Orthopedic surgeons debate at length the relative merits of this or that operation. But the best operation will fail in the face of a wrong diagnosis. Our first task is therefore to come up with the right diagnosis:
- Why does the knee hurt?
- If the kneecap is slipping, what are the specific anatomic deficiencies?
Listed below are conditions that can lead to pain at the front of the knee. You see that the list is quite long! Note that I specifically DO NOT mention Chondromalacia, anterior knee pain syndrome, or patellofemoral syndrome. I explain this further down in the Chondromalacia section.
I divide Kneecap pain into three broad categories:
- Conditions not pertaining to the patella proper (the kneecap has nothing to do with the pain)
- Tightness of the iliotibial band, Referred pain (hip, spine). Neuroma Tendinitis (various), Osgood-Schlatter’s condition, Plica Fibrosis, Inflammatory conditions (RA, Lupus, etc.) RSD / Complex regional pain syndrome
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- Identifiable lesions within the patella (the doctor can see something within the kneecap). These conditions are unusual.
- Bipartite Patella, Dorsal Defect, Stress fracture, Osteochondritis dissecans, Tumors, Infection
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- Non-focal disorders of the patella (the problem lies with the kneecap and the surrounding tissues, but there is no obvious problem within the kneecap itself)
Patella Malalignment
Every bone, muscle and tendon in the human body has a normal and an abnormal position. Of course, there can be variations from one person to another, and doctors may quibble (and they do) over where to draw the line between normal and abnormal. And not every abnormality hurts. For example, flat feet aren’t always painful. It therefore a serious mistake for a doctor to attribute pain to the first abnormality he encounters. (I see this most frequently in cases where the doctor uses an MRI report to make a diagnosis).
When the kneecap is tilted and sits in the knee like a beret would on the side of your head, this is a potential source of pain. In the history of medicine, it is only relatively recently that tilting of the patella has come to be appreciated as a source of pain, and tilting remains ignored or unaccepted by a number of physicians. In the United States, for example, tilting of the kneecap is very, very rarely mentioned on x-ray or MRI reports. I must emphasize again that tilting of the kneecap is not automatically a source of pain.
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