PATELLAR SYNDROME

DEFINITION

It's one of the most common causes of anterior knee pain. Highly limiting is particularly common in young people and teenagers, determined by a set of morpho functional on the patellofemoral joint, in the absence of other pathologies extra and intra patellar.

DEFINITION

It 'a common disorder, with an e s t i m a t e d p re v a l e n c e o f between 8% and 40% and with a higher incidence in females. Among the contributing factors were included a deficit of motor control and / or a weakness of the proximal and distal muscles, overuse, the stiffness of the soft tissues, an increased Q angle and altered biomechanics of the foot.

DEFINITION

Classical pathology from overuse, caused by activities that cause pressure or friction in the cartilage behind the kneecap, is common in athletes who participate in sports that involve running, jumping and squatting, but is also found in non-sporting youth. Knee pain occurs in certain positions of the knee that cause an increase or the emergence of incorrect mechanical forces between the patella and the femur.

EPIDEMIOLOGY

It affects about 25% of the athletes and can also affect children, athletes and not. Girls are more affected by a 'incidence of 7% in males and 10% in females. Usually bilateral, although one side is more symptomatic of the other.

ANATOMY AND BIOMECHANICS

The patella protects, as a shield the front of the knee. A direct impact on the level of it can cause damage to the cartilage that covers the back surface. Furthermore, the patella acts as a fulcrum allowing the insertion of common heads of the quadriceps muscle.

It increases the lever arm a n d t h e m e c h a n i c a l functionality of the extensor. In th i s way, the mere presence of the patella a s a v i n g o f q u a d r i c e p s strength in flexion-extension of the knee.

ANATOMY AND BIOMECHANICS

During knee flexion the pressure on the patella makes the cartilage susceptible to the forces of friction. The patella should flow in the center of the vertical groove formed by the intercondylar femoral trochlea and the surface, in this case the pressure is distributed on the area as wide as possible. If on the contrary the patella is positioned outside of this groove, the pressure is unevenly distributed and excessive forces can cause more likely knee pain.

ANATOMY AND BIOMECHANICS

This anomalous dislocation can occur for a variety of causes inc luding abnor mal p lantar support, valgus or varus knees, femoral internal rotation, tibial external rotation, or weakness of the muscles of the hip or the thigh.

ETIOPATHOGENESIS

The pathogenesis is multifactorial. Direct and indirect trauma, combined with predisposing risk factors, can cause inflammation at the level of the patella, and the establishment of a hypoxic state. The alteration of homeostasis activates peripheral nociceptors, in the synovium, adipose tissue and subchondral bone, head of mechanical allodynia, typical of patients with this syndrome.

SYMPTOMS

Ø  anterior knee pain, peripatellare or retropatellar

Ø  generalized pain of the knee

Ø  joint line pain

Ø  pain behind the knee.

SYMPTOMS

The pain may be short-term, recurring or chronic, often exacerbates concomitantly with an increase in intensity or frequency of training. Pain worse at running, jumping, doing squats, climbing stairs, walking or sitting down for long periods. Also, people with altered plantar support (flat feet), altered conformation of the knees (varus or valgus) may be more susceptible to this condition. The weakness of the muscles on the front of the thigh and hip muscles is predisposing factor to this syndrome because of the effects that these anomalies have the forces that focus on the patella.

DIAGNOSIS

Ø  Clinical examination

Ø  Rx

Ø  MRI

DIFFERENTIAL DIAGNOSIS Ø  Osgood-Schlatter: localized pain just below the knee, at

the tibial tuberosity

Ø  Patellar tendinitis: localized pain along the patellar tendon at the level of the bottom of the kneecap (can be a pain for growth in the case of young patients)

Ø  ITB syndrome: pain on the lateral side of the knee, friction syndrome or syndrome of the iliotibial band.

Ø  pain associated with swelling, deficit of flexion-extension, instability, or interruption of daily activities or in association with fever or other diseases should be further investigated with instrumental methods more accurate.

TREATMENT Initially is conservative and includes:

Ø  Reducing the activities that cause pain (running jumps, squats etc ..)

Ø  ice, and NSAIDs for pain reduction

Ø  swimming (no frog) and / or cycling (no climbing) low resistance

Ø  a rehabilitation program well structured and personalized (quadriceps muscle, anterior muscles and hamstrings, iliotibial bandelletta, retinaculum lateral gastrocnemius)

Ø  patellar taping

Surgical treatment is indicated in severe cases and in case of failure of conservative therapy.

Many authors have investigated in recent years the role of the muscles of the hip and of the lumbar-pelvic area: a weakness of the proximal muscles could alter the kinematics and increase stress the patellofemoral joint. A program with therapeutic exercises proximal causes an improvement in the short and long-term pain and gives more functionality, when compared with programs with exercises for the knee. It has been hypothesized that the exercises will improve the alignment of the lower limb proximal reducing stress to the patellofemoral joint.

CONCLUSIONS

To solve the patellofemoral syndrome is useful to identify and correct the causes of pain. Once you have found the origin of the disease then you can decide the type of treatment for a particular individual. A doctor, a physiotherapist, an osteopath or an athletic trainer can help to identify the causes and recommend specific treatments. They can also help the recovery of joint function and functional knee for a gradual and safe return to sports activities.

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u  Dixit, et al. 2007. AAFP. 2007.

u  Haim, Amir, et al. 2012. The outcome of a novel biomechanical therapy for patients suffering from anterior knee pain. The Knee. 2012.

u  Houghton KM. 2010. Review for the generalist: evaluation of low back pain in children and adolescents. Pediatr Rheumatol Online J. Nov 2010, Vol. 10, p. 1186/1546-0096.

u  Luhmann JS, et al. 2008. JCO. 2008.

u  Nelitz Manfred, et al. 2013. Anatomic recostruction of the Medial Patellofemoral Ligament in Children and Adolescents With Open Growth Plates Surgical Technique and Clinical Outcome. The American Journal of Sports Medicine. 2013, Vol. 41.1, p. 58-63.

u  Phillips, Coetsee. 2007. SAJSM. 2007.

u  Piva SR, Fitzgerald GK, Irrgang JJ, et al. 2009. Associates of physical function and pain in patients with patellofemoral pain syndrome. Arch Phys Med Rehabil. Feb 2009, Vol. 90(2), p. 285-95.

u  Rathleff. 2012. BMC. 2012.http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3811739/