PATELLO-FEMORAL PAIN SYNDROME (CHONDROMALACIA OF THE PATELLA;

PATELLOFEMORAL OVERLOAD SYNDROME)

There is no clear consensus concerning the terminology, aetiology and

treatment of pain and tenderness in the anterior part of the knee. This
syndrome is common among active adolescents and young adults. It is
often (but not invariably) associated with softening and fibrillation of the
articular surface of the patella chondromalacia patellae. Having no
other pathological label, orthopaedic surgeons have tended to regard
chondromalacia as the cause (rather than one of the effects) of the
disorder. Against this are the facts that (1) chondromalacia is commonly
found at arthroscopy in young adults who have no anterior knee pain,
and (2) some patients with the typical clinical syndrome have no
cartilage softening.
 PATELLO-FEMORAL PAIN SYNDROME (CHONDROMALACIA OF THE PATELLA;
PATELLOFEMORAL OVERLOAD SYNDROME)

Pathology
The basic disorder is probably mechanical overload of the patello-femoral joint.
Rarely, a single injury (sudden impact on the front of the knee) may damage the
articular surfaces. Much more common is repetitive overload due to either (1)
malcongruence of the patello-femoral surfaces because of some abnormal shape of
the patella or intercondylar groove, (2) malalignment of the lower extremity and/or
the patella, (3) muscular imbalance of the lower extremity with decreased strength
due to atrophy or inhibition, or relative weakness of the vastus medialis, which
causes the patella to tilt, or subluxate, or bear more heavily on one facet than the
other during flexion and extension, and (4) overactivity. Overload, as used here,
means either direct stress on a load-bearing facet or sheer stresses in the depths of
the articular cartilage at the boundary between high-contact and low-contact areas
(Goodfellow et al., 1976). Personality and chronic pain response issues must also be
considered (Thomee et al., 1999).
 PATELLO-FEMORAL PAIN SYNDROME (CHONDROMALACIA OF THE PATELLA;
PATELLOFEMORAL OVERLOAD SYNDROME)

Pathology
The basic disorder is probably mechanical overload of the patello-femoral joint.
Rarely, a single injury (sudden impact on the front of the knee) may damage the
articular surfaces. Much more common is repetitive overload due to either (1)
malcongruence of the patello-femoral surfaces because of some abnormal shape of
the patella or intercondylar groove, (2) malalignment of the lower extremity and/or
the patella, (3) muscular imbalance of the lower extremity with decreased strength
due to atrophy or inhibition, or relative weakness of the vastus medialis, which
causes the patella to tilt, or subluxate, or bear more heavily on one facet than the
other during flexion and extension, and (4) overactivity. Overload, as used here,
means either direct stress on a load-bearing facet or sheer stresses in the depths of
the articular cartilage at the boundary between high-contact and low-contact areas
(Goodfellow et al., 1976). Personality and chronic pain response issues must also be
considered (Thomee et al., 1999).
 PATELLO-FEMORAL PAIN SYNDROME (CHONDROMALACIA OF THE PATELLA;
PATELLOFEMORAL OVERLOAD SYNDROME)

Table 20.1 Causes of anterior knee pain

1. Referred from hip

2. Patellofemoral disorders
Patellar instability
Patello-femoral overload
Osteochondral injury
Patello-femoral osteoarthritis

3. Knee joint disorders

Osteochondritis dissecans
Loose body in the joint
Synovial chondromatosis
Plica syndrome

4. Peri-articular disorders
Patellar tendinitis
Patellar ligament strain
Bursitis
OsgoodSchlatter disease
 PATELLO-FEMORAL PAIN SYNDROME (CHONDROMALACIA OF THE PATELLA;
PATELLOFEMORAL OVERLOAD SYNDROME)

a c
Chondromalacia of the patella There is no pathognomonic feature on which to base the diagnosis of
chondromalacia, but several signs are suggestive. (a) Hold the patella against the femoral condyles and
ask the patient to tighten the thigh muscles; even in normal people this may be uncomfortable, but
patients with chondromalacia experience sudden acute pain in the patello-femoral joint. (b) A skyline x-
ray with the knee in partial flexion may show obvious tilting of the patella. (c) In the lateral x-ray, with
the knee flexed to 45, the lengths of the patella and the patellar ligament are normally about equal (a
ratio of 1:1); in patella alta the ratio is less than 1:1.
 PATELLO-FEMORAL PAIN SYNDROME (CHONDROMALACIA OF THE PATELLA;
PATELLOFEMORAL OVERLOAD SYNDROME)

Imaging
X-ray examination should include skyline views of the patella, which
may show abnormal tilting or subluxation, and a lateral view with the
knee half-flexed to see if the patella is high or small. The most
accurate way of showing and measuring patello-femoral malposition
is by CT or MRI with the knees in full extension and varying degrees of
flexion.
Arthroscopy
Cartilage softening is common in asymptomatic knees, and painful
knees may show no abnormality. However, arthroscopy is useful in
excluding other causes of anterior knee pain; it can also serve to
gauge patello-femoral congruence, alignment and tracking.
 PATELLO-FEMORAL PAIN SYNDROME (CHONDROMALACIA OF THE PATELLA;
PATELLOFEMORAL OVERLOAD SYNDROME)

Differential diagnosis
Other causes of anterior knee pain must be excluded before finally accepting the
diagnosis of patellofemoral pain syndrome. Even then, the exact cause of the syndrome
must be established before treatment: e.g. is it abnormal posture, overuse, patellar
malalignment, subluxation or some abnormality in the shape of the bones?
Treatment
CONSERVATIVE MANAGEMENT
In the vast majority of cases the patient will be helped by adjustment of stressful activities
and physiotherapy, combined with reassurance that most patients eventually recover
without physiotherapy. Exercises are directed specifically at strengthening the medial
quadriceps so as to counterbalance the tendency to lateral tilting or subluxation of the
patella. Some patients respond to simple measures such as providing support for a valgus
foot. Aspirin does no more than reduce pain, and corticosteroid injections should be
avoided.
 PATELLO-FEMORAL PAIN SYNDROME (CHONDROMALACIA OF THE PATELLA;
PATELLOFEMORAL OVERLOAD SYNDROME)

Treatment
OPERATIVE MANAGEMENT
Surgery should be considered only if (1) there is a
demonstrable abnormality that is correctable by operation,
or (2) conservative treatment has been tried for at least 6
months and (3) the patient is genuinely incapacitated.
Operation is intended to improve patellar alignment and
patella femoral congruence and to reduce patello-femoral
pressure.
 OSTEOCHONDRITIS DISSECANS
Pathology
The basic disorder is probably mechanical overload of the patello-femoral joint.
Rarely, a single injury (sudden impact on the front of the knee) may damage the
articular surfaces. Much more common is repetitive overload due to either (1)
malcongruence of the patello-femoral surfaces because of some abnormal shape of
the patella or intercondylar groove, (2) malalignment of the lower extremity and/or
the patella, (3) muscular imbalance of the lower extremity with decreased strength
due to atrophy or inhibition, or relative weakness of the vastus medialis, which
causes the patella to tilt, or subluxate, or bear more heavily on one facet than the
other during flexion and extension, and (4) overactivity. Overload, as used here,
means either direct stress on a load-bearing facet or sheer stresses in the depths of
the articular cartilage at the boundary between high-contact and low-contact areas
(Goodfellow et al., 1976). Personality and chronic pain response issues must also be
considered (Thomee et al., 1999).
 OSTEOCHONDRITIS DISSECANS
Classification
Osteochondritis dissecans of the knee is classified according to anatomical location, arthroscopic
appearance, scintigraphic or MRI findings and chronological age. For prognostic and treatment purposes
it is divided into juvenile and adult forms, either stable or unstable (Kocher et al., 2006).

Clinical features
- male
- age 1520 years
- presents with intermittent ache or swelling
- attacks of giving way such that the knee feels unreliable; locking sometimes occurs.
-Quadriceps muscle is wasted and there may be a small effusion
Soon after an attack there are two signs that are almost diagnostic:
(1) tenderness localized to one femoral condyle
(2) Wilsons sign: if the knee is flexed to 90 degrees, rotated medially and then gradually straightened,
pain is felt; repeating the test with the knee rotated laterally is painless.
 OSTEOCHONDRITIS DISSECANS
Imaging
Plain x-rays may show a line of demarcation around a lesion in situ, usually in the lateral part of the
medial femoral condyle. This site is best displayed in special intercondylar (tunnel) views, but even
then a small lesion or one situated far back may be missed. Once the fragment has become
detached, the empty hollow may be seen and possibly a loose body elsewhere in the joint.
 OSTEOCHONDRITIS DISSECANS
Imaging
Radionuclide scans show increased activity around the lesion, and MRI consistently shows an area of
low signal intensity in the T1 weighted images; the adjacent bone may also appear abnormal,
probably due to oedema. These investigations usually indicate whether the fragment is stable or
loose. MRI may also allow early prediction of whether the lesion will heal or not.
Arthroscopy
with early lesions the articular surface looks intact, but probing may reveal that the cartilage is soft.
Loose segments are easily visualized.
 OSTEOCHONDRITIS DISSECANS
Differential diagnosis
Avascular necrosis of the femoral condyle usually associated with corticosteroid therapy or alcohol
abuse may result in separation of a localized osteocartilaginous fragment. However, it is seen in an
older age group and on x-ray the lesion is always on the dome of the femoral condyle, and this
distinguishes it from osteochondritis dissecans.

Treatment
For the purposes of management, it is useful to stage the lesion; hence the importance of radionuclide
scanning, MRI and arthroscopy. Lesions in adults have a greater propensity to instability whereas
juvenile osteochondritis is typically stable. Those lesions with an intact articular surface have the
greatest potential to heal with non-operative treatment if repetitive impact loading is avoided.
 OSTEOCHONDRITIS DISSECANS
In the earliest stage, when the cartilage is intact and the lesion is stable, no treatment is
needed but activities are curtailed for 612 months. Small lesions often heal spontaneously.
If the fragment is unstable, i.e. surrounded by a clear boundary with radiographic sclerosis
of the underlying bone, or showing MRI features of separation, treatment will depend on
the size of the lesion. A small fragment should be removed by arthroscopy and the base
drilled; the bed will eventually be covered by fibrocartilage, leaving only a small defect. A
large fragment (say more than 1 cm in diameter) should be fixed in situ with pins or Herbert
screws. In addition, it may help to drill the underlying sclerotic bone to promote union of the
necrotic fragment. For drilling, the area is approached from a point some distance away,
beyond the articular cartilage.
If the fragment is completely detached but in one piece and shown to fit nicely in its bed, the
crater is cleaned and the floor drilled before replacing the loose fragment and fixing it with
Herbert screws. If the fragment is in pieces or ill-shaped, it is best discarded; the crater is
drilled and allowed to fill with fibrocartilage.
 OSTEOCHONDRITIS DISSECANS

(a) (b)
20.27 Osteochondritis dissecans Intraoperative pictures showing the articular lesion (a) and the defect left after
removal of the osteochondral fragment (b).
 LOOSE BODY
The knee relatively capacious, with large synovial folds is a common haven for loose
bodies. These may be produced by: (1) injury (a chip of bone or cartilage); (2)
osteochondritis dissecans (which may produce one or two fragments); (3) osteoarthritis
(pieces of cartilage or osteophyte); (4) Charcots disease (large osteocartilaginous bodies);
and (5) synovial chondromatosis (cartilage metaplasia in the synovium, sometimes producing
hundreds of loose bodies).
 LOOSE BODY

(a) (b) (c)

20.28 Loose bodies (a) This loose body slipped away from the fingers when touched; the
term joint mouse seems appropriate. (b) Which is the loose body here? Not the large one
(which is a normal fabella), but the small lower one opposite the joint line. (c) Multiple loose
bodies are seen in synovial chondromatosis, a rare disorder of cartilage metaplasia in the
synovium.
 LOOSE BODY
Clinical features
-symptomless
-attacks of sudden locking without injury
-The joint gets stuck in a position which varies from one attack to another. Sometimes the
locking is only momentary and usually the patient can wriggle the knee until it suddenly
unlocks. The patient may be aware of something popping in and out of the joint.
-In adolescents, a loose body is usually due to osteochondritis dissecans, rarely to injury. In
adults
-osteoarthritis is the most frequent cause.
-Only rarely is the patient seen with the knee still locked. Sometimes, especially after the
first attack, there is synovitis or there may be evidence of the underlying cause. A
pedunculated loose body may be felt; one that is truly loose tends to slip away during
palpation (the well-named joint mouse).
 LOOSE BODY

Imaging
X-ray Most loose bodies are radio-opaque. The films also
show an underlying joint abnormality.
Treatment
A loose body causing symptoms should be removed unless the joint is
severely osteoarthritic. This can usually be done through the
arthroscope, but finding the loose body may be difficult; it may be
concealed in a synovial pouch or sulcus and a small body may even
slip under the edge of one of the menisci.
 SYNOVIAL CHONDROMATOSIS
This is a rare disorder in which the joint comes to contain multiple
loose bodies, often in pearly clumps resembling sago (snowstorm
knee). The usual explanation is that myriad tiny fronds undergo
cartilage metaplasia at their tips; these tips break free and may
ossify. It has, however, been suggested that chondrocytes may be
cultured in the synovial fluid and that some of the products are
then deposited onto previously normal synovium, so producing the
familiar appearance (Kay et al., 1989).
 SYNOVIAL CHONDROMATOSIS

Imaging
X-rays reveal multiple loose bodies; on arthrography they
show as negative defects.
Treatment
Treatment The loose bodies should be removed arthroscopically. At
the same time an attempt should be made to remove all abnormal
synovium.
 PLICA SYNDROME
A plica is the remnant of an embryonic synovial partition which persists into
adult life. During development of the embryo, the knee is divided into three
cavities a large suprapatellar pouch and beneath this the medial and lateral
compartments separated from each other by membranous septa. Later these
partitions disappear, leaving a single cavity, but part of a septum may persist as
a synovial pleat or plica (from the Latin plicare = fold). This is found in over 20
per cent of people, usually as a median infrapatellar fold (the ligamentum
mucosum), less often as a suprapatellar curtain draped across the opening of
the suprapatellar pouch or a mediopatellar plica sweeping down the medial wall
of the joint.
 PLICA SYNDROME
Pathology
The plica in itself is not pathological. But if acute trauma, repetitive strain or some
underlying disorder (e.g. a meniscal tear) causes inflammation, the plica may
become oedematous, thickened and eventually fibrosed; it then acts as a tight
bowstring impinging on other structures in the joint and causing further synovial
irritation.
 PLICA SYNDROME
Clinical features
-An adolescent or young adult
-an ache in the front of the knee (occasionally both knees),
-intermittent episodes of clicking or giving way
-a history of trauma or markedly increased activity
-aggravated by exercise or climbing stairs, especially if this follows a long period of
sitting.
-muscle wasting and a small effusion.
-tenderness near the upper pole of the patella and over the femoral condyle.
-Occasionally the thickened band can be felt
-Movement of the knee may cause catching or snapping.
 PLICA SYNDROME
Diagnosis
The diagnosis is often not made until arthroscopy is undertaken. The presence of
a chondral lesion on the femoral condyle secondary to plica impingement confirms
the diagnosis.
Treatment
-rest
-anti-inflammatory drugs
-adjustment of activities
If symptoms persist the plica can be divided or excised by arthroscopy.