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