Instabilité méniscale par subluxation récurrente de la corne postérieure du ménisque latéral

A young football player presented several episodes of locking knee associated with pain of the lateral compartment while MRI was considered normal. The occurrence of an irreducible blocking requires performing arthroscopy with evidence of instability of the posterior horn of the lateral meniscus. After reviewing the literature, it appears that popliteomeniscal fasciculi play an important role in maintaining the stability of the posterior horn of the lateral meniscus. Disruption of these structures, either by default or rupture leads to hypermobility of the lateral meniscus. Clinical examination is not contributory; at most, one finds a pain when tensioning the posterolateral compartment at the “Figure-4 Test” and hypermobility in internal rotation of the knee. The popliteomeniscal fasciculi can be viewed on the “classic” MRI of the knee. We need to know the search during an episode of locking knee without meniscal lesion. The management is surgical with the aim of preserving the meniscus.     

Fracture-avulsion de l’épine iliaque antéro-inférieure et du petit trochanter chez un jeune adolescent

The avulsion fractures of the anterior-inferior iliac spine and lesser trochanter are rare. They occur most often in adolescents during sports activities. The forms in adults are rare. We report a case in a young 15-year-old teenager. He had consulted for pelvic trauma with groin pain and functional impotence of the right lower limb occurred during a recent game in triple jump. Physical examination revealed pain in the mobilization of the right hip in extension. Standard radiography of the pelvis has highlighted an avulsion fracture of the anterior-inferior iliac spine avulsion of the right with small trochanter, which has been confirmed by computed tomography. The patient has been treated orthopedically by rest and landfilling lower limb trauma, evolution was marked the disappearance of pain a few weeks later and resumption of the sporting activity in order to 6 months.     

Ostéochondrites disséquantes rares du genou chez l’enfant. À propos d’un cas tibial et d’ un cas rotulien et revue de la littérature

Osteochondritis dissecans is a rare condition and often involves the medial femoral condyle. We are here reporting two uncommon localizations in children involving the lateral portion of the tibial plateau in one and the patella in the other. They were two fourteen-year-old boys with respectively 4 and 3 months history of a right knee pain and locking. No previous trauma had been noted. X-ray studies and MR images provided definitive diagnosis. However, in the tibial localization, osteochondritis was associated to a damaged lateral discoid menisci and in the patellar localization, the osteochondral fragment was detached in the joint. Regularization of the lateral menisci and removal of a loose body were respectively performed under arthroscopy in the two knees. Literature is reviewed with an emphasis particularly on pathogenesis of these rare localizations.     

ASB clinical biomechanics award winner 2006 prospective study of the biomechanical factors associated with iliotibial band syndrome

BACKGROUND: Iliotibial band syndrome is the leading cause of lateral knee pain in runners. Despite its high prevalence, little is known about the biomechanics that lead to this syndrome. The purpose of this study was to prospectively compare lower extremity kinematics and kinetics between a group of female runners who develop iliotibial band syndrome compared to healthy controls. It was hypothesized that runners who develop iliotibial band syndrome will exhibit greater peak hip adduction, knee internal rotation, rearfoot eversion and no difference in knee flexion at heel strike. Additionally, the iliotibial band syndrome group were expected to have greater hip abduction, knee external rotation, and rearfoot inversion moments. METHODS: A group of healthy female recreational runners underwent an instrumented gait analysis and were then followed for two years. Eighteen runners developed iliotibial band syndrome. Their initial running mechanics were compared to a group of age and mileage matched controls with no history of knee or hip pain. Comparisons of peak hip, knee, rearfoot angles and moments were made during the stance phase of running. Variables of interest were averaged over the five running trials, and then averaged across groups. FINDINGS: The iliotibial band syndrome group exhibited significantly greater hip adduction and knee internal rotation. However, rearfoot eversion and knee flexion were similar between groups. There were no differences in moments between groups. INTERPRETATION: The development of iliotibial band syndrome appears to be related to increased peak hip adduction and knee internal rotation. These combined motions may increase iliotibial band strain causing it to compress against the lateral femoral condyle. These data suggest that treatment interventions should focus on controlling these secondary plane movements through strengthening, stretching and neuromuscular re-education.     

Saphenous nerve injury following medial knee joint injection: a case report

Knee joint injection is a procedure commonly performed for pain management of osteoarthritis. Although several techniques have been described, it is usually performed by either medial or lateral approach with the lower limb extended on the examination table. We present the case of a patient who developed saphenous neuropathy following knee joint injection via medial approach. The clinical picture suggests that the needle pierced the nerve during the procedure. The patient was moderately obese. This is the first case report in the literature of saphenous nerve injury following medial knee joint injection. Practitioners should be aware of this complication in choosing an approach to the knee joint injection, especially when the patient is obese and the anatomic landmarks are obscured.     

Differences in lumbopelvic motion between people with and people without low back pain during two lower limb movement tests

Background

Clinical data suggest that active limb movements may be associated with early lumbopelvic motion and increased symptoms in people with low back pain.

Methods

Forty-one people without low back pain who did not play rotation-related sports and 50 people with low back pain who played rotation-related sports were examined. Angular measures of limb movement and lumbopelvic motion were calculated across time during active knee flexion and active hip lateral rotation in prone using a three-dimensional motion capture system. Timing of lumbopelvic motion during the limb movement tests was calculated as the difference in time between the initiation of limb movement and lumbopelvic motion normalized to limb movement time.

Findings

During knee flexion and hip lateral rotation, people with low back pain demonstrated a greater maximal lumbopelvic rotation angle and earlier lumbopelvic rotation, compared to people without low back pain (P < 0.05).

Interpretation

The data suggest that people with low back pain who play rotation-related sports may move their lumbopelvic region to a greater extent and earlier during lower limb movements than people without low back pain. Because people perform many of their daily activities in early to midranges of joint motion the lumbopelvic region may move more frequently across the day in people with low back pain. The increased frequency may contribute to increased lumbar region tissue stress and potentially low back pain symptoms. Lower limb movements, therefore, may be important factors related to the development or persistence of low back pain.     

Physical examination and patellofemoral pain syndrome

Patellofemoral pain syndrome, which accounts for 25% of all sports-related knee injuries, is multifactorial in origin. A combination of variables, including abnormal lower limb biomechanics, soft-tissue tightness, muscle weakness, and excessive exercise, may result in increased cartilage and subchondral bone stress, patellofemoral pain, and subtle or more overt patellar maltracking. Because of the multiple forces affecting the patellofemoral joint, the clinical evaluation and treatment of this disorder is challenging. An extensive search of the literature revealed no single gold-standard test maneuver for that disorder, and the reliability of the maneuvers described was generally low or untested. An abnormal Q-angle, generalized ligamentous laxity, hypomobile or hypermobile tenderness of the lateral patellar retinaculum, patellar tilt or mediolateral displacement, decreased flexibility of the iliotibial band and quadriceps, and quadriceps, hip abductor, and external rotator weakness were most often correlated with patellofemoral pain syndrome.     

Clinical tests for differentiating between patients with and without patellofemoral pain syndrome

Patellofemoral pain syndrome (PFPS) is a very common knee condition with various aetiologies. Because of the nebulous factors of the syndrome, physiotherapists often find it difficult to assess and treat these patients. The aim of this study was to identify the clinical assessment tool that can differentiate PFPS patients from patients with other lower limb conditions. Fifty-two patients from the National Health System (26 with PFPS and 26 with other lower limb conditions) took part in this study. They underwent a series of strength, flexibility, and stress tests. Their pain levels were also recorded. The results showed that among the various clinical tests, only the hip flexion component of the Thomas test was able to differentiate between the two groups. In addition, the stress test showed that the PFPS group could not recover their gluteal muscle strength in the same way the group with the other lower limb conditions did. The Lower Extremity Functional Scale was found to be more able to differentiate between the two groups than the Anterior Knee Pain Scale. This study has shown that it is difficult to find specific clinical tests to diagnose PFPS. More research is needed in this important area.     

Iliotibial band syndrome: a common source of knee pain

Iliotibial band syndrome is a common knee injury. The most common symptom is lateral knee pain caused by inflammation of the distal portion of the iliotibial band. The iliotibial band is a thick band of fascia that crosses the hip joint and extends distally to insert on the patella, tibia, and biceps femoris tendon. In some athletes, repetitive flexion and extension of the knee causes the distal iliotibial band to become irritated and inflamed resulting in diffuse lateral knee pain. Iliotibial band syndrome can cause significant morbidity and lead to cessation of exercise. Although iliotibial band syndrome is easily diagnosed clinically, it can be extremely challenging to treat. Treatment requires active patient participation and compliance with activity modification. Most patients respond to conservative treatment involving stretching of the iliotibial band, strengthening of the gluteus medius, and altering training regimens. Corticosteroid injections should be considered if visible swelling or pain with ambulation persists for more than three days after initiating treatment. A small percentage of patients are refractory to conservative treatment and may require surgical release of the iliotibial band.     

Intérêt de l’arthroscopie du genou dans le traitement du syndrome de la bandelette iliotibiale

Iliotibial band syndrome is a common cause of lateral knee pain in athletes. The diagnosis is clinical. Surgery can be proposed if well-conducted conservative treatment is unsuccessful for 6 months. We reviewed a retrospective series of seven patients at mean 3.7 years postoperative follow-up. Six practiced sports regularly. The preoperative work-up included a physical examination, standard X-rays and MRI of the knee joint and arthroscopy for all patients. Open surgery was performed with transverse section of the posterior fibers (10 mm). The outcome assessment was based on the pain score, the subjective IKDC score, and resumption of sports activities. Six patients had intra-articular lesions, which for three patients had been missed preoperatively. Arthroscopy was performed for complementary treatments in four patients. In 2008, six patients responded to a telephone interview. Outcome was very satisfactory: mean IKDC score was 84 in five patients who had resumed their sports activities at the same level. One patient underwent arthroscopy to rule out any intra-articular lesion causing lateral pain. Possible intercurrent conditions could be the cause of persistent pain despite adequate medical treatment and physiotherapy. Certain authors propose arthroscopic release. This option enables complementary treatments in the same operative time.     

Activation of the quadriceps muscle during semisquatting with different hip and knee positions in patients with anterior knee pain.

OBJECTIVE: We measured the surface electromyographic activities of vastus medialis obliquus and vastus lateralis in 16 subjects with patellofemoral joint pain syndrome. DESIGN: Each subject performed bilateral static knee extension exercises at 60% of his or her maximal voluntary effort under different combinations of hip rotation (30 degrees of medial rotation, neutral, 45 degrees of lateral rotation) and knee flexion (20 and 40 degrees) in a standing position. The ratio of surface-integrated electromyographic signals of vastus medialis obliquus over vastus lateralis was calculated for each of the six conditions. Because of significant interaction of hip rotation and knee flexion in the two-way analysis of variance, data were analyzed separately with paired t tests for the effect of knee positions and one-way repeated measures analysis of variance for hip positions. RESULTS: At 20 degrees of knee flexion, there was no significant difference among the three hip positions, whereas at 40 degrees of knee flexion, medial rotation of the hip resulted in significantly higher vastus medialis obliquus over vastus lateralis activity ratio than lateral rotation (P < 0.05). CONCLUSIONS: There was relatively more activation of vastus medialis obliquus than vastus lateralis at 40 degrees of semisquat with the hip medially rotated by 30 degrees. This finding has clinical implications for training the vastus medialis obliquus in patients with patellofemoral joint pain syndrome.     

Ultrasound-Guided Treatment of Extrusive Medial Meniscopathy: A 3-Step Protocol

Medial knee pain is commonplace in clinical practice and can be related to several pathologic conditions: ie, medial plica syndrome, saphenous nerve entrapment, pes anserine syndrome, medial collateral ligament injury, and medial meniscus disorders. Ultrasound (US) imaging represents a valuable first-line diagnostic approach to adequately visualize the superficial structures in the medial compartment of the knee to easily plan for prompt treatment. Currently, the management of chronic degenerative diseases involving the menisci, and causing their extrusion, consists of surgery (arthroscopic partial meniscectomy). This procedure often allows only a partial resolution of pain and functional impairment. In the pertinent literature, US-guided interventions for the medial meniscus are proposed, mainly to decrease pain and inflammation or to induce regeneration. Likewise, this Technical Innovation describes in detail the US findings of medial extrusive meniscopathy and also illustrates a novel US-guided technique to treat the bursa of the medial collateral ligament, the extruded fragment of the medial meniscus, and the synovial parameniscal recesses simultaneously.     

Investigation and Macroscopic Anatomical Study of Referred Pain in Patients with Hip Disease

[Purpose] The aim of this study was to examine the incidence and patterns of referred pain in patients with hip disease, as well as the nerve distribution in the hip and knee joints of 2 cadavers. [Subjects and Methods] A total of 113 patients with hip joint disease were included in the investigation. The incidence of regional pain and referred pain patterns were evaluated before and after arthroplasty. Two cadavers were macroscopically observed to verify the nerve innervation of the hip and knee joints. [Results] Anterior knee pain was observed preoperatively in 13.3% (in resting) and 33.6% (in motion) of the patients, which was comparable with the incidence of greater trochanter pain. In addition, the preoperative incidence rates of knee pain in resting and motion markedly decreased postoperatively. Of note is the remarkable incidence of pain radiating to the ventral lower limb. An anteromedial innervation was determined in the cadavers by the articular branches of the obturator and femoral nerve, which supply small branches to the knee joints. [Conclusion] Our results suggest that the distribution of the incidence of pain among the patients with hip disease is diverse owing to the sensory distribution of the femoral and obturator nerves.Key words: Hip joint disease, Referred pain, Macroscopic anatomy     

Assessment of quality of movement during a lateral step-down test: Narrative review

IntroductionAltered lower limb movement patterns during weight-bearing activities have been described as risk factors for several injuries. The lateral step-down test (LSD) was developed to be a simple, clinician-friendly tool to facilitate the assessment of lower extremity quality of movement during a functional activity. However, there is still conflicting information across the literature regarding how the LSD should be performed.ObjectiveTo critically review the literature regarding the assessment of quality of movement using the LSD and to provide an overview of how this test has been used, describing confounding factors and factors associated with altered movement patterns.MethodsA literature review was conducted in PubMed/MEDLINE, COCHRANE, PEDro, SciELO and LILACS databases, by two independent reviewers.ResultsSixteen articles met the inclusion criteria. One was a prospective cohort study to identify risk factors for injuries in military recruits. The fifteen remaining were cross-sectional studies involving healthy military recruits, physically active individuals, athletes and/or sedentary subjects, as well as participants with knee and ankle disorders. Worst quality of movement during the LSD has been associated with deficits in hip external rotation and knee extension strength as well as in ankle dorsiflexion range of motion. The reliability of the LSD has been reported to be moderate (κ = 0.59–0.81).ConclusionsThe LSD has adequate reliability and is a simple tool that can be used to quantify lower extremity quality of movement. Future studies should include standardized methods for application, scoring and interpretation of the test, so that confounding factors can be minimized.     

Les lésions de la jonction myotendineuse du psoas-iliaque en traumatologie du sport

The psoas muscle, the main flexor of the hip joint, is highly solicited in sports activities. Sports injuries are however rarely encountered and described. We report a retrospective series of 33 cases of psoas musculotendinous tears at the point where the muscle changes direction over the iliopectineal eminence. History taking is essential to identify anterior hip pain with rapid or progressive onset. The physical examination searches for pain at hip flexion against resistance, observed in 78% of our cases, and a less sensitive sign, pain at muscle stretching. The morphology should be explored with ultrasound, which is highly contributive in the acute phase. MRI can provide complementary information if the injury is older or recurrent. If there is doubt about the diagnosis, the examination should be able to rule out other hypotheses: traumatic injury to the lower tendons, associated or not with bone detachment, abscess formation, or the more widely encountered psoas hematoma. Early management should focus on puncture aspiration of a hematoma associated with selective rest then rehabilitation over 4 to 6 weeks. Chronic and recurrent injuries may require local injections. An analysis of the sports movement should enable a specific management for each sport.     

The Effect of a Patellar Bandage on the Postural Control of Individuals with Patellofemoral Pain Syndrome

A patellar bandage is often used by individuals with patellofemoral pain syndrome (PPS) to reduce pain and the additional sensorial input improves proprioception of the knee joint. The aim of this work was to assess the effect of a patellar bandage on the postural control of individuals with and without PPS. [Subjects and Methods] An analysis was performed of variables of center of pressure (CoP) as recorded by a force plate. Information about the forces and moments in three directions was used to obtain the CoP. Thirty women participated in this study: 15 with PPS and 15 without PPS. All subjects performed 3 trials in a unipodal stance with and without a patellar bandage. The force plate data were used to calculate the following variables: CoP sway area, CoP displacement frequency, and CoP mean velocity for the anteroposterior (AP) and mediolateral (ML) directions. A the linear mixed effects model was used for statistical analysis. [Results] Postural sway was significantly reduced in individuals with PPS when a patellar bandage was applied. [Conclusion] Additional sensory input from a patellar bandage increase proprioceptive feedback and this could be related to the improvement in postural control of PPS subjects.Key words: Patellofemoral pain syndrome, Postural control, Patellar bandage     

Individualized Physiotherapy in the Treatment of Patellofemoral Pain

Background and Purpose. Patellofemoral pain (PFP) is associated with a wide range of local and global physical factors possibly contributing to pain and thus requires detailed assessment and individualized treatment. Yet, no cohort study was found that assessed the value of individualized physiotherapy, probably because this approach lends itself to clinical practice but not to scientific research. Most studies focus on a ‘knee’ or ‘hip’ treatment approach irrespective of individual global differences in lower limb alignment, movement patterns and muscle tightness. Therefore, this study aimed to determine the effectiveness of supplementing local treatment of PFP with individualized treatment targeting global contributing factors. Secondarily it aimed to subgroup the patients according to variations in lower limb alignment/laxity, movement patterns, biarticular muscle tightness and joint degeneration. Method. Forty‐one patients (60 knees) with PFP who had followed a programme of local quadriceps strengthening, quadriceps stretching and taping for one fortnight were prescribed an individualized programme based on assessment. This global assessment included lower limb postural alignment, movement patterns, muscle tightness and range of motion. Another fortnights treatment was prescribed accordingly and included specific, individualized postural and movement retraining, stretching and functional weight‐bearing, strengthening exercises. Seven outcome measures, namely four pain measures, isokinetic quadriceps strength, quadriceps length and eccentric knee control, assessed improvement. Results. All outcome measures showed further significant improvement following individualized treatment (p < 0.03). Patients fell into four broad physical subgroups: hypermobility (often with malalignment), hypomobility (with three of four tight muscle groups), faulty movement patterns (mostly dynamic knee valgus) and patellofemoral osteoarthritis. Conclusions . Individualized treatment supplementing local standard physiotherapy for PFP leads to further significant improvement over 2 weeks. This study highlights the importance of assessing patients globally in order to optimize treatment and ongoing improvement. Recognition of different subgroups may guide treatment that should include both local and deficit‐targeted global treatment. Copyright © 2014 John Wiley & Sons, Ltd.     

Agénésie du ligament croisé antérieur et du ligament croisé postérieur du genou

This case report is an agenesia of the anterior and posterior cruciate ligament of the knee on a young man 35 year old. This malformation is rare and exceptional. The clinic is principally a knee laxity. On the plains radiographics, the diagnostic can be made because there is a hypoplasia or an agenesia of the tibial eminence and a malformation of the femoral intercondylar notch. MRI confirms the diagnostic.     

Polygenic Contributions to Chronic Overlapping Pain Conditions in a Large Electronic Health Record Sample

Chronic overlapping pain conditions (COPCs) are believed to share common etiological mechanisms involving central sensitization. Genetic and environmental factors putatively combine to influence susceptibility to central sensitization and COPCs. This study employed a genome-wide polygenic risk score approach to evaluate genetic influences on 8 common COPCs. COPCs were identified by International Classification of Disease codes in Vanderbilt's deidentified clinical biorepository (BioVU), with each COPC condition empirically weighted for the level of central sensitization based on prior work. A centralized pain score (CPS) was calculated for 55,340 individuals by summing the weighted number of COPCs. Overall, 12,502 individuals (22.6%) were diagnosed with at least 1 COPC, with females exhibiting nearly twice the mean CPS as males. To assess the genetic influence on centralized pain in COPCs, 6 pain polygenic risk scores (PRSs) were developed using UK Biobank data to predict 6 pain criteria (no pain, neck/shoulder, abdomen, hip, knee, low back pain). These PRSs were then deployed in the BioVU cohort to test for association with CPS. In regression models adjusted for age, sex, and BMI, all pain PRSs except hip pain were significantly associated with CPS. Our findings support a shared polygenic influence across COPCs potentially involving central sensitization mechanisms.PerspectiveThis study used a polygenic risk score approach to investigate genetic influences on chronic overlapping pain conditions. Significant findings in this study provide evidence supporting previous hypotheses that a shared polygenic influence involving central sensitization may underly chronic overlapping pain conditions and can guide future biomarker and risk assessment research.     

Effects of iliotibial band syndrome on pain sensitivity and gait kinematics in female runners: A preliminary study

BackgroundRunners with iliotibial band syndrome display symptoms similar to chronic tendinopathy and distinct gait patterns compared to healthy controls. Although altered pain processing has been demonstrated in chronic tendinopathies, central pain processing and its relationship to motor control has not been measured in iliotibial band syndrome. The purpose of this study was to examine pain sensitivity, hip strength, and gait kinematics in runners with and without iliotibial band syndrome.MethodsNine female runners with iliotibial band syndrome and eight healthy controls participated. Subjective pain was reported and pressure pain threshold measured at the bilateral foot, tibialis anterior, contralateral hand. Isometric hip strength was assessed. Three-dimensional joint angles were collected while running. Differences in pain and strength were determined using 1-way ANOVAs. Discrete hip and knee joint angles during stance phase were calculated and waveform analysis performed.FindingsRunners with iliotibial band syndrome exhibited bilaterally diminished pain at the foot (injured-limb: 1.54 (SD = 0.51); non-injured limb: 1.54 (SD = 0.55); control: 4.01 (SD = 2.30) kg, P < .001) and ipsilateral tibialis anterior (injured-limb: 2.33 (SD = 1.10); control: 6.13 (SD = 4.89) kg, P = .03). Hip strength was not different between groups. Runners with iliotibial band syndrome had greater hip adduction at touchdown, knee internal rotation during loading, and knee abduction and flexion at toe-off than controls.InterpretationRunners with iliotibial band syndrome demonstrated expanded somatic pain sensitivity without hip strength differences, but concomitant with altered gait patterns. Bilateral pain symptoms and gait deviations exist in runners with iliotibial band syndrome even with unilateral symptoms, highlighting the importance of bilateral assessment.