|Wednesday, September 1
It's an inescapable fact that knee injuries are a part of sports. One of the most complex joints in the body, the knee must withstand and absorb an incredible assortment of forces, both natural and unnatural, in order for an athlete to jump, run or cut. One of the structures of the knee, the patella (or kneecap) is particularly prone to pain and discomfort primarily because it sits at the juncture of ligaments, tendons, cartilage and bone.
These afflictions, collectively referred to as patellofemoral pain syndrome, may have many causes. Dr. Giles Scuderi, a member of the Association of Professional Team Physicians (PTP) and an attending orthopedic surgeon at Beth Israel Medical Center, joins us to discuss this syndrome -- the causes, treatments and prognosis.
What is patellofemoral pain syndrome?
Dr. Scuderi: Patellofemoral pain syndrome syndrome is really a group of conditions that cause pain around the kneecap, and it can be related to many conditions such as bursitis, tendinitis, torn menisicus, ligament instability and even arthritis. But there are also some specific conditions about the kneecap that involve the articular cartilage. You can have chondromalacia, osteoarthritis, chondral fracture or osteochondritis dissecans; these can all be a source of patellofemoral pain.
There are other conditions that can cause patellofemoral pain syndrome that may or may not be associated with articular damage and those are patellar instability or synovial plica, which is a leaf of tissue from the synovium that gets caught between the kneecap and the femur. It can also be referred pain from another location, perhaps from the back, hip or ankle. Therefore with patellofemoral pain syndrome, it's important to listen to the patient's symptoms and perform a good exam because of the myriad of causes. This is crucial to starting a treatment program.
What are the symptoms?Dr. Scuderi: Usually the patient will come in and complain of pain in the front of the knee. One case may be an adolescent girl who is complaining of the gradual onset of pain, a general aching in the front of her knee that is worse with stairclimbing or with sitting for an extended period of time. Usually she won't have any swelling and there is no instability, but she may say that her knee feels "weak." Another case is a patient who has instability that is the result of a specific event -- he's had a "giving way" episode where he may have had a moment of sharp pain that was associated with a twisting or cutting motion such as in football. There is a feeling that the kneecap is unstable and is slipping out of place. Another case can be one of overuse. Maybe an athlete is training for a marathon and his training program is a little bit too vigorous and over-reaching. This can result in anterior knee pain and that usually suggests an overuse syndrome where the physical demands were beyond what the knee could withstand.
Which athletes are susceptible to patellofemoral pain syndrome?
Dr. Scuderi: Many athletes are prone to patellofemoral pain syndrome; there is no one specific sport that is primarily affected. Yet we usually think about sports that involve running, jumping and cutting because they can contribute to patellofemoral pain syndrome due to the mechanics of the knee -- the way the patella tracks. Cyclists and runners who may be going too far, too fast and are exceeding their limits may experience patellofemoral pain syndrome. Basketball or volleyball players who are repetitively jumping put a lot of stress and strain on the patella. If an athlete changes playing surfaces from grass to hardwood floors, that can contribute to patellar pain. Finally, direct impact on the kneecap, as in a fall or tackle in football or rugby, can damage the patellar articular surface. So I really don't think any sport or athlete is immune.
How is patellofemoral pain syndrome diagnosed and treated?
Dr. Scuderi: The important thing is to listen to patients' history and perform a physical examination. This is essential to isolating the source of pain. The physical exam is really going to provide the groundwork from which the diagnosis is developed. X-rays are also helpful in determining bony abnormalities, such as a malalignment of the limb or the knee joint or a loose body in the knee. These are almost standard in addressing the source of patellofemoral pain syndrome. Occasionally, MRI tests, CAT cans or bone scans may be needed to look for additional sources of pain around the knee.
Most of the time, patellofemoral pain syndrome is treated with physical therapy and a non-operative approach. As I said before, you really want to make a specific diagnosis because if you find the correct etiology of the pain, both the physician and the therapist are going to have a happy patient because they can work together to customize an individual therapy program for that patient. As with any non-operative approach, the main concerns are relieving the pain and then restoring function. With a patient that has symptoms consistent with overuse, you have them rest and then begin the therapy. Anti-inflammatory medication and ice are very helpful in reducing the pain. And as the pain diminishes, you begin the strengthening and stretching exercises. These include toning the quad muscles and getting the hamstrings flexible. You also don't want to neglect the hip and lower-leg muscles.
As the condition improves, depending upon the athlete or patient, you start considering sport-specific exercises and a maintenance program. You want to work on correcting any deficits in strength speed, agility and flexibility because that's going to allow them to return to unrestricted and full participation.
Surgery is rarely an option other than for some specific conditions. No one procedure can address all the instances of patellofemoral pain syndrome, so if surgery is required, it's all the more essential to make that correct diagnosis.
What is the prognosis?
Dr. Scuderi: The prognosis is good overall for the majority of patients. I would say that 80-90 percent of the patients will improve with non-operative treatment. With proper conditioning and improvement in strength and flexibility of the muscleclature around the knee, they can resume a very active lifestyle. There are some patients, however, that will continue to experience pain after this type of treatment, and these patients need to be reassessed, carefully diagnosed and then considered for surgical treatment. But again, you need to have a specific diagnosis so you can perform the correct procedure for that patient.