chapter 12: Nonoperative Treatment
Nonoperative treatment may be fruitless in the patient with a painful, mechanically irritable plica. Stretching the quadriceps with the patient prone, local modalities, and selective injection of a painful plica with corticosteroid may bring the problem under control, however, arthroscopic excision of a painful, snapping plica will often be necessary.
In most patients with inflamed synovium, nonsteroidal anti‑inflammatory medication and/or corticosteroid injection will be helpful. In the patient with rheumatoid disease or more prolific synovitis, arthroscopic synovectomy may become necessary. Physical therapy alone is less helpful in these patients, although maintaining or improving strength in the rheumatoid patient may bring functional improvement while the inflammatory disease is coming under control. Restoration of motion and strength following arthroscopic synovectomy is important also.
When pain is identified in the distal quadriceps muscle immediately around the patellofemoral joint, the physician or therapist should remember the possibility of skeletal muscle hemangioma or referred pain. In muscle or tendon pain related to chronic overuse and strain, stretching, local modalities, anti‑inflammatory medication, and selective local anesthetic with corticosteroid injection will often bring relief. Again, it is most important to identify a very specific pain focus so that treatment may be directed appropriately. Nonspecific treatment, including strengthening, may be ineffective and, when pushed excessively, may actually make the patient worse when muscle or tendon is the source of pain.
One of the great dangers of applying nonspecific treatment to patients with anterior knee pain without a specific awareness of the source of pain is treating a patient's knee when the pain is coming from another area, usually the back or hip. Problems in the hip joint are particularly likely to refer pain to the anterior knee region. By obtaining a careful history, watching how the patient localizes pain in the anterior knee and doing a thorough physical examination (including evaluation of hip rotation with the patient prone), the examiner is far less likely to mistake a degenerative hip for patellofemoral pain. Before starting nonoperative treatment for anterior knee pain, every patient should be placed prone both for examination of quadriceps tightness and evaluation of hip rotation. If internal rotation of the hip is limited, a radiograph of the hip should rule out degenerative change or slipped capital femoral epiphysis. Missing the latter diagnosis in a young patient can be catastrophic.
Back problems can also cause pain in the anterior knee region. A herniated disk, particularly at the L3 to L4 level, can cause pain in the anterior aspect of the knee. Before initiating treatment in a patient with anterior knee pain, the physician or therapist should consider the possibility of discogenic pain, perform a straight leg raising test to rule out radicular pain, and check for neurologic signs such as numbness or weakness. Even worse, one might risk missing a spinal cord tumor in nonspecific treatment of anterior knee pain.
Inside Chapter 12: