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Anterior knee pain is a common complaint among athletes and active, young individuals. Its causes are broad, but
the correct diagnosis can usually be made after a thorough history and physical examination. The history should
include a complete investigation of the nature and onset of the athlete's symptoms, past medical history, and the
nature of any previous treatment he or she may have received for the problem. The physical examination includes a
general lower extremity musculoskeletal examination with determinations of flexibility and limb alignment. The
spine and hips are also evaluated to rule out radicular or referred pain to the knee. The knee examination must
include assessment of the peripatellar tissues as well as the patellofemoral joint. Although patients often perceive
their pain as being poorly localized,the pain source can usually be preciselylocalizedon examination.The information
presented here should enable the clinicianto make an accurate diagnosis on which to base initial treatment.
KEY WORDS: patellofemoral, pain, knee, anterior, athlete, evaluation, examination
Anterior knee pain is a common problem among athletes also be aware of the potential of posterior instability and
and active young patients. There are many causes, but a secondary patellofemoral symptoms from increased com-
correct diagnosis can usually be made in most patients pressive forces across the joint.
after a thorough history and physical examination. This
article discusses the aspects of clinical evaluation that are Pain. The patient should be asked to point to the location
most important in patients and athletes with anterior knee of the pain. Knee pain diagrams (Fig 1) can be helpful and
pain. have been shown to be accurate in predicting areas of
tenderness on physical examination. 1 Other characteristics
HISTORY of the patient's pain that should be specifically addressed
include quality, radiation, and exacerbating and relieving
Symptomatology factors. In addressing these characteristics, the clinician
should be able to differentiate somatic pain from pain that
Onset. Athletes and active young people with anterior is referred or radicular in nature. Anterior knee pain is
knee pain commonly present with symptoms that are frequently reported by patients to be poorly localized,
chronic in duration and insidious in onset, and patients positional, and activity-related. It is usually relieved by
frequently have some component of overuse a n d / o r under- passive extension and exacerbated by prolonged flexion
lying malalignment. However, a more acute onset of (the "movie theater sign") because of increased tension in
symptoms after a traumatic episode may suggest patellar the extensor mechanism as wetl as the posterior and lateral
instability, a retinacular tear, or osteochondral injury, de- forces imparted by the retinacular attachments of the
pending on the mechanism. An indirect mechanism consist- iliotibial band, which is posterior to the knee axis in flexion
ing of a strong quadriceps contraction, a flexed and valgus greater than 30 °. It is also exacerbated by stair climbing
knee position, and internal rotation of the femur on the and, particularly, descending stairs, because of the strong,
tibia is a common one for patellar dislocation. The classic eccentric quadriceps contractions that are required. Ask
example of this is a baseball batter swinging and missing a the athlete if pain is experienced with any particular
pitch. Such patients frequently report seeing their kneecap sport-specific activities to gain an understanding of how
"off to the side," which either spontaneously reduces or pain is produced.
requires manipulation. A direct mechanism, such as con- In contrast, pain that is constant a n d / o r not related to
tact with another player, can result in a chondral lesion activity or knee position should make the clinician suspi-
from direct trauma to the patella or distal femur. Many cious of referred pain, neurogenic pain, or reflex sympa-
patellar crush injuries occur with the knee flexed so that thetic dystrophy (RSD). Referred pain from the hip typi-
the lesion involves the proximal pole of the patella. In the cally affects the anterior distal thigh and knee, and,
setting of a posteriorly directed force to the knee, one must therefore, a history of hip problems should be sought. Pain
with a burning quality is also suggestive of neurogenic
From the Universityof Connecticut School of Medicine, Farmington, CT pain or RSD. Associated numbness or tingling suggests a
and OrthopedicAssociates of Hartford, PC, Hartford, CT. neuroma (especially if the pain is located below a scar) or a
Address reprint requests to John P. Fulkerson, MD, Clinical Professor, radicular problem. All patients should be asked if they
University of Connecticut School of Medicine, Orthopedic Associates of
Hartford, PC, 270 Farmington Avenue, Suite 364, Farmington, CT 06032. have any hip or low back pain. Pain that is sharp,
Copyright © 1999 by W.B. Saunders Company intermittent, or unpredictable is characteristic of loose
1060-1872/0702-0002510.00/0 bodies or an unstable chondral flap.
reproduction of the patient's symptoms represent a posi- categorize the cause as peripatellar or patellofemoral.
tive test. W h e n an impression of medial or lateral patellar Peripatellar syndromes include synovial abnormalities
instability is established, the examiner m a y confirm the (pathologic plicae, bursitides), retinacular strain, iliotibial
diagnosis by applying a Trupull brace (Depuy-Orthotech, band friction syndrome, and extensor mechanism overuse
Tracy, CA) to correct the problem and see if the patient syndromes (patellar and quadriceps tendonitis, retinacular
experiences relief (Fig 4). strain, iliotibial band strain, Osgood-Schlatter disease,
Patients with patellofemoral dysfunction m a y have patel- Sinding-Larsen-Johansson disease). These diagnoses can
lar tilt w i t h o u t subluxation. This is because of a tight lateral be fairly easily differentiated through palpation on physi-
retinaculum and is referred to as excessive lateral pressure cal examination. If the athlete has a patellofemoral prob-
syndrome. It is assessed with the patellar tilt test. In normal lem, it m a y be one of patellar instability (subluxation or
knees, the patella can be passively elevated from the lateral recurrent dislocation), tilt (excessive lateral pressure syn-
side with the knee in full extension so that it is parallel to or drome), or arthrosis (degenerative or delaminating lesion
tilted slightly b e y o n d the horizontal plane. involving the patella a n d / o r femoral trochlea). Instability
and tilt can coexist and are determined by assessing limb
alignment and rotation, patellar tracking, pateUar glide,
DIFFERENTIAL DIAGNOSIS
and patellar tilt. Patellofemoral arthrosis m a y become
After the history and physical examination, the physician manifest on physical examination as painful patellar crepitus
should be able to determine, first, whether the pain the on knee range of motion with compression of the patella.
patient is experiencing is referred, radicular, or somatic in
nature. For true anterior knee pain, the next step is to SUMMARY
Anterior knee pain is c o m m o n in athletes and active
individuals, and the causes are fairly broad. However, by
performing a thorough history and physical examination,
the clinician should be able to make the correct diagnosis.
REFERENCES
1. Post WR, Fulkerson J: Knee pain diagrams: Correlation with physical
examination findings in patients with anterior knee pain. Arthroscopy
10:618-623, 1994
2. Fulkerson JP: The etiology of patellofemoral pain in young, active
patients: A prospective study. Clin Orthop 179:129-133, 1983
3. Fulkerson JP, Tennant R, Jaivin JS, et al: Histologic evidence of
retinacular nerve injury associatedwith patellofemoralmalalignment.
Clin Orthop 197:196-205, 1985
4. Kolowich PA, Paulos LE, Rosenberg TD, et al: Lateral release of the
patella: Indications and contraindications. Am J Sports Med 18:359-
Fig 4. A Trupull brace (DePuy Orthotech, Tracy, CA) may be 365, 1990
applied to correct either medial or lateral subluxation. The 5. Fulkerson JP: A clinical test for medial patella tracking (medial
diagnosis is confirmed if symptoms are relieved. subluxafion).TechOrthop 12:144, 1997.