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Anterior (Front) Knee Pain

Injury Information

Patella Dislocation/Subluxation

The patella, or knee-cap as it is commonly known, is the round shaped bone at the front of the knee. It is used by the powerful leg muscles such as the quadriceps to provide the fulcrum for leverage and power.

The patella tendon runs down from the knee-cap to connect to the lower leg bone, tibia.

When bumped with force, the knee-cap can sometimes be moved from its place at the front of the knee to either side but most commonly to the outside. A dislocation has been sustained when it ‘pops’ out of its groove and stays there. If the patella only slides out part of the way this is known as a subluxation.

Intense pain and patellofemoral joint swelling will be experienced.

Patella tendonitis

Patella tendonitis usually is caused from excessive stress to the patella tendon. Jumpers knee is a term commonly used. It is not a sudden injury but a wear and tear soreness the you may notice over time during and after activity. Pain will be felt as a burning and will be worst following exercise. Quadriceps tightness and weakness may accompany patella tendon pain Kicking a ball regularly or constantly squatting or climbing stairs might trigger the soreness.

Anterior Knee Pain (Patello Femoral Joint Pain)

Anterior knee pain or what is commonly known as patellofemoral joint (PFJ) syndrome is a very common cause of pain at the front of the knee. This problem occurs especially in children, and especially in girls. PFJ syndrome has many causes such as flat feet, low back problems and thigh muscle tightness. Pain presents as a vague ache in the front of the knee.

Muscle weakness may be experienced on the inside of the knee and thigh whilst muscle tightness may be felt on the outside of the knee and thigh. Treatment options include strengthening and stretching the hip and thigh, patella taping and foot supports.

In severe cases the cartilege lining the patello-femoral joint can be damaged. The most common symptom of patellar cartilage damage is pain associated with prolonged sitting and descending stairs. The reason the pain is more severe when descending stairs rather than climbing is due to the mechanics of the knee joint. The force on the patella is about two times body weight when climbing stairs, and seven times body weight when descending. This increased burden when going down stairs causes a magnification of pain during that time.

Anterior cruciate Ligament (ACL) Tears

The ACL is the ligament that limits forward motion of the shin bone (tibia). The ACL is the most important provider of stability within the knee joint. Essentially, the femur (thigh bone) sits on top of the tibia (shin bone), and the knee joint allows movement at the junction of these bones. Without ligaments to stabilise the knee, the joint would be unstable and prone to dislocation. The ACL prevents the tibia from sliding too far forward underneath the femur. The ACL also contributes stability to other movements at the joint including the angulation and rotation at the knee joint. The ACL functions by attaching to the femur on one end, and to the tibia on the other.

The ACL is most commonly injured during sporting activities when an athlete suddenly pivots causing excessive rotational forces on the ligament. Other mechanisms that can cause an ACL tear include severe trauma and work injuries. Individuals who experience ACL tears usually describe a feeling of the joint ‘giving out,’ or buckling; people also often say they hear a “pop.” One of the initial signs of an ACL tear is swelling of the joint. This occurs due to bleeding into the joint space from the rupture of small blood vessels that course through the ligament. Joint instability can also be assessed by specific manoeuvres performed by your physiotherapist. It is important to note, however, that many of the signs of instability may not be present early after an acute injury. This is due to factors such as muscle spasm, swelling in the joint and pain which make the tests of instability difficult to assess. Your doctor may need to evaluate x-rays of the knee to assess for any possible fractures, and a MRI may be required to evaluate for ligament or cartilage damage.

Injury Treatment

Exercises

Strengthening programs should only be commenced when:

  • The injury is not painful to touch.
  • The injury is not painful in the morning.
  • The injury is not painful to stretch.
  • The injury is not painful with light to moderate exercise.

Exercises should be 3 sets of 8-12 repetitions.

Early Injury Management

For approximately the first 72 hours following an injury, the RICE regime should be followed to ensure control of inflammation and pain relief.

R - Rest

I – Ice

C - Compression

E – Elevation

Rest from aggravating activity.

Ice should be applied in the first 72 hours or when inflammation persists. Ice should be applied for 15 to 20 minutes at a time. Ice should not be applied directly to the skin, but through a wet towel or cloth.

Compression can be achieved with an elastic bandage.

Elevation is used to help swelling to return to the heart through the blood stream.

The injured area should be elevated above the level of the heart.

ACL Tears

Some patients who experience ACL tears are able to resume normal daily activities without surgical repair of this ligament. There are some important factors to consider in making the decision as to whether or not operative treatment is needed. These factors include the age of the patient, the activity level of the patient (both recreational and occupational), the expectations of the patient regarding future knee function, the ability and commitment of the patient to participate in post-operative rehabilitation, the degree of instability of the joint, and any other associated injuries to the knee (e.g. other ligamentous or meniscal problems).

ACL reconstruction is usually not performed until several weeks after the injury. Studies have shown improved results when surgery is delayed several weeks from the time of injury. This time allows the inflamed and irritated knee to cool down. Swelling decreases, inflammation subsides, and range of motion improves. Resolution of swelling and stiffness prior to surgery improves the post-operative function of the joint. The surgical procedure is variable, but commonly involves using a segment of another larger ligament or tendon to replace the torn ACL. The ligament most commonly used is the patellar ligament which connects the kneecap (patella) to the tibia. About one-third of this ligament is excised and subsequently secured to the femur and tibia to replace the torn ACL. It is unusual to be able to repair the torn ACL by simply reconnecting the torn ends, and the

Physiotherapy following surgery

The degree of commitment to rehabilitation to determines how well their knee will perform after reconstruction. Most patients experience full recovery and resume their previous lifestyle, including professional athletes. However, some patients complain of pain, stiffness and limited motion in the joint for months or years following the reconstructive surgery.

Patello-femoral Joint problems

Patello-femoral joint syndrome is interesting in that it often strikes young, otherwise healthy, active women due to do with anatomical differences between men and women, in which women experience increased lateral (outside) forces on the patella. The treatment of this disorder remains controversial, but most individuals can be effectively treated by adhering to a proper physiotherapy program. This program should emphasise strengthening and flexibility of the quadriceps and hamstring muscle groups. Consult your local physiotherapist for such a rehabilitation porgram. Surgical intervention is declining in popularity for two reasons: good outcomes without surgery, and the small number of patients who actually benefit from surgical intervention.

Unfortunately, some patients are not cured by conservative therapy, subsequently surgery is needed. By looking into the knee with an arthroscope, the surgeon can assess the damage done to the cartilage. They can also assess the mechanics of the joint to ascertain if there is an anatomic malalignment that could be corrected. One common malalignment is due to abnormal tracking of the patella (tracking is the movement of the patella on the femur beneath as the knee bends and extends) caused by too much lateral tension. For this problem, a procedure known as a lateral release can be performed. This procedure involves cutting the tight lateral ligaments to allow for normal position of the patella. If this is not sufficient to correct the malalignment there are more extensive surgeries which can be performed.

Stretches

  • Stretches to be held for three sets of 20 to 30 seconds
  • A light warm-up such as walking, exercise bike, or range of movement exercises (moving the joint through a gentle, comfortable range) for five to ten minutes, should be undergone before stretching
  • Stretches should be held just at the first point of tension.
  • Stretching should be slow and gentle and no excessive tension or discomfort should be felt during stretching.
  • Stretches can be done to help treat an injury but should also be done before and after exercise.

Exercises

Strengthening programs should only be commenced when:

  • The injury is not painful to touch.
  • The injury is not painful in the morning.
  • The injury is not painful to stretch.
  • The injury is not painful with light to moderate exercise.

Exercises should be 3 sets of 8-12 repetitions.

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