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KNEE PAIN IN ATHLETES

The painful knee is a very troublesome problem to a keen athlete. The majority of athletic endeavour places tremendous demand on the largest most complicated joint in the body.

Chronic pain is most resistant to treatment. Patella tendonitis is extremely common in many sports, specially basketball, tennis and weight lifting. The frustration with this condition is that although it is a catastrophe to the athlete, the physical signs are minimal. Management of such a condition is the essence of Sports Medicine. The understanding of a person’s desire to choose continued participation over rest or retirement is essential to the practitioner dealing with sportsmen.

The commonest causes of chronic knee pain in athletes are patella tendonitis, chondromalacia patella and iliotibial band friction syndrome.

Meniscal lesions in athletes do not usually present with pain. Chronic ligament lesions almost never present with pain as a chief symptom.

ACUTE KNEE PAIN

Acute knee pain is most often due to haematoma from direct contusion. Sever twisting injuries, although they cause immediate pain, may be completely painless, especially if the capsule of the joint is totally ruptured.

Haemarthrosis is the most sever pain outside of pyarthrosis (infected knee), the athlete can experience. Tension in the joint is unrelenting but is immediately relieved by aseptic drainage.

A provisional diagnosis of ruptured anterior cruciate ligament should be made in all cases of haemarthrosis. Test have been described which measure anterior transition of tibia on femur. These tests are the Lachman, dynamic extension, Jerk and pivot shift tests. If positive, they will confirm the diagnosis.

Unusual acute pain should alert one to the possibility of fracture. I have seen three undisputed fractures of the tibial plateau in patients originally treated for meniscal injuries. Of course undisplaced epiphyseal injuries are notoriously missed in the skeletally immature athlete.

Haemorrhage into a prepatella bursa may be a difficult diagnosis. I have seen even experienced practitioners mistake it for haemarthrosis. Of course the patella can not be palpated by CAREFUL PHYSICAL EXAMINATION in cases of prepatella bursae.

CAUSES OF ACUTE KNEE PAIN

1. Ligament sprain
2. Haemarthrosis
3. Haemorrhage prepatella bursa
4. Fracture
5. Subperiostal haematoma

It is important to x-ray all causes in order to rule out fracture even through this is the least common cause of pain.

ANATOMICAL SITES OF KNEE PAIN

• Capsule
• Bone
• Ligaments
• Meniscus
• Tendon
• Nerve
• Vessel
• Referred Pain
  • Spine
  • Hip
  • Local

PATHOLOGICAL CAUSES

• Trauma
  • Direct
  • Indirect
• Stress (repetitive)
• Haemorrhage
• Dystrophic calcification
• Referred
• Atrophy (sympathetic dystrophy)
• Malalignment tumour

CHRONIC KNEE PAIN

CHONDROMALACIA PATELLA

This is the most common perplexing problem with the knee. It is most resistant to treatment as its causes are multi-factorial. Difficulty arises also as the pathological state of the patella does not parallel the degree of symptoms.

• Subluxing patella
• Direct trauma
• Patella migraine
• Internal derangement
• Hamstrung knee
• Malalignment
• Posterior cruciate rupture
• Lateral pressure
• Synovial plica

Treatment is primarily based on physical therapy with extensive vastus medialis obliquus rehabilitation. Rarely is surgery of benefit. Chondroplasty of the patella is of questionable value. Patella realignment is indicated only in gross malalignment situations.

Lateral release was fashionable for lateral pressure symptoms for a time, but the long term benefits are not yet available.

Excision of synovial plicae was fashionable also for some time but is only rarely indicated today.

PATELLA TENDONITIS

This condition is commonly resistant to treatment. In many cases physical therapy with ice, quadriceps stretching and rehabilitation effect a cure. In the chronic cases peritendinosus cortisone injection may be beneficial. Patella tendon strapping and bracing is very beneficial. I have found alteration of training or performance technique to be beneficial, especially in tennis players. This condition is also known as Jumper’s Knee and if proper landing techniques are practised, symptoms can be alleviated. Surgery is sometimes necessary and exploration under local anaesthesia helps to isolate the specific torn tendinous area. Exploration sometimes does not relieve the classic swollen haemorrhagic tendon tear. Some authors even recommend distal patella pole excision. It is interesting that some patients who go on to rupture and eventual repair that the condition is then cured.

ILIO-TIBIAL BAND FRICTION SYNDROME

This condition is the bane of long distance runners. They are usually slightly varus and their symptoms are easily reproducable. Many times this condition is confused with lateral meniscal tears.

Other tests will give the diagnosis and ilio-tibial band stretching combined with orthotics will alleviate the patient’s symptoms.

MENISCAL LESIONS

Parrot beak tears of the lateral meniscus are a common cause of chronic knee pain. They cause pain on running up inclines and ascending stairs. Their pain is commonly associated with radiation into the calf and thigh. In 30% of cases, a small lump is visible and palpable on the lateral joint line when the knee is examined at 40° short of full extension. These tears may progress to form a cyst of the lateral meniscus and the cyst becomes painful after activities of running and after excessive use.

Medial meniscal lesions causing chronic pain are posterior cleavage tears and are most common over the age of 30 years. They are rare in younger athletes but should be considered in the differential diagnoses.

Tendonitis of the semimembranosus sometimes causes difficulty in distinguishing between these lesions.

Referred pain from the hip and lumbar spine should always be considered in the differential diagnosis. Hip pain usually presents on the medial side of the knee as the obturator nerve is involved and interestingly it is more common when the acetabulum is primarily involved in the hip disorder.

SUMMARY

It is only by taking a careful history as to the site, nature and other characteristics of the pain, by understanding the nature of the athlete’s sport and training conditions, added with a thorough physical examination, will one be able to solve the problem of knee pain in athletes.