Patello-femoral pain syndrome:

- Is a broad term used to describe pain in the front of the knee

and around the patella, or kneecap.
- It is sometimes called "runner's knee" or "jumper's knee"
because it is common in people who participate in sports—
particularly females and young adults—but patella-femoral pain
syndrome can occur in non-athletes, as well.
- The pain and stiffness it causes can make it difficult to climb
stairs, kneel down, and perform other everyday activities.
- occurs when nerves sense pain in the soft tissues and bone
around the kneecap. These soft tissues include the tendons,
the fat pad beneath the patella, and the synovial tissue that
lines the knee joint.

Factors that may contribute to the development of patellofemoral pain

syndrome:

- Problems with the alignment of the kneecap, and,

- Overuse from vigorous athletics or training are often significant
factors.
- Vigorous physical activities that put repeated stress on the knee
(i.e., jogging, squatting, and climbing stairs)
- Sudden change in physical activity. This change can be in the
frequency of activity—such as increasing the number of days of
exercise each week, the duration or intensity of activity—such as
running longer distances
- Use of improper sports training techniques or equipment
- Changes in footwear or playing surface

Symptoms are often relieved with conservative treatment, such as changes in

activity levels or a therapeutic exercise program.

The most common symptoms of patella-femoral pain syndrome:

- Dull, aching pain in the front of the knee.

- Pain usually begins gradually and is frequently activity-related—
may be present in one or both knees.
- Pain during exercise and activities that repeatedly bend the knee,
such as climbing stairs, running, jumping, or squatting.
- Pain after sitting for a long period of time with your knees bent,
such as one does in a movie theater or when riding on an
airplane.
 - Pain related to a change in activity level or intensity, playing
surface, or equipment.
- Popping or crackling sounds in your knee when climbing stairs or
when standing up after prolonged sitting.

Treatment:
- Activity Changes

o Stop doing the activities that make your knee hurt until your pain
is resolved. This may mean changing your training routine or
switching to low-impact activities that will place less stress on
your knee joint. Biking and swimming are good low-impact
options. If you are overweight, losing weight will also help to
reduce pressure on your knee.
- The RICE Method

o RICE stands for rest, ice, compression, and elevation.

o Rest. Avoid putting weight on the painful knee.

o Ice. Use cold packs for 20 minutes at a time, several times a

day. Do not apply ice directly on skin.
o Compression. To prevent additional swelling, lightly wrap the
knee in an elastic bandage, leaving a hole in the area of the
kneecap. Make sure that the bandage fits snugly and does not
cause additional pain.
o Elevation. As often as possible, rest with your knee raised up
higher than your heart.
Medication
- Non-steroidal anti-inflammatory drugs (NSAIDs)

Evaluation:

- When did your knee pain start?

- Severity and nature of the pain (dull vs. sharp)
- What activities cause the pain to worsen?
- To determine the exact location of the pain:
o Gently press and pull on the front of the knees and kneecaps.
o Ask your patient to squat, jump, or lunge during the exam in
order to test your knee and core body strength.
o Check:
 Alignment of the lower leg and the position of the
kneecap
  Knee stability, hip rotation, and range of motion of knees
and hips
 The kneecap for signs of tenderness
 The attachment of thigh muscles to the kneecap
 Strength, flexibility, firmness, and tone of the hips, front
thigh muscles (quadriceps), and back thigh muscles
(hamstrings)
 Tightness of the heel cord and flexibility of the feet
 Examine gait (the way the patient walks).
- X-Rays or MSKUS
o Used to rule out damage to the structure of the knee and to the
tissues that connect to it.
Treatment:

- Medical treatment for patella-femoral pain syndrome is designed:

o To relieve pain
o Restore range of motion and strength.
o In most cases, patella femoral pain can be treated non-
surgically.
- Nonsurgical Treatment
o Patello-femoral pain syndrome is usually fully relieved with
simple measures or physical therapy. It may recur, however, if
you do not make adjustments to your training routine or activity
level. It is essential to maintain appropriate conditioning of the
muscles around the knee, particularly the quadriceps and the
hamstrings.
o In addition to activity changes, the RICE method, and anti-
inflammatory medication, your doctor may recommend the
following:
 Physical therapy exercises. 
 exercises to help improve range of motion, strength, and
endurance.
 It is especially important to focus on strengthening and
stretching of quadriceps since these muscles are the
main stabilizers of your kneecap.
 Core exercises may also be recommended to strengthen
the abdominal and lower back muscles.
 Orthotics. Shoe inserts can help align and stabilize the
foot and ankle, taking stress off of the lower leg. Orthotics
can either be custom-made or purchased "off the shelf."
- Surgical Treatment
o Surgical treatment for patellofemoral pain is very rarely
needed and is done only for severe cases that do not
respond to nonsurgical treatment. Surgical treatments may
include:
  Arthroscopy 
 Debridement. In some cases, removing damaged
articular cartilage from the surface of the patella can
provide pain relief.
 Lateral release. If the lateral retinaculum tendon is tight
enough to pull the patella out of the trochlear groove, a
lateral release procedure can loosen the tissue and
correct the patellar malalignment.
 Tibial Tubercle Transfer. In some cases, it may be
necessary to realign the kneecap by moving the
patellar tendon along with a portion of the tibial
tubercle—the bony prominence on the tibia (shinbone).
A traditional open surgical incision is required for this
procedure. The doctor partially or totally detaches the
tibial tubercle so that the bone and the tendon can be
moved toward the inner side of the knee. The piece of
bone is then reattached to the tibia using screws. In
most cases, this transfer allows for better tracking of
the kneecap in the trochlear groove.
- Preventive Measures:
o Wearing shoes appropriate to your activities
o Warming up thoroughly before physical activity
o Incorporating stretching and flexibility exercises for the
quadriceps and hamstrings into your warm-up routine, and
stretching after physical activity
o Increasing training gradually
o Reducing any activity that has hurt your knees in the past
o Maintaining a healthy body weight to avoid overstressing your
knees

Patellar Malalignment:

- Patello-femoral pain syndrome maybe caused by abnormal

tracking of the kneecap on the trochlear groove.
- In this condition, the patella is pushed out to one side of the
groove when the knee is bent.
- This abnormality may cause increased pressure between the back
of the patella and the trochlea, which can irritate the surrounding
soft tissues.
- Factors that contribute to poor tracking of the kneecap include:
o Problems with the alignment of the legs between the hips and
the ankles. Problems in alignment may result in a kneecap that
shifts too far toward the outside or inside of the leg, or one that
rides too high in the trochlear groove—a condition called patella
alta.
 o Muscular imbalances or weaknesses, especially in the
quadriceps muscles at the front of the thigh. When the knee
bends and straightens, the quadriceps muscles and quadriceps
tendon help to keep the kneecap within the trochlear groove.
Weak or imbalanced quadriceps can cause poor tracking of the
kneecap within the groove.

Patella Baja:

The Insall-Salvati ratio (TL/PL) is considered normal between 0.8

and 1.2: 

 patella baja: <0.8 (perhaps <0.74)

 patella alta: >1.2 (perhaps >1.5)

Patella Baja or patella infera is an abnormally low lying patella

[compare with patella alta, the high riding patella].It is
associated with a restricted range of motion, crepitations, and
retropatellar pain.

Patella baja could be congenital, acquired, or a combination of

the two is commonly encountered in total knee arthroplasty.

Any cause that would lead to shortening of the patellar tendon

would lead to patella baja.

Causes of Patella Baja

Injuries

 proximal tibial osteotomy – most common complication

following proximal tibial opening-wedge osteotomy

o shortening of the patellar tendon during tibial

osteotomy
o Scarring of the patellar tendon post-operatively
 Tibial tubercle slide or transfer
 Joint line elevation during total knee arthroplasty
[pseudo patella baja]
  ACL reconstruction
 Bony or ligamentous trauma

Achondroplasia

Quadriceps dysfunction

 Poliomyelitis
 Tourniquet paralysis

What is Pseudo Patella Baja

Pseudo patella baja is a condition where the cause of lower

patella is not due to shortened patellar tendon but elevated joint
line.

As we noted before, the cause of true patella baja is shortened

patellar tendon.

Pseudo patella baja is seen commonly after total knee

arthroplasty. The patella remains in a normal position relative to
the femoral trochlea but the level of the joint line is elevated,
pseudo-patella-baja is present.

This complication can occur due to higher femoral cut or tibial

under-resection (compared to the prosthetic tibial component
which is thicker)

Excessive soft tissue release may necessitate elevation of the

tibiofemoral joint line to provide stability.

Clinical Features

 Decrease in range of motion

 Extensor lag
 Anterior knee pain
 Tiredness as the knee consumes more energy due to a
short lever arm
 Rupture of quadriceps tendon or patellar tendon
Imaging

X-rays are done for the involved knee. Like patella alta, different
indices have been devised for confirmation of patella baja

A number of methods for determining patella height have been

devised.

Insall-Salvati ratio

according to the relative height of the patella and length of the

patellar tendon. It is assessed on lateral radiographs or sagittal
cross-sectional imaging.

Blackburne-Peel ratio

Ratio of the vertical distance between the tibial plateau and

patellar articular surface and length of the patellar articular
surface.

Caton-Linclau method

Vertical patella height is assessed by dividing the distance

between the anterosuperior rim of the tibia and the lowermost
end of the patellar articular surface by total length of the patellar
articular surface.

Norman, Egund and Ekelund method

This method assesses the vertical position of the patella on a

cross-table lateral view with knee maximally extended and
quadriceps muscle contracted prior to exposure.

The foot is externally rotated by 10-15 degrees in order to

superimpose femoral condyles.

The measured parameters include vertical position of the patella,

length of patella and length of patella tendon are expressed
relative to body height in centimeters.
Blumensaat’s technique

The lower pole of the patella normally lies at the level of the
Blumensaat line.

Treatment for Patella Baja

Post-surgical or post-traumatic patella baja is often symptomatic

and requires early surgical correction.

The aim of a surgical intervention is to make the patella

proximal.

Transfer of the tibial tubercle

Proximal transfer of tibial tubercle allows for early mobilization

to prevent the recurrence. But the extensor mechanism changes
that could occur with the proximal transfer is a concern.

Lengthening of Patellar Tendon

It is done by either using the contralateral bone tendon bone

graft or allografts.

Conventional z-plasty is convenient but weakens the tendon. V-Y

lengthening and frontal lengthening is also reported.

Patella Alta:

Patella alta, or a high riding patella, is a situation where the

position of the patella is considered high in relation to distal
femur. It may be idiopathic or may result secondary to an injury
or disease process.

The patella is up and above the knee joint instead of a normal

position in the groove.

As the patella is out of the groove and there is a very small

barrier [which normally groove offers] to keep the high-riding
patella in place, a strong contraction of the quadriceps muscle
can easily pull the patella over the edge and out of the groove,
leading to a patellar dislocation.

Apart from patellar dislocation, chondromalacia patella and

patellofemoral osteoarthritis are also associated with patella
alta.

It is considered a predisposing factor for the development of

patellofemoral pain.

Effects of Patella Alta on Biomechanics

Instability and patellofemoral arthritis are two major occurrences

in patella alta.

Normally on knee flexion, patella glides into a reciprocal groove

in the front of the femur, called the trochlear groove.  The groove
keeps the patella stable in the middle of the knee [sidewise
barrier] as it moves up and down.

The patella in straight knee sits above this groove, entering the

trochlear groove at about 20 or 30 degrees of knee flexion.

Till the time it enters the groove, the patella has the potential to
slide sideways especially laterally.

If the patella is sitting too high then the patella will only engage
in the trochlear groove later in the flexion arc (i.e. >20-30
degrees). This means that the patella is less stable for a greater
percentage of the time.

Another thing is the greater ‘windscreen wiper’ effect.

The shorter the patellar tendon the more restricted the potential
side-to-side movement of the patella will be.
The longer the patellar tendon by virtue of the longer the radius
of the arc of potential movement can lead to more side-to-side
movement.

Causes of Patella Alta

Though there is no exact etiology or cause for the existence of

the patella alta. Following factors can be considered in relation
to this condition

 Thin built.
 Patellofemoral Pain
 Knee Injuries
 Congenital /developmental
 Abnormally long patellar tendons (>52 mm).

Clinical Features

The patient may not have a complaint for a long period. Anterior
knee pain, especially in the patellar portion, can be present.

There could be instability of the gait. Or the patient may present

with recurrent dislocation of patella.

It can be present in patella-femoral osteoarthritis as well.

Symptoms may be slowly progressive or there may be an acute

presentation.

Activities which increase joint reaction force are ambulation on

an incline, squatting, prolonged sitting, and going up and down
stairs.

Often, the knee may be normal and most comparable to

the other side as it is difficult to appreciate patella alta
clinically especially in mild cases.

An effusion though may indicate a chronic pathology.

For clinical examination of patellar height, the patient sits on the
edge of the examination table with the feet on the ground, knees
bent at 90 degrees, and the thighs horizontally positioned.

The position of the patella is best observed from lateral side.

In patella alta, a partially tilted patella protrudes above the level

of the thigh, more remarkably so in unilateral cases.

Camelback Sign

Normally, the patella points straight forward. And there is only

one prominence noted and that is of tibia tuberosity.

In patients with a high-riding patella, the patella points upward.

In these patients, there is a prominence of the infrapatellar fat

pad in extension along with tibial tuberosity, giving an
impression of double prominence like camel’s back.

Grasshopper Eyes

This is better appreciated in bilateral patella alta. Some patients

may have externally rotated patellae consistent with patella alta
and lateral tilt. This is known as the “grasshopper eyes” sign.

In case of patellar instability,  Patellar apprehension test would

be positive.

Associations

Following conditions may be associated with patella alta and

There are a lot of conditions that are known to be associated
with patella alta. For example

 Patellofemoral instability
  Recurrent patellofemoral dislocation
• Neuromuscular diseases like poliomyelitis
• spastic cerebral palsy
 • Osgood Schlatter disease
• Sinding Larsen Johanssen disease
• Patella tendo-lateral femoral condyle friction syndrome
• Chondromalacia patella

Imaging and Confirmation of Patellar Height

X-rays of knee are basic investigations. Various ratios have been

devised to confirm patellar height. These ratios vary on various
parameters and are measured on lateral views of knee x-rays. On
radiography, it is important that standard positioning is used,
with the knee flexed at 30 degrees. An off-angle x-ray beam or
nonstandard positioning may result in a spuriously abnormal
ratio.

Several methods are used to determine the presence of patella

alta.

Following methods are used commonly

 Insall-Salvati ratio and modified Insall-Salvati ratio

 Caton-Deschamps index
 Blackburne Peel Method
 Blumensaat Method

Different indices for patellar height measurement, Image Credit:

Normal Patellar
Index Name Patella Alta Patella Baja
Height

Insall Salvati
1.0 >1.2 0.8
Ratio
Modified Insall
1.25 >2.0
Salvati Ratio

Blackburn-Peel
0.6 >1.0 <0.5
Ratio

Caton-Dechamps
1 >1.3 <0.6
Index

Treatment of Patella Alta

Conservative

 RICE treatment
 NSAIDs
 Physical therapy
 Braces

Operative Treatment

Tibial tubercle transfer

With this surgery, they move the attachment of the patellar

ligament downwards to the tibia. The patella is also attached to
this ligament, so the patella moves downwards.
Other Surgeries

Other Surgeries which may be considered considering the

different conditions associated with patella alta are

 Patellectomy
 Lateral release to loosened lateral tightness
 Vastus Medialis Oblique advancement surgery

Chondromalacia Patella:

Chondromalacia patella is a condition characterized by softening

and degeneration of the patellar articular cartilage.
Chondromalacia patella is a term sometimes considered
synonymous with patellofemoral pain syndrome but
patellofemoral pain syndrome is a term that applies only to
individuals without cartilage damage.

Chondromalacia patella is considered the most common cause of

chronic knee pain. There are no nerves in articular cartilage—so damage
to the cartilage itself cannot directly cause pain. Can lead to inflammation of
the synovium and pain in the underlying bone.

Cartilage under patella or kneecap acts as natural shock

absorber.  Overuse, injury, and many other factors can cause
increased deterioration and breakdown of the cartilage.

Chondromalacia is common among young, athletic individuals,

but may also occur in older adults who have arthritis of the knee.
There is a female predilection.

Causes of Chondromalacia Patella

The patella is normally pulled over the end of the femur in a

straight line by the quadriceps muscle. Patients with
chondromalacia patella frequently have abnormal patellar
tracking toward the lateral side of the femur causing femur to
grate on and cause chronic inflammation and pain. Abnormal
patellar movement occurs due to improper working of bones,
tendons or ligaments.
The general causes are

Risk Factors for Chondromalacia patella

Age

Adolescents and young adults are at high risk as during growth

spurts, the muscles and bones develop rapidly which may cause
short-term muscle imbalances.

Flat Feet

Flat feet puts higher stress on knee joints.

Trauma

A prior injury like dislocation or subluxation of patella can

increase risk of chondromalacia patella.

Chronic friction between the patella and femoral groove can also
result in this.

Activity

High-activity level or that places pressure on your knee joints,

this can increase the risk for knee problems.

Knee Pathologies

Inflammation as in arthritis can prevent the kneecap from

functioning properly. Other conditions of the knee which can
cause chondromalacia patella is patella alta [high riding patella]
quadriceps imbalance, weak hamstrings, congenital
abnormalities, patellar maltracking, synovial plicae, tight
iliotibial band, neuromas, bursitis etc.

Overuse
Persons engaging in soccer, gymnastics, cycling, rowing, tennis,
ballet, basketball, volleyball, running, combat sports,
snowboarding, skateboarding and even swimming are at
increased risk.

Clinical Presentation of Chondromalacia Patella

Chondromalacia patella is suspected in a person with anterior

knee pain, especially in teenage females or young adults.

Patients with chondromalacia patellae usually present with

anterior knee pain or vague discomfort of the inner side of the
knee, aggravated by activity (running, jumping, climbing or
descending stairs) or by prolonged sitting. There may be knee
pain when kneeling or squatting or after sitting for long periods
of time.

The patient may also complain of knee stiffness or tightness. The

examination may reveal mild swelling of the knee.

Imaging

Plain radiographs of the knee cannot assess for cartilage

changes and can only show bony changes if present e.g. that of
osteoarthritis.

MRI is the modality of choice for assessing patellar cartilage and

is able to display cartilage abnormalities.

Grading of Chondromalacia Patella

Grade I

Softening of the cartilage in the knee area.

Grade II 
Softening of the cartilage along with abnormal surface
characteristics. This usually indicates the beginning of tissue
erosion. 

Grade III 

Thinning of cartilage with the active deterioration of the tissue. 

Grade IV

Significant cartilage loss with bone exposure

Differential Diagnosis  

 Patellar Tendinosis
 Sinding-Larsen-Johansson disease
 Patellar sleeve fractures

Treatment of Chondromalacia Patella

 RICE therapy
 Curtailing the activities
 NSAIDs
 Exercises

o Stretch and strengthen quadriceps especially vastus

medialis
o Cardiovascular conditioning

 stationary bicycling
 swimming
 Proper training schedule
 Proper footwear

With proper treatment, the patient generally return to full

functional level.
Surgical options may be needed when the imbalance is severe or
the patient does not show improvement, surgical options may be
considered

 Arthroscopic debridement and lavage

 Articular resurfacing
 Instability correction
 Patellectomy

Prevention 

 Avoid repeated stress to your kneecaps.

 Use knee pads
 Quadriceps and hamstrings strengthening exercises, as
well as your abductors and adductors.
 Wear shoe inserts that correct flat feet
 Maintain proper weight

Patellofemoral arthritis

affects the underside of the patella (kneecap) and the channel-like groove in
the femur (thighbone) that the patella rests in. It causes pain in the front of
your knee and can make it difficult to kneel, squat, and climb and descend
stairs
Patellofemoral arthritis occurs when the articular cartilage along the
trochlear groove and on the underside of the patella wears down and becomes
inflamed. When cartilage wears away, it becomes frayed and, when the weais
severe, the underlying bone may become exposed. Moving the bones along
this rough surface may be painful.

Cause
Dysplasia
Dysplasia occurs when the patella does not fit properly in the trochlear groove
of the femur. Because of this, when the knee moves, there are increased
stresses on the cartilage. This begins to wear the cartilage down.
Kneecap Fracture
Patellar (kneecap) fractures often damage the articular cartilage that covers
and protects the underside of the bone. Even though the broken bone heals,
the joint surface may no longer be smooth. There is friction when the patella
moves against the joint surface of the femur. Over time, this can lead to
arthritis.
Symptoms
The main symptom of patellofemoral arthritis is pain. Because the patellofemoral joint is in front
of the knee, you may have pain in this area. The pain can be present at rest or with no activity at
all. Most of the time, however, it is brought on by activities that put pressure on the kneecap, such
as kneeling, squatting, climbing and descending stairs, and getting up from a low chair.

In addition, you may experience a crackling sensation called crepitus when you move your knee.
Crepitus is sometimes painful and can be loud enough for other people to hear. When the disease
is advanced, your kneecap may get stuck or "catch" when you straighten your knee

Treatment
Nonsurgical Treatment
Treatment of patellofemoral arthritis is similar to the treatment of knee arthritis in general. Most
cases can be treated without surgery. Nonsurgical options include:

Nonsteroidal anti-inflammatory drugs (NSAIDs). Drugs like aspirin, naproxen, and ibuprofen

reduce both pain and swelling.

Exercise. Regular exercise can decrease stiffness and strengthen the muscles that support your
knee. Patients who have patellofemoral arthritis should try to avoid activities that put stress on
the front of the knee, such as squatting. If you regularly do high-impact exercise, switching to low-
impact activities will put less stress on your knee. Walking and swimming are good low-impact
options.

Activity modification. In many cases, avoiding activities that bring on symptoms — such as
climbing stairs — will help relieve pain.

Weight loss. If you are overweight, losing just a few pounds can make a big difference in the
amount of stress you place on your knee. Losing weight can also make it easier to move and
maintain independence.

Physical therapy. Specific exercises can improve range-of-motion in your knee. Exercises to

strengthen the quadriceps muscles will help relieve pressure on the kneecap when you straighten
your leg. If an exercise causes pain, stop the exercise and talk to your doctor or physical therapist.

Cortisone (steroid) injections. Cortisone is a powerful anti-inflammatory medicine that can be

injected directly into your knee.

Viscosupplementation. In this procedure, a substance is injected into the joint to improve the
quality of the joint fluid.  The effectiveness of viscosupplementation in treating arthritis is unclear
and continues to be studied by researchers.

Surgical Treatment
Surgery is an option when nonsurgical treatment has failed. Several types of surgical procedures
are available.

Chondroplasty. This procedure is done with arthroscopy — inserting thin surgical instruments

into small incisions around your knee. During a chondroplasty, your surgeon trims and smooths
roughened arthritic joint surfaces. Chondroplasty is an option in cases of mild to moderate
cartilage wear.
Realignment. The soft tissues on either side of the kneecap are tightened or released to change the
position of the kneecap in the trochlear groove.

Cartilage grafting. Normal healthy cartilage tissue may be taken from another part of the knee or
from a tissue bank to fill a hole in the articular cartilage. This procedure is typically considered
only for younger patients who have small areas of cartilage damage.

Tibial tuberosity transfer. This procedure can help relieve pain in patients with arthritis in specific
portions of the patella. The patellar tendon below the kneecap attaches to a bump on the front of
the knee called the tibial tuberosity. Shifting the bump in any direction will change the position of
the kneecap. After the procedure, the patella should move more smoothly in the trochlear groove,
reducing pressure on the arthritic areas and relieving pain.

Patellofemoral replacement. During this "partial" knee replacement, damaged bone and cartilage
surfaces are removed and replaced with metal and polyethylene (plastic) components. A thin
metal shield is used to resurface the trochlear groove at the end of the femur. A plastic “button” or
cover is used to resurface the backside of the patella. These components are typically held to the
bone with cement.

Patellofemoral replacement surgery cannot be carried out if there is arthritis

involving other parts of the knee. If this is the case, your doctor may
recommend a total knee replacement.

Total knee replacement.  In a total knee replacement, all the cartilage surfaces
of the knee are resurfaced.  The end of the femur and the top of the tibia are
capped with a metal prosthesis.  A plastic spacer is placed in between these
components to create a smooth gliding surface.  Additionally, the patella itself
is usually resurfaced with a plastic “button.”

Outcomes
For most patients, treatment for patellofemoral arthritis is successful in
relieving pain and improving function. Outcomes vary, however, depending
on patient-specific factors and the type of treatment. Your doctor will talk
with you about the expected outcome of treatment in your specific situation.  

Sinding Larsen Johansson disease

[ also known as Sinding-Larsen disease or Larsen-Johannson

syndrome] is a type of osteochondrosis that affects the proximal
end of the patellar tendon as it inserts into the inferior pole of the
patella, and represents a chronic traction injury or overuse injury
of the immature osteotendinous junction. It is a closely related
condition to Osgood-Schlatter disease. Sinding Larsen Johansson
disease is an important cause of anterior knee pain in
adolescents.
Sinding Larsen Johansson disease is also called as pediatric
Jumper’s knee.

Both Sinding Larsen Johansson disease and Osgood Schlatter

disease can coexist. Sinding Larsen Johansson disease is seen
in active adolescents typically between 10-14 years of age.
Children with cerebral palsy are particularly prone to it.

The disease most often is seen in males who play sports like
football, running, volleyball, gymnastics. Norwegian physician
Christian Magnus Falsen Sinding-Larsen in 1921 and Swedish
physician Sven Christian Johansson in 1922 had described the
same entity independently.

Pathophysiology

The Sinding-Larsen-Johansson syndrome is caused by persistent

traction at the cartilaginous junction of the patella causes
chronic stress injury with overuse of the patella-patellar tendon
junction. Strain due to repetitive traction by the patellar tendon
on the lower pole of the patella [which is still partly cartilaginous
in adolescents] during quadriceps muscle contraction leads to
cartilage damage, swelling and later to tendon thickening and
fragmentation of the lower pole of the patella and sometimes to
bursitis.

Presentation

Clinically it is characterized by activity-related pain localized to

the anterior aspect of the lower pole of the patella. On
examination, there is inferior patella tenderness and focal
swelling may be noted.

Imaging

Xrays may be normal or may show thickening of the proximal

patellar tendon may be seen with stranding of the adjacent
portions of Hoffa’s fat pad [Fat that is situated under and behind
the patella bone within the knee.] Dystrophic calcification or
ossification may be noticed.
Ultrasound shows thickening and heterogeneity of the proximal
patellar tendon. Ultrasound can evidence all manifestations of
the Sinding-Larsen-Johansson disease.

MRI shows thickening of proximal and posterior part of the

patellar tendon.

Differential diagnosis

 Patella avulsion fractures

 Patella stress fracture
 Bipartite patella
 Osgood Schlatter disease – inferior attachment of the
patellar tendon into the tibial tuberosity
 Jumper’s knee – same location and similar pathology, but
seen in adults.
 Infrapatellar bursitis

Treatment

Rest and restriction of activity for at least 1–2 months that loads
knee such as football games and running. NSAIDs and ice may be
used in acute episodes or after the activity.

Physiotherapy including quadriceps strengthening exercises are

begun. Full recovery usually takes 12–24 months. Stretching and
strengthening exercises are started.
Sinding Larsen Johansson disease is self-limiting disease and the
pain would disappear when the patella is completely ossified. As
the skeleton matures, symptoms usually improve and, in this
way, it is regarded as a self-limiting process. However, symptoms
may be present for at least a year.

Patellar tendinosis

refers to anterior knee pain due to tendinosis resulting from

repeated loading of the knee extensors. It is also called Jumper’s
knee. Patellar tendinosis is found in sportsperson who play
sports that involve jumping and heavy landing, rapid acceleration
or deceleration and kicking, such as basketball, volleyball,
soccer, tennis, long jump, and high jump.

Tendinosis is characterized by progressive tissue degeneration with a failed

reparative response and the complete absence of inflammatory cells.
Unfortunately, the precise mechanism by which patellar
tendinosis develops is currently unknown.

Patellar tendinosis, if not treated can become chronic.

Causes of Patellar Tendinosis

Two kinds of factors affect this condition

Intrinsic Factors

Patellar height, malalignment, limb length discrepancy, muscular

imbalance or a combination of these, poor base strength of the
quadriceps muscles[

Extrinsic factors

Training frequency, the intensity of training, repeated training on

a rigid surface, the transition from one training method to
another,
improper mechanics during training and genetic abnormalities of
the knee joint.

History and clinical examination

Pain, well-localized anterior dull ache, usually is insidious in

onset and may be precipitated by activity. Initially, pain may
present as a dull ache at the beginning of or after activity. With
continued use, however, pain can progress to be present during
activity and can ultimately interfere significantly with
performance.

Constant pain at rest and night pain that disturbs sleep may
occur with time. Pain also may occur when a person is seated for
long periods, and when one climbs up and down the stairs.
On clinical examination, the most consistent finding is patellar
tendon tenderness at the inferior pole of the patella which is
more severe when the knee is extended and decreases in
severity when a knee is flexed to 90 degrees.

Wasting of the quadriceps and calf atrophy may also be present.

Functional strength testing of the quadriceps and calf muscles
may be decreased.

Decline Squat Test

Squatting on declined surfaces places the greater load. The

number of decline squats before the onset of pain and the level of
pain is noted.

Passive Extension Flexion Sign

In the supine position, with the knee in full extension, the

anterior aspect of the knee is palpated to and point of maximal
tenderness is noted which is most commonly located at the
origin of the tendon at the inferior pole of the patella. After that,
the knee is flexed to 90° and pressure is again applied to the
tendon. A marked reduction of tenderness to palpation when the
knee is flexed or the quadriceps confirms the diagnosis of
patellar tendinosis.

Standing Active Quadriceps Sign

While the patient stands, the point of maximal tenderness

identified. The patient then stands only on the involved extremity
with 30° of knee flexion and the tendon is repalpated. The
reduction in tenderness confirms the diagnosis of patellar
tendinosis.

Classification of Patellar Tendinosis

Blazina et al classification modified by Roels et al

 Stage 0 –  No pain
  Stage 1  – Pain only after intense sports activity, no
functional impairment
 Stage 2  – Pain at the beginning and after sports activity,
still able to perform at a satisfactory level
 Stage 3  – Pain during sports activity, increasing difficulty
in performing at a satisfactory level
 Stage 4 –  Pain during sports activity, unable to participate
in sport at a satisfactory level
 Stage 5 –  Pain during daily activity, unable to participate in
sport at any level

Differential Diagnoses of Patellar Tendinosis

Osgood-Schlatter’s disease which is a form of osteochondroses

is a differential diagnosis. In cases of adolescents it can be
confused with Sinding-Larsen-Johansson disease, also called as
pediatric jumper knee.

Patellofemoral pain syndrome,  chondromalacia patellae, fat-pad

syndrome should also be ruled out. Meniscal tears and cartilage
degeneration may need to may coexist.

Imaging Study

Ultrasonography reveals an area of hypoechoic [low

echogenicity] signal change and increased thickness
corresponding to the area of clinical tenderness.

Colour Doppler examination can identify the vascularity and

formation of new vessels in the area of structural change.

MRI shows a signal defect in the proximal patellar tendon and

increased thickness in the tendon. MRI provides high spatial
resolution and patellar tendinosis is characterized by a focal
increase in signal within the tendon as well as an alteration in its
size.

Whether ultrasonography or MRI, imaging is not useful in

monitoring outcomes following an intervention.
Treatment of Patellar Tendinosis

Conservative method is initiated at first and it aims at deloading

the tendon and to encourage regeneration. NSAIDs may be used
for pain relief if required. Corticosteroid injections may also be
used to reduce pain. Local ice application reduces pain in acute
situations.

The mainstay of the treatment is activity modification so that

patellar tendon is not loaded as much. This involves modification
of pain-provoking activities, reduction in training hours,
biomechanical correction [like improving strength and flexibility
of the muscles and shoe orthoses].

Surgery for patellar tendinosis is only indicated if the patient

does not become better even after 6 months of conservative
therapy. Surgical options available are arthroscopic debridement,
open excision of degenerated areas, repair of defects, multiple
longitudinal tenotomies, drilling of the inferior pole of the patella,
realignment of the tibial attachment of the patellar tendon.

Rehabilitation includes further strengthening and loading

exercises and then gradual return to play.

Osteochondritis Dissecans
Osteochondritis dissecans (OCD) is a condition that develops in joints, most
often in children and adolescents. It occurs when a small segment of bone begins
to separate from its surrounding region due to a lack of blood supply. As a result,
the small piece of bone and the cartilage covering it begin to crack and loosen.

The most common joints affected by osteochondritis dissecans are the knee,
ankle and elbow, although it can also occur in other joints. The condition
typically affects just one joint, however, some children can develop OCD in
several joints.

In many cases of OCD in children, the affected bone and cartilage heal on their
own, especially if a child is still growing. In grown children and young adults,
OCD can have more severe effects. The OCD lesions have a greater chance of
separating from the surrounding bone and cartilage, and can even detach and
float around inside the joint. In these cases, surgery may be necessary.
Cause
It is not known exactly what causes the disruption to the blood supply and the resulting OCD.
Doctors think it probably involves repetitive trauma or stresses to the bone over time.

Symptoms
Pain and swelling of a joint — often brought on by sports or physical activity — are the most
common initial symptoms of OCD. Advanced cases of OCD may cause joint catching or locking.

Doctor Examination
After discussing your child's symptoms and medical history, your doctor will perform a physical
examination of the affected joint.

Other tests which may help your doctor confirm a diagnosis include:

X-rays. These imaging tests provide detailed pictures of dense structures, like bone. An x-ray of
the affected joint is essential for an initial OCD diagnosis, and to evaluate the size and location of
the OCD lesion.
Magnetic resonance imaging (MRI) and ultrasound. These studies can create
better images of soft tissues like cartilage. An MRI can help your doctor
evaluate the extent to which the overlying cartilage is affected.

Treatment
Observation and Activity Changes
In most cases, OCD lesions in children and young teens will heal on their
own, especially when the body still has a great deal of growing to do. Resting
and avoiding vigorous sports until symptoms resolve will often relieve pain
and swelling.
Nonsurgical Treatment
If symptoms do not subside after a reasonable amount of time, your doctor
may recommend the use of crutches, or splinting or casting the affected arm,
leg or other joint for a short period of time.

In general, most children start to feel better over a 2- to 4-month course of

rest and nonsurgical treatment. They usually return to all activities as
symptoms improve.

Surgical Treatment
Your doctor may recommend surgery if:
 Nonsurgical treatment fails to relieve pain and swelling
 The lesion is separated or detached from the surrounding bone
and cartilage, moving around within the joint
 The lesion is very large (greater than 1 centimeter in diameter),
especially in older teens
There are different surgical techniques for treating OCD, depending upon the
individual case.
  Drilling into the lesion to create pathways for new blood vessels
to nourish the affected area. This will encourage healing of the
surrounding bone.
 Holding the lesion in place with internal fixation (such as pins
and screws).
 Replacing the damaged area with a new piece of bone and
cartilage (called a graft). This can help regenerate healthy bone
and cartilage in the area damaged by OCD.

In general, crutches are required for about 6 weeks after surgical treatment,
followed by a 2- to 4-month course of physical therapy to regain strength and
motion in the affected joint.

A gradual return to sports may be possible after about 4 to 5 months.

Bowed Legs (Blount's Disease)

Bowed legs in a toddler is very common. When a child with bowed legs stands
with his or her feet together, there is a distinct space between the lower legs and
knees. This may be a result of either one, or both, of the legs curving outward.
Walking often exaggerates this bowed appearance.

In most cases, bowed legs will naturally begin to straighten as the child grows. If
bowed legs have not resolved by the age of 3 years, there may be an underlying
cause, such as Blount’s disease or rickets.

Adolescents occasionally have bowed legs. In many of these cases, the child is
significantly overweight.

Cause
Physiologic Genu Varum
In most children under 2 years old, bowing of the legs is simply a normal
variation in leg appearance. Doctors refer to this type of bowing as physiologic
genu varum.

In children with physiologic genu varum, the bowing begins to slowly improve at
approximately 18 months of age and continues as the child grows. By ages 3 to 4,
the bowing has corrected and the legs typically have a normal appearance.

Blount's Disease
Blount's disease is a condition that can occur in toddlers, as well as in
adolescents. It results from an abnormality of the growth plate in the upper part
of the shinbone (tibia). Growth plates are located at the ends of a child's long
bones. They help determine the length and shape of the adult bone.
In a child under the age of 2 years, it may be impossible to distinguish infantile Blount's disease
from physiologic genu varum. By the age of 3 years, however, the bowing will worsen and an
obvious problem can often be seen in an x-ray.
Rickets
Rickets is a bone disease in children that causes bowed legs and other bone deformities. Children
with rickets do not get enough calcium, phosphorus, or Vitamin D — all of which are important
for healthy growing bones.

Nutritional rickets is unusual in developed countries because many foods, including milk
products, are fortified with Vitamin D. Rickets can also be caused by a genetic abnormality that
does not allow Vitamin D to be absorbed correctly. This form of rickets may be inherited.

Symptoms
Bowed legs are most evident when a child stands and walks. The most common symptom of
bowed legs is an awkward walking pattern.

Toddlers with bowed legs usually have normal coordination and are not delayed in learning how
to walk. The amount of bowing can be significant, however, and can be quite alarming to parents
and family members.

Turning in of the feet (intoeing) is also common in toddlers and frequently occurs in combination
with bowed legs.

Bowed legs do not typically cause any pain. During adolescence, however, persistent bowing can
lead to discomfort in the hips, knees, and/or ankles because of the abnormal stress that the
curved legs have on these joints. In addition, parents are often concerned that the child trips too
frequently, particularly if intoeing is also present.

Doctor Examination
Your doctor will begin your child's evaluation with a thorough physical examination.

If your child is under age 2, in good health, and has symmetrical bowing (the same amount of
bowing in both legs), then your doctor will most likely tell you that no further tests are currently
needed.

However, if your doctor notes that one leg is more severely bowed than the other, he or she may
recommend an x-ray of the lower legs. An x-ray of your child's legs in the standing position can
show Blount's disease or rickets.

If your child is older than 2 1/2 at the first doctor's visit and has symmetrical bowing, your doctor
will most likely recommend an x-ray. The likelihood of your child having infantile Blount's disease
or rickets is greater at this age. If the x-ray shows signs of rickets, your doctor will order blood
tests to confirm the presence of this disorder.

Treatment
Natural Progession of Disease
Physiologic genu varum nearly always spontaneously corrects itself as the child grows. This
correction usually occurs by the age of 3 to 4 years.

Untreated infantile Blount's disease or untreated rickets results in progressive worsening of the
bowing in later childhood and adolescence. Ultimately, these children have leg discomfort
(especially the knees) due to the abnormal stresses that occur on the joints. Adolescents with
Blount's disease are most likely to experience pain with the bowing.
Nonsurgical Treatment
Physiologic genu varum. Although physiologic genu varum does not require active treatment,
your doctor will want to see your child every 6 months until the bowing has resolved.
Blount's disease. Infantile Blount's disease does require treatment for the bowing to improve. If
the disease is caught early, treatment with a brace may be all that is needed. Bracing is not
effective, however, for adolescents with Blount's disease.
Rickets. If your child has rickets, your doctor will refer you to a metabolic specialist for medical
management, in addition to regular orthopaedic followup. The effects of rickets can often be
controlled with medication.
Surgical Treatment
Physiologic genu varum. In rare instances, physiologic genu varum in the toddler will not
completely resolve and during adolescence, the bowing may cause the child and family to have
cosmetic concerns. If the deformity is severe enough, then surgery to correct the remaining
bowing may be needed.
Blount's disease. If bowing continues to progress in a child with infantile Blount's disease despite
the use of a brace, surgery will be needed by the age of 4 years. Surgery may stop further
worsening and prevent permanent damage to the growth area of the shinbone.

Older children with bowed legs due to adolescent Blount's disease require surgery to correct the
problem.

Rickets. Surgery may also be needed for children with rickets whose deformities persist despite
proper management with medications.
Surgical procedures. There are different procedures to correct bowed legs, and they fall into two
main types.
 Guided growth. This surgery of the growth plate stops the growth on
the healthy side of the shinbone which gives the abnormal side a
chance to catch up, straightening the leg with the child's natural
growth.
 Tibial osteotomy. In this procedure, the shinbone is cut just below
the knee and reshaped to correct the alignment. The bone is held in
place while it heals with either an internal plate and screws, or an
external frame that is positioned on the outside of the leg.
After surgery, a cast may be applied to protect the bone while it heals. Crutches may be necessary
for a few weeks, and your doctor may recommend physical therapy exercises to restore strength
and range of motion. Your doctor will talk to you about full recovery time and return to regular
activities.

Genu valgum

valgus knee is used to describe knock-knee deformity. Knock-

knee deformity is commonly seen as-as a passing trait in
otherwise healthy children but some individuals retain or develop
this deformity due to hereditary, metabolic or other causes.

As genu valgum is a normal physiologic process in children,

therefore it is critical to differentiate between a physiologic and
pathologic process
Both deformities in the upper tibia and distal femur can give rise
to genu valgum. The distal femur is the most common location of
primary pathologic genu valgum.

Adolescent idiopathic genu valgum may be familial or it may

occur sporadically. The true incidence is unknown.

Anatomy and Relevant Measurements

The normal physiologic process of genu valgum starts between

3-4 years of age children and have up to 20 degrees of genu
valgum can be seen. Genu valgum rarely worsens after age 7 and
after age 7 valgus should not be worse than 12 degrees of genu
valgum.

Intermalleolar distance is the distance between the two malleoli

measured when knee touch each other with patella facing
forward. After the age of 7 years, the intermalleolar distance
should be <8 cm.

[read about anatomy of knee]

Measurements are based on full length standing AP xray of lower

limbs including hip, knee and ankle

The lateral distal femoral angle is the angle between the femoral
shaft and its condyles. The normal angle is 84°.

Proximal medial tibial angle is the angle between the tibial shaft
and its plateau. The normal angle is 87°.

The mechanical axis (center of gravity) is a straight line drawn

from the center of the femoral head to the center of the ankle;
this should bisect the knee. An axis within the two central
quadrants (zones +1 or -1) of the knee is deemed acceptable.
Pathophysiology of Genu Valgum

With normal alignment, the lower-extremity lengths are equal,

and the mechanical axis bisects the knee when the patient is
standing erect with the patellae facing forward.

With normal alignment, the physes and epiphyses are subjected

to physiologic and intermittent compression and tension.
Balanced growth is important for preserving straight legs,
symmetrical limb lengths, and normal function.

When genu valgum is present, there is a shift of the mechanical

axis laterally which causes pathologic stress on the lateral femur
and tibia.

Moreover, the normal expansion of entire hemiphysis is

prevented [Hueter-Volkmann effect–continuous or excessive
compressive forces on the epiphysis have an inhibitory effect on
growth. ]

A vicious cycle ensues.

The growth suppression of the lateral condyle of the femur leads

to shallow femoral sulcus and increased the propensity for the
patella to tilt and subluxate laterally. In extreme cases, patellar
dislocation with or without osteochondral fractures may ensue.

The shallow, incongruous, or unstable patellofemoral joint may

cause activity-related anterior pain, causing activity-related
anterior knee pain.

During walking thrust of the tibia relative to the femur may cause
strain of medial collateral ligaments, resulting in localized pain
and progressive joint laxity.

The patients may develop a circumduction gait because outward

swinging of the legs is required to avoid knocking their knees
together leading to an awkward and laborious.
Depending on the severity, the patient may find it difficult to run,
ride a bicycle, play sports.

Left untreated, the condition may progress and deteriorate.

Meniscal tears, articular cartilage attrition, and arthrosis of the

anterior and lateral compartments may occur during adult years.

Causes of Genu Valgum

Bilateral Genu Valgum

 Physiologic
 Metabolic [Nutritional rickets]
 Renal osteodystrophy (renal rickets)
 Genetic Disorders
 Skeletal dysplasia

o Morquio syndrome
o Spondyloepiphyseal dysplasia
o Chondroectodermal dysplasia

Unilateral Genu Valgum

 physeal injury from trauma, infection, or vascular insult

 Fracture malunion

o Distal femur fracture

o proximal metaphyseal tibia fracture
 Poliomyelitis
 Benign tumors
o fibrous dysplasia
o osteochondromas
o Ollier’s disease

Physiologic Genu Valgum or Not?

Physiologic genu valgum is seen in aged 2-6 years may have

physiologic genu valgum.
The typical features include symmetrical deformity, ligamentous
laxity, and lack of pain or functional limitations. It is important to
differentiate physiologic genu valgum from the rest as it does not
require any treatment.

And it is also important not to miss pathological causes of genu

valgum.

Postaxial limb deficiencies, genetic disorders such as  Down

syndrome, hereditary multiple exostoses, neurofibromatosis, and
vitamin D–resistant rickets may cause persistent and
symptomatic genu valgum and present early.

In contrast, adolescent idiopathic genu valgum is not benign or

self-limiting. Teenagers may present with a circumduction gait,
anterior knee pain, and, occasionally, patellofemoral instability.

Clinical Presentation of Genu Valgum

Usually, the genu valgum apparently when the child reaches the
walking age.

The physiologic genu valgum generally resolves spontaneously

by age of six years.

The deformity could be seen early in life when there is some kind
of localized or generalized skeletal malformation or dysplasia.

Family history is to consider or rule out hereditary multiple

exostoses, Marfan syndrome, osteogenesis imperfecta,
or vitamin D–resistant rickets.

Nutritional deficiency vitamin D and calcium is prevalent in

certain countries and nutritional rickets should be considered as
a differential diagnosis.

A unilateral valgus is always pathological and investigated

accordingly.
The physical examination should assess the gait and evaluation
of the lower extremities.

Stature, craniofacial features, the spine, and the upper

extremities should be evaluated.

Compare the relative limb and look for any torsional deformities
of the femur, tibia, or both. Look for retropatellar crepitus and
tenderness and note patellar tilt, tracking, and stability.

Lab Studies

Relevant blood and urine studies are warranted.

This includes routine tests, calcium levels, and vitamin D levels.

Endocrine studies may be done depending on the condition
suspected.

Bone densitometry may be warranted in certain patients.

Imaging Studies

X-rays

Standing anteroposterior radiograph of the lower extremities,

taken with the patellae facing forwards the standard exposure.
This allows visualization of both the true and the apparent limb
lengths and deformities.

The mechanical axis is a line drawn from the center of the head
of the femur to the center of the ankle; this line should bisect the
knee. Genu valgum is defined by lateral deviation of the axis or
deviation toward or beyond the joint margin.

The deformity may be in the femur, the tibia, or both. The normal
lateral distal femoral angle is 84° (6° of valgus), and the medial
proximal tibial angle is 87° (3° of varus).
When the physeal abnormalities are suspected, AP and lateral
radiographs of the hip or knee provide better visualization of the
physis. If a skeletal dysplasia is suggested, a skeletal survey is
warranted.

A skyline or sunrise or Merchant view of the knee may reveal tilt,

subluxation, and, occasionally, osteochondral defects or loose
bodies of the patella.

An AP radiograph of the wrist for bone age is done to know the

remaining growth potential.

Treatment of Genu Valgum

The treatment aims at correction of genu valgum and

neutralization of the forces across the knee are the goals of
treatment and, if necessary, repeated intervention.

Non-Operative Treatment

The child with vitamin D–resistant rickets should be on

appropriate medication to optimize bone formation and
mineralization. Likewise, children with osteogenesis imperfecta
may benefit from treatment with bisphosphonates to increase
bone density and decrease the risk of fractures.

Nutritional deficiency is corrected when required.

Observation is indicated in genu valgum <15 degrees in a child <6

years of age. Bracing is rarely used.

It is not effective in pathologic genu valgum and unnecessary in

physiologic genu valgum

Operative Treatment

Hemiepiphysiodesis or Physeal Tethering of Medial Side

This aims at arresting the growth of medial physis. As the lateral
condyle continues to grow, the limb straightens. Its indicated in
> 15-20° of valgus in a patient <10 years of age

Its also indicated if the line drawn from center of femoral head to
center of ankle falls in the lateral quadrant of tibial plateau in
patient > 10 yrs of age.

The arrest of growth could be temporary or permanent. Staples

are used for a temporary halt.  Growth begins within 24 months
after removal of the tether

Apart from staples, screws or plate and screws can also be

used.

It is important to place them extraperiosteally as to avoid

physeal injury.

Hemiphysiodesis works only when sufficient growth potential is

remaining.

When the mechanical axis has been restored to neutral, the

implants are removed. Growth should be monitored because if
the valgus recurs, guided growth may have to be repeated.

Corrective Osteotomy

Distal femoral varus osteotomy and other corrective

osteotomies are used when there is insufficient remaining
growth for hemiepiphysiodesis or after skeletal maturity.

Peroneal nerve injury is common and it is important to perform a

peroneal nerve release prior to surgery

Prognosis

Untreated,  this condition may result in premature degenerative

changes in the patellofemoral joint and in the lateral
compartment of the knee.
The threshold of deformity that leads to future degenerative
changes is unknown

Results of guided growth [controlling the growth of physis by

hemiphysiodesis]  are uniformly gratifying.

Genu recurvatum 

a deformity in the knee  where the knee angulates backwards

because of hyperextension occurs in the tibiofemoral joint [the
knee goes further into extension beyond the neutral]

Genu recurvatum is also called knee hyperextension and back

knee.

Depending upon hyperextension, the recurvatum could be mild,

moderate or severe.

The normal range of motion of the knee joint is from 0 to 135

degrees in an adult. Genu recurvatum is operationally defined as
knee extension greater than 5°[Also labeled as -5 and implies 5
degrees beyond zero.]

Genu recurvatum may cause knee pain, an extension pattern gait

and have poor proprioceptive control of terminal knee extension.

The condition can be congenital or acquired.

Congenital genu recurvatum is apparent at birth. It can occur as

an isolated entity or can be associated with other
musculoskeletal anomalies, or part of a syndrome. [see the list of
causes]

Isolated congenital genu recurvatum is thought to be associated

with include breech positioning and oligohydramnios.
Congenital dislocation of the knee is the major cause of
pathological genu recurvatum and some authors consider them
entities in the continuum.

Factors Causing Genu Recurvatum

The following factors may be involved in causing this deformity

 Laxity of the knee ligaments

 Muscle Weakness

o Biceps femoris muscle

o Hip extensor muscles
o Gastrocnemius muscle
o Popliteus muscle weakness

 Malalignment of the tibia and femur as in malunion

 Instability of the knee joint due to ligaments and joint
capsule injuries
 Deficit in joint proprioception
 Lower limb length discrepancy

Conditions Associated with knee recurvatum

 Spastic lesions
 Lower motor neuron lesions like Polio
 Congenital genu recurvatum
 Cerebral palsy
 Multiple sclerosis
 Muscular dystrophy
 Plantar flexion contracture
 Arthrogryposis multiplex congenita
 Congenital knee dislocation
 Connective tissue disorders (e.g. Ehlers-Danlos
disease, Larsen syndrome)
 Connective tissue disorders
o

 Marfan syndrome
  Ehlers-Danlos syndrome
 Benign hypermobile joint syndrome
 Osteogenesis imperfecta disease
 Proximal growth plate injury
 Osgood-Schlatter disease
 osteomyelitis)
 Ligament injury as in sports

 Cruciate ligament injury

 Posterolateral corner injury
 Superficial medial collateral knee
 Posterior oblique ligament.

Clinical Presentation

Knee recurvatum may be asymptomatic or may cause

 Knee giving way into hyperextension

 Difficulty with endurance activities
 Pinching in the front of the knee

An assessment of a patient for ligament hypermobility should be

made.

Imaging

X-rays rule out bony injuries or subluxation.

Assessment of knee alignment must be performed via a long leg

x-ray. Their posterior tibial slope must also be calculated on a
lateral knee x-ray.

Patients who have a decreased posterior tibial slope tend to have

more problems with knee hyperextension.

Treatment for Genu Recurvatum

Positional congenital knee recurvatum gets resolved

spontaneously.
For other types of congenital recurvatum treatment may include
watchful waiting, flexion exercises, splinting, casting, or surgery.
The treatment is guided by severity.

Treatment of acquired genu recurvatum would depend on the

cause. Not all causes would be curable though and treatment
may aim at functional improvement.

For example, ligament reconstruction should be done in cases of

ligament injury and osteotomy may improve the knee in case of
malalignment.

Proximal tibial osteotomy in cases where the tibial slope is

increased may be done.

Anterior Cruciate Ligament (ACL) Injuries

One of the most common knee injuries is an anterior cruciate ligament
sprain or tear.

Athletes who participate in high demand sports like soccer, football, and
basketball are more likely to injure their anterior cruciate ligaments.

If you have injured your anterior cruciate ligament, you may require surgery to
regain full function of your knee. This will depend on several factors, such as the
severity of your injury and your activity level.

Anatomy
Three bones meet to form your knee joint: your thighbone (femur), shinbone
(tibia), and kneecap (patella). Your kneecap sits in front of the joint to provide
some protection.

Bones are connected to other bones by ligaments. There are four primary
ligaments in your knee. They act like strong ropes to hold the bones together and
keep your knee stable.

Collateral Ligaments
These are found on the sides of your knee. The medial collateral ligament is on
the inside and the lateral collateral ligament is on the outside. They control the
sideways motion of your knee and brace it against unusual movement.
Cruciate Ligaments
These are found inside your knee joint. They cross each other to form an "X" with
the anterior cruciate ligament in front and the posterior cruciate ligament in
back. The cruciate ligaments control the back and forth motion of your knee.

The anterior cruciate ligament runs diagonally in the middle of the knee. It
prevents the tibia from sliding out in front of the femur, as well as provides
rotational stability to the knee.

Description
About half of all injuries to the anterior cruciate ligament occur along with
damage to other structures in the knee, such as articular cartilage, meniscus,
or other ligaments.

Injured ligaments are considered "sprains" and are graded on a severity scale.

Grade 1 Sprains. The ligament is mildly damaged in a Grade 1 Sprain. It has been slightly
stretched, but is still able to help keep the knee joint stable.
Grade 2 Sprains. A Grade 2 Sprain stretches the ligament to the point where it becomes loose.
This is often referred to as a partial tear of the ligament.
Grade 3 Sprains. This type of sprain is most commonly referred to as a complete tear of the
ligament. The ligament has been split into two pieces, and the knee joint is unstable.

Partial tears of the anterior cruciate ligament are rare; most ACL injuries are complete or near
complete tears.

Cause
The anterior cruciate ligament can be injured in several ways:
 Changing direction rapidly
 Stopping suddenly
 Slowing down while running
 Landing from a jump incorrectly
 Direct contact or collision, such as a football tackle
Several studies have shown that female athletes have a higher incidence of ACL injury than male
athletes in certain sports. It has been proposed that this is due to differences in physical
conditioning, muscular strength, and neuromuscular control. Other suggested causes include
differences in pelvis and lower extremity (leg) alignment, increased looseness in ligaments, and
the effects of estrogen on ligament properties.

Symptoms
When you injure your anterior cruciate ligament, you might hear a "popping" noise and you may
feel your knee give out from under you. Other typical symptoms include:
 Pain with swelling. Within 24 hours, your knee will swell. If ignored,
the swelling and pain may resolve on its own. However, if you
attempt to return to sports, your knee will probably be unstable and
you risk causing further damage to the cushioning cartilage
(meniscus) of your knee.
 Loss of full range of motion
 Tenderness along the joint line
  Discomfort while walking

Doctor Examination
Physical Examination and Patient History
During your first visit, your doctor will talk to you about your symptoms and medical history.

During the physical examination, your doctor will check all the structures of your injured knee,
and compare them to your non-injured knee. Most ligament injuries can be diagnosed with a
thorough physical examination of the knee.

Imaging Tests
Other tests which may help your doctor confirm your diagnosis include:
X-rays. Although they will not show any injury to your anterior cruciate ligament, x-rays can show
whether the injury is associated with a broken bone.
Magnetic resonance imaging (MRI) scan. This study creates better images of soft tissues like the
anterior cruciate ligament. However, an MRI is usually not required to make the diagnosis of a
torn ACL.

Treatment
Treatment for an ACL tear will vary depending upon the patient's individual needs. For example,
the young athlete involved in agility sports will most likely require surgery to safely return to
sports. The less active, usually older, individual may be able to return to a quieter lifestyle without
surgery.
Nonsurgical Treatment
A torn ACL will not heal without surgery. But nonsurgical treatment may be effective for patients
who are elderly or have a very low activity level. If the overall stability of the knee is intact, your
doctor may recommend simple, nonsurgical options.
Bracing. Your doctor may recommend a brace to protect your knee from instability. To further
protect your knee, you may be given crutches to keep you from putting weight on your leg.
Physical therapy. As the swelling goes down, a careful rehabilitation program is started. Specific
exercises will restore function to your knee and strengthen the leg muscles that support it.
Surgical Treatment
Rebuilding the ligament. Most ACL tears cannot be sutured (stitched) back together. To surgically
repair the ACL and restore knee stability, the ligament must be reconstructed. Your doctor will
replace your torn ligament with a tissue graft. This graft acts as a scaffolding for a new ligament to
grow on.

Grafts can be obtained from several sources. Often they are taken from the patellar tendon, which
runs between the kneecap and the shinbone. Hamstring tendons at the back of the thigh are a
common source of grafts. Sometimes a quadriceps tendon, which runs from the kneecap into the
thigh, is used. Finally, cadaver graft (allograft) can be used.

There are advantages and disadvantages to all graft sources. You should discuss graft choices with
your own orthopaedic surgeon to help determine which is best for you.

Because the regrowth takes time, it may be six months or more before an athlete can return to
sports after surgery.

Procedure. Surgery to rebuild an anterior cruciate ligament is done with an arthroscope using

small incisions. Arthroscopic surgery is less invasive. The benefits of less invasive techniques
include less pain from surgery, less time spent in the hospital, and quicker recovery times.
Rehabilitation
Whether your treatment involves surgery or not, rehabilitation plays a vital role in getting you
back to your daily activities. A physical therapy program will help you regain knee strength and
motion.

If you have surgery, physical therapy first focuses on returning motion to the joint and
surrounding muscles. This is followed by a strengthening program designed to protect the new
ligament. This strengthening gradually increases the stress across the ligament. The final phase of
rehabilitation is aimed at a functional return tailored for the athlete's sport.

Posterior Cruciate Ligament Injuries

The posterior cruciate ligament is located in the back of the knee. It is one of
several ligaments that connect the femur (thighbone) to the tibia (shinbone). The
posterior cruciate ligament keeps the tibia from moving backwards too far.

An injury to the posterior cruciate ligament requires a powerful force. A common

cause of injury is a bent knee hitting a dashboard in a car accident or a football
player falling on a knee that is bent.

Anatomy
Two bones meet to form your knee joint: your thighbone (femur) and shinbone
(tibia). Your kneecap sits in front of the joint to provide some protection.

Bones are connected to other bones by ligaments. There are four primary
ligaments in your knee. They act like strong ropes to hold the bones together and
keep your knee stable.

Collateral ligaments. These are found on the sides of your knee. The medial
collateral ligament is on the inside and the lateral collateral ligament is on the
outside. They control the sideways motion of your knee and brace it against
unusual movement.
Cruciate ligaments. These are found inside your knee joint. They cross each other
to form an "X" with the anterior cruciate ligament in front and the posterior
cruciate ligament in back. The cruciate ligaments control the back and forth
motion of your knee.
The posterior cruciate ligament keeps the shinbone from moving backwards too far. It is stronger
than the anterior cruciate ligament and is injured less often. The posterior cruciate ligament has
two parts that blend into one structure that is about the size of a person's little finger.

Description
Injuries to the posterior cruciate ligament are not as common as other knee ligament injuries. In
fact, they are often subtle and more difficult to evaluate than other ligament injuries in the knee.

Many times a posterior cruciate ligament injury occurs along with injuries to other structures in
the knee such as cartilage, other ligaments, and bone.

Injured ligaments are considered "sprains" and are graded on a severity scale.
Grade 1 Sprains. The ligament is mildly damaged in a Grade 1 Sprain. It has been slightly
stretched, but is still able to help keep the knee joint stable.
Grade 2 Sprains. A Grade 2 Sprain stretches the ligament to the point where it becomes loose.
This is often referred to as a partial tear of the ligament.
Grade 3 Sprains. This type of sprain is most commonly referred to as a complete tear of the
ligament. The ligament has been split into two pieces, and the knee joint is unstable.
Posterior cruciate ligament tears tend to be partial tears with the potential to heal on their own.
People who have injured just their posterior cruciate ligaments are usually able to return to sports
without knee stability problems.

Cause
An injury to the posterior cruciate ligament can happen many ways. It typically requires a
powerful force.
 A direct blow to the front of the knee (such as a bent knee hitting a
dashboard in a car crash, or a fall onto a bent knee in sports)
 Pulling or stretching the ligament (such as in a twisting or
hyperextension injury)
 Simple misstep

Symptoms
The typical symptoms of a posterior cruciate ligament injury are:
 Pain with swelling that occurs steadily and quickly after the injury
 Swelling that makes the knee stiff and may cause a limp
 Difficulty walking
 The knee feels unstable, like it may "give out"

Doctor Examination
During your first visit, your doctor will talk to you about your symptoms and
medical history.

During the physical examination, your doctor will check all the structures of
your injured knee, and compare them to your non-injured knee. Your injured
knee may appear to sag backwards when bent. It might slide backwards too
far, particularly when it is bent beyond a 90° angle. Other tests which may
help your doctor confirm your diagnosis include X-rays and magnetic
resonance imaging (MRI). It is possible, however, for these pictures to appear
normal, especially if the injury occurred more than 3 months before the tests.

X-rays. Although they will not show any injury to your posterior cruciate
ligament, X-rays can show whether the ligament tore off a piece of bone when
it was injured. This is called an avulsion fracture.
MRI. This study creates better images of soft tissues like the posterior
cruciate ligament.

Treatment
Nonsurgical Treatment
If you have injured just your posterior cruciate ligament, your injury may heal quite well without
surgery Your doctor may recommend simple, nonsurgical options.
RICE. When you are first injured, the RICE method - rest, ice, gentle compression and elevation
— can help speed your recovery.
Immobilization. Your doctor may recommend a brace to prevent your knee from moving. To
further protect your knee, you may be given crutches to keep you from putting weight on your leg.
Physical therapy. As the swelling goes down, a careful rehabilitation program is started. Specific
exercises will restore function to your knee and strengthen the leg muscles that support it.
Strengthening the muscles in the front of your thigh (quadriceps) has been shown to be a key
factor in a successful recovery.
Surgical Treatment
Your doctor may recommend surgery if you have combined injuries. For example, if you have
dislocated your knee and torn multiple ligaments including the posterior cruciate ligament,
surgery is almost always necessary.
Rebuilding the ligament. Because sewing the ligament ends back together does not usually heal, a
torn posterior cruciate ligament must be rebuilt. Your doctor will replace your torn ligament with
a tissue graft. This graft is taken from another part of your body, or from another human donor
(cadaver). It can take several months for the graft to heal into your bone.
Procedure. Surgery to rebuild a posterior cruciate ligament is done with an arthroscope using
small incisions. Arthroscopic surgery is less invasive. The benefits of less invasive techniques
include less pain from surgery, less time spent in the hospital, and quicker recovery times.

Surgical procedures to repair posterior cruciate ligaments continue to improve. More advanced
techniques help patients resume a wider range of activities after rehabilitation.

Rehabilitation
Whether your treatment involves surgery or not, rehabilitation plays a vital role in getting you
back to your daily activities. A physical therapy program will help you regain knee strength and
motion. If you had surgery, physical therapy will begin 1 to 4 weeks after your procedure.

How long it takes you to recover from a posterior cruciate ligament injury will depend on the
severity of your injury. Combined injuries often have a slow recovery, but most patients do well
over time.

If your injury requires surgery, it may be several weeks before you return to a desk job - perhaps
months if your job requires a lot of activity. Full recovery typically requires 6 to 12 months.

Although it is a slow process, your commitment to therapy is the most important factor in
returning to all the activities you enjoy.

Meniscus Tears
Meniscus tears are among the most common knee injuries. Athletes,
particularly those who play contact sports, are at risk for meniscus
tears. However, anyone at any age can tear a meniscus. When people
talk about torn cartilage in the knee, they are usually referring to a
torn meniscus.

Anatomy
Three bones meet to form your knee joint: your thighbone (femur), shinbone
(tibia), and kneecap (patella).
Two wedge-shaped pieces of cartilage act as "shock absorbers" between your
thighbone and shinbone. These are called meniscus. They are tough and rubbery
to help cushion the joint and keep it stable.

Description
Menisci tear in different ways. Tears are noted by how they look, as well as
where the tear occurs in the meniscus. Common tears include bucket handle,
flap, and radial.

Sports-related meniscus tears often occur along with other knee injuries, such
as anterior cruciate ligament tears.

Cause
Sudden meniscus tears often happen during sports. Players may squat and twist the knee, causing
a tear. Direct contact, like a tackle, is sometimes involved.

Older people are more likely to have degenerative meniscus tears. Cartilage weakens and wears
thin over time. Aged, worn tissue is more prone to tears. Just an awkward twist when getting up
from a chair may be enough to cause a tear, if the menisci have weakened with age.

Symptoms
You might feel a "pop" when you tear a meniscus. Most people can still walk on their injured knee.
Many athletes keep playing with a tear. Over 2 to 3 days, your knee will gradually become more
stiff and swollen.

The most common symptoms of meniscus tear are:

 Pain
 Stiffness and swelling
 Catching or locking of your knee
 The sensation of your knee "giving way"
 You are not able to move your knee through its full range of motion
Without treatment, a piece of meniscus may come loose and drift into the joint. This can cause
your knee to slip, pop, or lock.

Doctor Examination
Physical Examination and Patient History
After discussing your symptoms and medical history, your doctor will examine your knee. He or
she will check for tenderness along the joint line where the meniscus sits. This often signals a tear.

One of the main tests for meniscus tears is the McMurray test. Your doctor will bend your knee,
then straighten and rotate it. This puts tension on a torn meniscus. If you have a meniscus tear,
this movement will cause a clicking sound. Your knee will click each time your doctor does the
test.

Imaging Tests
Because other knee problems cause similar symptoms, your doctor may order imaging tests to
help confirm the diagnosis.
X-rays. Although x-rays do not show meniscus tears, they may show other causes of knee pain,
such as osteoarthritis.
Magnetic resonance imaging (MRI). This study can create better images of the soft tissues of your
knee joint, like a meniscus.

Treatment
How your orthopaedic surgeon treats your tear will depend on the type of tear you have, its size,
and location.

The outside one-third of the meniscus has a rich blood supply. A tear in this "red" zone may heal
on its own, or can often be repaired with surgery. A longitudinal tear is an example of this kind of
tear.

In contrast, the inner two-thirds of the meniscus lacks a blood supply. Without nutrients from
blood, tears in this "white" zone cannot heal. These complex tears are often in thin, worn
cartilage. Because the pieces cannot grow back together, tears in this zone are usually surgically
trimmed away.

Along with the type of tear you have, your age, activity level, and any related injuries will factor
into your treatment plan.

Nonsurgical Treatment
If your tear is small and on the outer edge of the meniscus, it may not require surgical repair. As
long as your symptoms do not persist and your knee is stable, nonsurgical treatment may be all
you need.
RICE. The RICE protocol is effective for most sports-related injuries. RICE stands for Rest, Ice,
Compression, and Elevation.
 Rest. Take a break from the activity that caused the injury. Your
doctor may recommend that you use crutches to avoid putting
weight on your leg.
 Ice. Use cold packs for 20 minutes at a time, several times a day. Do
not apply ice directly to the skin.
 Compression. To prevent additional swelling and blood loss, wear an
elastic compression bandage.
 Elevation. To reduce swelling, recline when you rest, and put your
leg up higher than your heart.
Non-steroidal anti-inflammatory medicines. Drugs like aspirin and ibuprofen reduce pain and
swelling.
Surgical Treatment
If your symptoms persist with nonsurgical treatment, your doctor may
suggest arthroscopic surgery.
Procedure. Knee arthroscopy is one of the most commonly performed surgical
procedures. In it, a miniature camera is inserted through a small incision
(portal). This provides a clear view of the inside of the knee. Your orthopaedic
surgeon inserts miniature surgical instruments through other portals to trim
or repair the tear.
 Partial meniscectomy. In this procedure, the damaged meniscus
tissue is trimmed away.
 Meniscus repair. Some meniscus tears can be repaired by suturing
(stitching) the torn pieces together. Whether a tear can be
 successfully treated with repair depends upon the type of tear, as
well as the overall condition of the injured meniscus. Because the
meniscus must heal back together, recovery time for a repair is much
longer than from a meniscectomy.
 Once the initial healing is complete, your doctor will prescribe rehabilitation exercises.
Regular exercise to restore your knee mobility and strength is necessary. You will start
with exercises to improve your range of motion. Strengthening exercises will gradually be
added to your rehabilitation plan.

 For the most part, rehabilitation can be carried out at home, although your doctor may
recommend physical therapy. Rehabilitation time for a meniscus repair is about 3
months. A meniscectomy requires less time for healing — approximately 3 to 4 weeks.

 Recovery
 Meniscus tears are extremely common knee injuries. With proper diagnosis, treatment,
and rehabilitation, patients often return to their pre-injury abilities.

Pes Anserine (Knee Tendon) Bursitis

 Bursae are small, jelly-like sacs that are located throughout the body,
including around the shoulder, elbow, hip, knee, and heel. They contain a
small amount of fluid, and are positioned between bones and soft tissues,
acting as cushions to help reduce friction.
 Pes anserine bursitis is an inflammation of the bursa located between the
shinbone (tibia) and three tendons of the hamstring muscle at the inside of
the knee. It occurs when the bursa becomes irritated and produces too
much fluid, which causes it to swell and put pressure on the adjacent parts
of the knee.
 Pain and tenderness on the inside of your knee, approximately 2 to 3
inches below the joint, are common symptoms of pes anserine bursitis of
the knee.

Cause
Bursitis usually develops as the result of overuse or constant friction and stress on the bursa. Pes
anserine bursitis is common in athletes, particularly runners. People with osteoarthritis of the
knee are also susceptible.

Several factors can contribute to the development of pes anserine bursitis, including:

 Incorrect training techniques, such as neglecting to stretch, doing

excessive hill running, and sudden increases in mileage
 Tight hamstring muscles
 Obesity
 An out-turning of the knee or lower leg
 Osteoarthritis in the knee
 Medial meniscus tear
Symptoms
The symptoms of pes anserine bursitis include:
 Pain slowly developing on the inside of your knee and/or in the
center of the shinbone, approximately 2 to 3 inches below the knee
joint.
 Pain increasing with exercise or climbing stairs

Doctor Examination
Your doctor will examine your knee and talk to you about your symptoms.

Symptoms of pes anserine bursitis may mimic those of a stress fracture, so an x-ray is usually
required for diagnosis.

Treatment
Athletes with pes anserine bursitis should take steps to modify their workout program so that the
inflammation does not recur.

Other treatments include:

 Rest. Discontinue the activity or substitute a different activity until

the bursitis clears up.
 Ice. Apply ice at regular intervals three or four times a day for 20
minutes at a time.
 Anti-inflammatory medication. Aspirin and nonsteroidal anti-
inflammatory medication (such as ibuprofen) may ease the pain and
reduce the inflammation.
 Injection. Your doctor may inject a solution of anesthetic and steroid
into the bursa, which often provides prompt relief.
 Physical therapy. Your doctor may recommend physical therapy for
specific stretching exercises, and ice and ultrasound treatments.
If your symptoms continue, your orthopaedic surgeon may recommend surgical removal of the
bursa. This is typically performed as an outpatient (same-day) procedure.

If putting weight on your leg causes discomfort after the procedure, your doctor will recommend
using crutches for a short time. Normal activities can typically be resumed within 3 weeks of the
procedure.

Prepatellar (Kneecap) Bursitis

Bursae are small, jelly-like sacs that are located throughout the body, including
around the shoulder, elbow, hip, knee, and heel. They contain a small amount of
fluid, and are positioned between bones and soft tissues, acting as cushions to
help reduce friction.

Prepatellar bursitis is an inflammation of the bursa in the front of the kneecap

(patella). It occurs when the bursa becomes irritated and produces too much
fluid, which causes it to swell and put pressure on the adjacent parts of the knee.
Cause
Prepatellar bursitis is often caused by pressure from constant kneeling.
Plumbers, roofers, carpet layers, coal miners, and gardeners are at greater
risk for developing the condition.

A direct blow to the front of knee can also cause prepatellar bursitis. Athletes
who participate in sports in which direct blows or falls on the knee are
common, such as football, wrestling, or basketball, are at greater risk for the
condition.

Other people who are more susceptible to the condition include those with
rheumatoid arthritis or gout.

Prepatellar bursitis can also be caused by a bacterial infection. If a knee injury

—such as an insect bite, scrape, or puncture wound—breaks the skin, bacteria
may get inside the bursa sac and cause an infection. This is called infectious
bursitis. Infectious bursitis is less common, but more serious and must be
treated more urgently.

Symptoms
 Pain with activity, but not usually at night
 Rapid swelling on the front of the kneecap
 Tenderness and warmth to the touch
 Bursitis caused by infection may produce fluid and redness, as
well as fever and chills

Doctor Examination
Medical History and Physical Examination
Your doctor will talk with you about your symptoms, such as the severity of your pain, how long
you have had symptoms, and your risk factors for developing prepatellar bursitis.

Your doctor will likely ask questions regarding any signs or symptoms of infection, such as fever
or chills. Prepatellar bursitis caused by an infection requires a different treatment plan.

During the physical examination, your doctor will inspect your affected knee and compare it to
your healthy knee. He or she will examine your knee, checking for tenderness, and will also assess
the range of motion in your knee and whether pain prevents you from bending it.

Tests
 X-rays. X-rays provide clear pictures of bone. Your doctor may order
them to make sure there is not a fracture that is causing your
symptoms.
 Other imaging tests. The diagnosis of bursitis is usually made on
physical examination, but computerized tomography (CT) and
 magnetic resonance imaging (MRI) scans may be ordered to check
for other soft tissue injury.
 Aspiration. If your doctor is concerned about the possibility of
infection, he or she may aspirate (draw fluid with a needle) the bursa
and send this sample to the lab for analysis.

Treatment
Nonsurgical treatment is usually effective as long as the bursa is simply inflamed and not
infected:
 Activity modification. Avoid the activities that worsen symptoms.
Substitute another activity until the bursitis clears up. Low-impact
exercise, such as cycling, is a good option.
 Ice. Apply ice at regular intervals 3 or 4 times a day for 20 minutes at
a time. Each session should reduce swelling considerably if the knee
is also being rested.
 Elevation. Elevate the affected leg except when it is necessary to
walk.
 Nonsteroidal anti-inflammatory drugs (NSAIDs). Medications such
as naproxen and ibuprofen may relieve pain and control
inflammation.
If the swelling and pain do not respond to these measures, your doctor may drain (aspirate) the
bursa with a needle, then inject the bursa with a corticosteroid. The corticosteroid is an anti-
inflammatory drug that is stronger than the medication that can be taken by mouth.

Infectious bursitis is initially treated with antibiotics. Surgical drainage is required if the infection
does not respond to antibiotics alone.

Draining the bursa may also treat chronic swelling that causes disability, but if the swelling
continues, your orthopaedic surgeon may recommend surgical removal of the bursa. After
surgery, the knee should regain its flexibility in a few days and normal activities can be resumed
in a few weeks.

Prevention
You can help prevent bursitis by following these simple recommendations:
 Wear kneepads if you work on your knees or participate in contact
sports such as football, basketball, or wrestling.
 Rest your knees regularly by stopping to stretch your legs. You may
also consider switching activities on a regular basis to avoid
prolonged stress on your knees.
 Apply ice and elevate your knees after a workout.

Compartment Syndrome
Compartment syndrome is a painful condition that occurs when pressure within
the muscles builds to dangerous levels. This pressure can decrease blood flow,
which prevents nourishment and oxygen from reaching nerve and muscle cells.

Compartment syndrome can be either acute or chronic.

Acute compartment syndrome is a medical emergency. It is usually caused by a
severe injury. Without treatment, it can lead to permanent muscle damage.

Chronic compartment syndrome, also known as exertional compartment

syndrome, is usually not a medical emergency. It is most often caused by athletic
exertion.

Anatomy
Compartments are groupings of muscles, nerves, and blood vessels in your arms
and legs. Covering these tissues is a tough membrane called a fascia. The role of
the fascia is to keep the tissues in place, and, therefore, the fascia does not stretch
or expand easily.

Description
Compartment syndrome develops when swelling or bleeding occurs within a compartment.
Because the fascia does not stretch, this can cause increased pressure on the capillaries, nerves,
and muscles in the compartment. Blood flow to muscle and nerve cells is disrupted. Without a
steady supply of oxygen and nutrients, nerve and muscle cells can be damaged.

In acute compartment syndrome, unless the pressure is relieved quickly, permanent disability
and tissue death may result. This does not usually happen in chronic (exertional) compartment
syndrome.

Compartment syndrome most often occurs in the anterior (front) compartment of the lower leg
(calf). It can also occur in other compartments in the leg, as well as in the arms, hands, feet, and
buttocks.

Cause
Acute Compartment Syndrome
Acute compartment syndrome usually develops after a severe injury, such as a car accident or a
broken bone. Rarely, it develops after a relatively minor injury.

Conditions that may bring on acute compartment syndrome include:

 A fracture.
 A badly bruised muscle. This type of injury can occur when a
motorcycle falls on the leg of the rider, or a football player is hit in
the leg with another player's helmet.
 Reestablished blood flow after blocked circulation. This may occur
after a surgeon repairs a damaged blood vessel that has been blocked
for several hours. A blood vessel can also be blocked during sleep.
Lying for too long in a position that blocks a blood vessel, then
moving or waking up can cause this condition. Most healthy people
will naturally move when blood flow to a limb is blocked during
sleep. The development of compartment syndrome in this manner
usually occurs in people who are neurologically compromised. This
can happen after severe intoxication with alcohol or other drugs.
  Crush injuries.
 Anabolic steroid use. Taking steroids is a possible factor in
compartment syndrome.
 Constricting bandages. Casts and tight bandages may lead to
compartment syndrome. If symptoms of compartment syndrome
develop, remove or loosen any constricting bandages. If you have a
cast, contact your doctor immediately.
Chronic (Exertional) Compartment Syndrome
The pain and swelling of chronic compartment syndrome is caused by exercise. Athletes who
participate in activities with repetitive motions, such as running, biking, or swimming, are more
likely to develop chronic compartment syndrome. This is usually relieved by discontinuing the
exercise, and is usually not dangerous.

Symptoms
Acute Compartment Syndrome
The classic sign of acute compartment syndrome is pain, especially when the muscle within the
compartment is stretched.
 The pain is more intense than what would be expected from the
injury itself. Using or stretching the involved muscles increases the
pain.
 There may also be tingling or burning sensations (paresthesias) in
the skin.
 The muscle may feel tight or full.
 Numbness or paralysis are late signs of compartment syndrome.
They usually indicate permanent tissue injury.
Chronic (Exertional) Compartment Syndrome
Chronic compartment syndrome causes pain or cramping during exercise. This pain subsides
when activity stops. It most often occurs in the leg.

Symptoms may also include:

 Numbness
 Difficulty moving the foot
 Visible muscle bulging

Doctor Examination
Acute Compartment Syndrome
Go to an emergency room immediately if there is concern about acute
compartment syndrome. This is a medical emergency. Your doctor will
measure the compartment pressure to determine whether you have acute
compartment syndrome.
Chronic (Exertional) Compartment Syndrome
To diagnose chronic compartment syndrome, your doctor must rule out other conditions that
could also cause pain in the lower leg. For example, your doctor may press on your tendons to
make sure you do not have tendonitis. He or she may order an X-ray to make sure your shinbone
(tibia) does not have a stress fracture.
To confirm chronic compartment syndrome, your doctor will measure the pressures in your
compartment before and after exercise. If pressures remain high after exercise, you have chronic
compartment syndrome.

Treatment
Acute Compartment Syndrome
Acute compartment syndrome is a surgical emergency. There is no effective nonsurgical
treatment.

Your doctor will make an incision and cut open the skin and fascia covering the affected
compartment. This procedure is called a fasciotomy.

Sometimes, the swelling can be severe enough that the skin incision cannot be closed
immediately. The incision is surgically repaired when swelling subsides. Sometimes a skin graft is
used.

Chronic (Exertional) Compartment Syndrome

Nonsurgical treatment. Physical therapy, orthotics (inserts for shoes), and anti-inflammatory
medicines are sometimes suggested. They have had questionable results for relieving symptoms.

Your symptoms may subside if you avoid the activity that caused the condition. Cross-training
with low-impact activities may be an option. Some athletes have symptoms that are worse on
certain surfaces (concrete vs. running track, or artficial turf vs. grass). Symptoms may be relieved
by switching surfaces.

Surgical treatment. If conservative measures fail, surgery may be an option. Similar to the surgery
for acute compartment syndrome, the operation is designed to open the fascia so that there is
more room for the muscles to swell.

Usually, the skin incision for chronic compartment syndrome is shorter than the incision for
acute compartment syndrome. Also, this surgery is typically an elective procedure -- not an
emergency.