Dolor anterior de rodilla

miércoles, 25 de noviembre de 2020 9:59 a. m.

Anterior knee pain — Pain at the anterior knee is the most common complaint among patients presenting with atraumatic knee pain without an effusion. Such pain often stems
from a specific structure and therefore the patient can either "point with one finger" to the painful site, or the clinician can recreate the pain with focused palpation. The
conditions causing such pain include Osgood-Schlatter disease, Hoffa's fat pad syndrome, patellar and quadriceps tendinopathy (tendinosis), bursitis, and plica syndrome.
Important structures to palpate in patients with anterior pain include the patella, patellofemoral joint, patellar tendon, tibial tubercle, and quadriceps tendon (picture 2).

●Osgood-Schlatter disease – Pain from Osgood-Schlatter disease is caused by tibial tubercle apophysitis at the insertion of the patellar tendon. The condition is most common
in active older children and adolescents, but some adults may experience ongoing pain after the apophysis has fused. Pain and tenderness are localized to the tibial tubercle (figure
1 and figure 2 and picture 3). Pain increases with activity, particularly jumping and running. Poor flexibility of the quadriceps, and possibly the hip flexors, may be
noted. (See "Osgood-Schlatter disease (tibial tuberosity avulsion)".)

Recorte de pantalla realizado: 25/11/2020 10:13 a. m.

●Hoffa's fat pad syndrome – The infrapatellar (ie, Hoffa's) fat pad (IFP) is a highly innervated and vascularized extra-articular structure located distal to the patella and directly
beneath the patellar tendon. Edema within the fat pad can be painful and has been implicated in patellofemoral maltracking; patients with a diagnosis of patellofemoral pain (PFP)
should be evaluated for possible IFP involvement [6]. IFP-related pain generally presents as anterior knee pain distal to the patella. It is often made worse by sprinting
activities or squatting, and shares historical characteristics with patellar tendinopathy and PFP.
While no special tests are available to diagnose IFP, the physical examination may help to distinguish it from alternative diagnoses. Knee inspection is usually
unremarkable, but inflammation of the IFP may be noted as asymmetric swelling of the patellar tendon. IFP syndrome should not cause visible maltracking of the
patella during knee flexion or extension. Maneuvers that impinge the IFP, such as squatting or direct downward pressure on the patellar tendon, reproduce the
patient’s anterior knee pain. Tenderness with palpation deep to the patellar tendon on either side, but not at its insertion, suggests inflammation and edema of the Recorte de pantalla realizado: 25/11/2020 10:03 a. m.
IFP [7]. Musculoskeletal ultrasound can be used to demonstrate that the patellar tendon, bursa, and other adjacent structures appear normal, and may reveal signs
suggestive of IFP pathology. (See "Musculoskeletal ultrasound of the knee".)

Recorte de pantalla realizado: 25/11/2020 10:13 a. m.

●Quadriceps and patellar tendinopathy – The distal quadriceps tendon is a conjoined tendon of the vastus lateralis, vastus medialis, vastus intermedius, and rectus femoris
muscles. As it proceeds distally, the quadriceps tendon envelops the patella and becomes the patellar tendon distally, inserting on the anterior tibial tubercle. Both the quadriceps
and patellar tendon are susceptible to many of the same conditions and injuries. Explosive movements involving knee extension, such as jumping, running, or squatting (eccentric
stress) reproduce the pain associated with both quadriceps and patellar tendinopathy. Quadriceps tendinopathy, the more common condition, characteristically causes pain
proximal to the superior patellar pole. Physical examination findings include focal pain with resisted knee extension and often some atrophy of the quadriceps muscle (typically the
vastus medialis) on the involved side in comparison with the unaffected leg. Focal tenderness with direct palpation at, or just proximal to, the superior patellar pole is
characteristic. In contrast, patellar tendinopathy causes pain distal to the patella. Focal tenderness at or just distal to the inferior patellar pole is common. (See "Quadriceps
muscle and tendon injuries", section on 'Quadriceps and patellar tendinopathy'.)
The quadriceps and patellar tendons are visualized readily with ultrasound, which can be used as an adjunct to the physical examination for diagnosing
tendinopathy. Tendinopathic changes visualized on ultrasound may include loss of the normal fibrillar structure of the tendon with reduced echogenicity, tendon
thickening, and possibly calcific tendinopathy. (See "Musculoskeletal ultrasound of the knee".)

Recorte de pantalla realizado: 25/11/2020 10:13 a. m.

●Bursitis – Acute prepatellar or superficial infrapatellar bursitis presents with localized redness, swelling, and marked tenderness anterior to the patella or patellar tendon. The
condition is usually associated with a history of direct trauma or repetitive pressure (prolonged kneeling) at the patellar region but may also be crystal-induced or due to a bacterial
infection. Examination reveals pre-patellar swelling and edema between the skin and the patella. Ultrasound examination can be used to assess the anatomic relations of the
above structures, and the exact location of bursitis. Care should be taken to not compress the superficial structures when performing the examination. The motion and stability of
the knee joint itself remain unaffected by bursitis. (See "Knee bursitis" and "Musculoskeletal ultrasound of the knee".)

Recorte de pantalla realizado: 25/11/2020 10:14 a. m.

●Plica syndrome – Individuals who have sustained trauma to the medial peripatellar area or dislocations or subluxations of the patella may develop thickening of the medial
patellar plica [8]. This condition can also develop chronically from overuse, particularly in runners with some degree of genu valgus ("knock knees"). A thickened
medial plica may catch at the medial edge of the patella or the medial femoral condyle causing localized anteromedial knee pain that increases with movement, and
possibly chondral injury. Examination reveals thickening of the plica (palpable in most patients) with focal tenderness at the medial underside of the patella.
Ultrasound can be used to visualize thickened plica tissue. A useful examination maneuver is the medial patellar plica test (figure 3). (See "Plica syndrome".)

Recorte de pantalla realizado: 25/11/2020 10:02 a. m.

The causes of anterior knee pain listed above are often readily diagnosed by history and examination. The causes listed below—patella subluxation, PFP,
chondromalacia patella, and patellar stress fracture—present without acute trauma or joint effusion, and do not lend themselves to pinpoint localization.

●Chronic patella dislocation or subluxation – Patients with a history of patellar dislocation have damaged the medial patellofemoral ligament and thus are at increased risk
for recurrent or chronic subluxation and dislocation (figure 4). These patients typically describe anteromedial patellar discomfort and a sensation of the knee snapping or
giving way during activity. Examination often reveals atrophy of the vastus medialis and a positive apprehension test (figure 5). Individuals with hypermobility
disorders, such as Ehlers-Danlos Syndrome, are at risk for chronic patella subluxation. (See "Recognition and initial management of patellar dislocations".)

Recorte de pantalla realizado: 25/11/2020 10:14 a. m.

Casos clínicos resúmenes página 1

●Patellofemoral pain (PFP) – PFP is a frequently encountered overuse disorder that involves the patellofemoral region and often presents as anterior knee pain. PFP is
diagnosed primarily from the history and is characterized by pain around or behind the patella that cannot be attributed to another discrete intra-articular (eg, meniscus tear) or
peripatellar (eg, patellar tendinopathy) pathology. PFP is aggravated by one or more activities that involve loading the patellofemoral joint during weight bearing on a flexed knee.
Common historical features include vague, poorly localized anterior knee pain (usually "under" or around the patella) that is made worse with squatting, running, prolonged sitting
(theater sign), or going up or down stairs. Mechanical symptoms (eg, locking, catching) and the presence of an effusion are NOT associated with PFP. Many people with PFP report
instability or their knee "giving out", which stems from pain causing reflex inhibition of the quadriceps. It bears emphasis that patellar instability and ligamentous injury of the knee
should be ruled out by examination before ascribing the patients symptoms to PFP. Ultrasound can be used to assess peripatellar structures of the knee and to help rule out other
diagnoses. However, there are no ultrasound-specific changes or criteria for diagnosing PFP. (See "Patellofemoral pain" and "Musculoskeletal ultrasound of the knee".)

Recorte de pantalla realizado: 25/11/2020 10:15 a. m.

●Chondromalacia patella – Chondromalacia patella is a cause of peripatellar pain and the term is commonly used interchangeably with PFP. However, chondromalacia patella
is a distinct radiologic diagnosis defined by the presence of pathologic changes in the articular cartilage on the underside of the patella, such as softening, erosion, and
fragmentation [9]. The clinical history and examination findings are similar to PFP, but an effusion may also be present if articular cartilage damage is sufficiently
severe. The articular damage is usually secondary to a prior injury or chronic maltracking of the patella in the trochlear groove. MRI is needed to make the diagnosis
but is usually unnecessary as treatment is similar to that for PFP.

Recorte de pantalla realizado: 25/11/2020 10:15 a. m.

●Patella stress fracture – Patella stress fractures develop after repeated application of submaximal stress leading to cortical disruption and pain. These fractures are seen in
highly active individuals participating in explosive jumping or plyometric activities, and does not occur in sedentary individuals or "weekend warriors." Often, there is an abrupt
increase in the volume or intensity of exercise or athletic training several weeks prior to the onset of pain. Although rare, patella stress fractures are considered to be at high risk
for nonunion and should be referred to a provider with expertise in musculoskeletal medicine [10]. The history and examination findings are often nonspecific in the early
stages, but pain becomes more localized to the patella as the injury progresses. Ultrasound can be used to evaluate for acute patellar fracture or bipartite patella;
however, it is not sensitive or specific for stress fracture. MRI is typically needed to make a definitive diagnosis. (See "Overview of stress fractures" and "Approach to
chronic knee pain or injury in children or skeletally immature adolescents", section on 'Patellar stress fracture'.)

Recorte de pantalla realizado: 25/11/2020 10:15 a. m.

Desde <https://nebulosa.icesi.edu.co:2104/contents/approach-to-the-adult-with-unspecified-knee-pain?search=dolor%20rodilla%20anterior&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1#H85038444>

Anatomía de la patela medial y estabilización

Recorte de pantalla realizado: 25/11/2020 10:01 a. m.

Casos clínicos resúmenes página 2