Pediatric emergency medicine trisk 3969 3969

or intensity of training, hard or uneven running surfaces, and inadequate shoes
have been blamed.
Initial Assessment/H&P
Symptoms consist mainly of anterior knee pain often described as arising from
beneath or on the sides of the patella. Pain is usually of gradual onset and is
exacerbated by exercise. Pain or stiffness in the knee is common after arising
from prolonged sitting. Activities that involve loading of the knee when it is in
flexion, such as climbing steps, are particularly painful.
The physical examination is notable for tenderness along the patellar margins
or the posterior surface, which is accessible when the patella is manually
displaced medially or laterally. Pain, and occasionally crepitus, are elicited with
flexion and extension of the knee, or tightening the quadriceps while compressing
the patella against the femoral condyles. Range of motion is not limited, and
swelling is rare. The presence of an effusion is suggestive of significant
cartilaginous damage. Provocative tests that reproduce the pain include climbing
steps, squatting, or knee extension against resistance.
Management/Diagnostic Testing
Patellofemoral syndrome is a clinical diagnosis and imaging is not generally
indicated. Radiographs may be obtained to more accurately measure the
intracondylar sulcus or Q angle, or to rule out alternative diagnoses. MRI, with
sensitivity greater than 80%, is considered the best noninvasive diagnostic
modality for chondromalacia patellae. True confirmation of lesions requires
arthroscopy but may not always be necessary.
Treatment is conservative. More than 90% of cases of patellofemoral pain
syndrome resolve after instituting a program of rest, anti-inflammatory
medications, and ice followed by physical therapy. Exercises that begin once the
initial pain has resolved emphasize strengthening of the quadriceps muscles.
Recommended exercise regimens include isometric contractions of the quadriceps
with the knee in extension, straight leg raises, and knee extensions, first without
and then with weights. Training routines for athletes may need modification and
should emphasize soft, even running surfaces; proper biomechanics; and shoes

with appropriate cushioning and support. Surgery is recommended only as a last
resort in the most recalcitrant cases because results have been generally less than
satisfactory. Surgery is directed at either correcting unequal tension applied to the
patella or removing loose or nonviable cartilage from the posterior patellar
surface.