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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
parameters.
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