Patellar Instability Or Maltracking

Lc1 Pelvic Ring Fracture Ray

Angles can help measure the level of mal-tracking. MRI and arthroscopy may be important for evaluating alternative diagnoses. There is a high risk that cartilage on the kneecap as well as on the femur condyle will have been damaged if there was a previous dislocation. The combination of partial ACL rupture and patellar instability is not uncommon. TREATMENT An athlete with anterior knee pain and recurrent instability of the patella should be seen by an orthopaedic surgeon and a physiotherapist. Most cases can be treated without surgery and with physiotherapy, working in particular on muscle strength and control of the entire kinetic chain. In cases with an increased Q-angle of over 20 degrees, surgical treatment with anterior medialisation of the tuberositas tibia may be indicated if physiotherapy fails. REFERRALS Refer to orthopaedic surgeon for further investigations to verify the diagnosis. Physiotherapists should be involved in close collaboration with the surgeon.

Hidden Home Exercises

Ankle Exercises After Surgery

Anterior cruciate ligament tear (ACL) Anterior knee pain Cartilage injuries Chondromalacia patella Gout arthropathies Iliotibial band friction syndrome Lateral collateral ligament tear (LCL) Medial collateral ligament tear (MCL) Medial plica syndrome Meniscus tear Osgood-Schlatter's disease Osteoarthritis

Proprioceptive taping

What Vmo Muscle 2019

The patellofemoral joint has been described as the most researched small joint in the body, producing pain and disability far out of proportion to its shape and size (Gerrard 1995). One of the underlying theories behind the cause of patellofemoral pain syndrome (PFPS) is that there is an imbalance between the contraction of vastus lateralis (VL) and vastus medialis obliquus (VMO) muscles (McConnell 1986). Gerrard B 1995 The patellofemoral complex. In Zuluaga M (ed.) Sports physiotherapy. Churchill Livingstone, Melbourne, pp 587-611 Gilleard W, McConnell J, Parsons D 1998 The effect of patellar taping on the onset of vastus medialis oblique and vastus lateralis muscle activity in persons with patellofemoral pain. Physical Therapy 78 25-32 Herrington L 2000 Electromyographic problems. Physiotherapy 86(7) 390-392 Janwantankul P, Gaogasigam C 2005 Vastus lateralis and vastus medialis obliquus muscle activity during the application of inhibition and facilitation taping techniques. Clinical...

Cartilage Injuries Cont

SYMPTOMS There is gradual onset of diffuse exercise-induced pain around the anterior part of the knee. Prolonged sitting or squatting often trigger the symptoms (positive movie sign). Walking down stairs is more difficult than up. AETIOLOGY Chondromalacia means 'soft cartilage'. The exact aetiology is unknown. The correct diagnosis must be identified, by arthroscopic probing, before treatment can be successful, since this is only one of many diagnoses that result in anterior knee pain.

Effects of running training

In dogs, light or moderate intensity level training improves the properties of articular cartilage while repetitive, intensive and strenuous training can cause injury to the cartilage. Response of the articular cartilage of young beagle knee (stifle) joint to running training has been studied with three different training programs. Running exercise of 4 km day on a treadmill, 5 days a week, for 15 weeks increases the thickness and PG content (16-26 ) in the femoral cartilage, whereas collagen content is unaltered 35,43 . A slight stiffening of the cartilage takes place in the proximal part of the patellar surface and patellofemoral and tibial cartilages. The rate of cartilage deformation during compression decreases. Using the same model, running exercise of either 20 km day or 40 km day for 15 weeks reduces the GAG content in the superficial zone of femoral and tibial condylar cartilages 35,44 , increases water content and decreases the concentration of collagen in the cartilage of...

Impact loading of articular cartilage in situ

Useful as the impacted explant model is, it still lacks important elements as a simulation of joint trauma. Cellular response probably depends on microenviron-mental and loading conditions. Consequently, several investigators have developed in vivo models of cartilage and joint trauma. Thompson et al. 23,24 used a falling weight on the anesthetized canine patellofemoral joint as a model of joint trauma. This was a closed model, without invasion of the joint. Immediately after impact, there were surface fissures in the patellar cartilage that did not extend to the calcified cartilage and subchondral bone, and also cracks through the calcified cartilage and bone, into the uncal-cified cartilage (Fig. 1.7.1). A 'bone bruise'was visible on magnetic resonance imaging (MRI) 24 . At 3 months after impact, loss of PG in the area of damage was evident. At 6 months after impact, there was further loss of PG in the cartilage, fibrillation was increased, and cloning of chondrocytes was evident...

Single Bundle versus Double Bundle Techniques

With the patient supine, a 2-cm incision over the anterior knee is necessary and should be placed just medial to the articular edge of the trochlear groove and distal to the vastus medialis obliquus. The retinaculum is incised in line with the skin incision. The proximal portion of the femoral tunnel guide is positioned midway between the patella and medial epicondyle, at least 1 cm from the patellofemoral articular edge to ensure that the joint is not violated. The tip of the drill guide is placed through the medial portal onto the anterior half of the femoral PCL footprint, 8 to 9 mm above the articular surface. The guide pin should be driven with the knee in 70 to 90 degrees of flexion and exit high in the notch at the 11- or 1-o'clock position (for left or right knees, respectively) within the anterior half of the anatomic footprint.10,16 The tunnel is then created by drilling over the wire. Most authors drill the femoral tunnel outside-in in this manner, although an inside-out...

Physical Examination

Skin condition and configuration of previous incisions should be inspected. Presence or absence of an effusion should be noted. Clinical varus or valgus alignment should be evaluated. Range of motion should be carefully documented and the presence and degree of flexion contracture recorded. Prone heel heights in flexion and extension can be used to assess knee flexion and extension contractures. Varus and valgus laxity should be tested at 0 and 30 degrees of flexion to evaluate collateral ligament integrity. Anterior drawer, Lachman, and pivot-shift testing should be performed and results compared to those of the contralateral, normal knee to identify the degree of instability present. Posterior drawer testing should be conducted to rule out concomitant posterior cruciate ligament injury, and the dial test should be performed at 30 and 90 degrees of flexion to rule out injury to the posterolateral corner. Patellar mobility and the presence of patellofemoral crepitation should be...

Nonoperative Treatment

The normal instability seen with PCL injury is more of a straight posterior displacement that allows some compensation by the quadriceps. There is greater lateral compartment displacement that manifests as increased external tibial rotation in the PCL-deficient patient. The patients who do not do well typically develop medial compartment arthritis and patellofemoral pain. This is provided via education of the patient as the nonoperative program is instituted. A phased approach to rehabilitation is implemented with the maximal protection including protected ROM (not greater than 0 to 60 to 70 degrees), protected weight bearing, open-chain quadriceps strengthening, no hamstring strengthening, and control of inflammation. This is followed by moderate protection including full weight bearing, full ROM, emphasis on open-chain quadriceps strengthening, pool activities (which are excellent), and avoiding large closed-chain loaded activities. A functional training program is then used after...

Diagnostic Arthroscopy

Although the diagnosis should be clear before surgery, anesthesia will allow full examination of all structures, and numerous arthroscopic signs of PCL injury have been described. These include partial or complete disruption of fibers, insertion site avulsions, hemorrhage, and decreased ligament tension. Indirect evidence includes ACL pseudolaxity resulting from posterior tibial displacement, altered contact points between the tibia and femur, and degenerative patellofemoral and medial compartment changes.2,6 The PCL can usually be seen in its entirety using a 70-degree scope placed through the notch if the tibial insertion is not visualized, a posteromedial portal will allow access. Because the PCL lies extrasynovially, it may appear normal unless the synovium is debrided.

Complex Ligamentous Conditions

Flexed during gait by wearing a heel or heel lift under the involved extremity. In the clinic, patients may be instructed in an exaggerated form of this by walking in significant flexion (Groucho walk, as in Groucho Marx). Another activity to avoid is heavy closed-chain loading as the posterolateral corner and PCL both lead to posterior arthritic changes. Open-chain strengthening is often the modality of choice but should be limited in its ROM (typically 90 to 30 degrees) as we do not want to aggressively load the last 30 degrees of extension (thus minimizing loading to the posterolateral corner as well as minimizing possible patellofemoral reaction). Again, it is imperative for the therapist and surgeon to have strong communication and provide a unified standard of expectation. Unfortunately, some of these patients expect too much improvement and are not able to accept that there are limitations as to what level of success will be achieved following surgery and rehabilitation.

Radiographs routine Xray

AP (anteroposterior) and lateral radiographs fulfil the minimum requirement for the knee following trauma. In addition, tunnel views are routinely obtained. Evaluation of condyles requires both oblique projections 24 . For adequate evaluation of the patellofemoral joint axial views beside the lateral view is necessary 25 . An anteroposterior radiograph of the knee is obtained with the beam directed 5-7 toward the head, and a lateral radiograph is obtained with the knee flexed 20-35 . A 45 oblique view is

History and physical examination

In addition, it is useful to have the patient describe what type of problems they have with their knee. It is also helpful to have them point to the area where their knee hurts. This helps to determine whether pain is located in their patellofemoral joint or in their tibiofemoral joint. Patellofemoral joint symptoms are most commonly located over the anterior aspect of the knee, while tibiofemoral joint problems are usually associated with pain localized to the joint line or feelings of instability.

Medial Plica Syndrome

TREATMENT Arthroscopic excision of the painful plica shows excellent outcomes. REFERRALS These patients are very much helped by being evaluated clinically by their physician, surgeon and physiotherapist in close collaboration since there are many differential diagnoses (see anterior knee pain).


The technique of swimming is very demanding and often hampers its aerobic and anaerobic effects and thus the time spent in the water. To swim for 30 minutes requires a well-developed technique. Even though there is no direct impact, swimming may cause problems if the training is not precisely defined it is important to recommend or restrict different techniques of swimming for different injuries. For example, swimming the breaststroke can exacerbate knee injuries such as medial meniscus tears, osteoarthritis, anterior knee pain and most shoulder injuries. Most swimming techniques will provoke sub-acromial impingement and patients with multidirectional instability in the shoulder should not be prescribed swimming. Low back pain and neck pain may well be aggravated if the athlete does not lower the head down into the water in the swimming stride but looks up, protecting the face or eyes from the chlorine but hyper-extending the cervical and lumbar spine. Such simple mistakes often mean...


Patellofemoral pain with an increased activity of the vastus lateralis (VL) muscle in relation to the vastus medialis obliquus. This technique can also be useful for other conditions in which a decrease in VL activity is desirable. The tape can decrease the muscle activity of the VL during weight-bearing activities and may restore balance of the quadriceps muscle function and decrease patellofemoral pain.

Relevant Anatomy

The PLC of the knee has classically been described to include the lateral collateral ligament (LCL), popliteofibular ligament, popliteus tendon, and the arcuate ligament complex. Some authors have included the iliotibial band2,5 and the fabello-fibular ligament5,6 in this group. Seebacher et al7 divided the lateral aspect of the knee into three layers (1) lateral fascia, iliotibial tract, and biceps femoris tendon (2) patellar retinaculum and patellofemoral ligament and (3) joint capsule, LCL, arcuate ligament, fabellofibular ligament, and popliteus tendon. It is this third layer that is the focus of this discussion.

Mechanism of injury

It is extremely helpful to review the mechanism of injury with the patient to assist in understanding their knee pathology. Injuries to the patellofemoral joint are usually caused by direct trauma or a contact valgus injury. In this instance, a direct blow to the patella, retinaculum or fat pad could result in a contusion, hemorrhage and effusion. In addition, a sudden twist or pivot could result in a lateral patellar subluxation or dislocation event. Which structures are injured with a direct blow to a flexed knee usually depends upon the ankle position. In the case of a dorsiflexed ankle, a direct blow to a flexed knee may cause an injury to the patellofemoral joint. Likewise, in a plantar flexed ankle, a blow to the anterior aspect of a flexed knee may result in an injury to the PCL, because the force is transmitted to the intra-articular structures via the tibial tubercle (rather than by the patella).

Knee Injuries

Quadriceps muscle strength can be trained with leg press, squats or leg extension manoeuvres. The vastus medialis muscles require special attention after patella (kneecap) dislocation or in mal-tracking conditions that cause anterior knee pain. If the patella is subluxated or out of place and knee extensions cause pain, a soft knee brace can be useful and give very good results. The quadriceps muscles are essential for knee stability in activities such as jumping, sprinting, twisting and turning. The rectus femoris muscle, the most

Knee Complex

A synovial bicondylar joint with two degrees of motion. Articulations occur between the two condyles of the femur and the two tibial plateaus, producing flexion and extension. In addition, the tibiofemoral joint allows for minimal axial rotation with the pivot point, located medially on the medial tibial plateau. Patellofemoral joint. Articulation is between the inter-condylar notch of the femur and the patella and shares the same joint capsule as the tibiofemoral joint. The patellofemoral joint directly serves the tibiofemoral joint however, because of the vast differences in clinical problems and pathologies, the two joints will be discussed independently. V Patellofemoral disorder is one of the most common knee disorders seen in patients who visit orthopedic clinics. The disorder is usually caused by excessive pressure or malalignment between the patella and the femur, resulting in pain at the patellofemoral joint. Capsule. Surrounds the knee joint and includes...

In This Chapter

Tibial Tubercle Transfer

Medial patellofemoral ligament (MPFL) reconstruction Finally, the role of proximal and distal realignment for treatment of patients with patellofemoral malalignment and or instability is explored. The decision-making process in assessing malalignment instability of the patellofemoral articulation, the criteria for tibial tubercle transfer in both the medial and anteromedial direction versus proximal realignment, and details of the surgical techniques are addressed. Patellofemoral instability encompasses a continuum of abnormal patellofemoral joint mechanics, ranging from subluxation to dislocation, the cause of which can be either traumatic or atraumatic. Patellofemoral instability is defined as abnormal, clinically symptomatic, lateral, or, in rare cases, medial translation of the patella out of the trochlear groove. In cases of recurrent subluxation, there is lateral translation of the patella early in the flexion range. The anatomy of the entire lower extremity is paramount in the...

Shoulder Instability

Breast Tumor Jpg

Anterior Knee Pain Difficulties with patellofemoral tracking can result in acute injuries (patellar subluxation or dislocation) or overuse problems (patellofemoral stress syndrome or anterior knee pain). Patellar subluxation and dislocation are discussed in detail in Chapter 57 and are not covered in this section. Patellofemoral stress syndrome is a name given to the syndrome of anterior knee pain or patellofemoral pain associated with diffuse anterior knee pain that increases with such activities as squatting, kneeling, running, walking down steps, or walking downhill and is common in women athletes, especially young women. The diagnosis of patellofemoral stress is based on history and clinical examination (Table 8-1). Squats and lunges (i.e., those activities that increase patellofemoral forces) frequently enhance symptoms. Swelling is rarely present. Other symptoms of this syndrome include popping, catching, and snapping. Athletes may experience acute episodes of the knee giving...


Posterolateral Corner Reconstruction

Key considerations in the postoperative care of PLC reconstructions are prevention of (1) varus and external rotation of the tibia, (2) active knee flexion against gravity, and (3) extension hyperextension of the tibia to protect the grafts. Therefore, no active knee flexion against gravity is done until 12 weeks post-operatively due to the internal rotation of the tibia during the first 10 degrees of flexion and the posterior translation, which places tensile forces on the graft. Passive extension to 0 degrees with gravity eliminated and without overpressure is advocated. Additionally, full hyperextension is not emphasized until up to 3 months postoperatively. Hyperextension should be based on bilateral comparison of the uninvolved limb. Achieving extension of the involved limb should be based on the uninvolved. Contrary to isolated ACL reconstruction in which hyperextension is emphasized immediately, hyperextension after PLC reconstruction can potentially lead to graft failure,30...

Natural History

Petitive rugby players with isolated PCL injuries were able to return to preinjury levels of play, some patients took as long as 7 months to recover and nearly all reported subjective sensations of impaired ability, most commonly manifesting in highspeed running (slower acceleration and delayed response) and while turning.18 Long-term follow-ups have found that as many as 90 of patients with isolated PCL injuries may have persistent pain while walking, 45 report episodic instability, 65 report limitations of activity, and more than 50 demonstrate evidence of degenerative changes.4,7 Increasing literature points to a significant incidence of knee pain, patellofemoral symptoms, and medial compartment degeneration in the PCL-deficient knee. This is likely due to altered knee kinematics, with increased quadriceps activity, altered articular contact pressures (especially patellofemoral) and abnormal tibial translation and rotation noted under complex muscle loads in the PCL-deficient

Patellar dislocation

Is young ( 25), recurrent dislocations may occur. A patellofemoral brace may reduce the number of redislocations, as will proper strength in the extensor apparatus, specifically the vastus medialis obliquus, but only surgery has been shown to prevent redislocations. Today the torn structures are usually repaired. In cases where malalignment of the extensor apparatus is found, a distal-proximal realignment may be the surgery of choice.

Bones of the knee

There are three other joints involved in the knee, the tibofibular, the patellofemoral and the patel-lotibial. The tibia and fibula come together proximally to form a syndesmosis. There is very little motion at this joint and it thus has little influence on the knee joint's mechanics as a whole. The patella's articulation in and out of the trochlear groove comprises the patellofemoral joint. This joint's mechanics are highly dependent on whether the patella is in or out of the groove and on the level of activation of the quadriceps muscle. The patellotibial joint only comes to mind when trying to understand or calculate the mechanical advantage created by the patella for the quadriceps mechanics. This joint does not have any articulations in the usual meaning. Only the tibiofemoral joint affects the overall static stability of the knee and it will be the focus of the remaining part of the chapter.

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