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Anterior knee pain: Remember to

look up and be aware of structural

Patellofemoral Update

Unfortunately, when an orthopedic surgeon sees a patient with

anterior knee pain in the office, he or she normally only focuses on
the knee. If we do this we are making a big mistake.
We must remember to look up and evaluate the pelvis and
proximal femur as well as psychological factors that modulate the
pain to fully understand what is happening and to be able to solve
this challenging problem. Moreover, we must be aware of structural
anomalies (i.e., chondropathy and patellofemoral (PF) malalignment
patellar tilt and lateral patellar subluxation) given the correlation
between structural anomalies and anterior knee pain is low.
Be aware of structural anomalies
Structural anomalies should not give us a green light to correct
them surgically. In fact, in my experience, the worst cases of
patients with anterior knee pain are secondary to a surgical
procedure that aimed to correct structural anomalies that were
possibly not the cause of the pain and disability.
Vicente Sanchis-Alfonso

However, we must not be dogmatic and remember that in selected

cases, structural anomalies could be the cause of anterior knee
pain. We have observed, as other authors have, that a softening of
the cartilage of the distal pole of the patella can be a source of
disabling pain completely recalcitrant to conservative treatment. In
these cases, a focal bone overload can occur because the
cartilages lack of absorption places excessive stress on the
underlying innervated bone, causing pain.
John P. Fulkerson, MD, has observed that when he does a short
steep anteromedial tibial tubercle transfer, pain goes away in the
vast majority of patients. In my experience, similar results are
obtained after a deepening trochleoplasty. With both surgical
techniques, we decrease the PF joint reaction force and this could
explain the resolution of pain. I believe this overload of the distal
pole of the patella could be related among other causes to trochlear
dysplasia. In fact, in all of my cases of severe chondropathy of the
distal pole of the patella there was a trochlear dysplasia grade D.
Primary cause

In many patients the primary cause of anterior knee pain is not in the
PF joint. There is a growing body of literature linking abnormal femur
rotation with anterior knee pain. The rotation of the femur
underneath the patella in the transverse plane leads to abnormal
patellar tracking, PF imbalance and finally anterior knee pain. This
means the primary problem is not in the patella but in the femur. In
this sense, there is a growing body of literature supporting the link
between anterior knee pain in young females and lack of dynamic
control in lower limbs that may have an influence on the PF joint and
may also be the main cause of pain. This link is supported by the
fact that an isolated hip abductor and external rotator muscle
strengthening is effective in improving pain in this subgroup of
females with anterior knee pain. Finally, in a small number of
patients this malrotation can be structural because of a femoral
anteversion or any other torsional anomaly of the femur.
Interestingly, we have found a novel link between femoroacetabular
impingement (FAI) and anterior knee pain. Once again, in some
patients the underlying cause of anterior knee pain is not in the PF
joint. In my experience, all of these patients went to the orthopedic
surgeon for the first time due to anterior knee pain that was
recalcitrant to conservative treatment. The patient gets tired of doing
physical therapy because he or she does not get the expected
results and stops going to the physician. After some time, the patient
comes back to the office with hip pain that could be disabling. We
hypothesize that in these patients there is a functional external
femoral rotation to avoid the FAI, hence the hip pain. This femoral
rotation could provoke a PF imbalance that could be responsible, in
theory, for anterior knee pain. Our kinetic and kinematic findings are
in agreement with our hypothesis. Moreover, FAI resolution is
related to the resolution of pain and normalization of biomechanical
Psychological factors
Patients with anterior knee pain often have severe pain with
insignificant clinical and radiological findings. Moreover, many
patients have allodynia or hyperalgesia. In addition, they have a high
incidence of anxiety, depression, kinesophobia and catastrophizing.
All this makes the orthopedic surgeon think that the main problem is
in the psyche. It is incorrect. Psychological factors are the result of
the severity of the patients pain, not the cause of pain.
Psychological factors only play a role as modulators. It has been
demonstrated that clinical improvement in pain is associated with a
reduction in catastrophizing and kinesophobia. This finding is
clinically relevant because it contradicts the belief that patients with

anterior knee pain are patients with pre-existing psychological

problems frequently responsible for pain. We believe nothing is
farther from the truth. Furthermore, we must not forget that in
patients with anterior knee pain there is a biomechanical and
neuroanatomical objective base for their pain.
Both the pelvifemoral dysfunction and the psychological factors must
be included in our therapeutic targets for the multidisciplinary
treatment of anterior knee pain patients. Moreover, in selected cases
we must consider surgical techniques to unload areas that could be
the source of pain, such as the softening of the distal pole of the
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Sanchis-Alfonso V. Knee Surg Sports Traumatol Arthrosc.
Vicente Sanchis-Alfonso, MD, PhD, is consultant orthopaedic surgeon,
Hospital Nisa 9 de Octubre, Valencia, Spain. He is also member of the
International Patellofemoral Study Group (IPSG). He can be reached at
Valle de la Ballestera # 59, 46015 - Valencia, Spain; e-mail:
Disclosure: Sanchis-Alfonso has no relevant financial disclosures.