Description and Diagnosis

Patients complain of pain over the front of their knee with symptoms worse on sitting or standing, they are generally young and do not have clear osteoarthritis. There may be a history of patella dislocation.

There are multiple causes generally grouped into three diagnoses:

• Objected patella instability: history of true dislocation or ability to dislocate patella.
• Potential patella instability: maltracking of the patella with instability leading to overload of part of the joint.
• Anterior knee pain syndrome: covering a multitude of issues such as excessive lateral pressure syndrome, neuromas, patella tendinopathy, quadriceps tendinitis, medial plica syndrome etc.

The key to assessment for investigation of anterior knee pain is detecting the presence of mal-alignment – either limb mal-alignment (varus/valgus) or patella maltracking by examining tracking of the patella as the knee bends and extends against gravity.

Category and Action

Category I: conservative options

This is the group of patients who have no mal-alignment or patella maltracking, symptoms are not intrusive and they may well have general features of anterior knee pain syndrome.

Treatment option is physiotherapy at core physio level.

Category II: referral to MSCAT treatment

This group of patients has mal-alignment or may have failed core physio/level 1 treatment.

Treatment options include referral to MSCAT assessment and treatment with specialist physiotherapy including consideration for orthotics, podiatry or more specific physical evaluation.

Category III: significant symptoms requiring referral to secondary care

This category is for patients who have failed physiotherapy at category I or category II. They may have severe pain or have had multiple episodes of patella dislocation.

Treatment options include referral to secondary care for consideration for patella stabilisation surgery, management advice or specific knee braces.