AOSSM 2014 Annual Meeting

SEATTLE – Correcting jumping and landing techniques may prevent lower-limb stress fractures in active young people, based on the results of a prospective study of 1,772 cadets at the United States Military Academy in West Point, N.Y.

Scores on the Landing Error Scoring System (LESS), which assesses 17 components of jumping and landing, were predictive of lower extremity stress fractures in the study, which was reported at the annual meeting of the American Orthopaedic Society for Sports Medicine.

Based on the results, freshman at West Point are now being screened for movement problems that are corrected when necessary. "We’ve seen a pretty impressive reduction – on average 30%-40% – in stress fractures, said lead investigator Kenneth Cameron, Ph.D., director of orthopedic research at Keller Army Community Hospital in West Point.

The reductions have not yet reached statistical significance because the program is fairly new, said Dr. Cameron, who added that the findings might prove useful for preventing post-traumatic osteoarthritis, anterior cruciate ligament tears, and other injuries.

For the study, cadets were instructed to jump off a 30-cm high box, then to leap as high as they could. Subjects were about 19 years old, on average, and had a body mass index of about 24 kg/m² in men and 23 kg/m² in women. The investigators videotaped the cadets and graded their movements using the LESS criteria.

Overall, there were 94 first-time fractures in the cohort, giving a cumulative incidence of 5.3%. Stress fractures were three times more likely in women, about one-third of the study population (incidence rate ratio = 2.86; 95% confidence interval, 1.88-4.34; P less than .001).

Controlling for sex and year of entry into the cohort, cadets who consistently landed flat footed or heel to toe were more than twice as likely (IRR = 2.32; 95% CI, 1.35-3.97; P = .002) to have a lower-extremity stress fracture during 4 years of follow-up. Similarly, a higher rate of stress fractures was noted in those who consistently landed asymmetrically (IRR = 2.53; 95% CI, 1.35-4.77; P = .004). Each additional movement error increased the incidence rate of lower-extremity stress fracture by 15% (IRR = 1.15; 95% CI, 1.02-1.31; P = .025).

"Typically, we don’t focus on changing movement patterns" when people have stress fractures, so most "move just as badly if not worse" and are at risk for another injury, he said. "Strength training isn’t enough; there’s a neuromuscular control issue, as well."

In stress fracture, "we see excessive motion in the frontal plane and transverse plane, and not much [side] plane motion. We also see hamstring and quadriceps weakness. Instead of flexing [the hip, knee, and ankle] to absorb force, [subjects] focus on compensatory movements," like internal rotation and abduction.

Hitting the floor with abnormal ankle flexion, stance width, and trunk flexion also increases the stress fracture risk.

The work was funded by the Department of Defense and National Institutes of Health, among others. Dr. Cameron had no relevant disclosures.

[email protected]

SEATTLE – Correcting jumping and landing techniques may prevent lower-limb stress fractures in active young people, based on the results of a prospective study of 1,772 cadets at the United States Military Academy in West Point, N.Y.

Scores on the Landing Error Scoring System (LESS), which assesses 17 components of jumping and landing, were predictive of lower extremity stress fractures in the study, which was reported at the annual meeting of the American Orthopaedic Society for Sports Medicine.

Based on the results, freshman at West Point are now being screened for movement problems that are corrected when necessary. "We’ve seen a pretty impressive reduction – on average 30%-40% – in stress fractures, said lead investigator Kenneth Cameron, Ph.D., director of orthopedic research at Keller Army Community Hospital in West Point.

The reductions have not yet reached statistical significance because the program is fairly new, said Dr. Cameron, who added that the findings might prove useful for preventing post-traumatic osteoarthritis, anterior cruciate ligament tears, and other injuries.

For the study, cadets were instructed to jump off a 30-cm high box, then to leap as high as they could. Subjects were about 19 years old, on average, and had a body mass index of about 24 kg/m² in men and 23 kg/m² in women. The investigators videotaped the cadets and graded their movements using the LESS criteria.

Overall, there were 94 first-time fractures in the cohort, giving a cumulative incidence of 5.3%. Stress fractures were three times more likely in women, about one-third of the study population (incidence rate ratio = 2.86; 95% confidence interval, 1.88-4.34; P less than .001).

Controlling for sex and year of entry into the cohort, cadets who consistently landed flat footed or heel to toe were more than twice as likely (IRR = 2.32; 95% CI, 1.35-3.97; P = .002) to have a lower-extremity stress fracture during 4 years of follow-up. Similarly, a higher rate of stress fractures was noted in those who consistently landed asymmetrically (IRR = 2.53; 95% CI, 1.35-4.77; P = .004). Each additional movement error increased the incidence rate of lower-extremity stress fracture by 15% (IRR = 1.15; 95% CI, 1.02-1.31; P = .025).

"Typically, we don’t focus on changing movement patterns" when people have stress fractures, so most "move just as badly if not worse" and are at risk for another injury, he said. "Strength training isn’t enough; there’s a neuromuscular control issue, as well."

In stress fracture, "we see excessive motion in the frontal plane and transverse plane, and not much [side] plane motion. We also see hamstring and quadriceps weakness. Instead of flexing [the hip, knee, and ankle] to absorb force, [subjects] focus on compensatory movements," like internal rotation and abduction.

Hitting the floor with abnormal ankle flexion, stance width, and trunk flexion also increases the stress fracture risk.

The work was funded by the Department of Defense and National Institutes of Health, among others. Dr. Cameron had no relevant disclosures.

[email protected]

SEATTLE – Correcting jumping and landing techniques may prevent lower-limb stress fractures in active young people, based on the results of a prospective study of 1,772 cadets at the United States Military Academy in West Point, N.Y.

Scores on the Landing Error Scoring System (LESS), which assesses 17 components of jumping and landing, were predictive of lower extremity stress fractures in the study, which was reported at the annual meeting of the American Orthopaedic Society for Sports Medicine.

Based on the results, freshman at West Point are now being screened for movement problems that are corrected when necessary. "We’ve seen a pretty impressive reduction – on average 30%-40% – in stress fractures, said lead investigator Kenneth Cameron, Ph.D., director of orthopedic research at Keller Army Community Hospital in West Point.

The reductions have not yet reached statistical significance because the program is fairly new, said Dr. Cameron, who added that the findings might prove useful for preventing post-traumatic osteoarthritis, anterior cruciate ligament tears, and other injuries.

For the study, cadets were instructed to jump off a 30-cm high box, then to leap as high as they could. Subjects were about 19 years old, on average, and had a body mass index of about 24 kg/m² in men and 23 kg/m² in women. The investigators videotaped the cadets and graded their movements using the LESS criteria.

Overall, there were 94 first-time fractures in the cohort, giving a cumulative incidence of 5.3%. Stress fractures were three times more likely in women, about one-third of the study population (incidence rate ratio = 2.86; 95% confidence interval, 1.88-4.34; P less than .001).

Controlling for sex and year of entry into the cohort, cadets who consistently landed flat footed or heel to toe were more than twice as likely (IRR = 2.32; 95% CI, 1.35-3.97; P = .002) to have a lower-extremity stress fracture during 4 years of follow-up. Similarly, a higher rate of stress fractures was noted in those who consistently landed asymmetrically (IRR = 2.53; 95% CI, 1.35-4.77; P = .004). Each additional movement error increased the incidence rate of lower-extremity stress fracture by 15% (IRR = 1.15; 95% CI, 1.02-1.31; P = .025).

"Typically, we don’t focus on changing movement patterns" when people have stress fractures, so most "move just as badly if not worse" and are at risk for another injury, he said. "Strength training isn’t enough; there’s a neuromuscular control issue, as well."

In stress fracture, "we see excessive motion in the frontal plane and transverse plane, and not much [side] plane motion. We also see hamstring and quadriceps weakness. Instead of flexing [the hip, knee, and ankle] to absorb force, [subjects] focus on compensatory movements," like internal rotation and abduction.

Hitting the floor with abnormal ankle flexion, stance width, and trunk flexion also increases the stress fracture risk.

The work was funded by the Department of Defense and National Institutes of Health, among others. Dr. Cameron had no relevant disclosures.

[email protected]

SEATTLE – Postoperative femoral nerve blocks prolong quadricep and hamstring weakness after anterior cruciate ligament reconstruction in young athletes, and delay recovery, according to investigators from the Mayo Clinic in Rochester, Minn.

Because of that, "I’ve stopped using them," said investigator Dr. Amy McIntosh, a pediatric orthopedic surgeon in Rochester.

M. Alexander Otto/Frontline Medical News

In a retrospective study of patients no older than 18 years, her team found that 68% (42 of 62 patients) who got the block – weight-based bupivacaine HCl in all cases – were cleared for sports at 6 months, meaning that their operated knee was at least 85% as strong as their uninjured knee, and at least 90% as functional. Among children who didn’t get the blocks after anterior cruciate ligament reconstruction (ACL), 90% (56 of 62) were ready to return to sports, a significant difference. Overall, unblocked kids were 4.4 times more likely to be cleared at 6 months.

"Kids who didn’t clear at 6 months usually took another 3-4 months. At a year, everybody looked about the same," Dr. McIntosh said at the American Orthopaedic Society for Sports Medicine annual meeting.

Also at 6 months, kids who got the nerve block had significantly greater mean deficits in fast isokinetic knee extensions, a measure of quadricep strength (17.6% in the operated knee vs. 11.2% in the uninjured knee), and fast (9.9% vs. 5.7%) and slow (13.0% vs. 8.5%) isokinetic flexion, a measure of hamstring strength. It didn’t seem to matter if they got a one-shot femoral nerve block or a continuous pump infusion.

Dr. McIntosh initially lobbied Mayo anesthesiologists to use femoral blocks in kids, opting first for the pump. "Then I saw that those kids had a lot of quad atrophy and were taking a longer time to get off their crutches, so I started going to the one-shot block, but they still had quad atrophy, and took a little longer to get off their crutches and get their normal gait back. Now, after seeing this data, I’m done with it," she said.

She’s not alone. Long considered a benign and effective method for short-term pain control, surgeons have been reconsidering the blocks because of similar findings in adults.

"I tell patients [and parents] that they have to decide if they want great pain control up front, or a little more pain in the first few days after surgery," but a quicker return to sports. When offered the choice, young athletes opt against the block because it will likely mean missing an entire season. "That’s what matters to these kids," Dr. McIntosh said.

The nerve block group and control groups were evenly matched; children in both were about 16 years old, on average, with a mean body mass index of about 24 kg/m². There were slightly more girls in the study than boys.

Most of the kids in both groups had patellar tendon autografts, and the rest had hamstring autografts. Those who got nerve blocks had shorter tourniquet (82 vs. 93 minutes), operative (134 vs. 155 minutes.), and anesthesia times (177 vs. 200 minutes).

Dr. McIntosh said he had no relevant financial disclosures. The project was funded internally.

[email protected]

SEATTLE – Postoperative femoral nerve blocks prolong quadricep and hamstring weakness after anterior cruciate ligament reconstruction in young athletes, and delay recovery, according to investigators from the Mayo Clinic in Rochester, Minn.

Because of that, "I’ve stopped using them," said investigator Dr. Amy McIntosh, a pediatric orthopedic surgeon in Rochester.

M. Alexander Otto/Frontline Medical News

In a retrospective study of patients no older than 18 years, her team found that 68% (42 of 62 patients) who got the block – weight-based bupivacaine HCl in all cases – were cleared for sports at 6 months, meaning that their operated knee was at least 85% as strong as their uninjured knee, and at least 90% as functional. Among children who didn’t get the blocks after anterior cruciate ligament reconstruction (ACL), 90% (56 of 62) were ready to return to sports, a significant difference. Overall, unblocked kids were 4.4 times more likely to be cleared at 6 months.

"Kids who didn’t clear at 6 months usually took another 3-4 months. At a year, everybody looked about the same," Dr. McIntosh said at the American Orthopaedic Society for Sports Medicine annual meeting.

Also at 6 months, kids who got the nerve block had significantly greater mean deficits in fast isokinetic knee extensions, a measure of quadricep strength (17.6% in the operated knee vs. 11.2% in the uninjured knee), and fast (9.9% vs. 5.7%) and slow (13.0% vs. 8.5%) isokinetic flexion, a measure of hamstring strength. It didn’t seem to matter if they got a one-shot femoral nerve block or a continuous pump infusion.

Dr. McIntosh initially lobbied Mayo anesthesiologists to use femoral blocks in kids, opting first for the pump. "Then I saw that those kids had a lot of quad atrophy and were taking a longer time to get off their crutches, so I started going to the one-shot block, but they still had quad atrophy, and took a little longer to get off their crutches and get their normal gait back. Now, after seeing this data, I’m done with it," she said.

She’s not alone. Long considered a benign and effective method for short-term pain control, surgeons have been reconsidering the blocks because of similar findings in adults.

"I tell patients [and parents] that they have to decide if they want great pain control up front, or a little more pain in the first few days after surgery," but a quicker return to sports. When offered the choice, young athletes opt against the block because it will likely mean missing an entire season. "That’s what matters to these kids," Dr. McIntosh said.

The nerve block group and control groups were evenly matched; children in both were about 16 years old, on average, with a mean body mass index of about 24 kg/m². There were slightly more girls in the study than boys.

Most of the kids in both groups had patellar tendon autografts, and the rest had hamstring autografts. Those who got nerve blocks had shorter tourniquet (82 vs. 93 minutes), operative (134 vs. 155 minutes.), and anesthesia times (177 vs. 200 minutes).

Dr. McIntosh said he had no relevant financial disclosures. The project was funded internally.

[email protected]

SEATTLE – Postoperative femoral nerve blocks prolong quadricep and hamstring weakness after anterior cruciate ligament reconstruction in young athletes, and delay recovery, according to investigators from the Mayo Clinic in Rochester, Minn.

Because of that, "I’ve stopped using them," said investigator Dr. Amy McIntosh, a pediatric orthopedic surgeon in Rochester.

M. Alexander Otto/Frontline Medical News

In a retrospective study of patients no older than 18 years, her team found that 68% (42 of 62 patients) who got the block – weight-based bupivacaine HCl in all cases – were cleared for sports at 6 months, meaning that their operated knee was at least 85% as strong as their uninjured knee, and at least 90% as functional. Among children who didn’t get the blocks after anterior cruciate ligament reconstruction (ACL), 90% (56 of 62) were ready to return to sports, a significant difference. Overall, unblocked kids were 4.4 times more likely to be cleared at 6 months.

"Kids who didn’t clear at 6 months usually took another 3-4 months. At a year, everybody looked about the same," Dr. McIntosh said at the American Orthopaedic Society for Sports Medicine annual meeting.

Also at 6 months, kids who got the nerve block had significantly greater mean deficits in fast isokinetic knee extensions, a measure of quadricep strength (17.6% in the operated knee vs. 11.2% in the uninjured knee), and fast (9.9% vs. 5.7%) and slow (13.0% vs. 8.5%) isokinetic flexion, a measure of hamstring strength. It didn’t seem to matter if they got a one-shot femoral nerve block or a continuous pump infusion.

Dr. McIntosh initially lobbied Mayo anesthesiologists to use femoral blocks in kids, opting first for the pump. "Then I saw that those kids had a lot of quad atrophy and were taking a longer time to get off their crutches, so I started going to the one-shot block, but they still had quad atrophy, and took a little longer to get off their crutches and get their normal gait back. Now, after seeing this data, I’m done with it," she said.

She’s not alone. Long considered a benign and effective method for short-term pain control, surgeons have been reconsidering the blocks because of similar findings in adults.

"I tell patients [and parents] that they have to decide if they want great pain control up front, or a little more pain in the first few days after surgery," but a quicker return to sports. When offered the choice, young athletes opt against the block because it will likely mean missing an entire season. "That’s what matters to these kids," Dr. McIntosh said.

The nerve block group and control groups were evenly matched; children in both were about 16 years old, on average, with a mean body mass index of about 24 kg/m². There were slightly more girls in the study than boys.

Most of the kids in both groups had patellar tendon autografts, and the rest had hamstring autografts. Those who got nerve blocks had shorter tourniquet (82 vs. 93 minutes), operative (134 vs. 155 minutes.), and anesthesia times (177 vs. 200 minutes).

Dr. McIntosh said he had no relevant financial disclosures. The project was funded internally.

[email protected]

SEATTLE – Arthroscopic Bankart lesion repairs don’t seem to work well in patients who have lost more than 13.5% of their glenoid fossa after dislocating their shoulders; an open inferior capsular shift or Latarjet procedure is likely to be a better bet, according to a review of 72 consecutive soldiers at Tripler Army Medical Center in Honolulu, who had an arthroscopic Bankart repair after shoulder dislocation.

Seven of the 29 patients (24%) who went into the operation with greater levels of bone loss redislocated over an average of about 4 years of follow-up, versus 2 of 37 (5%) who had less than 13.5% of their glenoid fossa missing. When patients who redislocated were excluded, the mean Western Ontario Shoulder Instability (WOSI) score was 43% of normal in the 13.5% or more bone loss group, but about 80% of normal in those who had lost less bone.

In short, bone loss of 13.5% led to "unacceptable clinical outcomes. Patients with bone loss beyond this threshold should be counseled accordingly with consideration for alternative surgical procedures," the investigators concluded.

Surgeons "have to pay a lot more attention to how much bone loss is there. We have traditionally defined the level of bone loss" that triggers an open procedure at 20%. "In today’s world, everybody agrees that 20% is too high, but the" question has been by how much. At 13.5% – judged by preoperative MRI or CT – "two things become clear. They redislocate at too high a level, and they" report too much instability on the WOSI," said lead investigator Dr. John Tokish, now an orthopedic surgeon at the Greenville (S.C.) Health System.

"If you are just evaluating your results based on whether or not the person redislocates, you missed the point. When we evaluate function in these patients with well below 20% bone loss, they have pain and apprehension. Even if their shoulders don’t come out again, these patients are self-limiting," he said.

When arthroscopic Bankart repair is ruled out, Dr. Tokish cautioned, it "doesn’t necessarily mean we should jump right away to a Latarjet," in which the tip of the coracoid process is repositioned to increase glenoid surface area. "Some would argue that a Latarjet is too big a step. An open inferior capsular shift" may be enough, or even superior.

There were 73 operated shoulders in the 72 patients, 68 of whom were men. The average age at surgery was 26.3 years. Glenoid bone loss was calculated by overlaying a circle onto preop images of the fossa. Patients were excluded if they had a previous shoulder operation.

Dr. Tokish had no disclosures. The work was funded internally.

[email protected]

SEATTLE – Arthroscopic Bankart lesion repairs don’t seem to work well in patients who have lost more than 13.5% of their glenoid fossa after dislocating their shoulders; an open inferior capsular shift or Latarjet procedure is likely to be a better bet, according to a review of 72 consecutive soldiers at Tripler Army Medical Center in Honolulu, who had an arthroscopic Bankart repair after shoulder dislocation.

Seven of the 29 patients (24%) who went into the operation with greater levels of bone loss redislocated over an average of about 4 years of follow-up, versus 2 of 37 (5%) who had less than 13.5% of their glenoid fossa missing. When patients who redislocated were excluded, the mean Western Ontario Shoulder Instability (WOSI) score was 43% of normal in the 13.5% or more bone loss group, but about 80% of normal in those who had lost less bone.

In short, bone loss of 13.5% led to "unacceptable clinical outcomes. Patients with bone loss beyond this threshold should be counseled accordingly with consideration for alternative surgical procedures," the investigators concluded.

Surgeons "have to pay a lot more attention to how much bone loss is there. We have traditionally defined the level of bone loss" that triggers an open procedure at 20%. "In today’s world, everybody agrees that 20% is too high, but the" question has been by how much. At 13.5% – judged by preoperative MRI or CT – "two things become clear. They redislocate at too high a level, and they" report too much instability on the WOSI," said lead investigator Dr. John Tokish, now an orthopedic surgeon at the Greenville (S.C.) Health System.

"If you are just evaluating your results based on whether or not the person redislocates, you missed the point. When we evaluate function in these patients with well below 20% bone loss, they have pain and apprehension. Even if their shoulders don’t come out again, these patients are self-limiting," he said.

When arthroscopic Bankart repair is ruled out, Dr. Tokish cautioned, it "doesn’t necessarily mean we should jump right away to a Latarjet," in which the tip of the coracoid process is repositioned to increase glenoid surface area. "Some would argue that a Latarjet is too big a step. An open inferior capsular shift" may be enough, or even superior.

There were 73 operated shoulders in the 72 patients, 68 of whom were men. The average age at surgery was 26.3 years. Glenoid bone loss was calculated by overlaying a circle onto preop images of the fossa. Patients were excluded if they had a previous shoulder operation.

Dr. Tokish had no disclosures. The work was funded internally.

[email protected]

SEATTLE – Arthroscopic Bankart lesion repairs don’t seem to work well in patients who have lost more than 13.5% of their glenoid fossa after dislocating their shoulders; an open inferior capsular shift or Latarjet procedure is likely to be a better bet, according to a review of 72 consecutive soldiers at Tripler Army Medical Center in Honolulu, who had an arthroscopic Bankart repair after shoulder dislocation.

Seven of the 29 patients (24%) who went into the operation with greater levels of bone loss redislocated over an average of about 4 years of follow-up, versus 2 of 37 (5%) who had less than 13.5% of their glenoid fossa missing. When patients who redislocated were excluded, the mean Western Ontario Shoulder Instability (WOSI) score was 43% of normal in the 13.5% or more bone loss group, but about 80% of normal in those who had lost less bone.

In short, bone loss of 13.5% led to "unacceptable clinical outcomes. Patients with bone loss beyond this threshold should be counseled accordingly with consideration for alternative surgical procedures," the investigators concluded.

Surgeons "have to pay a lot more attention to how much bone loss is there. We have traditionally defined the level of bone loss" that triggers an open procedure at 20%. "In today’s world, everybody agrees that 20% is too high, but the" question has been by how much. At 13.5% – judged by preoperative MRI or CT – "two things become clear. They redislocate at too high a level, and they" report too much instability on the WOSI," said lead investigator Dr. John Tokish, now an orthopedic surgeon at the Greenville (S.C.) Health System.

"If you are just evaluating your results based on whether or not the person redislocates, you missed the point. When we evaluate function in these patients with well below 20% bone loss, they have pain and apprehension. Even if their shoulders don’t come out again, these patients are self-limiting," he said.

When arthroscopic Bankart repair is ruled out, Dr. Tokish cautioned, it "doesn’t necessarily mean we should jump right away to a Latarjet," in which the tip of the coracoid process is repositioned to increase glenoid surface area. "Some would argue that a Latarjet is too big a step. An open inferior capsular shift" may be enough, or even superior.

There were 73 operated shoulders in the 72 patients, 68 of whom were men. The average age at surgery was 26.3 years. Glenoid bone loss was calculated by overlaying a circle onto preop images of the fossa. Patients were excluded if they had a previous shoulder operation.

Dr. Tokish had no disclosures. The work was funded internally.

[email protected]

SEATTLE – In about 80% of patients, patellofemoral knee pain is due to muscular dysfunction and often responds to strengthening and other conservative measures, according to Dr. Christian Lattermann of the department of orthopedic surgery at the University of Kentucky, Lexington.

Surgery should be the last option, and "only if you have identified a structural or functional pathology that you can correct." When surgery is indicated, lateral releases should be avoided; lateral retinacular lengthening is the better option because it preserves the anatomical bridle that keeps the knee cap tracking properly. "Surgically, you can lengthen it by about 2 cm, and that’s usually enough," Dr. Lattermann said at the annual meeting of the American Orthopaedic Society for Sports Medicine.

Patellofemoral pain is common but also frustrating to treat. Finding the cause is difficult; whether it’s subluxation, instability, plica, tendinitis, or simply a noisy knee, "all of it will be described to you as pain. You need to figure it out," he said.

Injections might help. "If you inject them, and they have absolutely no pain," it suggests extraarticular issues. In those cases, "rehab is probably your first bet." Meanwhile, effusions hint at intraarticular pathology, he said.

"McConnell taping is an excellent tool, and will help make the surgical decision. If it’s truly effective," soft tissue realignment might be enough, he said.

"If you have a patient who tells you they have pain all the time everywhere, then think about deconditioning." After perhaps years of compensating for chronic knee problems, the musculature is weak – perhaps in both knees – and gait alterations are also likely. Patients "are basically slamming into their knee cap with every step. You have to start the process of getting them out of that," and it doesn’t involve surgery, at least at first, he said.

"Many of these patients are difficult to manage because as soon as you want to look at their knee, they start becoming apprehensive. It’s not because they are crazy, but because they’ve had experiences that were hard to deal with. You can often help them by talking and identifying those for them, and putting them into perspective," he said.

If they only have pain, "we essentially start with physical therapy," including strengthening and stretching the core, hip, and leg muscles. Even in patients with apprehension or instability, "I’d be very careful to try to identify muscular dysfunction. You always need to treat that," Dr. Lattermann said.

Runners and other athletes might get into problems by overdoing it, which can lead to chronic muscle fatigue and patella overload. For some, the root of the problem might be an odd gait or an odd way or running. "You need to basically teach these people how to move properly," he said.

In addition to MRI and CT to assess anatomy and biomechanics, bone scans might demonstrate a "hot spot that will help guide you." Also, when it’s an issue, weight is a "discussion that happens almost every time with every patient," he said.

Dr. Lattermann is a consultant for Ceterix, Icartilage, and Sanofi/Genzyme.

[email protected]

SEATTLE – In about 80% of patients, patellofemoral knee pain is due to muscular dysfunction and often responds to strengthening and other conservative measures, according to Dr. Christian Lattermann of the department of orthopedic surgery at the University of Kentucky, Lexington.

Surgery should be the last option, and "only if you have identified a structural or functional pathology that you can correct." When surgery is indicated, lateral releases should be avoided; lateral retinacular lengthening is the better option because it preserves the anatomical bridle that keeps the knee cap tracking properly. "Surgically, you can lengthen it by about 2 cm, and that’s usually enough," Dr. Lattermann said at the annual meeting of the American Orthopaedic Society for Sports Medicine.

Patellofemoral pain is common but also frustrating to treat. Finding the cause is difficult; whether it’s subluxation, instability, plica, tendinitis, or simply a noisy knee, "all of it will be described to you as pain. You need to figure it out," he said.

Injections might help. "If you inject them, and they have absolutely no pain," it suggests extraarticular issues. In those cases, "rehab is probably your first bet." Meanwhile, effusions hint at intraarticular pathology, he said.

"McConnell taping is an excellent tool, and will help make the surgical decision. If it’s truly effective," soft tissue realignment might be enough, he said.

"If you have a patient who tells you they have pain all the time everywhere, then think about deconditioning." After perhaps years of compensating for chronic knee problems, the musculature is weak – perhaps in both knees – and gait alterations are also likely. Patients "are basically slamming into their knee cap with every step. You have to start the process of getting them out of that," and it doesn’t involve surgery, at least at first, he said.

"Many of these patients are difficult to manage because as soon as you want to look at their knee, they start becoming apprehensive. It’s not because they are crazy, but because they’ve had experiences that were hard to deal with. You can often help them by talking and identifying those for them, and putting them into perspective," he said.

If they only have pain, "we essentially start with physical therapy," including strengthening and stretching the core, hip, and leg muscles. Even in patients with apprehension or instability, "I’d be very careful to try to identify muscular dysfunction. You always need to treat that," Dr. Lattermann said.

Runners and other athletes might get into problems by overdoing it, which can lead to chronic muscle fatigue and patella overload. For some, the root of the problem might be an odd gait or an odd way or running. "You need to basically teach these people how to move properly," he said.

In addition to MRI and CT to assess anatomy and biomechanics, bone scans might demonstrate a "hot spot that will help guide you." Also, when it’s an issue, weight is a "discussion that happens almost every time with every patient," he said.

Dr. Lattermann is a consultant for Ceterix, Icartilage, and Sanofi/Genzyme.

[email protected]

SEATTLE – In about 80% of patients, patellofemoral knee pain is due to muscular dysfunction and often responds to strengthening and other conservative measures, according to Dr. Christian Lattermann of the department of orthopedic surgery at the University of Kentucky, Lexington.

Surgery should be the last option, and "only if you have identified a structural or functional pathology that you can correct." When surgery is indicated, lateral releases should be avoided; lateral retinacular lengthening is the better option because it preserves the anatomical bridle that keeps the knee cap tracking properly. "Surgically, you can lengthen it by about 2 cm, and that’s usually enough," Dr. Lattermann said at the annual meeting of the American Orthopaedic Society for Sports Medicine.

Patellofemoral pain is common but also frustrating to treat. Finding the cause is difficult; whether it’s subluxation, instability, plica, tendinitis, or simply a noisy knee, "all of it will be described to you as pain. You need to figure it out," he said.

Injections might help. "If you inject them, and they have absolutely no pain," it suggests extraarticular issues. In those cases, "rehab is probably your first bet." Meanwhile, effusions hint at intraarticular pathology, he said.

"McConnell taping is an excellent tool, and will help make the surgical decision. If it’s truly effective," soft tissue realignment might be enough, he said.

"If you have a patient who tells you they have pain all the time everywhere, then think about deconditioning." After perhaps years of compensating for chronic knee problems, the musculature is weak – perhaps in both knees – and gait alterations are also likely. Patients "are basically slamming into their knee cap with every step. You have to start the process of getting them out of that," and it doesn’t involve surgery, at least at first, he said.

"Many of these patients are difficult to manage because as soon as you want to look at their knee, they start becoming apprehensive. It’s not because they are crazy, but because they’ve had experiences that were hard to deal with. You can often help them by talking and identifying those for them, and putting them into perspective," he said.

If they only have pain, "we essentially start with physical therapy," including strengthening and stretching the core, hip, and leg muscles. Even in patients with apprehension or instability, "I’d be very careful to try to identify muscular dysfunction. You always need to treat that," Dr. Lattermann said.

Runners and other athletes might get into problems by overdoing it, which can lead to chronic muscle fatigue and patella overload. For some, the root of the problem might be an odd gait or an odd way or running. "You need to basically teach these people how to move properly," he said.

In addition to MRI and CT to assess anatomy and biomechanics, bone scans might demonstrate a "hot spot that will help guide you." Also, when it’s an issue, weight is a "discussion that happens almost every time with every patient," he said.

Dr. Lattermann is a consultant for Ceterix, Icartilage, and Sanofi/Genzyme.

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