Abstract
Anterior knee pain (AKP) is the most common reason for adolescents, adults, and physically active people to consult with an orthopedic surgeon who specializes in the knee. Despite the high incidence and prevalence of AKP and an abundance of clinical and basic science research, the etiology of this condition is not well-known. This chapter synthesizes a review of the literature and our research and clinical experience on pathophysiology of AKP in the young patient.
Access this chapter
Tax calculation will be finalised at checkout
Purchases are for personal use only
References
Büdinger K. Üeber ablösung von gelenkteilen und verwandte prozesse. Dtsch Z Chir. 1906;84:311–65.
Dye SF. The pathophysiology of patellofemoral pain: a tissue homeostasis perspective. Clin Orthop Relat Res. 2005;436:100–10.
Royle SG, Noble J, Davies DR, et al. The significance of chondromalacic changes on the patella. Arthroscopy. 1991;7:158–60.
Ficat P, Ficat C, Bailleux A. Syndrome d’hyperpression externe de la rotule (S.H.P.E). Rev Chir Orthop. 1975;61:39–59.
Ficat P, Hungerford DS. Disorders of the Patello-Femoral Joint. Baltimore: Williams & Wilkins; 1977.
Hughston JC. Subluxation of the patella. J Bone Joint Surg. 1968;50–A:1003–1026.
Insall J. “Chondromalacia Patellae”: Patellar malalignment syndrome. Orthop Clin North Am. 1979;10:117–27.
Merchant AC, Mercer RL. Lateral release of the patella: a preliminary report. Clin Orthop Relat Res. 1974;103:40.
Staeubli HU, Bosshard C, Porcellini P, et al. Magnetic resonance imaging for articular cartilage: cartilage-bone mismatch. Clin Sports Med. 2002;21:417–33.
James SL. Chondromalacia of the Patella in the adolescent. In: Kennedy JC. editor. The injured adolescent knee. Baltimore: The Williams & Wilkins Company, 1979.
Orthopaedic Knowledge Update 3 Home Study Syllabus Published by American Academy of Orthopaedic Surgeons, Park Ridge, Illinois, January 1990, pp 563–567.
Meister K, James SL. Proximal tibial derotation osteotomy for anterior knee pain in the miserably malaligned extremity. Am J Orthop (Belle Mead NJ). 1995;24:149–55.
Cooke TD, Price N, Fisher B, et al. The inwardly pointing knee. An unrecognized problem of external rotational malalignment. Clin Orthop Relat Res. 1990;56–60.
Dye SF. The knee as a biologic transmission with an envelope of function: a theory. Clin Orthop Relat Res. 1996;325:10–8.
Dye SF, Staubli HU, Biedert RM, et al. The mosaic of pathophysiology causing patellofemoral pain: therapeutic implications. Oper Techni Sports Med. 1999;7:46–54.
Powers CM, Ward SR, Fredericson M, et al. Patellofemoral kinematics during weightbearing and non-weightbearing knee extension in persons with patellar subluxation: a preliminary study. J Orthop Sports Phys Ther. 2003;33:677–85.
Souza RB, Draper CE, Fredericson M, et al. Femur rotation and patellofemoral joint kinematics: a weight-bearing MRI analysis. J Orthop Sports Phys Ther. 2010;40:277–85.
Lee TQ, Morris G, Csintalan RP. The influence of tibial and femoral rotation on patellofemoral contact area and pressure. J Orthop Sports Phys Ther. 2003;33:686–93.
Sanchis-Alfonso V. Anterior Knee Pain and Patellar Instability. London: Springer; 2011.
Sanchis-Alfonso V, Gastaldi-Orquín E, Martinez-SanJuan V. Usefulness of computed tomography in evaluating the patellofemoral joint before and after Insall’s realignment. Correlation with short-term clinical results. Am J Knee Surg. 1994;7:65–72.
Sanchis-Alfonso V, Roselló-Sastre E, Martinez-SanJuan V. Pathogenesis of anterior knee pain syndrome and functional patellofemoral instability in the active young. A review Am J Knee Surg. 1999;12:29–40.
Dye SF. Functional anatomy and biomechanics of the patellofemoral joint. In: Scott WN, editor. The Knee. St. Louis: Mosby; 1994. p. 381–9.
Dye SF. Forward. In Fulkerson JP. Disorders of the Patellofemoral Joint. Ed 4. Philadelphia, Lippincott Williams and Wilkins xi–xii, 2004.
Hungerford DS, Barry M. Biomechanics of the patellofemoral joint. Clin Orthop. 1979;144:9–15.
Reilly DT, Martens M. Experimental analysis of the quadriceps muscle force and patellofemoral joint reaction force for various activities. Acta Orthop Scand. 1972;73:146–137.
Smith AJ. Estimates of muscle and joint force at the knee and ankle during jumping activities. J Hum Movement Stud. 1975;1:78–86.
Steinkamp LA, Dillinghan MF, Markel MD, et al. Biomechanical considerations in patellofemoral joint rehabilitation. Am J Sports Med. 1993;21:438–44.
Van Haver A, De Roo K, De Beule M, et al. The effect of trochlear dysplasia on patellofemoral biomechanics: a cadaveric study with simulated trochlear deformities. Am J Sports Med. 2015;43(6):1354–61.
Powers CM. Patellar kinematics, part II: the influence of the depth of the trochlear groove in subjects with and without patellofemoral pain. Phys Ther. 2000;80(10):965–78.
Ho KY, Hu HH, Colletti PM, et al. Recreational runners with patellofemoral pain exhibit elevated patella water content. Magn Reson Imaging. 2014;32(7):965–8.
Sanchis-Alfonso V. Holistic approach to understanding anterior knee pain. Clinical implications. Knee Surg Sports Traumatol Arthrosc. 2014;22(10):2275–2285.
Barton RS, Ostrowski ML, Anderson TD, et al. Intraosseous innervation of the human patella: a histologic study. Am J Sports Med. 2007;35:307–11.
Teitge RA. Patellofemoral syndrome a paradigm for current surgical strategies. Orthop Clin N Am. 2008;287–311.
Teitge RA. Does lower limb torsion matter? Tech Knee Surg. 2012;11:137–46.
van Kampen A, Huiskes R. The three-dimensional tracking pattern of the human patella. J Orthop Res. 1990;8(3):372–82.
Sanchis-Alfonso V, Roselló-Sastre E. Anterior knee pain in the young patient—what causes the pain? “Neural model.” Acta Orthop Scand. 2003;74:697–703.
Biedert RM, Sanchis-Alfonso V. Sources of anterior knee pain. Clin Sports Med. 2002;21:335–47.
Fulkerson JP. The etiology of patellofemoral pain in young active patients: a prospective study. Clin Orthop Relat Res. 1983;179:129–33.
Kasim N, Fulkerson JP. Resection of clinically localized segments of painful retinaculum in the treatment of selected patients with anterior knee pain. Am J Sports Med. 2000;28:811–4.
Sanchis-Alfonso V, Roselló-Sastre E. Immunohistochemical analysis for neural markers of the lateral retinaculum in patients with isolated symptomatic patellofemoral malalignment. A neuroanatomic basis for anterior knee pain in the active young patient. Am J Sports Med. 2000;28:725–731.
Sanchis-Alfonso V, Roselló-Sastre E, Revert F. Neural growth factor expression in the lateral retinaculum in painful patellofemoral malalignment. Acta Orthop Scand. 2001;72:146–9.
Sanchis-Alfonso V, Roselló-Sastre E, Revert F, et al. Histologic retinacular changes associated with ischemia in painful patellofemoral malalignment. Orthopedics. 2005;28:593–9.
Sanchis-Alfonso V, Roselló-Sastre E, Monteagudo-Castro C, et al. Quantitative analysis of nerve changes in the lateral retinaculum in patients with isolated symptomatic patellofemoral malalignment. A preliminary study. Am J Sports Med. 1998;26:703–709.
Fulkerson JP, Tennant R, Jaivin JS, et al. Histologic evidence of retinacular nerve injury associated with patellofemoral malalignment. Clin Orthopn Relat Res. 1985;197:196–205.
Mori Y, Fujimoto A, Okumo H, et al. Lateral retinaculum release in adolescent patellofemoral disorders: its relationship to peripheral nerve injury in the lateral retinaculum. Bull Hosp Jt Dis Orthop Inst. 1991;51:218–29.
Baker V, Bennell K, Stillman B, et al. Abnormal knee joint position sense in individuals with patellofemoral pain syndrome. J Orthop Res. 2002;20(2):208–14.
Jerosch J, Prymka M. Knee joint propioception in patients with posttraumatic recurrent patella dislocation. Knee Surg, Sports Traumatol Arthrosc. 1996;4:14–8.
Wilson AS, Lee HB. Hypothesis relevant to defective position sense in a damaged knee. J Neurol Neurosurg Psychiatry. 1986;49:1462–3.
Jensen R, Hystad T, Kvale A, et al. Quantitative sensory testing of patients with long lasting patellofemoral pain síndrome. Eur J Pain. 2007;11:665–76.
Ahmed M, Bergstrom J, Lundblad H, et al. Sensory nerves in the interface membrane of aseptic loose hip prostheses. J Bone Joint Surg. 1998;80-B:151–155.
Ashton IK, Ashton BA, Gibson SJ, et al. Morphological basis for back pain: the demonstration of nerve fibers and neuropeptides in the lumbar facet joint capsule but not in ligamentum flavum. J Orthop Res. 1992;10:72–8.
Ashton IK, Roberts S, Jaffray DC. Neuropeptides in the human intervertebral disc. J Orthop Res. 1994;12:186–92.
Ashton IK, Walsh DA, Polak JM, et al. Substance P in intervertebral discs. Binding sites on vascular endothelium of the human annulus fibrosus. Acta Orthop Scand. 1994;65:635–639.
Coppes MH, Marani E, Thomeer RT, et al. Innervation of “painful” lumbar discs. Spine. 1997;22:2342–9.
Freemont AJ, Peacock TE, Goupille P, et al. Nerve ingrowth into diseased intervertebral disc in chronic back pain. Lancet. 1997;350:178–81.
Grönblad M, Korkala O, Konttinen YT, et al. Silver impregnation and immunohistochemical study of nerves in lumbar facet joint plical tissue. Spine. 1991;16:34–8.
Kocher MS, Fu FH, Harner ChD. Neuropathophysiology. In: Fu FH, Harner ChD, Vince KG, editors. Knee Surgery. Baltimore: Williams and Wilkins; 1994. p. 231–49.
Konttinen YT, Grönblad M, Antti-Poika I, et al. Neuroimmunohistochemical analysis of peridiscal nociceptive neural elements. Spine. 1990;15:383–6.
Korkala O, Grönblad M, Liesi P, et al. Immunohistochemical demonstration of nociceptors in the ligamentous structures of the lumbar spine. Spine. 1985;10:156–7.
Palmgren T, Grönblad M, Virri J, et al. Immunohistochemical demonstration of sensory and autonomic nerve terminals in herniated lumbar disc tissue. Spine. 1996;21:1301–6.
Witonski D, Wagrowska-Danielewicz M. Distribution of substance-P nerve fibers in the knee joint in patients with anterior knee pain syndrome. Knee Surg Sports Traumatol Arthrosc. 1999;7:177–83.
Wojtys EM, Beaman DN, Glover RA, et al. Innervation of the human knee joint by substance-P fibers. Arthroscopy. 1990;6:254–63.
Byers PD. Solitary benign osteoblastic lesions of bone. Osteoid osteoma and benign osteoblastoma Cancer. 1968;22:43–57.
Alfredson H, Ohberg L, Forsgren S. Is vasculo-neural ingrowth the cause of pain in chronic Achilles tendinosis? An investigation using ultrasonography and colour Doppler, immunohistochemistry, and diagnostic injections. Knee Surg Sports Traumatol Arthrosc. 2003;11:334–8.
Sanchis-Alfonso V, Roselló-Sastre E, Subías-López A. Neuroanatomic basis for pain in patellar tendinosis (“jumper’s knee”): A neuroimmunohistochemical study. Am J Knee Surg. 2001;14:174–7.
Hasegawa T, Hirose T, Sakamoto R, et al. Mechanism of pain in osteoid osteomas: an immunohistochemical study. Histopathology. 1993;22:487–91.
Grönblad M, Weinstein JN, Santavirta S. Immunohistochemical observations on spinal tissue innervation. A review of hipothetical mechanisms of back pain. Acta Orthop Scand. 1991;62:614–622.
Dicou E, Pflug B, Magazin M, et al. Two peptides derived from the nerve growth factor precursor are biologically active. J Cell Biol. 1997;136:389–98.
Gigante A, Bevilacqua C, Ricevuto A, et al. Biological aspects in patello-femoral malalignment. 11th Congress European Society of Sports Traumatology, Knee Surgery and Arthroscopy. Book of Abstracts. Athens 5–8 May, 2004.
Malcangio M, Garrett NE, Cruwys S, et al. Nerve growth factor- and neurotrophin-3-induced changes in nociceptive threshold and the release of substance P from the rat isolated spinal cord. J Neurosci. 1997;17:8459–67.
Abe T, Morgan DA, Gutterman DD. Protective role of nerve growth factor against postischemic dysfunction of sympathetic coronary innervation. Circulation. 1997;95:213–20.
Lee TH, Kato H, Kogure K, et al. Temporal profile of nerve growth factor-like immunoreactivity after transient focal cerebral ischemia in rats. Brain Res. 1996;713:199–210.
Isaacson LG, Crutcher KA. The duration of sprouted cerebrovascular axons following intracranial infusion of nerve growth factor. Exp Neurol. 1995;13:174–9.
Kawaja MD. Sympathetic and sensory innervation of the extracerebral vasculature: roles for p75NTR neuronal expression and nerve growth factor. J Neurosci Res. 1998;52:295–306.
Society for Ultrastructural Pathology. Handbook of diagnostic electron microscopy for pathologists-in-training. New York-Tokyo: Igaku-Shoin Medical Publishers Committee; 1995.
Shweiki D, Itin A, Soffer D, et al. Vascular endothelial growth factor induced by hypoxia may mediate hypoxia-initiated angiogenesis. Nature. 1992;359:843–5.
Liu Y, Cox SR, Morita T, et al. Hypoxia regulates vascular endothelial growth factor gene expression in endothelial cells. Identification of a 5’ enhancer. Circ Res. 1995:77:638–643.
Minchenko A, Bauer T, Salceda S, et al. Hypoxic stimulation of vascular endothelial growth factor expression in vitro and in vivo. Lab Invest. 1994;71:374–9.
Nagashima M, Yoshino S, Ishiwata T, et al. Role of vascular endothelial growth factor in angiogenesis of rheumatoid arthritis. J Rheumatol. 1995;22:1624–30.
Yamada T, Sawatsubashi M, Yakushiji H, et al. Localization of vascular endothelial growth factor in synovial membrane mast cells: examination with “multilabelling subtraction immunostaining.” Virchows Arch. 1998;433:567–70.
Pufe T, Petersen W, Tillmann B, et al. The splice variants VEGF121 and VEGF189 of the angiogenic peptide vascular endothelial growth factor are expressed in osteoarthritic cartilage. Arthritis Rheum. 2001;44:1082–8.
Jackson JR, Minton JAL, Ho ML, et al. Expression of vascular endothelial growth factor in synovial fibroblasts is induced by hipoxia and interleukin 1ß. J Rheumatol. 1997;24:1253–9.
Calzà L, Giardino L, Giuliani A, et al. Nerve growth factor control of neuronal expression of angiogenetic and vasoactive factors. Proc Natl Acad Sci USA. 2001;98:4160–5.
Sandow MJ, Goodfellow JW. The natural history of anterior knee pain in adolescents. J Bone Joint Surg. 1985;67-B:36–38.
Selfe J, Karki A, Stevens D. A review of the role of circulatory deficit in the genesis of patellofemoral pain. Phys Therapy Rev. 2002;7:169–72.
Selfe J, Harper L, Pedersen I, et al. Cold legs: a potential indicator of negative outcome in the rehabilitation of patients with patellofemoral pain syndrome. Knee. 2003;10:139–43.
Gelfer Y, Pinkas L, Horne T, et al. Symptomatic transient patellar ischemia following total knee replacement as detected by scintigraphy. A prospective, randomized, double-blind study comparing the mid-vastus to the medial para-patellar approach. Knee. 2003;10:341–345.
Naslund J. Patellofemoral pain syndrome. Clinical and pathophysiological considerations. Thesis. Karolinska Institutet, Stockholm, 2006.
Damasio AR, Grabowky TJ, Bechara A, et al. Subcortical and cortical brain activity during the feeling of self-generated emotions. Nat Neurosci. 2000;3:1049–56.
Diekfuss JA, Grooms DR, Nissen KS, et al. Does central nervous system dysfunction underlie patellofemoral pain in young females? Examining brain functional connectivity in association with patient-reported outcomes. J Orthop Res. 2022;40(5):1083–96.
Foss KDB, Slutsky-Ganesh AB, Diekfuss JA, et al. Brain activity during experimental knee pain and its relationship with kinesiophobia in patients with patellofemoral pain: a preliminary functional magnetic resonance imaging investigation. J Sport Rehabil. 2022;12:1–10. https://doi.org/10.1123/jsr.2021-0236.
Slutsky-Ganesh AB, Diekfuss JA, Grooms DR, et al. A preliminary investigation of the effects of patellar displacement on brain activation and perceived pain in young females with patellofemoral pain. J Sci Med Sport. 2022;31;S1440–2440(22)00030–5. https://doi.org/10.1016/j.jsams.2022.01.006.
Domenech J, Sanchis-Alfonso V, López L, et al. Influence of kinesiophobia and catastrophizing on pain and disability in anterior knee pain patients. Knee Surg Sports Traumatol Arthrosc. 2013;21(7):1562–8.
Doménech J, Sanchis-Alfonso V, Espejo B. Changes in catastrophizing and kinesiophobia are predictive of changes in disability and pain after treatment in patients with anterior knee pain. Knee Surg Sports Traumatol Arthrosc. 2014;22(10):2295–300.
Sanchis-Alfonso V, Montesinos-Berry E, Domenech J. Catastrophic thinking is a new puzzle piece in understanding anterior knee pain. Orthopaedics Today Europe Official Newspaper of EFORT. 2014;17(2):44–50.
Gracely RH. Pain catastrophizing and neural responses to pain among persons with fibromyalgia. Brain. 2004;127:835–43.
Rathleff MS, Petersen KK, Arendt-Nielsen L, et al. Impaired conditioned pain modulation in young female adults with long-standing patellofemoral pain: a Single Blinded Cross-Sectional Study. Pain Med. 2016;17(5):980–8.
IASP terminology. International Association for the Study of Pain Web site. https://www.iasp-pain.org/terminology.
Sigmund KJ, Hoeger Bement MK, Earl-Boehm JE. Exploring the pain in patellofemoral pain: a systematic review and meta-analysis examining signs of central sensitization. J Athl Train. 2021;56(8):887–901.
De Oliveira SD, Rathleff MS, Petersen K, et al. Manifestations of pain sensitization across different painful knee disorders: a systematic review including meta-analysis and metaregression. Pain Med. 2019;20(2):335–58.
Rathleff MS, Roos EM, Olesen JL, et al. Lower mechanical pressure pain thresholds in female adolescents with patellofemoral pain syndrome. J Orthop Sports Phys Ther. 2013;43(6):414–21.
Rathleff MS, Roos EM, Olesen JL, et al. Self-reported recovery is associated with improvement in localized hyperalgesia among adolescent females with patellofemoral pain: results from a cluster randomized trial. Clin J Pain. 2016;32(5):428–34.
Lefaucheur JP, Drouot X, Ménard-Lefaucheur I, et al. Motor cortex rTMS restores defective intracortical inhibition in chronic neuropathic pain. Neurology. 2006;67:1568–74.
Young NA, Sharma M, Deogaonkar M. Transcranial magnetic stimulation for chronic pain. Neurosurg Clin N Am. 2014;25(4):819–32.
Powers CM, Bolgla LA, Callaghan MJ, et al. Patellofemoral pain: proximal, distal, and local factors, 2nd International Research Retreat. J Orthop Sports Phys Ther. 2012;42:A1-54.
Soifer TB, Levy HJ, Soifer FM, et al. Neurohistology of the subacromial space. Arthroscopy. 1996;12:182–6.
Solomonow M, D’Ambrosia R. Neural reflex arcs and muscle control of knee stability and motion. In: Scott WN, ed. Ligament and extensor mechanism injuries of the knee: Diagnosis and treatment. St. Louis: Mosby-Year Book, 1991; pp 389–400.
Nilsson G, Forsberg-Nilsson K, Xiang Z, et al. Human mast cells express functional TrkA and are a source of nerve growth factor. Eur J Immunol. 1997;27:2295–301.
Sherman BE, Chole RA. A mechanism for sympathectomy-induced bone resorption in the middle ear. Otolaryngol Head Neck Surg. 1995;113:569–81.
Woolf CJ. Pain: moving from symptom control toward mechanism-specific pharmacologic management. Ann Intern Med. 2004;140:441–51.
Author information
Authors and Affiliations
Corresponding author
Editor information
Editors and Affiliations
Rights and permissions
Copyright information
© 2023 The Author(s), under exclusive license to Springer Nature Switzerland AG
About this chapter
Cite this chapter
Sanchis-Alfonso, V., Roselló-Sastre, E., Dye, S.F., Teitge, R.A. (2023). Pathophysiology of Anterior Knee Pain. In: Sanchis-Alfonso, V. (eds) Anterior Knee Pain and Patellar Instability. Springer, Cham. https://doi.org/10.1007/978-3-031-09767-6_2
Download citation
DOI: https://doi.org/10.1007/978-3-031-09767-6_2
Published:
Publisher Name: Springer, Cham
Print ISBN: 978-3-031-09766-9
Online ISBN: 978-3-031-09767-6
eBook Packages: MedicineMedicine (R0)