PART III Case Studies

Transcription

1 PART III Case Studies Patellofemoral Disorders: Diagnosis and Treatment. Edited by Roland M. Biedert 2004 John Wiley & Sons, Ltd ISBN:

2 CASE STUDY 1 Unspecific patellofemoral pain What do we mean by unspecific? Where is the pain coming from? What should be our treatment plan? Do we need special investigations? Table CS1 Patellofemoral joint examination Diagnostic clues Findings Diagnostic clues Findings Pain Unspecific, in flexion Patellar gliding mechanism Normal Tenderness Diffuse, unspecific Patellar apprehension Negative Effusion Sometimes Q angle Normal Swelling Sometimes Catching Sometimes Patellar position, relaxed, 0 Centred Locking None Patellar position, contracted, 0 Centred Range of motion Normal Patellar position, 30 Centred Radiographs Normal Patellar mobility Normal Other None Patellofemoral Disorders: Diagnosis and Treatment. Edited by Roland M. Biedert 2004 John Wiley & Sons, Ltd ISBN:

3 150 CASE STUDY 1 UNSPECIFIC PATELLOFEMORAL PAIN History A 31 year-old female suffered from pain and swelling in the patellofemoral joint. Pain was increased during and after sports activities, such as skiing. She felt no instability; range of motion was unlimited. The clinical examination revealed no specific findings. Comments Unspecific patellofemoral pain during and after sport activities is one of the classic problems, especially in the young female. Unspecific means that both location and genesis of pain are not obvious upon initial physical examination. The patient s history does not help very much to answer questions. Various pathologies (e.g. patellar instability) can be excluded. In consequence, we must try to find the sources of this unspecific pain, as described in Chapter 4 Pathogenesis of patellofemoral pain. The relation to an anatomical structure or a pathological process can be difficult, but it is the diagnostic and therapeutic key to resolve such problems. Course of action Physical examination The physical examination is the initial and the most important step to achieving the correct diagnosis. The patient must be in a position of comfort and show the painful area. Gently feel the anatomical structures, starting the examination on the pain-free side. Examine precisely the anatomical structures involved. In the present case we found a normal-looking patellofemoral joint with full active and passive range of motion. No effusion or swelling was found. There existed an unspecific and diffuse tenderness in the whole patellofemoral joint. The patella was well-centred in a relaxed position in 0 of extension, with quadriceps muscle activation,andin30 of knee flexion. The Q angle and tubercle sulcus angle showed normal values. Pain was caused in the one-leg position with increased loaded flexion. The axis of the foot and the lower extremity were normal. The only pathological finding was difficulty in stabilizing the knee joint and in stabilizing the whole lower extremity during motion in the single-leg standing position. This revealed a deficit of the sensorimotor capabilities and control of dynamic stabilization. 1 Axial CT evaluation The anteroposterior and lateral radiographs were normal. In 0 extension with relaxed quadriceps muscle, the patella was well-centred on the axial CT scans (Figure CS1.1). The sulcus angle was normal; no tilt could be found. With full quadriceps contraction in 0 extension, the patella stayed well-centred in the trochlea, as well as in 30 of flexion (Figure CS1.2). The distances between the medial and lateral patellofemoral facets were equal and normal. We could therefore suggest that no important defect of the articular cartilage is present. Definitive proof can be achieved by performing an MRI. The CT evaluation was absolutely normal in this patient. This excluded many pathologies and confirmed the findings of the physical examination. A mechanical problem did not exist and Figure CS1.1 Normal figuration of patella and trochlea. The patella is well-centred (extension, relaxed)

4 SUMMARY 151 Figure CS1.2 Dynamic activation of the quadriceps muscle keeps the patella well-centred (extension, contracted) therefore no need for a so-called realignment was given. Plan Patients with unspecific patellofemoral pain and with normal radiographs, CT evaluation and physical examination, are in a domain of nonoperative treatment. Any surgical procedure must be strictly avoided because we have found no obvious structural pathology that has to be corrected. Surgery would probably impair the situation and create a secondary problem. In this patient, sensorimotor training under control of the physical therapist was the key to resolving the problem. 2 Improvement of the dynamic stabilization of the patellofemoral joint during sport activities was the deciding positive step (Figures CS1.3 and CS1.4). Training in the closed kinetic chain improved the stabilization of the whole lower extremity. Summary Unspecific patellofemoral pain is a frequent problem, especially in females. We need a detailed physical examination to decide what kind of Figure CS1.3 Sensorimotor training to improve the stabilization of the knee joint. Taping of the patellofemoral joint can improve the training capabilities at the beginning Figure CS1.4 conditions Sensorimotor training with unstable additional investigations are necessary. Radiographs and CT evaluation help to exclude any dysplastic or mechanical pathologies. An MRI could also be performed to identify small

5 152 CASE STUDY 1 UNSPECIFIC PATELLOFEMORAL PAIN Figure CS1.5 Technetium scintiscan in a female patient. Increased uptake with time cartilage lesions or bone bruises. 3,4 Unspecific patellofemoral pain can also be caused by increased osseous metabolic activity. The patellofemoral joint is one of several regions of dynamic metabolic adaptations characterized by increased turnover and remodelling. 5 Such dynamic osseous events can be detected by using scintigraphy with technetium imaging 3,4 (Figures CS1.5 and CS1.6). Mechanical, neurovascular and hormonal factors may trigger increased osseous metabolic activity. Supraphysiological loading or abnormal joint mechanics (pathological kinematics, i.e. ACL insufficiency) can produce increased, painful remodelling. Unphysiological loading, such as overweight, muscular weakness or insufficient sensorimotor control, create various forms of unspecific pain in the patellofemoral joint. Successful treatment for this unspecific pain must be combined with homeostasis of the involved structures. The treatment is specific and clear only when underlying mechanical pathologies can be identified, e.g. in ACL insufficiency. Figure CS1.6 Anterior technetium scintiscan showing increased activity in the patellofemoral joint. Overweight female patient References 1. Biedert RM (1999) Sensory Motor Function of the Knee Joint. Histologic, Anatomic, and Neurophysiologic Investigations. Thesis, University of Basel, Switzerland

6 SUGGESTED READING Barrack RL, Skinner HB (1990) The sensory function of knee ligaments. In: Daniel DM, Akeson WH, O Connor JJ (eds), Knee Ligaments: Structure, Function, Injury, and Repair. NewYork, Raven, pp Dye SF (1996) The knee as a biologic transmission with an envelope of function: a theory. Clin Orthop 325: Dye SF, Chew MH (1993) The use of scintigraphy to detect increased osseous metabolic transmission with an envelope of function. J Bone Joint Surg Am 75: Dye SF, Stäubli HU, Biedert RM, Vaupel GL (1999) The mosaic of pathophysiology causing patellofemoral pain: therapeutic implications. Operative Tech Sports Med 7: Suggested reading Dye SF (1996) The knee as a biologic transmission with an envelope of function: a theory. Clin Orthop 325: Dye SF, Chew MH (1993) The use of scintigraphy to detect increased osseous metabolic transmission with an envelope of function. J Bone Joint Surg Am 75: