The Painful Knee

One of the most common causes of knee pain without injury is patella (knee-cap) pain. This has been given various names over the years such as “chondromalacia patella”, “anterior knee pain”, “patellofemoral arthralgia”, etc. The theories that have been proposed as to the causes of this kind of knee pain are also numerous and non-specific.

This condition is one of the more frustrating to treat for both physician and patient. It can affect patients of both sexes although it tends to involve females more commonly. It can affect patients of all ages although younger females are the largest group demographically. As patients get older, it is more likely that arthritis plays some role in the development of this form of knee pain. However, younger patients can have significant pain with no evidence of arthritis.

Patients who have this kind of pain often complain of some or all of the following symptoms

  • Pain with impact activities; running, jumping, kicking, impact aerobics, lunges and squats
  • Pain with kneeling, squatting, prolonged sitting (called a movie sign) and going up or down stairs
  • A stiffness when getting up after prolonged sitting (start up pain) which goes away after a few moments or steps
  • Occasionally there may be locking, catching or swelling or the knee
  • In certain patients the knee cap may feel as if it will go out of place, or it actually does

For patients who present for treatment for these problems, a good orthopedic examination is the place to start. This problem can run in families and often a history will reveal that mothers or sisters have had these problems as well. An assessment of hip, knee and ankle alignment, motion and stability are helpful. One needs to check for subtle developmental rotational abnormalities, joints that are too loose or too tight. The knee is checked for joint swelling, tenderness around the kneecap and excessive motion about the patella. An x-ray examination may reveal some abnormal positioning of the kneecap.

Treatment will depend on several factors:

  • The activity history of that patient
  • The presence of patella instability (the kneecap pops out)
  • The presence of swelling, locking or catching of the knee
  • Specific abnormalities identified on the exam such as flat feet, tight hamstrings, loose patella ligaments, etc.
  • Previous treatment
  • The severity of the symptoms

Using our knowledge of basic science tells us that when someone has longstanding knee pain and/or swelling the supporting muscles about the knee will get weak. If there is tightness around the knee in the heel cords or hamstrings then there will be increased forces in the joint. For joints that are excessively loose or for those patients with tilted kneecaps, supportive bracing is often helpful.

Patients who are engaged in impact activities such as running or jumping may benefit by cross training and a general reduction of high stress activities relying more on substitution of such activities as elliptical trainers, XC ski machines, exercise bikes and water based aerobic exercises. For more mild pain during activity that does not prohibit involvement, impact-absorbing devices such as orthotics and modification of footwear is often helpful.

For the patient with tight tendons and weak muscles a course of physic al therapy is often beneficial. The use of anti- inflammation medicines and ice after activity is also of some benefit. For patients with no contra-indication for their use (bleeding tendencies, the use of blood thinners, bleeding ulcers, acid reflux, gastrointestinal sensitivity or allergic reaction to aspirin or similar medications) taking over the counter Advil or ibuprofen 2-3 pills 2-3 times a day with food, or 1-2 Aleve 1-2 times a day can also be very helpful. A prescription strength medicine may also be needed.

Most often with many of the measures discussed above these problems can be managed but often not “cured”. The idea is to understand the nature of your problem and be involved in the solution. Patients with unstable joints, persistent swelling, or mechanical symptoms of locking or catching of the knee are candidates for surgery.

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