Anterior Knee Pain

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An Athletes Guide To Chronic Knee Pain

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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.

CLINICAL FINDINGS This depends on the underlying diagnosis. If there is effusion, the cause is often intra-articular; if not, it is more likely to be extra-articular. If no structural pathologies can be found the problem can be functional, for example induced by poor core stability, pain referred from the back or poor ankle control. A systematic and thorough approach in the clinical examination is crucial for a successful outcome. Tests of core stability, proprioception, muscle strength and balance and flexibility of the entire kinetic chain must be thoroughly evaluated. INVESTIGATIONS X-ray can exclude fractures, OCD, patella abnormalities, other osteochondral injuries and bone tumours. MRI can exclude soft tissue tumours and other localised soft tissue lesions such as the presence of medial plicae. It often under-estimates chondromalacia and other superficial chondral injuries as well as many meniscal tears and medial plica syndrome. CT scans can rule out severe patella mal-tracking. Ultrasound can be useful for evaluating functional tendons and ligament disorders such as jumper's knee or tendinosis around the knee. Arthroscopy is often an excellent diagnostic tool when clinical findings are vague.

TREATMENT Depends on the diagnosis. REFERRALS These patients are very much helped by being evaluated clinically by their physician, surgeon and physiotherapist in close collaboration. EXERCISE PRESCRIPTION Cycling and water exercises are good alternatives to keep up general fitness.

EVALUATION OF TREATMENT OUTCOMES

Normal clinical symptoms and signs. DIFFERENTIAL DIAGNOSES Meniscus tear, chondral injuries, OCD, medial plica syndrome, chondromalacia patellae, patellar instability or mal-tracking, quadriceps insufficiency, Sinding-Larsen's syndrome, synovitis, Pigmented Villonodular Synovitis (PVNS), patellar tendon disorders, referred pain, reactive arthropathies, secondary symptoms from ankle or back insufficiency, core instability and more.

PROGNOSIS Because many cases never reach an absolute diagnosis and correct treatment, anterior knee pain ends the career of many young athletes.

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