INITIAL EVALUATION OF THE ATHLETE

WITH ANTERIOR KNEE PAIN

WILLIAM L. D A V I S , JR, MD and JOHN P. F U L K E R S O N , MD

Anterior knee pain is a common complaint among athletes and active, young individuals. Its causes are broad, but
the correct diagnosis can usually be made after a thorough history and physical examination. The history should
include a complete investigation of the nature and onset of the athlete's symptoms, past medical history, and the
nature of any previous treatment he or she may have received for the problem. The physical examination includes a
general lower extremity musculoskeletal examination with determinations of flexibility and limb alignment. The
spine and hips are also evaluated to rule out radicular or referred pain to the knee. The knee examination must
include assessment of the peripatellar tissues as well as the patellofemoral joint. Although patients often perceive
their pain as being poorly localized,the pain source can usually be preciselylocalizedon examination.The information
presented here should enable the clinicianto make an accurate diagnosis on which to base initial treatment.
KEY WORDS: patellofemoral, pain, knee, anterior, athlete, evaluation, examination

Anterior knee pain is a common problem among athletes
and active young patients. There are many causes, but a
correct diagnosis can usually be made in most patients
after a thorough history and physical examination. This
article discusses the aspects of clinical evaluation that are
most important in patients and athletes with anterior knee
pain.
HISTORY
Symptomatology
Onset. Athletes and active young people with anterior
knee pain commonly present with symptoms that are
chronic in duration and insidious in onset, and patients
frequently have some component of overuse a n d / o r under-
lying malalignment. However, a more acute onset of
symptoms after a traumatic episode may suggest patellar
instability, a retinacular tear, or osteochondral injury, de-
pending on the mechanism. An indirect mechanism consist-
ing of a strong quadriceps contraction, a flexed and valgus
knee position, and internal rotation of the femur on the
tibia is a common one for patellar dislocation. The classic
example of this is a baseball batter swinging and missing a
pitch. Such patients frequently report seeing their kneecap
"off to the side," which either spontaneously reduces or
requires manipulation. A direct mechanism, such as con-
tact with another player, can result in a chondral lesion
from direct trauma to the patella or distal femur. Many
patellar crush injuries occur with the knee flexed so that
the lesion involves the proximal pole of the patella. In the
setting of a posteriorly directed force to the knee, one must
From the Universityof Connecticut School of Medicine, Farmington, CT
and OrthopedicAssociates of Hartford, PC, Hartford, CT.
Address reprint requests to John P. Fulkerson, MD, Clinical Professor,
University of Connecticut School of Medicine, Orthopedic Associates of
Hartford, PC, 270 Farmington Avenue, Suite 364, Farmington, CT 06032.
Copyright © 1999 by W.B. Saunders Company
1060-1872/0702-0002510.00/0
also be aware of the potential of posterior instability and
secondary patellofemoral symptoms from increased com-
pressive forces across the joint.
Pain. The patient should be asked to point to the location
of the pain. Knee pain diagrams (Fig 1) can be helpful and
have been shown to be accurate in predicting areas of
tenderness on physical examination. 1 Other characteristics
of the patient's pain that should be specifically addressed
include quality, radiation, and exacerbating and relieving
factors. In addressing these characteristics, the clinician
should be able to differentiate somatic pain from pain that
is referred or radicular in nature. Anterior knee pain is
frequently reported by patients to be poorly localized,
positional, and activity-related. It is usually relieved by
passive extension and exacerbated by prolonged flexion
(the "movie theater sign") because of increased tension in
the extensor mechanism as wetl as the posterior and lateral
forces imparted by the retinacular attachments of the
iliotibial band, which is posterior to the knee axis in flexion
greater than 30 °. It is also exacerbated by stair climbing
and, particularly, descending stairs, because of the strong,
eccentric quadriceps contractions that are required. Ask
the athlete if pain is experienced with any particular
sport-specific activities to gain an understanding of how
pain is produced.
In contrast, pain that is constant a n d / o r not related to
activity or knee position should make the clinician suspi-
cious of referred pain, neurogenic pain, or reflex sympa-
thetic dystrophy (RSD). Referred pain from the hip typi-
cally affects the anterior distal thigh and knee, and,
therefore, a history of hip problems should be sought. Pain
with a burning quality is also suggestive of neurogenic
pain or RSD. Associated numbness or tingling suggests a
neuroma (especially if the pain is located below a scar) or a
radicular problem. All patients should be asked if they
have any hip or low back pain. Pain that is sharp,
intermittent, or unpredictable is characteristic of loose
bodies or an unstable chondral flap.

Operative Techniques in Sports Medicine, Vol 7, No 2 (April), 1999: pp 55-58 55


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M L
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Fig 1. Matched patient and physician pain diagrams showing
good correlation. (Reprinted with permission. 1)
Instability. Patients with anterior knee pain commonly
complain of instability or "giving way." It is important t o
determine if this feeling of instability is related to the
extensor mechanism or secondary to ligamentous insuffi-
ciency. This will be largely determined by physical exami-
nation. However, a lack of knee trauma will usually rule
out cruciate or collateral ligament pathology. Instability
related to the extensor mechanism may either be secondary
to malalignment, quadriceps insufficiency from long-term
deconditioning, previous surgery, or muscular inhibition
resulting from pain or effusion (the patient will say the
knee "goes out" or "gives way" for either the reflex
quadriceps inhibition because of sudden pain or the true
momentary patellar dislocation. It is the clinician's task to
differentiate the two). A history of patellar dislocation
should also be sought to determine if the patient has true
patellar instability.
Other symptoms. Crepitus or a grinding sensation under
the kneecap is a common complaint and usually implies
some degree of chondromalacia involving the patella
a n d / o r femoral trochlea. However, this should be differen-
tiated from a complaint of a snapping sensation, which is more
consistent with a pathologic plica. A sensation of locking may
be attributable to chondral or meniscal pathology.
A history of swelling, although nonspecific, is important
to investigate. If attributable to an effusion, it suggests
intra-articular (rather than peripatellar) pathology. If the
swelling followed trauma to the knee, it likely represents
hemarthrosis. However, it frequently arises insidiously
and indicates inflammation--either from a pathologic
plica or in reaction to articular cartilage debris.
Previous Treatment
It is helpful to know what prior treatment patients received
(bracing, taping, nonsteroidal anti-inflammatory drugs,
injections, physical therapy) for their knee problems and
whether or not the interventions were successful. If physi-
56
cal therapy has been tried, it is important to investigate
precisely what was done to determine if it was appropri-
ately prescribed and followed through by the patient and
therapist. If the patient underwent previous surgery, a
copy of the operative report, or, ideally, arthroscopic
photos should be obtained. The patient should be asked if
the procedure(s) had any effect on his or her symptoms,
and, particularly, if there was a change in the nature of the
pain.
Past medical history
The majority of athletes who present with anterior knee
pain are otherwise healthy. However, it is important to
determine if there is a personal or family history of any
problems that commonly cause musculoskeletal pain (gout
and inflammatory arthritides, sickle cell disease, etc. Patel-
lofemoral disorders show a strong familial pattern). The
patient should also be asked if other joints are symptom-
atic. Medications should be noted, including the use of
corticosteroids (possibly for asthma in an athlete) or
narcotics on a chronic basis. In younger athletes, a recent
growth spurt can cause increased tension in the extensor
mechanism because of the "lag" of its growth relative to
the skeleton. This can result in overuse problems such as
quadriceps and pate]Jar tendinitis, or Osgood-Schlatter's dis-
ease. Always consider the possibility of gout or Lyme disease.
PHYSICAL EXAMINATION
General
The patient should be dressed so that both lower extremi-
ties are visible in their entirety. One should note the
patient's body habitus and any evidence of general decon-
ditioning or atrophy of the involved lower extremity. The
gait and overall limb alignment should be carefully ana-
lyzed, noting any excessive pronation or genu valgum. The
range of motion of all lower extremity joints should be
recorded, because patellofemoral problems are frequently
associated with flexibility defecits. In contrast, general
ligamentous laxity may be suggestive of patellar subluxa-
tion, and, therefore, should be ruled out.
The hips should be examined initially with the patient in
the supine position. A hip flexion contracture must be
ruled out, because it can result in increased knee flexion
during gait and an abnormally high patellofemoral joint
reaction force. Increased internal rotation may be second-
ary to excessive femoral anteversion, which can be associ-
ated with patellar subluxation. Decreased internal rotation
(typical of osteoarthritis) and pain on hip motion may
imply inarticular pathology and referred pain to the knee.
The popliteal angle should be measured and should be
between 160 ° and 180 ° in young athletes. A measurement
less than this may be indicative of hamstring tightness,
which necessitates increased quadriceps force when extend-
ing the knee, and, therefore, an abnormally high patello-
femoral joint reaction force. Hamstring tightness is also
associated with spondylolisthesis, which should be sus-
pected in athletes, such as gymnasts, who are involved in
frequent lumbar spine hyperextension. A straight leg raise
should be performed to rule out the possibility of a
herniated nucleus pulposus.
DAVIS AND FULKERSON
Knee
A complete knee examination should always be per-
formed, including tests for ligamentous instability and
meniscal pathology. We will focus on that which pertains
to evaluating the athlete with anterior knee pain.
During initial inspection of the knee, one should note the
condition of the skin, including any previous incisions. It
should be determined through ballottement of the patella
whether any swelling is a local phenomenon or attribut-
able to effusion.
Knee range of motion should be measured initially with
the patient in the supine position. Full active and passive
extension should be achieved, and flexion should be
compared with the uninvolved side, because it may vary
with body habitus. The patient should be turned to the
prone position to appropriately assess extensor mecha-
nism flexibility, because the rectus femoris crosses the hip
(Fig 2). In most athletes, knee flexion in this position will
allow the heel to touch the buttock. Inability to do this, or
asymmetry on examination may indicate excessive tension
in the extensor mechanism, and this maneuver wilt fre-
quently be associated with pain in such patients. Hip
rotation can be reassessed while the patient is prone.
The knee should be palpated in an attempt to reproduce
and determine the source of the patient's pain. By doing so,
one should be able to quickly determine whether or not the
patient's problem is attributable to extensor mechanism
a n d / o r patellofemoral pathology. It should be noted
whether the patient's responses to palpation are appropri-
ate or suggestive of reflex sympathetic dystrophy, psychiat-
ric pathology, or secondary gain issues. The innervated
tissues of the anterior knee include patellar and quadriceps
tendons; synovium, plicae, and bursae; subchondral bone
of the patella and trochlea; and retinacular soft tissues.
Patellar tendinitis (jumper's knee) is more common than
quadriceps tendinitis. Tenderness is usually elicited at the
inferior pole of the patella in patients with this problem.
The distal quadriceps tendon should also be palpated. The
prepatellar, infrapatellar, and pes anserine bursae should
be palpated to ruie out bursitis. Palpating the articular
surfaces of the patella and trochlea necessitates compres-
sion of the intervening retinaculum and synovium, and,
therefore, is usually not helpful. However, the examiner's
Fig 2. Extensor mechanism flexibility should be measured in
the prone position. Note elevation of the pelvis attributable to
hip flexion in this patient with severe knee extensor mecha-
nism tightness.
EVALUATION OF ATHLETES WITH ANTERIOR KNEE PAIN
hand should be placed over the patella during knee range
of motion to detect any crepitus from the patellofemoral
joint that may present. It is important to note the degree of
flexion during which crepitus is elicited, because it is
usually indicative of the location of a patellar chondral
defect or abnormality. Crepitus early in flexion implies
distal pole involvement, and crepitus late in flexion implies
proximal pole involvement. Patellofemoral crepitus should
be easily differentiated from a pathologic plica, which is
usually medial to the patella and palpable as a band
snapping over the femoral condyle.
The retinaculum should be carefully palpated. Lateral
retinacular pain and tenderness is common in patients
with patellofemoral malalignment. In a prospective study
of 60 young, active patients, 90% experienced pain in some
portion of the lateral retinaculum, usually at or near the
retinaculopatellar junction. 2 The cause of the pain in these
patients has been shown to be nerve demyelination and
fibrosis, similar to what is seen in Morton's neuroma. 3
Patellofemoral mechanics should be analyzed. The
Q-angle should be measured to serve as an estimate of the
lateral moment on the patella° It is measured as the angle
formed between a line joining the anterior superior iliac
spine and center of the patella, and a line from the patella
to the tibial tubercle. A normal Q-angle is generally
considered to be less than 15 ° in females and less than 10 °
to 12 ° in males. Some believe that the Q-angle is not an
accurate tool for determining patellar alignment because it
is measured in extension, and a laterally subluxed patella
will yield a falsely low measurement. Therefore, Kolowich
et al 4 believe that the tubercle-sulcus angle measured at 90 °
of flexion is a more accurate assessment of the quadriceps
vector. It is defined by the angle between a line from the
center of the patella to the center of the tibial tubercle and a
line perpendicular to the transepicondylar axis. A tubercle-
sulcus angle of 0 ° is considered normal, and more than 10 °
is considered abnormal.
Patellar tracking should be visualized through the full
range of motion of the knee. The patella should smoothly
enter and leave the femoral trochlea on flexion and exten-
sion, respectively. A sudden lateral motion of the patella on
extension has been named the J-sign and is seen in patients
with lateral patellar instability. These patients usually have
excessive lateral patellar glide and a positive apprehenston
test. Patellar glide is assessed by passively translating the
patella medially and laterally with the knee in full exten-
sion. The patella is visually divided into four longitudinal
quadrants. The amount of glide is reported as the number
of quadrants of translation that is achieved. One quadrant
or less of translation is usually indicative of tight, passive
restraints, and three or greater indicates hypermobility or
incompetent restraints. A positive apprehension test is
indicative of patellar instability and is elicited when the
patient shows pain and guarding on passive lateral transla-
tion of the patella.
Medial patellar instability is much less common than
lateral instability, but should be ruled out, especially in
patients who remain symptomatic after previous realign-
ment procedures. Fulkerson 5 described a test for medial
subluxation that involves holding the patella medially as
the patient's knee is passively flexed (Fig 3). Pain and
57
Fig 3. Medial subluxation test. (A) Medial pressure is applied to the patella with the knee in full extension. (B) The knee is then
passively flexed, Reproduction of the patient's symptoms indicates a positive test,
reproduction of the patient's symptoms represent a posi-
tive test. W h e n an impression of medial or lateral patellar
instability is established, the examiner m a y confirm the
diagnosis by applying a Trupull brace (Depuy-Orthotech,
Tracy, CA) to correct the problem and see if the patient
experiences relief (Fig 4).
Patients with patellofemoral dysfunction m a y have patel-
lar tilt w i t h o u t subluxation. This is because of a tight lateral
retinaculum and is referred to as excessive lateral pressure
syndrome. It is assessed with the patellar tilt test. In normal
knees, the patella can be passively elevated from the lateral
side with the knee in full extension so that it is parallel to or
tilted slightly b e y o n d the horizontal plane.
DIFFERENTIAL DIAGNOSIS
After the history and physical examination, the physician
should be able to determine, first, whether the pain the
patient is experiencing is referred, radicular, or somatic in
nature. For true anterior knee pain, the next step is to
Fig 4. A Trupull brace (DePuy Orthotech, Tracy, CA) may be
applied to correct either medial or lateral subluxation. The
diagnosis is confirmed if symptoms are relieved.
58
categorize the cause as peripatellar or patellofemoral.
Peripatellar syndromes include synovial abnormalities
(pathologic plicae, bursitides), retinacular strain, iliotibial
band friction syndrome, and extensor mechanism overuse
syndromes (patellar and quadriceps tendonitis, retinacular
strain, iliotibial band strain, Osgood-Schlatter disease,
Sinding-Larsen-Johansson disease). These diagnoses can
be fairly easily differentiated through palpation on physi-
cal examination. If the athlete has a patellofemoral prob-
lem, it m a y be one of patellar instability (subluxation or
recurrent dislocation), tilt (excessive lateral pressure syn-
drome), or arthrosis (degenerative or delaminating lesion
involving the patella a n d / o r femoral trochlea). Instability
and tilt can coexist and are determined by assessing limb
alignment and rotation, patellar tracking, pateUar glide,
and patellar tilt. Patellofemoral arthrosis m a y become
manifest on physical examination as painful patellar crepitus
on knee range of motion with compression of the patella.
SUMMARY
Anterior knee pain is c o m m o n in athletes and active
individuals, and the causes are fairly broad. However, by
performing a thorough history and physical examination,
the clinician should be able to make the correct diagnosis.
REFERENCES
1. Post WR, Fulkerson J: Knee pain diagrams: Correlation with physical
examination findings in patients with anterior knee pain. Arthroscopy
10:618-623, 1994
2. Fulkerson JP: The etiology of patellofemoral pain in young, active
patients: A prospective study. Clin Orthop 179:129-133, 1983
3. Fulkerson JP, Tennant R, Jaivin JS, et al: Histologic evidence of
retinacular nerve injury associatedwith patellofemoralmalalignment.
Clin Orthop 197:196-205, 1985
4. Kolowich PA, Paulos LE, Rosenberg TD, et al: Lateral release of the
patella: Indications and contraindications. Am J Sports Med 18:359-
365, 1990
5. Fulkerson JP: A clinical test for medial patella tracking (medial
subluxafion).TechOrthop 12:144, 1997.
DAVIS AND FULKERSON