Pain Pain

IatrogenicIatrogenic

ArthritisArthritis InstabilityInstabilityPatelloPatello--femoralfemoral

Investigations Investigations & &

Management Management PatelloPatello--femoral Painfemoral Pain

David DEJOURDavid DEJOURCOROLYON COROLYON -- FRANCEFRANCE

Anterior Knee PainAnterior Knee Pain

SubluxationSubluxation

DislocationDislocation

TendinitisTendinitis

Osgood Osgood schalterschalterPsychologicPsychologic

InstabilityInstability

Patellar Patellar Painful Painful SyndromeSyndrome

HyperpressionHyperpression

Vascular disorder Vascular disorder

Step NStep N°° 1 1

Precise DiagnosisPrecise Diagnosis

PP--F Congruency and stabilityF Congruency and stability

Bony structuresBony structures Soft tissues balancingSoft tissues balancing

Extensor mechanismExtensor mechanismalignmentalignment

Vastus Vastus medialismedialis

Lateral retinaculumLateral retinaculum

MPFLMPFL

TrochlearTrochlear shapeshape

Patellar shapePatellar shape

Patient historyPatient history

Clinical Clinical examexam

RadiologyRadiology

ClassificationClassification

Treatment Treatment

InvestigationsInvestigationsFirst VisitFirst Visit

Standard XStandard X--Rays Rays are sufficient +++are sufficient +++

-- No dysplasiaNo dysplasia-- No patella altaNo patella alta

PatelloPatello femoral painfemoral pain

-- AnteriorAnterior-- Around the patellaAround the patella-- Medial joint line Medial joint line -- sometime lateral sometime lateral ……

None specificNone specific

Pain in FlexionPain in Flexion

StairsStairs5 times 5 times

Body weightBody weight

Instability ???Instability ???

SymptomeSymptome MechanicalMechanical

True dislocation True dislocation ““documenteddocumented””FamillyFamilly historyhistoryHigh energy activities, High energy activities, HemarthrosisHemarthrosis ......

Feeling of instabilityFeeling of instabilityGiving awayGiving awayLow energy activities +++Low energy activities +++

Quadriceps InhibitionQuadriceps Inhibition

SUBJECTIVE InstabilitySUBJECTIVE Instability OBJECTIVE InstabilityOBJECTIVE Instability

Patient classificationPatient classification

Pain and NO dislocationPain and NO dislocationAt least one dislocationAt least one dislocation++

Objective XObjective X--rays rays abnormalities abnormalities

••TrochlearTrochlear dysplasiadysplasia••Patella AltaPatella Alta••TTTT--TGTG••MPFL rupture = tiltMPFL rupture = tilt

Objective Patellar InstabilityObjective Patellar Instability

Normal standard Normal standard XX--RaysRays

Patellar Painful SyndromePatellar Painful Syndrome

Potential Patellar Instability

Anatomical study 1987 (Lyon)Anatomical study 1987 (Lyon)Control Control (n= 190)(n= 190) / Dislocation / Dislocation (n= 147)(n= 147)

Statistical differences Statistical differences 4 factors Instability4 factors Instability (H. Dejour (H. Dejour –– G. G. WalchWalch))

TTTT-- TG > 20 mmTG > 20 mm

TrochlearTrochlear dysplasiadysplasia

Tilt > 20Tilt > 20°°

Patella Alta > 1.2Patella Alta > 1.2

French J. Orthop. 1990Knee Surg. Trauma 1994

TrochlearTrochlear dysplasiadysplasia

Crossing SignCrossing Sign (H. Dejour)(H. Dejour)

Control Control 3 % P = 0,0013 % P = 0,001

96 % Dislocation 96 % Dislocation populationpopulation

First instability factor +++First instability factor +++

High grade High grade TrochlearTrochlear dysplasiadysplasia

MaltrackingMaltracking : : Horizontal planeHorizontal plane

ImpingementImpingement : : SagittalSagittal planeplane

Patella alta gives specificCartilage damage

Pain Pain and no and no

InstabilityInstability

Patellar Painful Syndrome Patellar Instability

PPatellar atellar PPainful ainful SSyndromeyndromeAAnterior nterior KKnee nee PPainain

StiffnessStiffnessAsymmetry Asymmetry

Global Global MorphotypeMorphotype

NoNoAbnormality Abnormality

QuickTime™ et un décompresseurCinepak sont requis pour visualiser

cette image.

Three types AKPThree types AKP

PrimitivePrimitive OverusedOverused SecondarySecondary

Quadriceps

Plicae

Primitive Primitive PPatellaratellar PPainfulainful SSymdromeymdrome

Patient Patient analysisanalysis

Post. Post. ChainsChains AntAnt. . ChainsChains

ANALYSISANALYSISGLOBALGLOBAL

Relationship between Relationship between morphotypemorphotype and the muscle and the muscle

organisation ?organisation ?

AdolescentAdolescentMostly femaleMostly femaleSometime initial traumaSometime initial traumaUniUni or bilateralor bilateralNone sport addictedNone sport addictedNo swelling kneeNo swelling knee

StiffnessStiffness and morphotypeand morphotype

External analysis rest positionExternal analysis rest position Think to the backThink to the back

RestRest position position Pelvis tiltPelvis tilt

Rachis Rachis deformationdeformation

Pelvis tiltPelvis tilt

FalseFalse limblimb shortnessshortness

Clinical Exam Clinical Exam

RectusRectus femorisfemoris stiffnessstiffness

Global Global AnalysisAnalysisPosteriorPosterior chainschains in in sitsit position position

Clinical Exam Clinical Exam

Global Global AnalysisAnalysisPosteriorPosterior chainschains in stand position in stand position

Clinical Exam Clinical Exam

Stiffness or muscle asymmetryStiffness or muscle asymmetry

Increase the Patello-femoral pressure in flexion

QuadQuad

AmstringsAmstrings

Pain !!!Pain !!!

Make the difference betweenMake the difference between

RecurvatumRecurvatum

≠≠HyperlaxityHyperlaxity

StiffnessStiffnessanterioranteriormuscle muscle chainschains

OOverver UUsedsed KKneeneeAdult 35 Adult 35 -- 4545Mostly MaleMostly MaleAlways Always unhabitualunhabitual effort : workout ++, long run, Hiking.. effort : workout ++, long run, Hiking.. UnilateralUnilateralSwelling KneeSwelling KneeMuscular stiffness +++Muscular stiffness +++

Cartilage stress fractureCartilage stress fracture

Muscular stiffnessMuscular stiffness

VeryVery badbad physicalphysical preparationpreparation

Management of Management of Patellar painful syndromePatellar painful syndrome

Do not say !Do not say !

•• It's nothing !It's nothing !•• It's psychological !It's psychological !•• It's not surgical : Goodbye !It's not surgical : Goodbye !

Treatment Patellar Painful SyndromeTreatment Patellar Painful Syndrome

But EXPLAIN !But EXPLAIN !

•• No future arthritisNo future arthritis•• No surgeryNo surgery•• Always back to normalAlways back to normal•• No sport limitationNo sport limitation•• What is muscle stiffness !!!What is muscle stiffness !!!

•• With Physiotherapist firstWith Physiotherapist first

•• Patient education two times / Week Patient education two times / Week (15 Min)To learn exercisesTo learn exercises

(15 Min)

New appointment New appointment after three monthsafter three months

-- Mild sport activities allowedMild sport activities allowed-- Quantification by the patient of his activitiesQuantification by the patient of his activities-- Respect Respect thethe painpain-- Give the patient a sense of Give the patient a sense of responsabiltyresponsabilty !!!!!!

If failed or if low back pain ++ If failed or if low back pain ++

Global physiotherapyGlobal physiotherapyMMéézizièèrere -- muscular chainsmuscular chains

Global Global rehabilitationrehabilitationClassicClassic rehabilitationrehabilitation

SecondarySecondary PPatellaratellar PPainfulainful SSymdromeymdromePost operativePost operativePCL deficient kneePCL deficient kneePatella BajaPatella BajaPlicae Plicae Cartilaginous flapCartilaginous flap

Sometimes needs Arthroscopy (be careful)

FlapFlap Patella BajaPatella Baja PlicaePlicae

ArthroArthro CT CT –– ArthroArthro MRIMRI

ConclusionConclusionPatellar painful syndrome Patellar painful syndrome IS NOTIS NOT InstabilityInstability

No surgery at any time +++ No surgery at any time +++

Simple standard XSimple standard X--Rays are required Rays are required

Listen and educated the patientListen and educated the patient

But But ItIt’’s time consuming !!!! Good Luck !!s time consuming !!!! Good Luck !!