. 2007 Jan 15;75(2):194-202.

Management of Patellofemoral Pain Syndrome

Sameer Dixit¹, John P DiFiori, Monique Burton, Brandon Mines

Patellofemoral Pain Syndrome(PFPS);膝蓋大腿痛症候群

膝の痛みの一般的な原因の1つ。

ランナーの16-25%に生じるとされる。

膝の屈曲・伸展中に生じる関節の過負荷でトラッキングを制御する力の不均衡が起こるためとされる。

膝の解剖；

膝関節には、膝蓋骨を制御するスタビライザーがあり、これらの働きで制御されるトラッキングの負担は、歩行で体重の1/3や1/2とされ、階段を上るときに3倍、しゃがむときに7倍とされる。

膝の鑑別疾患；

これらの多くは、病歴と身体所見で鑑別可能。

TABLE 2

Causes of Anterior Knee Pain

CAUSE	COMMENT
Articular cartilage injury；関節軟骨損傷	May describe history of trauma; mechanical symptoms may occur if loose body present; may have effusion; may have tenderness of involved structure (e.g., femoral condyles, patella)
Bone tumors；骨腫瘍	Pain may be insidious; may have tenderness of bony structures
Chondromalacia patellae；骨軟化症	Retropatellar pain; may have history of trauma; may have effusion on examination
Hoffa's disease；ホファ病	Pain and tenderness localized to infrapatellar fat pad
Iliotibial band syndrome；腸脛靭帯症候群	Typically presents with lateral pain and tenderness over lateral femoral epicondyle
Loose bodies；ルーズボディ	Symptoms variable; may have intermittent sharp pain, locking, or effusion
Osgood-Schlatter disease；オスグット・シュラッター病	Tenderness and swelling at insertion of patellar tendon at tibial tubercle in an adolescent
Osteochondritis dissecans；骨軟骨炎	Symptoms variable; may have intermittent pain, swelling, or locking
Patellar instability/subluxation；膝蓋骨亜脱臼・不安定	Intermittent pain with sensation of instability or movement of patella; may have swelling; locking can occur with loose body formation; may have tenderness over medial retinaculum
Patellar stress fracture；骨折	May have tenderness directly over patella
Patellar tendinopathy；腱障害	Tenderness of tendon; tendon may be thickened if chronic
Patellofemoral osteoarthritis；膝蓋大腿変形性関節	May have crepitus or effusion; characteristic radiographic findings
Patellofemoral pain syndrome；膝蓋大腿痛症候群	Anterior knee pain “behind” or around patella; usually no effusion; may have findings of patellar maltracking
Pes anserine bursitis；滑液包炎	Pain usually described as medial rather than anterior; tenderness over pes anserine bursa
Plica synovialis；	May be medial or lateral to patella; if symptomatic, tenderness can be demonstrated on examination
Prepatellar bursitis；滑液方炎	Characteristic swelling anterior to patella following trauma
Quadriceps tendinopathy；	Tenderness over tendon
Referred pain from the lumbar spine or hip joint pathology；	Symptoms depend on origin of pain; knee examination usually normal
Saphenous neuritis；伏在神経炎	Pain usually medial but poorly localized; may have history of surgery
Sinding-Larsen-Johansson syndrome；	Tenderness at patellar tendon insertion at inferior pole of patella in an adolescent
Symptomatic bipartite patella；二部膝蓋骨	May have tenderness directly over patella with characteristic radiographic findings

PFPSの病歴；

痛みは通常、膝蓋骨の後ろ・下・周囲に起こる。

徐々に始まることが多いが、外傷をきっかけとすることもある。

片側性が多いが、ときに両側性もある。

長時間の座った姿勢(シアターサイン)、階段昇降、しゃがむ、走るといったときにこわばりや痛みが起こる。

腫脹は基本的にない。

最近のトレーニング状況などについて聞くことも必要。

身体所見；

屈曲時の膝蓋骨の動きに注目したり、圧痛を確認することが必要。

もし腫脹があれば、PFPSの可能性は少し下がる。

Key Components and Findings of the Physical Examination of Patients with PFPS

COMPONENT AND FINDING			COMMENT
Inspection
	Lateral patellar tracking (“J” sign; Figure 2)		Suggests patellar maltracking as a result of tight lateral restraints or VMO dysfunction
	Poor VMO tone		May be displayed in PFPS
Palpation
	Effusion		Rare in PFPS; should prompt evaluation for other causes of pain
	Tenderness of:
		Medial or lateral retinaculum	Common in PFPS; tenderness of the medial retinaculum also may be found in patellar instability
		Medial and lateral facets	May be found in PFPS; may indicate articular cartilage injury
		Patella	Usually not tender in PFPS; may indicate patellar contusion or stress reaction; can be tender in symptomatic bipartite patella; tenderness at insertion sites of quadriceps and patellar tendons can be found in tendinopathies and Sinding-Larsen-Johansson syndrome
		Quadriceps and patellar tendons	Suggestive of tendinopathy or tear if injury is acute
		Pes anserine bursa	Tenderness and swelling typical of pes anserine bursitis
		ITB, lateral femoral epicondyle	Suggests ITB syndrome
		Surface of medial or lateral femoral condyles	Direct tenderness suggests contusion or articular cartilage injury; may be tender with injuries of the collateral ligaments
		Infrapatellar fat pad	May be seen in Hoffa's disease
		Joint line	Suggests meniscal injury
		Plica synovialis	Nontender plicae may be found in asymptomatic knees; tenderness that reproduces symptoms denotes plica syndrome
Range of motion			Knee and hip range of motion usually normal in PFPS
	Crepitus		Nonspecific finding; may occur with PFPS; can be appreciated in asymptomatic knees and those with osteoarthritis
	Popping/clicking		Patella may produce a palpable pop, click, or clunk with palpation during passive or active range of motion; may be a sign of patellar maltracking, perhaps caused by synovial hypertrophy, plica synovialis, or cyst formation; a popping sensation with marked lateral deviation of the patella in extension indicates patellar instability
Patellar glide (Figure 3)			Assesses patellar mobility; displacement of less than one quadrant indicates tight lateral structures; displacement of more than three quadrants suggests patellar hypermobility caused by poor medial restraints
Patellar tilt (Figure 4)			Positive test (i.e., lateral aspect of patella is fixed and cannot be raised to at least horizontal position) indicates tight lateral structures
Patellar grind (Figure 5)			Pain with test may indicate PFPS; must be compared with contralateral knee
Patellar apprehension			Positive test (i.e., pain or discomfort with lateral translation of the patella) suggests lateral patellar instability as a cause of pain
Flexibility			Flexibility of quadriceps, hamstrings, ITB, hip flexors, and gastrocnemius should be assessed routinely