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OBJECTIVE: To explore the relationship between knee crepitus, quadriceps muscle thickness and isometric strength in individuals with patellofemoral pain (PFP). DESIGN: Cross-sectional. PARTICIPANTS: Individuals with PFP. MAIN OUTCOME MEASURES: Participants with PFP underwent assessments for presence, frequency and severity of knee crepitus. Real-time ultrasound images of the quadriceps muscles (rectus femoris, vastus medialis and lateralis) at rest and during contraction were obtained, muscle thickness was measured in both conditions. Maximal voluntary isometric contraction tests were performed to measure knee extensor strength. The relationship between knee crepitus and quadriceps muscle thickness and knee extensor strength was explored using logistic and linear regressions. RESULTS: Sixty individuals with PFP were included (age: 24; 60% women; 38% with crepitus). Knee crepitus severity was related to rectus femoris and vastus medialis thickness during rest (R2 = 0.19 and 0.09, respectively) and contraction (R2 = 0.16 and 0.07, respectively) and with vastus lateralis during contraction (R2 = 0.08). Isometric knee extensor strength was not related to knee crepitus presence, frequency, or severity. CONCLUSION: Higher severity of knee crepitus is related to lower quadriceps muscle thickness in individuals with PFP. There is no relationship between the presence and frequency of knee crepitus with quadriceps muscle thickness or knee extensor strength.

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CONTEXT: People with patellofemoral pain (PFP) may have lower performance during the forward step-down and single-leg hop with their painful (unilateral complaints) or most painful (bilateral complaints) limb when compared to pain-free controls. Yet, no study has investigated the appropriateness of using the pain-free/less painful limb as a reference standard in clinical practice or whether deficits might be present depending on the laterality of pain. OBJECTIVE: To compare performance scores and proportion of side-to-side limb symmetry during the forward step-down and single-leg hop tests among people with unilateral and bilateral PFP, and pain-free controls. DESIGN: Cross-sectional study. SETTING: Laboratory. PATIENTS OR OTHER PARTICIPANTS: Fifty-two young adults (18-35 years old) with unilateral PFP, 72 with bilateral PFP, and 76 controls. MAIN OUTCOME MEASURE(S): Group-by-limb interactions on the performance during the step- down (repetitions) and hop test (distance [cm] normalized by the limb length) were investigated using a repeated-measures analysis of covariance controlling for sex. Pairwise comparisons were interpreted using effect sizes. A Chi-square test was used to compare the proportion of symmetry/asymmetry (cutoff point of ≥ 90% for symmetries indices) across groups and tests. RESULTS: Main effects for groups (small-to-medium effects) but not limbs indicated lower performance of both limbs of individuals with unilateral and bilateral PFP compared to controls during forward step-downs and single-leg hop tests. No significant differences for the proportion of symmetry/asymmetry were identified across groups (p ≥ 0.05), which further suggests an impaired physical performance of the contralateral limb. CONCLUSIONS: Our results indicate bilateral deficits in the physical performance of people with unilateral and bilateral PFP when compared to pain-free controls during the forward step-down and single-leg hop tests. Limb symmetries indices greater than 90% should be interpreted with caution, as they may overstate the physical performance by not assuming bilateral deficits.

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BACKGROUND: Anterior knee pain (AKP) following total knee arthroplasty (TKA) with patellar preservation is a common complication that significantly affects patients' quality of life. This study aimed to develop a machine-learning model to predict the likelihood of developing AKP after TKA using radiological variables. METHODS: A cohort of 131 anterior stabilized TKA cases (105 patients) without patellar resurfacing was included. Patients underwent a follow-up evaluation with a minimum 1-year follow-up. The primary outcome was AKP, and radiological measurements were used as predictor variables. There were 2 observers who made the radiological measurement, which included lower limb dysmetria, joint space, and coronal, sagittal, and axial alignment. Machine-learning models were applied to predict AKP. The best-performing model was selected based on accuracy, precision, sensitivity, specificity, and Kappa statistics. Python 3.11 with Pandas and PyCaret libraries were used for analysis. RESULTS: A total of 35 TKA had AKP (26.7%). Patient-reported outcomes were significantly better in the patients who did not have AKP. The Gradient Boosting Classifier performed best for both observers, achieving an area under the curve of 0.9261 and 0.9164, respectively. The mechanical tibial slope was the most important variable for predicting AKP. The Shapley test indicated that high/low mechanical tibial slope, a shorter operated leg, a valgus coronal alignment, and excessive patellar tilt increased AKP risk. CONCLUSIONS: The results suggest that global alignment, including sagittal, coronal, and axial alignment, is relevant in predicting AKP after TKA. These findings provide valuable insights for optimizing TKA outcomes and reducing the incidence of AKP.

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Anterior knee pain is a common condition that affects adolescent and young adult patients, being one of the most challenging consultations for a knee surgeon. The large number of distinct diagnoses makes it a peculiar syndrome, the only similarities being the presence of retro or peripatellar pain aggravated by at least one activity that loads the joint in flexion. From a pathophysiological perspective, an overuse injury should be considered, where the structural unit of the tissue is damaged or its capacity for reparative response is exceeded. The diagnosis is clinical. Images should be reserved for a particular group of patients. Early intervention is essential to achieve favorable results. Conservative treatment is the gold standard and it is based on multimodal management validated by international consensus. Based on a categorization by clinic and images, we can have a guide to those etiologies that are susceptible to surgical management. The goal of the intervention is to reduce joint stress. The present review defines a simplified algorithm for the study and management of anterior knee pain.

El dolor anterior de rodilla es una condición que afecta a pacientes adolescentes y adultos jóvenes, siendo una de las consultas más comunes y desafiantes para el cirujano de rodilla. La gran cantidad de diagnósticos diferenciales, lo convierten en un síndrome particular, que solo presentan en común la presencia de dolor retro o peripatelar agravado por al menos una actividad que cargue la articulación en flexión. Desde un punto de vista fisiopatológico, debe considerarse una lesión por sobrecarga, donde la unidad estructural del tejido se encuentra dañada o excedida su capacidad de respuesta reparadora. El diagnóstico es clínico. Las imágenes debiesen reservarse para un grupo particular de pacientes. La intervención precoz es fundamental para lograr resultados favorables. El tratamiento conservador es el estándar de oro y se basa en un manejo multimodal validado por consensos internacionales. Basados en una categorización por clínica e imágenes, podemos tener una guía de aquellos cuadros que son susceptibles de manejo quirúrgico. El objetivo de la intervención es reducir el estrés articular. La presente revisión define un algoritmo simplificado de estudio y manejo en dolor anterior de rodilla.

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INTRODUCTION AND IMPORTANCE: Fractures in the proximal tibial tuberosity are rare injuries. Even more uncommon are bilateral simultaneous fractures. Due to the few cases reported in the literature, we aimed to present a case which may contribute to the diagnosis and treatment of bilateral simultaneous tibial tubercle fractures. CASE PRESENTATION: A 13-year-old Hispanic male presented to the emergency department after experiencing sudden knee buckling while running after standing up from the catcher's position (squatted) during a baseball game, causing him to collapse to the ground. Plain radiographs revealed displaced tibial tubercle avulsion fractures in both knees. He underwent bilateral open reduction and internal fixation. Fracture healing was completed without complications. DISCUSSION: To the best of our knowledge, this is the first documented case of a Hispanic pediatric baseball player, adding to the small number of reported cases of bilateral tibial tubercle fractures. The presented case is rare in terms of the mechanism of injury, which has been scantly reported in the literature. CONCLUSION: Due to the rarity of atraumatic bilateral tibial tubercle fractures we believe this documentation may be of clinical relevance.

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OBJECTIVE: Analyze whether the effects of lower limb resistance training on pain and self-reported function were associated with the exercise volume prescribed for women with patellofemoral pain (PFP). METHODS: A systematic search was undertaken in four databases from inception to May 2023. Eligible trials examined the effects of resistance training programs on pain (visual analogue scale or numerical pain scale) and function (Anterior Knee Pain Scale) in women with PFP. Meta-analysis was undertaken with a random-effects model. The association of resistance training volume-related variables with mean difference effects on pain and function were tested by exploratory univariable meta-regression models. RESULTS: From 1,404 estudies retained for screening after duplicate removals, 16 studies (579 patients) were included. Changes in knee pain were inversely associated with weekly training frequency (ß = 0.5 ± 0.2, P = 0.012). No associations were found between the amount of resistance exercise prescribed per session or per week and effects on pain. Changes in function were associated with the number of sets per week (ß = 0.1 ± 0.1, P = 0.044) and number of sets per session (ß = 0.6 ± 0.2, P < 0.001) over the intervention. Most favorable results were achieved with 17 to 27 sets per session and >45 sets per week. CONCLUSIONS: The amount of prescribed resistance exercise does not seem to be critical for pain reduction in women with PFP. However, our findings support a dose-response effect in terms of improving function.

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PURPOSE: The purpose of this study was to assess patient satisfaction and identify risk factors for dissatisfaction after anterior stabilised conventional total knee arthroplasty (TKA) without patellar resurfacing, using the Goodman score. METHODS: We conducted a cross-sectional study using data from our institutional database from 1 January 2018 to 1 March 2021. Patients who underwent TKA with the Vanguard® Cruciate Retaining Anterior Stabilized Knee System (Zimmer Biomet, Warsaw, Indiana, USA) without patellar replacement were included. Patients with other bearing surfaces (posterior stabilised or medial congruent) or diagnosed with infection or instability were excluded. Patients' reported outcomes, body mass index (BMI), passive range of motion, the timed up-and-go test, sit-up test, and algometry were assessed. Patients were also asked if they had anterior knee pain. Satisfaction was assessed using the Goodman scale, and logistic multivariate regression was used to identify variables associated with dissatisfaction and perceived improvement in quality of life. RESULTS: A total of 131 TKA patients were included in the study. The median satisfaction score was 100 (interquartile range [IQR], 87.5 to 100), with the 75-point threshold at the 90th percentile according to Section A of Goodman. Section B of Goodman showed that 113 TKA patients (86.26%) reported "great improvement" or "more than I ever dreamed." Multivariate logistic regression revealed that anterior knee pain (OR 5.16, 95% CI 1.24 to 21.39), the sit-up test (OR 0.63, 95% CI 0.49 to 0.81), and BMI (OR 0.84, 95% CI 0.70 to 0.99) were significantly associated with patient dissatisfaction and a worse perceived improvement in quality of life. The receiver operating characteristics curve for the models had areas under the curve of 0.83 (95% CI 0.69 to 0.97) and 0.82 (95% CI 0.70 to 0.94), respectively. CONCLUSION: Anterior stabilised TKA without patellar resurfacing can achieve 90% satisfaction and 86% improvement in quality of life. To improve these results, it is essential to prevent and treat anterior knee pain and enhance quadriceps strength. LEVEL OF EVIDENCE: Level III (retrospective cohort study).

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Resumen: El dolor anterior de rodilla es una condición que afecta a pacientes adolescentes y adultos jóvenes, siendo una de las consultas más comunes y desafiantes para el cirujano de rodilla. La gran cantidad de diagnósticos diferenciales, lo convierten en un síndrome particular, que solo presentan en común la presencia de dolor retro o peripatelar agravado por al menos una actividad que cargue la articulación en flexión. Desde un punto de vista fisiopatológico, debe considerarse una lesión por sobrecarga, donde la unidad estructural del tejido se encuentra dañada o excedida su capacidad de respuesta reparadora. El diagnóstico es clínico. Las imágenes debiesen reservarse para un grupo particular de pacientes. La intervención precoz es fundamental para lograr resultados favorables. El tratamiento conservador es el estándar de oro y se basa en un manejo multimodal validado por consensos internacionales. Basados en una categorización por clínica e imágenes, podemos tener una guía de aquellos cuadros que son susceptibles de manejo quirúrgico. El objetivo de la intervención es reducir el estrés articular. La presente revisión define un algoritmo simplificado de estudio y manejo en dolor anterior de rodilla.

Abstract: Anterior knee pain is a common condition that affects adolescent and young adult patients, being one of the most challenging consultations for a knee surgeon. The large number of distinct diagnoses makes it a peculiar syndrome, the only similarities being the presence of retro or peripatellar pain aggravated by at least one activity that loads the joint in flexion. From a pathophysiological perspective, an overuse injury should be considered, where the structural unit of the tissue is damaged or its capacity for reparative response is exceeded. The diagnosis is clinical. Images should be reserved for a particular group of patients. Early intervention is essential to achieve favorable results. Conservative treatment is the gold standard and it is based on multimodal management validated by international consensus. Based on a categorization by clinic and images, we can have a guide to those etiologies that are susceptible to surgical management. The goal of the intervention is to reduce joint stress. The present review defines a simplified algorithm for the study and management of anterior knee pain.

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BACKGROUND: Patellofemoral pain (PFP) is a common knee disorder that causes persistent pain, lower self-reported function and quality of life. People with PFP also present with altered psychological factors, which are associated with higher levels of pain and dysfunction. Mindfulness-based interventions (MBI) generally consist of meditative practices developed to provide a holistic approach to chronic conditions. However, the effects of MBI on clinical and psychological outcomes for people with PFP remains understudied. METHODS: This assessor-blinded, parallel, two-arm randomized clinical trial aims to investigate the effects of adding an 8-week online MBI program to exercise therapy and patient education on clinical and psychological factors for people with PFP. We also aim to investigate whether psychological factors mediate changes in pain and function. Sixty-two participants with PFP will be recruited and randomized into one of two treatment groups (Mindfulness or Control group). Both groups will receive an 8-week intervention involving exercise therapy and education delivered through an online platform. The Mindfulness group will additionally receive a MBI component including formal and informal practices. Outcomes will be assessed online at baseline, intervention endpoint (follow-up 1) and 12 months after intervention completion (follow-up 2). Comparisons between groups will be performed at all time points with linear mixed models. A mediation analysis will be performed using a 3-variable framework. DISCUSSION: Exercise therapy and patient education are considered the "best management" options for PFP. However, unsatisfactory long-term prognosis remains an issue. It is known that people with PFP present with altered psychological factors, which should be considered during the evaluation and treatment of people with PFP. Adding a MBI to the current best treatment for PFP may improve short and long-term effects by addressing the underlying psychological factors. TRIAL REGISTRATION: Registro Brasileiro de Ensaios Clínicos (ReBEC) RBR-4yhbqwk, registered in April 6, 2021.

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BACKGROUND: People with patellofemoral pain (PFP) exhibit impaired psychological and pain processing factors (i.e., kinesiophobia, pain catastrophizing and pressure pain thresholds [PPTs]). However, it remains unclear whether these factors have different presentations in women and men with PFP, as well as whether their correlation with clinical outcomes differ according to sex. The aims of this study were to: (1) compare psychological and pain processing factors between women and men with and without patellofemoral pain (PFP); (2) investigate their correlation with clinical outcomes in people with PFP. METHODS: This cross-sectional study included 65 women and 38 men with PFP, 30 women and 30 men without PFP. The psychological and pain processing factors were assessed with the Tampa Scale of Kinesiophobia, Pain Catastrophizing Scale, and PPTs of shoulder and patella measured with an algometer. Clinical outcomes assessed were self-reported pain (Visual Analogue Scale), function (Anterior Knee Pain Scale), physical activity level (Baecke's Questionnaire), and physical performance (Single Leg Hop Test). Generalized linear models (GzLM) and effect sizes [Cohen's d] were calculated for group comparisons and Spearman's correlation coefficients were calculated to investigate correlations between outcomes. RESULTS: Women and men with PFP had higher kinesiophobia (d = .82, p = .001; d = .80, p = .003), pain catastrophizing (d = .84, p < .001; d = 1.27, p < .001), and lower patella PPTs (d = -.85, p = .001; d = -.60, p = .033) than women and men without PFP, respectively. Women with PFP had lower shoulder and patella PPTs than men with PFP (d = -1.24, p < .001; d = -.95, p < .001), but there were no sex differences in those with PFP for psychological factors (p > .05). For women with PFP, kinesiophobia and pain catastrophizing had moderate positive correlations with self-reported pain (rho = .44 and .53, p < .001) and moderate negative correlations with function (rho = -.55 and -.58, p < .001), respectively. For men with PFP, only pain catastrophizing had moderate positive correlations with self-reported pain (rho = .42, p = .009) and moderate negative correlations with function (rho = -.43, p = .007). CONCLUSIONS: Psychological and pain processing factors differ between people with and without PFP and between sexes, respectively. Also, correlations between psychological and pain processing factors with clinical outcomes differ among women and men with PFP. These findings should be considered when assessing and managing people with PFP.

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