David Kempin, Zac Snow, adam mathers, jimmy wernel KNEE PAIN David Kempin, Zac Snow, adam mathers, jimmy wernel

Patellofemoral Pain Syndrome Anterior knee pain due to biomechanical pathophysiology Improper joint tracking secondary to imbalances of lines of pull from quadriceps musculature Or, structural abnormalities on posterior patella or anterior femur MOI is not well known, but most likely due to repetitive microtraumas resulting in inflammation and pain in the underlying cartilage and subchondral bone At risk population are runners, jumping athletes (basketball, volleyball), and females with large Q angles

Need to have a balance of forces between vastus medialis and vastus lateralis/IT band Or, improper tracking can lead to microtraumas causing pain and inflammation http://1.bp.blogspot.com/_Nau-ZomG9MM/SNqx3yzBk3I/AAAAAAAAABs/wFBsY5Hvweg/s400/194-f1.jpg http://www.eorthopod.com/sites/default/files/images/knee_patella_cause01.jpg

Signs, Symptoms, and Contributing Factors Insidious, poorly-defined ache localized to the anterior knee or “behind the knee cap” Aggravated by squatting, running, prolonged sitting, stairs (worse with descending) Patellar instability – sensation of possible subluxation with twisting and cutting Abnormal static alignment Femoral Anteversion, Genu Varum or Valgum, Tibial external rotation, Pronation or supination of subtalar joint, abnormal Q angle

Signs, Symptoms, and Contributing Factors Abnormal Dynamic Alignment with single leg squat or 6” step down Contralateral pelvic drop Hip adduction and internal rotation Knee abduction Tibial external rotation? Hyperpronation J Sign – patella moves laterally

Pt complains of anterior knee pain Structural Observation: Tibial valgus, Tibial/femoral torsion, Q angle, STJ/TCJ Pronation/Supination Observational swelling and circumference measurement Positive Stability testing Possible patellar bursitis Negative Meniscal testing Possible PFPS

Patient c/o anterior knee pain Stability tests (ACL, PCL, MCL, LCL) Positive Refer to Primary Care Physician for imaging Negative ACL: Lachman, Anterior Drawer, Varus/Valgus at 0 degrees PCL: Posterior Drawer, Posterior sag MCL: Valgus stress test at 20 degrees knee flexion LCL: Varus strest test at 20 degrees knee flexion Meniscal Tests (Appley’s, McMurray, Thessely) Positive Refer to Primary Care Physician for imaging Negative Continue

Patient c/o anterior knee pain Functional Step Down Test Positive Negative Pain with Jump? Functional Single Leg Squat Positive Negative Positive Negative Patellar Tendonosis Patellar Bursitis Reassess Continue Quad MMT

Patient c/o anterior knee pain Positive Functional Single Leg Squat Test Critical Test Positive (Probable PFPS) Negative Modified Ober’s Positive (IT band pulling patella out of proper tracking = possible PFPS) Negative Quad MMT

Pt c/o anterior knee pain Negative Modified Ober and Critical Tests: Glute MMT, Navicular Drop Test, Apprehension Test, Patellar Tilt

Take Home Messages Knee pain is not always as straight forward as it may seem. Knowing the correct tests and a progression for those tests is important. The use of this algorithm and the positive AND negative tests will help you narrow down the possible cause. Remember, the treatment for the knee dysfunction you diagnose may not be directly related to the knee (for example: hip strengthening). Educating your patient on the reasoning will be important.