Patellofemoral Pain

Dr. Michael Vella

Your knees carry the weight burden of your body and are subject to the rigors associated with that responsibility.  When combined with the stress of high impact activities such as running, jumping, skiing, and other strenuous activities, a condition referred to as patellofemoral pain syndrome (Runner’s Knee) can develop.  This condition is characterized by pain in the front of the knee which is caused by the irritation of the cartilage (flexible connective tissue connecting bones to bones) located on the back of the kneecap (patella).

Causes

Although a number of factors can contribute to this condition, the exact cause is unknown.  Most typically it is caused by:

·    Overuse from high impact activities that cause improper tracking of the patella on the femur (thigh bone)

·    Injury or dislocation (displacement or misalignment) of the kneecap

·    Thigh muscles that are too weak or too tight; inadequate stretching

·    Flat feet

·    Wearing down, roughening or softening of the cartilage under the kneecap

·    Misalignment of the kneecap which can be caused by vigorous activities causing excessive wear and tear on the kneecap cartilage.  The resultant softening and breakdown of the patellar cartilage irritates the joint lining which causes pain.

Symptoms

·   Most common:  a dull aching pain under and around the kneecap where it connects to the femur

·    Pain most frequently occurs when climbing up or down stairs, kneeling, squatting, and sitting for prolonged periods of time with the knee in a flexed position

·    The knee might also “catch”, grind, or pop

Prevention

·    Maintain a healthy weight and stay in good shape

·    Stretch and sufficiently warm up before participating in any exercise or activity (especially running)

·    Gradually increase your work out or training program over time.  Avoid sudden and intense increases in the intensity of exercise

·    Wear proper running gear and footwear with sufficient shock absorption features and of quality design and materials.  Footwear should fit properly and be changed out frequently when worn

·    Shoe inserts may be necessary if you have flat feet

·    Use proper form when exercising and running.  Running surfaces should be smooth, even, and somewhat resilient.  Avoid running down a steep hill (slow the pace to a brisk walk or use a serpentine pattern when descending)

Diagnosis

·    History – your physician will explore your symptoms, exercise/sports participation patterns, and any recent injuries

·    Physical Exam – your physician will want to assess your knee’s strength, motility, and alignment by watching you stand, walk, jump, squat, and will also put your knee and leg through a series of maneuvers to assess the alignment and stability of your lower leg and kneecap

·    Imaging – your physician may order diagnostic imaging studies such as x-ray, MRI, or CT based on the findings of the history and physical exam

Treatment

Depends on the underlying cause of the knee pain but is generally nonsurgical

            First Aid Treatment: 

·    Immediately cease any activity that causes the knee pain (running or jumping)

·    RICE

o   Rest – avoid putting weight on the painful knee; change to non-weight bearing exercise such as swimming or stationary biking

o   Ice – apply cold packs for 20 minutes several times each day

o   Compression – wrap the area or cover the area with an elastic bandage or elastic knee sleeve that fits snuggly

o   Elevation – keep the knee raised at a level higher than your heart when at rest   

·    Medications such as nonsteroidal anti-inflammatory drugs to relieve pain

·    Consult your physician if the knee pain does not subside or improve with RICE

o   Runner’s knee generally improves with early treatment

Nonsurgical Treatment

Once the knee pain and swelling has subsided, reconditioning is often needed to restore the full range of motion, strength, and agility present prior to the condition’s onset.  Your physician and physical therapist can assist with prescribing an exercise program that will assist with this.  Occasionally interventions such as taping the knee, wearing a brace, or using specialized shoe lifts might be used to relieve the discomfort.

 

Surgical Treatment

Not frequently necessary except in severe cases but might include

·    Arthroscopy – surgery made through a small incision in which the surgeon removes small fragments of the damaged kneecap through a small tube-like instrument called an arthroscope

·    Realignment – there are many realignment procedures to relieve pain.  Some involve small releases, patellofemoral ligament reconstruction or bony procedures to improve tracking of the patellofemoral joint.  Lastly, in older individuals or most severe cases, there is a limited patellofemoral joint replacement.

Dr. Michael Vella specializes in adult reconstruction of hips and knees, sports medicine including arthroscopy of the knee, shoulder, and ankle,  fracture care, and general orthopedics.  He attended medical school at Upstate Health Science Center, completed two years of general surgery residency at Brown University, and fellowship trained at Harvard.  Dr. Vella has been practicing here since 1989 and participates in the care of many high school, collegiate, and minor professional athletes.  He is a member of several medical societies and is president of Midstate IPA, serving over 1200 health care providers. 

 

Shoulder Injuries in Athletes

Bradley S. Raphael M.D.

RSM Medical Associates

          

As spring sports start up (lacrosse, baseball, tennis) so to can shoulder pain.  Shoulder injuries are common in overhead athletes (swimming, tennis, baseball, football), but can also occur in overhead workers.  This is especially true with heavy laborers or jobs which require repetitive overhead activities at work.

Different shoulder problems from overuse:

                -Impingement

   -Rotator cuff tears

                -Rotator cuff tendinitis

                -Labral tears

                -Instability/dislocation

               

Anatomy:

-The shoulder is essentially a ball in socket with less restriction than any other joint in the body.  This allows the shoulder to be the most mobile joint in the body.

                -Rotator cuff is a series of 4 muscles that center the ball on socket during shoulder motion, maximizing the efficiency of shoulder movement.  These can be inflamed with repetitive motion and can make overhead activity painful.

                -The rotator cuff can also become inflamed as it rubs under the color bone and shoulder blade (often described as a “bone spur”)

                -The labrum is made of a thick tissue that rings the shoulder socket and is susceptible to injury with trauma to the shoulder joint. When a patient sustains a shoulder injury, it is possible for the labrum to tear. Some symptoms are an achy sensation to the shoulder joint, catching of the shoulder with movement and pain with specific activities

Treatment:

                -These injuries are often treated with physical therapy, strengthening, stretching, (especially baseball players and other overhead athletes)

                -It’s important to do appropriate warm up before long pitching outings, lacrosse games, tennis matches and overhead work activity in order to prevent injuries.

                -If physical therapy fails, may need an injection to help decrease pain (steroid).

                - These injuries usually respond to conservative measures, but sometimes it can become refractory and may need arthroscopic procedure to clean out bursitis, remove bone spurs or repair the tendons or labrum.

               

Prevention:

                -Important to follow little league pitching guidelines at young age (littleleague.org)

                -Pre-game, pre-work, and pre-activity stretching

                -Hip and core strengthening to alleviate stress on shoulder with your local therapist or athletic trainer.

                -See your doctor as soon as you start having soreness that doesn’t go right away, because it could be the sign of something more serious

Bradley S. Raphael M.D. completed his sports medicine training in Los Angeles at the Kerlan Jobe Orthopedic Clinic and is in practice at RSM Medical Associates where he specializes in Shoulder and Knee problems. He is also a team physician for Syracuse University Athletics.  For appointments or questions: 315-701-4024 or on the web at raphaelmd.com

Rotator Cuff Tears

By Ryan Smart, MD

Syracuse Orthopedic Specialists

Intro

Rotator cuff tears are among the most commonly encountered disorders of the shoulder.  They can be debilitating and difficult to treat.  Chronic rotator cuff tears are common and with the aging population the incidence of new tears continues to rise.  More than 50% of individuals older than 60 years have at least a partial rotator cuff tear and full thickness tears are found in almost half of individuals older than 80 years. (1)  Approximately two-thirds of all rotator cuff tears in the general population are asymptomatic and factors found to be associated with symptoms when one has a rotator cuff tear are a positive impingement sign, weakness in external rotation, and presence of a tear in the dominant arm. (2)  Procedures done to treat rotator cuff disease are among the most common of all orthopaedic surgeries.

Anatomy

The glenohumeral joint has very little bony support.  The rotator cuff, which is made up of four muscles (subscapularis, supraspinatus, infraspinatus, and teres minor), plays a major role in both the mobility and stability of the shoulder.  Of these two roles, stability appears to be the larger function.  To maintain a ball-and-socket articulation during motion, the humeral head is compressed into the glenoid socket by the rotator cuff.  Without such compression, the humeral head can undergo excessive translation within the socket which disrupts shoulder kinematics.  EMG studies have shown that the rotator cuff muscles fire prior to and then concurrently with the deltoid and pectoralis major muscles.(3)  This preceding and concurrent activation of the rotator cuff muscles maintains the shoulder joint for dynamic stability during larger muscle contractions.

History

Pain is the most frequent complaint.  It can at times radiate down the arm to the level of the elbow.  Many patients will complain of nighttime pain.  Typically, the pain will be worse with certain motions such a forward elevation or abduction.  As the tear progresses, weakness will become a more prevalent symptom.  Rotator cuff pain does not typically radiate down the arm to the level of the wrist or hand.  If such symptoms are present one should suspect the cervical spine as the pain generator.  A history of a trauma or fall will sometimes be present but many times patients cannot recall a specific inciting event.

Physical Exam

A thorough physical exam significantly aids in the diagnosis and management of rotator cuff tears.  A complete shoulder exam should be performed starting with inspection and palpation.  Range of motion is then assessed both passively and actively.  If both passive and active motion is limited one should consider an alternative diagnosis such as adhesive capsulitis (ie frozen shoulder).  Patients with rotator cuff pathology will typically have mid-arc pain.  A positive Neer and Hawkins maneuver is common.  Strength testing is performed for each rotator cuff muscle.  The empty can and drop arm maneuvers test the supraspinatus.  The lift-off, belly press and bear hug all test the subscapularis and external rotation strength tests the infraspinatus and teres minor.  The combination of a positive drop-arm sign, painful arc sign, and infraspinatus muscle strength test was most predictive for full thickness rotator cuff tears.(4)

Treatment

Conservative

Nonsurgical management is typically the first line of treatment for most rotator cuff pathology.  The natural history of rotator cuff tears is thought to be that of tear progression. (5)  It is believed that tear size progression is a factor in the development of symptoms.  Physical therapy and shoulder rehabilitation should focus on restoration of motion, flexibility and strength. (6)  Nonsurgical management may also include pain medication and anti-inflammatory drugs and subacromial cortisone injections.  Although injections are common a recent systematic review suggests that long-term benefits are limited. (7)  Multiple cortisone injection should be avoided in patients who may be best served with surgical intervention.  Successful non-operative management has been correlated with symptom duration of less than 3 months.  Factors that have been found to predict failure of conservative treatment are: 1) full-thickness tear greater than 1cm x 1cm, symptoms present for more than 1 year, and functional impairment and weakness. (8)  Nonsurgical treatment is often attempted for a minimum of 6 to 12 weeks before surgery is considered.

                Surgical

When patients fail conservative treatment surgery is usually indicated.  Tears can be repaired either arthroscopically or by open means.  The clinical results reported with arthroscopic repairs are equivalent to those reported for both open and mini-open. (9,10)  However, the deltoid muscle is undisturbed with arthroscopic repairs thus making it the favored approach by many.  The goal of surgery is to anatomically repair the rotator cuff securely to bone with as little tension as possible.   Reported healing rates, based on ultrasound and MRI, range from 91% in small tears to 10% in massive tears. (11)  With larger tears, the best clinical results are achieved in patients who experience tendon healing postoperatively. (12)

Rehab

The ideal rehabilitation program allows for tendon to bone healing and prevents stiffness.  Most agree the best clinical results occur when the rotator cuff heals to bone in its entirety.  Since the rotator cuff heals very slowly (~5% per week) most have adopted fairly conservative rehab protocols limiting motion the first 6 weeks.

Dr. L. Ryan Smart specializes in sports medicine, arthroscopic surgery, and shoulder surgery.  He completed his fellowship in sports medicine at the New England Baptist Hospital in Boston, MA and completed his orthopaedic surgery residency at Yale in New Haven, CT.   After completing his undergraduate studies at Cornell University, he went on to the University of Michigan for medical school.  He is the team physician for the Christian Brothers Academy football team, Cornell Men’s Ice Hockey, Syracuse Silver Nights soccer club and Fayetteville-Manlius High School. He played 4 years of varsity ice hockey at Cornell and was drafted by the New Jersey Devils in the 1994 NHL entry draft.  His professional memberships include Arthroscopy Association of North America and the American Orthopaedic Society for Sports Medicine.