Contents

Search

patellofemoral pain syndrome; chondromalacia patella (PFPS)

Etiology: 1) pain originating from irritation of the rich innervated subchondral bone & soft tissues around the patella 2) risk factors a) developmental anomalies b) overuse c) abnormal patellar tracking - excessive Q angle - shallow intercondylar sulcus - deformed patellar facets - weakness of the vastus medialis obliquus muscle - dysfunction of the medial retinaculum or lateral retinaculum Epidemiology: 1) frequently encountered in young athletes 2) young female runners Clinical manifestations: 1) vague, dull achy peripatellar (anterior) knee pain - generally gradual onset 2) pain on palpation of the medial articular surface of the patella - referred pain to the medial joint line & popliteal fossa 3) pain climbing stairs [2] (largely during descent) 4) knee pain exacerbated by activity or prolonged sitting [2,4,5,6] - transient pain switching from a sitting to a standing position 5) anterior knee pain worse with knee flexion during weight-bearing - running, climbing stairs, squatting, 6) compression of the patella with the knee in extension reproduces the pain - it may be necessary to move the patella medially & laterally (patellofemoral compression test) [2] 7) apprehension &/or quadriceps inhibition against resistance applied to the superior pole of the patella 8) positive crepitus test 9) positive compression test - patellar grind test 10) positive shrug test 11) anterior knee pain with extension of knee against resistance 12) passively stretching knee relieves pain 13) absence of edema, erythema or limited range of motion 14) no maneuver is sufficiently sensitive or specific to be considered diagnostic [4,5,6] Radiology: 1) radiographs are generally not helpful 2) patellofemoral osteoarthritis may be confirmed by a radiographs obtained with the knee in a flexed position 3) chondromalacia patellae may be associated with softening & erosion of patellar cartilage 4) other radiology testing is generally not helpful Differential diagnosis: 1) patellar chondromalacia a) older patients b) in association with trauma or malalignment 2) patellar subluxation a) giving way, popping or locking of knee with activity b) marked lateral patellar mobility c) apprehension of physical examination Management: 1) relative rest 2) non-steroidal anti-inflammatory drugs (NSAIDs) a) pain relief in acute cases b) use should not continue more than 2 weeks c) may be useful before & after exercise in patients with periodic exacerbation of symptoms 3) physical therapy a) strengthening quadriceps, especially vastus medialis obliquus to offset lateral tracking of patella b) physical therapy should not increase pain c) ice for 15-20 minutes after activity for up to 2-3 months 4) knee bracing a) used to correct abnormal patellar tracking b) no well-controlled trials demonstrating benefit 5) medial patellar taping 6) surgery a) failure of 3-6 months of medical management b) procedures 1] releasing lateral retinaculum 2] tightening medial retinaculum 3] transposing the vastus medialis obliquus tendon 4] transferring patellar tendon to a more medial position 5] in older patients with chondromalacia, arthroscopic or open debridement may offer relief

Related

patella (kneecap) patellofemoral joint

General

chondromalacia knee pain syndrome

References

  1. Saunders Manual of Medical Practice, Rakel (ed), WB Saunders, Philadelphia, 1996, pg 812-13
  2. Medical Knowledge Self Assessment Program (MKSAP) 11, 16, 17, 18, 19. American College of Physicians, Philadelphia 1998, 2012, 2015, 2018, 2021.
  3. Collado H, Fredericson M. Patellofemoral pain syndrome. Clin Sports Med. 2010 Jul;29(3):379-98 PMID: 20610028
  4. Thomee R et al Patellofemoral pain syndrome: a review of current issues. Sports Med 1999 Nov 24; 28:245 PMID: 10565551
  5. Bolgla LA and Boling MC. An update for the conservative management of patellofemoral pain syndrome: a systematic review of the literature from 2000 to 2010. Int J Sports Phys Ther 2011 Jun 30; 6:112. PMID: 21713229
  6. Cook C et al. Best tests/clinical findings for screening and diagnosis of patellofemoral pain syndrome: a systematic review. Physiotherapy 2012 Apr 18; 98:93 PMID: 22507358
  7. Mayo Clinic: Chondromalacia patella http://www.mayoclinic.com/health/chondromalacia-patella/DS00777
  8. Lankhorst NE, Bierma-Zeinstra SM, van Middelkoop M. Factors associated with patellofemoral pain syndrome: a systematic review. Br J Sports Med. 2013 Mar;47(4):193-206. Review. PMID: 22815424
  9. Kamat Y, Prabhakar A, Shetty V, Naik A. Patellofemoral joint degeneration: A review of current management. J Clin Orthop Trauma. 2021 Nov 13;24:101690. PMID: 34900577
  10. Gaitonde DY et al. Patellofemoral pain syndrome. Am Fam Physician 2019 Jan 15; 99:88. PMID: 30633480 Free article https://www.aafp.org/pubs/afp/issues/2019/0115/p88.html
  11. Willy RW, Hoglund LT, Barton CJ, et al. Patellofemoral pain. J Orthop Sports Phys Ther. 2019;49:CPG1-CPG95. PMID: 31475628