Nontraumatic knee pain: A diagnostic &amp; treatment guide

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Applied Evidence

Nontraumatic knee pain: A diagnostic & treatment guide

J Fam Pract. 2014 December;63(12):720-728

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References

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Treatment. The most effective and strongly supported treatment for PFPS is a 6-week physiotherapy program focusing on strengthening the quadriceps and hip muscles and stretching the quadriceps, ITB, hamstrings, and hip flexors.^4,5There is limited information about the use of nonsteroidal anti-inflammatory drugs (NSAIDs), but they can be considered for short-term management.²

Patellar taping and bracing have shown some promise as adjunct therapies for PFPS, although the data for both are non-conclusive. There is a paucity of prospective randomized trials of patellar bracing and a 2012 Cochrane review found limited evidence of its efficacy.³⁴But a 2014 meta-analysis revealed moderate evidence in support of patellar taping early on to help decrease pain,⁶and a recent review suggests that it can be helpful in both the short and long term.⁷

Taping or bracing may be useful when combined with a tailored physical therapy program. Evidence for treatments such as biofeedback, chiropractic manipulation, and orthotics is limited, and they should be used only as adjunctive therapy.⁴

CASE › When you examine Ms. T, you find no swelling of the affected knee. You perform the tilt test, which elicits pain. Squatting causes some pain, as well. You diagnose PFPS and provide a referral for 6 weeks of physiotherapy.

Patellar subluxation or chronic dislocation

Patellofemoral instability (PFI) occurs when the patella disengages completely from the trochlear groove.¹¹PFI’s etiology also relates to the complexity of the patellofemoral joint. Here, too, stability of the joint is achieved with a combination of soft tissue and bony restraints. At full extension and early flexion of the knee, however, the mechanisms of stability are limited, resulting in increased instability. Other associated factors include Q-angle, lateral pull from a tight ITB, and opposing forces from the vastus lateralis and vastus medialis obliquus (VMO).^8-10

Risk factors for PFI. The most common predisposing factors for PFI are trochlear dysplasia, patella alta, and lateralization of the tibial tuberosity or patella.^10,11Older patients (mostly women) have an increased risk for patellofemoral instability. Older patients, predominately women, have an increased risk for PFI.⁹Patients usually have a history of patellar subluxation or dislocation in their youth, with approximately 17% of those who had a first dislocation experiencing a recurrence.⁹A family history of PFI is common, as well.¹⁰

Diagnosis. Patients with PFI often present with nonspecific anterior knee pain secondary to recurrent dislocation.¹³Notable physical exam findings are:

a positive J sign (noted if the patella suddenly shifts medially during early knee flexion or laterally during full extension)
decreased quadriceps (specifically VMO) and hamstring strength and flexibility
patellar hypermobility, which should be no more than a quarter to a half of the patellar diameter bilaterally
pain during a patellar tilt test 
a positive patellar apprehension test.¹⁰(With the patient lying with the knee flexed to 20°, place thumbs on the medial patella and push laterally; the patient will straighten leg with pain or “apprehension” prior to patellar dislocation.)

Plain radiography should be ordered in all cases to assess for osseous trauma/ deformity and to help guide surgical consideration. Magnetic resonance imaging (MRI) can provide additional information when significant soft tissue damage is suspected or the patient does not improve with conservative therapy.^8,11

Treatment. A recent Cochrane review showed that conservative treatment (VMO strengthening, bracing, and proprioceptive therapy) prevented future dislocations more effectively than surgical intervention.¹¹However, surgery is indicated when obvious predisposing anatomic conditions (osteochondral fracture, intra-articular deformity, or a major tear of a medial soft tissue stabilizer) are clearly shown on imaging.^8,11

Patellar tendinopathy (jumper’s knee)

Patellar tendinopathy, an overuse injury often called “jumper’s knee” because it is associated with high-intensity jumping sports like volleyball and basketball, is an insertional tendinopathy with pain most commonly at the proximal patellar tendon.¹⁰The pathology of the injury is poorly understood, but is believed to be the result of an impaired healing response to microtears.^12,14

Diagnosis. Patients with patellar tendinopathy typically present with anterior suprapatellar pain aggravated by activity. Classically, the pain can occur in any of 4 phases:¹² 1. pain isolated after activity; 2. pain that occurs during activity but does not impede activity; 3. pain that occurs both during and after the activity and interferes with competition ; 4. a complete tendon disruption.

Examination should include an assessment of the patellar tendon for localized thickening, nodularity, crepitus, and focal suprapatellar tenderness. The muscle-tendon function should be evaluated by assessing knee mobility and strength of the quads via straight leg raise, decline squat, or single leg squats.¹²The Victorian Institute of Sport Assessment (VISA) questionnaire can be used to quantify the symptoms and to help track the patient’s progress throughout therapy.³¹There are no proven special tests or radiologic studies to aid in the diagnosis of patellar tendinopathy,¹⁴but magnetic resonance imaging (MRI) can be used for further evaluation when findings are equivocal.³⁵