Patellofemoral syndrome (PFS) is the most common diagnosis seen in the knee, and refers to pain more or less under the patella (kneecap). The exact pain generator for PFS is not clearly understood, yet thought to involve a variety of factors. These include muscular imbalances (weak quadriceps/hip flexors, tight Iliotibial band and hamstrings, weak hip abductors), inflammation and lesions to the cartilage surface underneath the kneecap, and abnormal tracking of the kneecap within its bony groove during knee movement (the kneecap can be tilted or sit higher/lower in certain people). Furthermore, some patient's have slightly different anatomy when it comes to bony alignment causing more stress on the kneecap and increasing the patient's chance of getting PFS.
Patients with PFS usually present with pain in and around the patella. At times, patients can report pain that radiates to the back of the knee or down the shin. Pain is usually worsened going up and especially down stairs, with squatting, deep knee bends or kneeling, and after prolonged periods of sitting with the knee bent (also known as "moviegoer's knee").
Dr. Lee will usually first order an Xray to evaluate how the kneecap sits within its groove and also to rule out other sources of pain. An MRI may also be ordered to assess the amount of damage to the articular cartilage on the undersurface of the kneecap.
Non-operative management is the mainstay treatment for PFS and consists of activity modifications, physical therapy, and anti-inflammatory medications (as long as there are no contraindications with their use). Dr. Lee recommends avoiding kneeling, resisted knee extensions, wearing high heels, and any activity that requires bending the knee greater than 45 degrees such as deep squats, lunges, or leg presses. Physical therapy normally involves strengthening the quadriceps, hip flexors, and other core muscles. Increasing flexibility of the Iliotibial band and hamstrings is extremely important. Weight loss is also encouraged for those who may be overweight as less weight equates to less force generated through the kneecap.
Surgery is a last resort option and usually only considered after an extensive period of non-operative management. For patient's with cartilage damage to the undersurface of the kneecap, debridement or repair of the cartilage may be recommended to help improve symptoms. Those patients with kneecaps that are pulled or tilted laterally (towards the outside of the knee) may benefit from a procedure called a lateral retinacular release. In this procedure, tissues on the outside of the knee are released to lessen the pull on the kneecap in this direction, ultimately causing the kneecap to sit more aligned within its groove. Both of the above treatments are performed arthroscopically, which is minimally invasive and can result in less soft tissue disruption, less pain, and minimal scar formation. It is important to realize that difficult or severe cases may occasionally require an open repair (i.e. not using an arthroscopic camera and instruments). Those patients whose kneecaps have significant malalignment may benefit from a more extensive open realignment procedure.
Patients undergoing a Lateral Retinacular Release or realignment procedure will usually be placed into a knee brace locked in extension. Immediate weightbearing will be allowed as long as the brace is worn, locked in extension. Sutures are usually removed during the first post-op appointment, 1-2 weeks after surgery. Patient's are normally then given Physical Therapy and progressively increased range of motion while in their knee brace. Physical Therapy usually lasts 2-3 months. Patients are usually cleared for normal activities including running and jumping activities 3-4 months status post surgery.
Patients undergoing only kneecap cartilage debridement can expect a much quicker recovery. The duration of Physical Therapy is usually shorter and patients are usually cleared for running and jumping activities sooner, as early as 6 weeks.
Learn more about post-operative care.
*It is important to note that all of the information above is not specific to anyone and is subject to change based on many different factors including but not limited to individual patient, diagnosis, and treatment specific variables. It is provided as an educational service and is not intended to serve as medical advice. Anyone seeking specific orthopedic advice or assistance should consult Dr. Steven Lee or an orthopedic specialist of your choice.
*Dr. Steven Lee is a board certified orthopedic surgeon and is double fellowship trained in the areas of Hand and Upper Extremity Surgery, and Sports Medicine. He has offices in New York City, Scarsdale, and Westbury Long Island.