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Patellofemoral Problems

Patellofemoral problems are among the most common problems we see in patients with knee pain. The patellofemoral joint may be injured either from a direct blow to the front of the knee, or more commonly with progression over time from squatting, kneeling, jumping, running or other vigorous flexed knee activities. The smooth articular cartilage on the patellofemoral joint becomes irritated, and in the initial stages it becomes soft and painful. Over time the softened cartilage can roughen and begin to pull away from the underlying bone. Another term for this problem is chondromalacia. In a small number of cases, the chondromalacia changes will progress to the point where the cartilage is completely lost from the bone, resulting in significant patellofemoral arthritis. Patellofemoral problems are particularly common in teenagers, with females affected more commonly than males. There may be some relationship to hormonal changes that occur during puberty, as this is a more common problem in the early teen years than in the later teen years. With increasing age, there is a higher incidence of arthritic change. Risk factors for this problem include being greater than 10 pounds above ideal body weight, abnormal tracking of the patella within the trochlear groove, abnormal lower limb alignment, including pes plano valgus alignment of the feet, weakness of the quadriceps muscles, hamstring tightness, frequent flexed knee activities, and female gender.

Most patellofemoral problems are treated conservatively without the need for surgery. Conservative measures are often helpful in relieving symptoms, although symptoms may not completely resolve, and may recur. Recurrence is particularly likely in patients who have gone on to develop significant chondromalacia changes or arthritic changes in the patellofemoral joint.

The extensor mechanism controlling the kneecap motion through the femoral groove is a complex one. The importance of a strong and coordinated quadriceps muscle was explained as well as the affect of lower extremity alignment. The treatment plan must be customized according to all of the unique factors in a given patient. The goal of treatment is to rehabilitate the thigh and surrounding musculature to their optimum performance allowing the most pain free return to activities. This is accomplished through a combination of treatments to include but not limited to:

  • Activity modification by avoiding repetitive bending, squatting and stooping, as well as running or ambulation on steep grades. This may diminish the joint reaction forces of the patellofemoral joint, thus reducing the amount of compression and eventually relieving the pain and discomfort in the anterior knee.
  • Anti-inflammatory medications to control pain and inflammation when necessary.
  • Therapeutic exercises either through a custom guided physical therapy program or as a home or gym program.
  • Braces if necessary to control kneecap tracking and to minimize symptoms during activities.
  • Patellar taping if necessary to control kneecap tracking during exercises.
  • Custom foot orthotics to correct lower extremity alignment and minimize patellofemoral forces.
  • There is some evidence that glucosamine/chondroitin sulfate combination nutritional supplements may diminish the amount of joint pain that may be present, although scientifically it has not proven to be much better than placebo in certain studies. I have offered this to the patient. If a trial is attempted I would recommend a total of 1,500/1,200 mg of the combination of glucosamine/chondroitin sulfate for a three-month period of time. If it is not beneficial I would recommend not taking it any longer.
  • The last resort I commonly will offer patients with this particular condition is corticosteroid injections to help diminish the amount of inflammation and swelling within the patellofemoral joint. This is commonly beneficial in relieving the patient’s symptoms. Although transient it can break a pain cycle and allow the individual to be more functional. I would not recommend more than three injections over a one-year period in that there are local effects that can cause soft tissue/collagen breakdown and eventually possible tearing of the structures in the joint.
  • Visco supplementation has also been beneficial in patients with degenerative changes of the medial and lateral compartments and has been released by the FDA for use in these conditions. Commonly, individuals with tricompartmental disease will notice a significant amount of improvement in anterior knee pain with use of visco supplementation, so this may also be an option. If there is a significant amount of degenerative change in addition to malalignment of the patellofemoral joint, this may be an option as well for the above-mentioned individual.

There is a 90 percent chance that patellofemoral pain symptoms can be brought under control through these nonsurgical techniques. No exact time frame can be given to predict when improvement will occur, however, 3-6 months of aggressive rehabilitation may be required before considering non-surgical treatment a failure.

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