Source Of Knee Pain Research Articles

Proximal Tibial Osteosarcoma in Pediatric Patient: A Case Report

Background: The most frequent primary malignant bone tumor in children is osteosarcoma. Patients with osteosarcoma are currently treated with a combination of neoadjuvant and adjuvant chemotherapy as well as surgery, either limb-sparing surgery or limb-ablation surgery. How to manage the remaining bone growth during the limb-sparing procedure in youngsters is one of the challenges. Unfortunately, amputation is still many perform for OS patients. The purpose of this study was to inform and educate doctors about the value of early OS diagnosis and treatment in pediatric patients. Case Presentation: We presented case from a male 16 years old Balinese complaint of pain on her left knee 12 months ago. The pain was continuous and got worse at night. The patient went to a traditional masseuse and was given topical herbal ointment. Three months later, a lump appeared on her knee at the size of a small ball and getting bigger. We did a review slide of the previous biopsy sample by the pathology of anatomy in our hospital. The result came out as osteosarcoma with osteoblastic cells. We performed to amputated the limb-affected tumor following wound care routinely controlled. Results: Intraoperatively, we performed wide excision, without patellar tendon, medial collateral ligament, and cruciate ligament preserve. We amputated the limb-affected tumor. The patient routinely controlled to our outpatient clinic every week. Unfortunately, the patient was died after 3 weeks of admission. Conclusion: To reduce the risk of misdiagnosis or delayed diagnosis of osteosarcoma, every source of knee pain with a mass in pediatric age groups should be thoroughly explored with a high index of suspicion for malignant lesions. Therefore, amputation is a cutting-edge osteosarcoma treatment that can be avoided if the patient can be identified early and treated quickly in pediatric oncology malignant instances. Keywords: osteosarcoma, long bone, diagnosis, tibia, pediatric Correspondence: Komang Septian Sandiwidayat. Oncology Division, Department of Orthopaedic & Traumatology, Sanglah General Hospital, Faculty of Medicine, Udayana University, Bali, Indonesia. Email: drseptianortho@gmail.com. Mobile: 62-821-4725-2042. Indonesian Journal of Medicine (2022), 07(03): 298-305 https://doi.org/10.26911/theijmed.2022.07.03.06

Quantitative volume and dynamic contrast-enhanced MRI derived perfusion of the infrapatellar fat pad in patellofemoral pain.

Patellofemoral pain (PFP) is a common knee condition and possible precursor of knee osteoarthritis (OA). Inflammation, leading to an increased perfusion, or increased volume of the infrapatellar fat pad (IPFP) may induce knee pain. The aim of the study was to compare quantitative dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI) parameters, as imaging biomarkers of inflammation, and volume of the IPFP between patients with PFP and controls and between patients with and without IPFP edema or joint effusion. Patients with PFP and healthy controls were included and underwent non-fat suppressed 3D fast-spoiled gradient-echo (FSPGR) and DCE-MRI. Image registration was applied to correct for motion. The IPFP was delineated on FSPGR using Horos software. Volume was calculated and quantitative perfusion parameters were extracted by fitting extended Tofts' pharmacokinetic model. Differences in volume and DCE-MRI parameters between patients and controls were tested by linear regression analyses. IPFP edema and effusion were analyzed identically. Forty-three controls and 35 PFP patients were included. Mean IPFP volume was 26.04 (4.18) mL in control subjects and 27.52 (5.37) mL in patients. Median Ktrans was 0.017 (0.016) min-1 in control subjects and 0.016 (0.020) min-1 in patients. None of the differences in volume and perfusion parameters were statistically significant. Knees with effusion showed a higher perfusion of the IPFP compared to knees without effusion in patients only. The IPFP has been implicated as source of knee pain, but higher DCE-MR blood perfusion, an imaging biomarker of inflammation, and larger volume are not associated with PFP. Patient's knees with effusion showed a higher perfusion, pointing towards inflammation.

A Rare Cause of Knee Pain in a Healthy Male Ultra-marathon Runner

HISTORY: A 58-year-old healthy male ultra-marathon runner presented with a 3-month history of atraumatic, gradually worsening right-sided anterior knee pain, aggravated by activity and associated with prominent morning stiffness and pain. Night pain was absent. Oral and parenteral NSAIDs provided no relief, nor did massaging. No history of smoking, alcohol or prior corticosteroid use was reported. PHYSICAL EXAMINATION: The R-knee was slightly swollen with no obvious deformities. No clinical intra-articular effusion was noted. Palpation revealed tenderness over the quadriceps tendon insertion and superomedial knee. In addition, the patient showed significant weakness of the right gluteus medius and quadriceps muscles. Tests for mechanical disruption and intra-articular injury were negative. Further examination of the hip and ankle joints as well as the general systemic examination were unremarkable. DIFFERENTIAL DIAGNOSIS: Quadriceps tendinopathy Patellar tendinopathy Patello-femoral pain syndrome Chondromalacia patellae Patellofemoral osteoarthritis Iliotibial band syndrome Other sources of knee pain (such as arthritis and gout) TEST AND RESULTS: Ultrasound: No soft tissue abnormalities. Suggestive area of a bony infarct in the distal femur. Plain radiographs (R-knee): Hypo-lucent area-distal femur (proximal to the condyles) MRI Knees: Bilateral areas of increased signal in the distal femoral shaft, suggestive of bilateral bony infarcts, were identified. Blood tests: within normal limits. FINAL WORKING DIAGNOSIS: Spontaneous osteonecrosis of the knee (SPONK)/ Ahlback`s Disease. TREATMENT AND OUTCOMES: 1. Initial management: Conservative - physical therapy and eccentric strengthening exercises. 2. Final outcome: Returned to physical activity, but it is still debated whether this athlete should return to full participation in ultra-marathon running.

Impact of Cane Use on Bone Marrow Lesion Volume in People With Medial Knee Osteoarthritis (CUBA Trial).

No effective cure exists for knee osteoarthritis (OA). Low-burden self-management strategies that can slow disease progression are needed. Bone marrow lesions (BMLs) are a source of knee pain and accelerate cartilage loss. Importantly, they may be responsive to biomechanical off-loading treatments. The study objective is to investigate whether, in people with medial tibiofemoral OA, daily cane use for 12 weeks reduces the volume of medial tibiofemoral BMLs and improves pain, physical function, and health-related quality of life. This study will be an assessor-masked, 2-arm, parallel-group, multisite randomized controlled trial. The community will serve as the setting for this study. The study participants will be people who are 50 years old or older and have medial tibiofemoral OA and at least 1 medial tibiofemoral BML. The participants will be allocated to either the cane group (using a cane daily whenever walking for 12 weeks) or the control group (not using any gait aid for 12weeks). Outcomes will be measured at baseline and 13 weeks. The primary outcome will be total medial tibiofemoral BML volume measured from magnetic resonance imaging. Secondary outcomes will include BML volume of the medial tibia and/or femur, knee pain overall and on walking, physical function, participant-perceived global change, and health-related quality of life. Additional measures will include physical activity, cointerventions, adverse events, participation, participant demographics, cane training process measures and feasibility, barriers to and facilitators of cane use, and loss to follow-up. People who are morbidly obese will not be included because of difficulties with magnetic resonance imaging. The findings of this study will help to determine whether cane use can alter disease progression in people with medial tibiofemoral OA and/or influence clinical symptoms. This study may directly influence clinical guidelines for the management of knee OA.

The relation of patellofemoral joint alignment and trochlear morphology to superolateral Hoffa’s fat pad edema: the most study

Purpose: The infrapatellar or Hoffa’s fat pad (HFP) is an intracapsular but extrasynovial fat tissue in the knee joint located inferior to the patella and posterior to the patellar tendon. It is highly innervated and may be a source of knee pain. Impingement of HFP between the lateral femoral condyle and the patellar tendon is hypothesized to cause inflammation/edema in the superolateral region of HFP. This impingement may be a result of patellofemoral joint (PFJ) alignment and abnormal trochlear morphology. Previous studies in young individuals have demonstrated conflicting results as to which measures of PFJ alignment and trochlear morphology are related to superolateral HFP edema. More generalized inflammation/edema in HFP is present in older individuals with knee osteoarthritis (OA). The aim of the current study was to assess whether measures of PFJ alignment and trochlear morphology are related to superolateral HFP edema and if superolateral HFP edema is related to knee pain in older individuals with or at risk for knee OA. Methods: The Multicenter Osteoarthritis (MOST) study is a NIH-funded longitudinal cohort study of older individuals with or at risk for knee OA. For the current cross-sectional study we used data from the 60-month study visit where all eligible subjects had their knee MRI assessed for other structural features of knee OA. Signal changes in three areas (superolateral, infrapatellar and intercondylar) of HFP were assessed on sagittal proton density-weighted fat-suppressed MRI images from 0 to 3 (0 = normal, 1 = mild, 2 = moderate, 3 = severe) by two musculoskeletal radiologists and dichotomized into presence (>1) and absence (=0). PFJ alignment (bisect offset and patellar tilt angle) and trochlear morphology (lateral trochlear inclination, sulcus angle and trochlear angle) were assessed on axial MRI images and divided into quintiles. Subjects were also queried about the presence of frequent knee pain (FKP) defined as pain on most days of the last month. We determined the relation of measures of PFJ alignment and trochlear morphology to the presence of superolateral HFP edema using logistic regression, adjusting for age, sex and body mass index. We additionally determined the relation of superolateral HFD edema to FKP using logistic regression, adjusting for age, sex, body mass index, depressive symptoms, catastrophizing and presence of signal changes in the infrapatellar/intercondylar HFP. Results: To date, 433 knees have been assessed for PFJ alignment, trochlear morphology and superolateral HFP edema. Superolateral HFP edema was present in 63 (17.7%) of knees. Compared with knees in the lowest quartile of bisect offset, those in the highest had 6.4 (2.6, 15.7) times the odds of having superolateral HFP edema. Compared with knees in the lowest quartile of trochlear angle, those in the highest had 2.7 (1.2, 6.3) times the odds of having superolateral HFP edema. There was no relation of other PFJ alignment/trochlear morphology measures to superolateral HFP edema. There was also no relation of superolateral HFP edema to FKP. Conclusions: Knees with the greatest lateral displacement of the patella had the greatest odds of superolateral HFP edema. Treatments that attempt to normalize PFJ alignment may help to reduce the prevalence of superolateral HFP edema.Tabled 1Table. Relation of PFJ alignment and trochlear morphology to superolateral HFP edema% Patella lateral to midline (Bisect Offset)Quartile 1Quartile 2Quartile 3Quartile 4Range33.91–52.5952.6–58.1658.17–64.664.61–92.79# of knees108109109108Superolateral HFP edema%≥16.511.113.828.7Adjusted OR* (95% CI)1.0 (reference)1.9 (0.70, 5.0)2.5 (0.95, 6.4)6.4 (2.6, 15.7)Trochlear Morpholgy (Trochlear Angle)Quartile 1Quartile 2Quartile 3Quartile 4 (flat trochlea)Range−5.32–0.940.95–3.553.56–5.835.84–26.57# of knees108109109108Superolateral HFP edema%≥18.313.814.724.3Adjusted OR* (95% CI)1.0 (reference)1.6 (0.65, 3.8)1.6 (0.67, 3.9)2.7 (1.2, 6.3)∗Adjusted for age, sex and BMI Open table in a new tab ∗Adjusted for age, sex and BMI

Elevated corticospinal excitability in patellar tendinopathy compared with other anterior knee pain or no pain.

Anterior knee pain (AKP) is a frequent clinical presentation in jumping athletes and may be aggravated by sustained sitting, stair use, and loading of the quadriceps. Corticospinal activation of the quadriceps in athletes with AKP has not yet been investigated, but is important in guiding efficacious treatment. This cross-sectional study assessed corticospinal excitability (CSE) of the quadriceps in jumping athletes using transcranial magnetic stimulation (TMS). Groups consisted of Control (no knee pain); patellar tendinopathy (PT) [localized inferior pole pain on single-leg decline squat (SLDS)]; and other AKP (nonlocalized pain around the patella). SLDS (numerical score of pain 0-10), Victorian Institute of Sport Assessment Patellar tendon (VISA-P), maximal voluntary isometric contraction (MVIC), active motor threshold (AMT), CSE, and Mmax were tested. Twenty nine athletes participated; control n = 8, PT n = 11, AKP n = 10. There were no group differences in age (P = 0.23), body mass index (P = 0.16), MVIC (P = 0.38) or weekly activity (P = 0.22). PT had elevated CSE compared with controls and other AKP (P < 0.001), but no differences were detected between AKP and controls (P = 0.47). CSE appears to be greater in PT than controls and other AKP. An improved understanding of the corticospinal responses in different sources of knee pain may direct better treatment approaches.

Low prevalence of isolated medial meniscal tears in young females with stable knees.

The information regarding isolated tears of the meniscus in stable knees (ie, without cruciate ligament tears), specifically in a younger population, is scarce. Although surgical treatment is preferred for young patients with meniscal tears, the diagnosis at this age may be misled by other sources of knee pain. The purpose of this study was to report on the prevalence and sex variance of isolated meniscal tears in a younger population based on arthroscopic findings. From a database of 2425 arthroscopic knee surgeries performed over a period of 6 years, 591 patients (480 males and 111 females) younger than 40 years were included. Patients were divided into 5 age groups and subdivided according to their surgical findings. Measures included the prevalence of meniscal tears according to sex and age groups and also odds ratio calculations for the presence of meniscal tears. Of 591 arthroscopic surgeries in young patients with stable knees, only 6 females (vs 87 males) younger than 30 years had isolated medial meniscus tears. The number of stable knees without meniscal tear at arthroscopy in all age groups was relatively high. The odds ratio for having a medial meniscal tear was significantly higher in males. The results suggest a protective mechanism for isolated medial meniscal tears in younger females as opposed to other injuries of the knee. Isolated medial meniscus tears in stable knees are uncommon in females younger than 30 years; thus, young females with suspected tears should be reevaluated and treated conservatively before considering surgical solutions.

Detection of pain-related molecules in the subchondral bone of osteoarthritic knees

Knee pain is predominant among osteoarthritis (OA) patients, but the mechanism is poorly understood. We investigated subchondral bone as a source of OA knee pain using immunohistochemistry. Fifteen medial-type OA knees with minimum involvement of the lateral compartment determined by X-ray as well as magnetic resonance imaging that received total knee arthroplasty (TKA) were involved. Each pair of the medial femoral condyle (MFC) and lateral femoral condyle (LFC) was compared obtained at the time of TKA. Osteocartilaginous MFC and LFC specimens were histologically examined and stained with antibodies against cyclooxygenase 1 (Cox-1), cyclooxygenase 2 (Cox-2), substance P, tumor necrosis factor-alpha (TNF-alpha), and neuron-specific class III beta-tubulin (TUJ1), a pan-neuronal marker. Formation of cystic lesions was more frequently seen in the MFC. The lesions were composed of vascular endothelial cells, osteoclasts, and mononuclear cells and were present in similar proportions between the MFC and the LFC. Four out of 15 MFC specimens were positive for Cox-1, 15 for Cox-2, and 13 for TNF-alpha. No LFC specimens were positive for any antibodies. Substance P-positive and TUJ1-positive fibers were found in the subchondral area of the MFC, but not in the LFC. Pathological changes in the subchondral bone can be a source of knee pain, which was detectable by the positive immunoreactivity of substance P, Cox-2, TNF-alpha, and TUJ1, in the subchondral bone of affected compartments. The relatively immediate reduction in pain obtained by TKA might account for the involvement of the subchondral bone in knee pain because most of the affected subchondral plate is excised in TKA (debridement effect of TKA).

Poster 98 avascular necrosis as a source of knee pain in a patient with multiple sclerosis: A case report. Yvette Ju, DO (Univ of Maryland/James Lawrence Kernan Hosp, Baltimore, MD); Peter H. Gorman, MD, e-mail: yvettelorraine@yahoo.com

Poster 98 avascular necrosis as a source of knee pain in a patient with multiple sclerosis: A case report. Yvette Ju, DO (Univ of Maryland/James Lawrence Kernan Hosp, Baltimore, MD); Peter H. Gorman, MD, e-mail: yvettelorraine@yahoo.com

Mucoid degeneration of the anterior cruciate ligament

A case of intraligamentous mucoid degeneration of the anteromedial band of the anterior cruciate ligament (ACL) is presented. The patient had knee pain without clinical or diagnostic evidence of instability. Isolated debridement of the anteromedial band resulted in immediate pain relief with rapid return to athletic activities without instability. We present this case to demonstrate the presence of intraligamentous mucoid degeneration in the ACL as a source of knee pain without instability. Partial ACL debridement did not preclude adequate knee stability.Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 17, No 9 (November-December), 2001: E37