Eventual Goal of Runner's Knee Therapy Is to Be NSAID Free

MIAMI — The first goal of treatment in patellofemoral pain syndrome is to reduce and eventually discontinue NSAIDs, Dr. Joseph Congeni said at a meeting on pediatric sports medicine sponsored by the American Academy of Pediatrics.

Patellofemoral pain syndrome is the most common sports-related overuse injury in young athletes, occurring at least once in an estimated 30%–40% of female athletes. Also known as runner's knee, the syndrome is usually caused by improper tracking of the kneecap in the patellofemoral groove. Instead of riding smoothly in the groove, the malaligned patella is shifted, a condition that causes pain and inflammation. A few cases result from compression of the kneecap, which can develop if the hamstring muscle is significantly stronger than the quadriceps, a situation seen in younger children who have just gone through their growth spurt or teenage boys.

The incidence of tracking PFS is about five times greater in girls than in boys. Several anatomical factors contribute to PFS, including femoral anteversion, kneecaps pointing toward each other (“squinting patella”), genu varum (bowleg), and tibia varum. The feet compensate for the malalignment by pronating, and these factors together result in the pain associated with PFS.

In many cases of PFS, a lateral-view x-ray will show that the kneecap rides high (patella alta). “When the kneecap rides this high, it's not as deep a groove and the kneecap tends to slide in and out of that groove readily,” said Dr. Congeni, medical director of the sports medicine center at the Children's Hospital Medical Center of Akron (Ohio). Children with tracking PFS present with pain around the knee that emerges without any specific injury. They may or may not have swelling around the kneecap. Clinicians may see that the patella tracks in a “J” pattern when the leg is extended, because the patella moves inward as it moves up along the knee. Increased ligament laxity or instability also is common.

The functional tests of a minisquat and a catcher's squat, which will likely be painful in PFS, can help in the diagnosis.

Aside from having a thorough patellar exam, athletes with suspected PFS should undergo a full structural exam—including a careful examination of the hip—to rule out a slipped capital femoral epiphysis (SCFE). Dr. Congeni recommended, at the very least, clinical evaluation of the internal and external rotation of the hip in these children, as vague knee pain is one of the signs of SCFE. PFS is usually a straightforward clinical diagnosis based on history and physical exam, and does not require additional tests. Dr. Congeni recommended x-rays for children who do not improve after a month to rule out other causes and to assess the state of the kneecap.

Dr. Congeni explained that the clinical course of PFS is likely to be a roller coaster of good and bad days, weeks, or months, as activity levels change. Sitting for long periods and walking on stairs or hills can aggravate symptoms.

Treating PFS is a slow process that involves rest and rehabilitation through strengthening (quadriceps and gluteals) and increasing flexibility (quadriceps, hamstrings, and iliotibial band).

Orthotics can be more helpful than bracing for correcting mechanical issues, he said. Chronic self-medication with over-the-counter NSAIDs is common.

MIAMI — The first goal of treatment in patellofemoral pain syndrome is to reduce and eventually discontinue NSAIDs, Dr. Joseph Congeni said at a meeting on pediatric sports medicine sponsored by the American Academy of Pediatrics.

Patellofemoral pain syndrome is the most common sports-related overuse injury in young athletes, occurring at least once in an estimated 30%–40% of female athletes. Also known as runner's knee, the syndrome is usually caused by improper tracking of the kneecap in the patellofemoral groove. Instead of riding smoothly in the groove, the malaligned patella is shifted, a condition that causes pain and inflammation. A few cases result from compression of the kneecap, which can develop if the hamstring muscle is significantly stronger than the quadriceps, a situation seen in younger children who have just gone through their growth spurt or teenage boys.

The incidence of tracking PFS is about five times greater in girls than in boys. Several anatomical factors contribute to PFS, including femoral anteversion, kneecaps pointing toward each other (“squinting patella”), genu varum (bowleg), and tibia varum. The feet compensate for the malalignment by pronating, and these factors together result in the pain associated with PFS.

In many cases of PFS, a lateral-view x-ray will show that the kneecap rides high (patella alta). “When the kneecap rides this high, it's not as deep a groove and the kneecap tends to slide in and out of that groove readily,” said Dr. Congeni, medical director of the sports medicine center at the Children's Hospital Medical Center of Akron (Ohio). Children with tracking PFS present with pain around the knee that emerges without any specific injury. They may or may not have swelling around the kneecap. Clinicians may see that the patella tracks in a “J” pattern when the leg is extended, because the patella moves inward as it moves up along the knee. Increased ligament laxity or instability also is common.

The functional tests of a minisquat and a catcher's squat, which will likely be painful in PFS, can help in the diagnosis.

Aside from having a thorough patellar exam, athletes with suspected PFS should undergo a full structural exam—including a careful examination of the hip—to rule out a slipped capital femoral epiphysis (SCFE). Dr. Congeni recommended, at the very least, clinical evaluation of the internal and external rotation of the hip in these children, as vague knee pain is one of the signs of SCFE. PFS is usually a straightforward clinical diagnosis based on history and physical exam, and does not require additional tests. Dr. Congeni recommended x-rays for children who do not improve after a month to rule out other causes and to assess the state of the kneecap.

Dr. Congeni explained that the clinical course of PFS is likely to be a roller coaster of good and bad days, weeks, or months, as activity levels change. Sitting for long periods and walking on stairs or hills can aggravate symptoms.

Treating PFS is a slow process that involves rest and rehabilitation through strengthening (quadriceps and gluteals) and increasing flexibility (quadriceps, hamstrings, and iliotibial band).

Orthotics can be more helpful than bracing for correcting mechanical issues, he said. Chronic self-medication with over-the-counter NSAIDs is common.

MIAMI — The first goal of treatment in patellofemoral pain syndrome is to reduce and eventually discontinue NSAIDs, Dr. Joseph Congeni said at a meeting on pediatric sports medicine sponsored by the American Academy of Pediatrics.

Patellofemoral pain syndrome is the most common sports-related overuse injury in young athletes, occurring at least once in an estimated 30%–40% of female athletes. Also known as runner's knee, the syndrome is usually caused by improper tracking of the kneecap in the patellofemoral groove. Instead of riding smoothly in the groove, the malaligned patella is shifted, a condition that causes pain and inflammation. A few cases result from compression of the kneecap, which can develop if the hamstring muscle is significantly stronger than the quadriceps, a situation seen in younger children who have just gone through their growth spurt or teenage boys.

The incidence of tracking PFS is about five times greater in girls than in boys. Several anatomical factors contribute to PFS, including femoral anteversion, kneecaps pointing toward each other (“squinting patella”), genu varum (bowleg), and tibia varum. The feet compensate for the malalignment by pronating, and these factors together result in the pain associated with PFS.

In many cases of PFS, a lateral-view x-ray will show that the kneecap rides high (patella alta). “When the kneecap rides this high, it's not as deep a groove and the kneecap tends to slide in and out of that groove readily,” said Dr. Congeni, medical director of the sports medicine center at the Children's Hospital Medical Center of Akron (Ohio). Children with tracking PFS present with pain around the knee that emerges without any specific injury. They may or may not have swelling around the kneecap. Clinicians may see that the patella tracks in a “J” pattern when the leg is extended, because the patella moves inward as it moves up along the knee. Increased ligament laxity or instability also is common.

The functional tests of a minisquat and a catcher's squat, which will likely be painful in PFS, can help in the diagnosis.

Aside from having a thorough patellar exam, athletes with suspected PFS should undergo a full structural exam—including a careful examination of the hip—to rule out a slipped capital femoral epiphysis (SCFE). Dr. Congeni recommended, at the very least, clinical evaluation of the internal and external rotation of the hip in these children, as vague knee pain is one of the signs of SCFE. PFS is usually a straightforward clinical diagnosis based on history and physical exam, and does not require additional tests. Dr. Congeni recommended x-rays for children who do not improve after a month to rule out other causes and to assess the state of the kneecap.

Dr. Congeni explained that the clinical course of PFS is likely to be a roller coaster of good and bad days, weeks, or months, as activity levels change. Sitting for long periods and walking on stairs or hills can aggravate symptoms.

Treating PFS is a slow process that involves rest and rehabilitation through strengthening (quadriceps and gluteals) and increasing flexibility (quadriceps, hamstrings, and iliotibial band).

Orthotics can be more helpful than bracing for correcting mechanical issues, he said. Chronic self-medication with over-the-counter NSAIDs is common.