chapter 12: Nonoperative Treatment



Once a specific focus of pain is identified in the physician's office, a single appropriate injection can be diagnostic. Intra‑articular local anesthetic should temporarily eliminate intra‑articular pain in the majority of patients. If the patient identifies a specific retinacular, tendon, or muscular pain site, injecting the focus of pain, possibly with a small amount of corticosteroid, will confirm or disprove this source of pain. Of course, one should warn the patient that there can be a temporary increase of pain when corticosteroid is injected into a retinacular area. If there is a noninflammatory source of pain, there may be temporary relief from local anesthetic but return of pain once it wears off, despite corticosteroid. Neuroma pain may subside temporarily after corticosteroid injection, but it often returns. This is equally true of surgically created neuromata and microneuromata related to chronic patellar malalignment and retinacular nerve strain.

Compartment Syndrome Treatment

Particularly in the high‑demand athlete, the clinician should consider a compartment syndrome of the quadriceps compartment or the anterior compartment of the lower leg. Bicyclists, in particular, are prone to quadriceps compartment syndrome. Runners and other high‑demand athletes can develop anterior compartment syndrome in the lower leg. Quadriceps compartment syndrome is particularly notable in the anterior knee region and should be considered in any athlete who points to the distal quadriceps when asked to localize his pain. In such patients, modification of activity, quadriceps stretching, ice application after activity, and reduced emphasis on quadriceps strengthening may help, particularly after a period of rest. It is very important to differentiate this problem from other sources of anterior knee pain, as treatment will generally be quite different and there will be less emphasis on quadriceps strength. In more extreme cases, compartment pressure manometry may be necessary. Straight leg raising with a 5‑ to 10‑pound weight on the ankle is the method of choice for gaining quadriceps strength after resolution of the compartment syndrome. This form of isometric strengthening, however, takes considerable self‑discipline, and patient compliance is probably less than with the exercise bicycle or another form of quadriceps exercise that gives aerobic benefit as well. Such exercise, however, must wait until complete resolution of the original compartment syndrome. In some patients, fasciotomy of the involved compartment may be necessary.




Inside Chapter 12: