Chronic traumatic anterior knee pain
Introduction
The patello-femoral joint is particularly vulnerable to injury when the knee is flexed [1], [2]. Damage can occur in one of two ways. Firstly a blow to the front of the knee such as a kick or a dashboard injury and secondly a fall forwards on to the bent knee. The patella is “sandwiched” between the distal femur and the causative object. Understandably significant damage can occur to the articular cartilage of the patello-femoral joint and it is well recognised that troublesome symptoms can follow [3], [4], [5], [6]. Symptoms may resolve with non-specialist treatment or without medical advice being sought, but in a proportion of cases they become chronic. Patients in this latter category group typically have persistent pain, which can be debilitating and unresponsive to treatment. Litigation can complicate the issue especially in the so called “dashboard” knee [7].
We have defined the syndrome of chronic traumatic anterior knee pain (CTAKP) as persistent anterior knee pain following a direct blow to the front of the knee in which other significant intra-articular pathology has been excluded by appropriate clinically guided investigation. Although there are many references in the literature to the painful patello-femoral joint, there is very little documentation of CTAKP. A Medline search has revealed only one article dealing specifically with the clinical aspects of this problem in the last 30 years [8]. Having defined the condition, the aim of this study was to document the clinical features, describe the natural history and comment on its prognosis.
Section snippets
Materials and methods
Between March 1995 and December 1997 a consecutive series of 50 patients with CTAKP following a blunt injury to the front of the knee presented to two orthopaedic surgeons (RLA and JRJ) in one trust serving a population of approximately 380,000. Prospective documentation was obtained. The plan of investigation and treatment was not standardised as the clinical presentation was variable and patients were investigated and treated as was deemed appropriate in each individual case. Patients with
Symptoms (Table 2)
At final follow-up (mean 4 years and 8 months) 44 (96%) patients had residual pain, with 10 (22%) reporting severe pain. Complete resolution of pain had occurred in only two (4%) patients. Of the remaining 44 patients, half complained of constant or daily pain and half complained of less frequent attacks. Twenty-nine patients (63%) had rest pain and 21 (46%) had night pain. Kneeling (91%), squatting (80%), running (74%) and climbing stairs (74%) were the commonest aggravating activities. A
Discussion
Anterior knee pain has many different aetiologies [2], including direct trauma to the front of the knee. This study confirms CTAKP as a definite, if imprecise clinical condition.
We have defined it as persistent anterior knee pain following a direct blow to the knee, where other significant intra-articular pathology has been excluded by appropriate clinically guided investigation. In clinical practice it is a diagnosis of exclusion. Following direct injury to the front of the knee most patients
Conclusion
Anterior knee pain following blunt injury to the front of the knee causes significant and persistent problems. The response to both non-operative and operative treatment is poor. For most patients improvement can occur for up to 2 years following injury; if symptoms persist after this then the prospect of further recovery is poor. A longer term follow-up will be carried out in these patients in due course.
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