Knee

Patellofemoral Pain (Kneecap Pain)

The number one cause of pain in a young, healthy athlete is patellofemoral pain. Its syndromes are referred to by many different names, some of which include anterior knee pain, patellofemoral malalignment, chondromalacia patellae, patellar hypermobility, lateral pressure phenomenon, and patellar tilt.

Causes

The primary cause of anterior knee pain is an unbalanced set of forces across the patellofemoral joint causing the knee bone to not be centered within the trochlear groove, which is a part of the thighbone. The abnormal forces that act on the knee bone to cause this problem can be as simple as a muscular weakness or an imbalance between the various portions of the thigh muscles, tight ligaments either on the outside or the inside, having flat feet, being knock-kneed, or having significant ligamentous laxity.

Although it is possible, traumatic causes of patellofemoral pain are not common. In a traumatic situation, pre-existing malalignment often exists and it is harder, but not impossible, to treat the pain and discomfort conservatively. When traumatic injuries do occur and a cartilage lesion is caused, treatment by any means is more involved and full recovery harder to achieve. In fact, it is not uncommon in these situations for surgical intervention to be suggested and/or required to return athletes to their full potential.

Symptoms

  • Aching around the kneecap.
  • No specific area of point tenderness.
  • Pain worsens with stairs – up or down.
  • Pain worsens with long periods of sitting – Theatre Goers’ Sign.
  • Clicks or pops (though some clicking and grinding under the kneecap is normal).

Treatment

The type and duration of treatment is dependent on the severity the condition. A period of non-operative treatment is normally the initial step taken to correct the problem.

The treatment of anterior knee pain centers on the factors which predispose it to occur. The most common of these is lateral (outside) tightness, especially of the ilio-tibial band (ITB). Stretching of the fibrous tissue on the outer side of the kneecap and ITB, though difficult, is very beneficial.

A significant knock-kneed position of the knees can also lead to and cause anterior knee pain. While reversing this knock-kneed condition is possible, it’s a large undertaking and usually unnecessary. Flatfoot deformity is another contributor to anterior knee pain symptoms. It requires a medial arch support and sometimes some medial posting in an orthotic to dynamically help the patellofemoral joint.

Overall, non-operative treatment of patellofemoral problems is successful 85 percent of the time. Patience and diligence increase the success rate with several courses of therapy, and activity modification is often necessary.

Alternative treatment options include glucosamine, hyaluronic acid, and non-steroidal anti-inflammatory medications (NSAIDs).

Though not common, operative management of patellofemoral problems is sometimes necessary. Long standing malalignment problems that are resistant to non-operative care as well as traumatically induced patellofemoral problems, which cause surface damage, can be treated surgically.

Operative treatment begins with an arthroscopic procedure to remove loose fragments from within the knee and to smooth out rough and/or irregular edges when they exist. Re-alignment procedures are then performed to correct abnormal forces as is appropriate. Re-aligning the forces within the joint, however, when subluxations, dislocations, and/or significant ligamentous laxity exist, requires more extensive procedures.