Is it just a made up term for people who have failed to identify the specific pathology that is the actual cause of the patient’s patellofemoral symptoms?

In a packed room, at our recent CPD meeting, with c. 20+ of our physiotherapist colleagues in attendance, Mr Ian McDermott, Consultant Knee Surgeon facilitated a lively interactive debate. 

Following lots of questions, practical assessment and evidenced by patient cases, the main conclusions were as follows:

• ‘Anterior Knee Pain’ is a symptom, not a diagnosis.
• There’s no such thing as ‘Patellofemoral Pain Syndrome’! – This is just a made up term for people who have failed to identify the specific pathology that is the actual cause of the patient’s patellofemoral symptoms.
• There is a long list of things that can cause anterior knee pain.
• Patellofemoral issues are very often multifactorial.
• Lateral patellar maltracking can be due to any one or any combination of the following:
  • excessive femoral anteversion / internal femoral torsion
  • genu valgum
  • external rotation of the tibial tuberosity (with an increased tibial-tuberosity-to-trochlea-groove (TTTG) distance)
  • planovalgus foot
• Apparent lateral patellar maltracking is sometimes actually due to patellar dysplasia.
• Factors predisposing to patellar instability include:
• patellar / trochlear / patellofemoral dysplasia
  • weak muscles / long legs (poor muscle power : lever arm ratio)
  • deficient VMO
  • deficiency of the medical retinaculum / medial patellofemoral ligament (MPFL) – and damage to this always occurs at the time of any patellar dislocation
  • history of previous dislocation(s): the medial retinaculum / MPFL rarely ever heals up properly, and the more times one dislocates ones patella, the more probable it will be that there will be further recurrent dislocations.
• If someone has dislocated their patella, then you must check for potential articular cartilage damage, particularly to the medial facet of the patella (and for potential loose bodies), plus one also needs to check for potential other associated damage in the knee, such as injury to the ACL.
• There is a place for conservative management of 1st time traumatic patellar dislocators who do not have significant underlying factors predisposing to instability.
• For people with significant underlying issues, and definitely for recurrent dislocators, it’s better to just get on and stabilise the patella surgically, because otherwise the longer you leave a patella unstable and the more dislocations there are, the more damage the patient will be accumulating to the articular cartilage in their patellofemoral joint, and the poorer the long-term prognosis will be, with a bigger risk of future patellofemoral arthritis.
• Importantly, you can’t fully assess the patellofemoral compartment without getting appropriate imaging.

• Useful imaging for patients with anterior knee pain can be:
  • X-rays, particularly including patellar skyline views
  • MRI (preferably 3T)
  • Ultrasound: if looking for tendinopathies or at the fat pad
  • CT, with 3D reconstruction and with special femoral views to assess trochlear morphology
• Physiotherapy is a crucial element of the treatment of pretty much every kind of patellofemoral issue, even if surgery is planned or even if it’s likely: appropriate physiotherapy may help the patient avoid the need for any actual surgery… but even if not, then pre-operative physio (‘Pre-hab’) will help the patient prepare better for their surgery and for the post-operative rehab that will be required afterwards, which will help them achieve a better outcome.
• Don’t forget the more rare potential causes of anterior knee pain, such as:
  • Osgood Schlatters’ ossicles
  • Fractures of the inferior pole of the patella
  • Tumours
  • Referred pain from the hip (especially in children) or from the back.

And finally, the main final take-home messages are:

1. Anterior knee pain is not a diagnosis!
2. ‘Patellofemoral Pain Syndrome’ is just a made-up term, which means that you simply haven’t yet indentified the actual cause(s) of the patient’s problem(s).
3. You can’t fully / properly assess the patellofemoral joint without full appropriate imaging.
4. Many (? most) patellofemoral problems are multifactorial.

The London Sports Orthopaedics Knee Team consists of:

• Mr Ian McDermott, Consultant Orthopaedic Surgeon & Managing Partner of London Sports Orthopaedics
• Mr Henry Atkinson, Consultant Orthopaedic Surgeon
• Mr Peter Hill, Consultant Orthopaedic Surgeon
• Mr Vipin Aspoa, Consultant Orthopaedic Surgeon

More information https://sportsortho.co.uk/specialists/

This event was one of a series of CPD events for our we run throughout the year for our allied healthcare professionals.  For more information or to register for one of our events visit https://sportsortho.co.uk/events/ or contact our Marketing Manager, Mary Wolff-Ingham  mary.wolff.ingham@sportsortho.co.uk