Our thought was that she had anterior knee pain that was exertion related. Once upon a time this would have been put under the umbrella of chondromalacia patella, a term that fortunately is just about dead. There are conditions in which the patellofemoral articular cartilage degeneration is an important part of the process. This patient has a more advanced case of it. It’s a process that you can’t see well on an A-P x-ray, perhaps in the lateral. But with prolonged patellofemoral mis-articulation there can be fairly severe patellofemoral osteoarthritis develop, with this person with lateral subluxation. She has worn a new groove in her trochlear sulcus and has a large osteophyte. Other consideration for her, but was probably ruled out by the physical examination, was patellar tendonitis and that is largely made by physical examination looking for tenderness at the tibial tuberosity.
Another intraarticular anatomic process that she might have going on is a problem with the fat pad. This is a shot looking down from the suprapatellar pouch, underneath the patella, trochlear groove below, patella above and that little white thing in the middle is a fat pad. That’s a normal structure in all knees, but with some overuse syndromes it can become impinged, inflamed and a source of pain. This schematic shows about where it lies.
Another intraarticular structure that could be deranged here is the synovial plica, I mentioned in the physical examination. If you reach down with your thumb medial to your patella and rub back and forth, a good three-fourths of you should be able to feel something twanging there. It’s a common structure, a remnant of when the knee had three sections at about four months of gestation. They coalesce into one but septations remain behind. Especially between the suprapatellar pouch and the medial tibial femoral compartment. This is a normal structure, however it can become inflamed either as a primary process or in response to biomechanical forces. When inflamed it can be treated in various ways. If it persists after a simpler, conservative therapy it can be injected.
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