5 PainFree nerve endings are concentrated in the patella tendon, retinaculum, fat pad1Patients with AKPS have perivascular proliferation of nociceptive axons in retinaclum2Substance P nerve fibers are widespread within the soft tissues around the knee (retinaculum, synovium, fat pad). In patients with AKPS, more Substance P fibers were found in the fat pad and retinaculum3(1) Biedert et al. Am J Sports Med 1992; 20: 430.(2) Sanchis-Alfonso et al. Am J Sports Med 1998; 26;703(3) Witonski et al. Knee Surg Sports Traumatol Arthrosc 1999; 7:
6 Clinical EvaluationNot all anterior knee pain associated with patella alignment abnormalitiesRadiographic findings not pathologic if patient not symptomatic
10 1. Witvrouw et al. Am J Sports Med 2000; 28: 480. Predictors of Pain282 adolescents10% Patellofemoral PainPredictors of developing pain:Decreased flexion of quadriceps, gastrocnemiusIncreased VMO response timeDecreased explosive strengthIncreased thumb to forearm mobility1. Witvrouw et al. Am J Sports Med 2000; 28: 480.
11 1. Zhang et al. Med Sci Sports Exer 2000; 32: 812. Role of the HipHip extensors absorb 25% energy during landingDeficits in hip strength add to load on the knee.11. Zhang et al. Med Sci Sports Exer 2000; 32: 812.
13 1. Witbrouw et al. Am J Sports Med 2000; 28: 687. Physical TherapyTraditional concept of trying to achieve isolated VMO strength not supported by literature.Closed vs open chain:Both types produced improvements in strength, pain relief and return to function11. Witbrouw et al. Am J Sports Med 2000; 28: 687.
14 Does Physical Therapy Help? 84% of patients improved after 8 weeks of quadriceps & hip rehabilitation.75% of patients maintain improvement 6 months to 7 years21. Doucette et al. Am J Sports Med 1992: 20: 434.2. Kannus et al. JBJS 1999; 81:
15 Physical Therapy Attention should be paid to quadriceps flexibility Strengthening done without causing painEmphasis on hip strengtheningContinued until plateau reached
16 Surgical Management Surgery is not necessary in most cases Successful surgical treatment requires an accurate diagnosis (patella instability or patellofemoral malalignment)Normal alignment and no instability may be symptomatic from tendinosis in the quadriceps or patella tendons, pathologic hypertrophy and inflammation in the medial plicaDamage to the articular surface may also cause pain
17 ChondroplastyArthroscopic debridement of grade 2 and 3 chondral lesions can be useful58% good or excellent results with traumatic onset41% good or excellent results with atraumatic onset11. Federico et al. Am J Sports Med 1997; 25:
18 Lateral releaseEffective in treating a well-defined subset of patientsMechanismrelieves pressure in lateral retinaculumdivides neuromatous nerves in the retinaculumrelieves pressure on the lateral facet of the patella
19 Lateral Release Ideal patient No instability Tight lateral retinaculum Outcome related to chondral damage59% satisfactory with >grade 3192% good to excellent with < grade 221. Aderinto et al. Arthroscopy 2002; 18:2. Shea et al. Arthroscopy 1992; 8:
20 Complications of Lateral Release Persistent painWorsening instabilitySuspect medial subluxation in any patient reporting persistent pain after lateral releaseTest in decubitus with lateral knee up, patella sags medially from gravityPatient unable to flex knee
21 Tibial tubercle transfer Lateral patellar tilt and subluxationResults correlated to location of patella chondral lesionsglobal and proximal lesions did less wellBiomechanical studies show that transfer while decreasing overall load, transfers it disproportionally to proximal patella
22 Cartilage Restoration OATS and autologous chondrocyte implantationSmall numbers have been reported and reports are mixedLess aggressive procedures (chondroplasty, microfracture or abrasion) may be equally effective
23 Patellofemoral Arthroplasty Low demand patientsCare at the time of surgery to ensure extensor mechanism is aligned
24 Summary Important to establish accurate diagnosis Non-surgical management remains the most predictable method of treatment