REVIEW ARTICLE

Anterior Knee Pain in the Young Athlete

Diagnosis and Treatment
Pradeep Kodali, MD,* Andrew Islam, MD,w and Jack Andrish, MDz

Despite extensive research, the exact etiology and

Abstract: The underlying etiology of anterior knee pain has been pathophysiology of AKP is often still unclear. This review
extensively studied. Despite many possible causes, often times the will discuss some of the common etiologies of AKP in the
diagnosis is elusive. The most common causes in the young athlete young athlete with an overview of diagnosis and manage-
are osteosynchondroses, patellar peritendinitis and tendinosis,
ment of the various disorders.
synovial impingement, malalignment, and patellar instability. Less
common causes are osteochondritis dissecans and tumors. It is
always important to rule out underlying hip pathology and
infections. When a diagnosis cannot be established, the patient is
SYNOVIAL IMPINGEMENT SYNDROMES
usually labeled as having idiopathic anterior knee pain. A careful Synovial impingement is a common cause of AKP.
history and physical examination can point to the correct diagnosis More specifically, synovial impingement may be associated
in the majority of cases. For most of these conditions, treatment is with a pathologic plica, or the result of fat pad impinge-
typically nonoperative with surgery reserved for refractory pain for ment. The 3 most commonly found plicae in the knee are
an established diagnosis. the superior, medial, and inferior plica.9 An inferolateral
plica10 and an arch-type suprapatellar plica11 have also
Key Words: anterior knee pain, patellofemoral syndrome, idio-
been described.
pathic knee pain
The diagnosis of a pathologic plica is a difficult one. It is
(Sports Med Arthrosc Rev 2011;19:27–33) important to note that synovial plicae are a normal finding,
and that identification of a plica on arthroscopic examina-
tion does not necessitate resection unless the physical
examination is abnormal. Controversy exists in defining
A nterior knee pain (AKP) is a broad clinical entity that
includes all causes of pain in the anterior aspect of the
knee. The differential diagnosis in the young athlete is
what constitutes a pathologic plica. Typically, focal pain that
impairs function in which the only objective finding is a
extensive (Table 1), and every effort should be made to thickened hypertrophic plica is considered a pathologic
narrow this list by history and physical examination. plica.12 This is an elusive diagnosis but careful history and
Although AKP technically describes a location of knee physical examination can identify those that are pathologic.
pain, it seems to be used frequently as a diagnosis and has Classically, the medial plica has been described to be
been used synonymously with patellofemoral syndrome or pathologic.12,13 At times, patients sustain a direct blow to
even chondromalacia patella.1 The latter should be used the knee and have a “window” period free of symptoms.
less frequently in the skeletally immature athlete as They subsequently develop pain that is most symptomatic
chondromalacia is an infrequent occurrence in this age with repetitive activities like running. The pain is char-
group.2,3 Chondromalacia should be reserved as a term to acteristically aggravated by knee flexion and relieved with
describe a degenerative condition of articular cartilage.4 extension. There may be an associated thick, palpable
The anatomic sources of intra-articular knee pain have cord.12,13 In addition, patients may have a positive active
been described by Dye et al,5 who underwent arthroscopic
evaluation of his own knees without general or regional
anesthesia and noted that the synovium and fat pad were TABLE 1. Differential Diagnosis of Knee Pain in the Adolescent
exquisitely sensitive in comparison to the menisci and Athlete
articular cartilage. This is consistent with other studies that
showed high amounts of substance-P nerve fibers in the Synovial impingement syndromes Infection
Pathologic plica
synovium and fat pad of knees in patients with AKP, even Hoffa syndrome
higher than in those with osteoarthritis.6 Other studies Osteochondroses/tendinitis Idiopathic anterior knee pain
describe a vascular phenomenon in which tight retinacular Osgood-Schlatter
structures about the knee cause subtle ischemia within the Sinding-Larsen-Johannsen
retinaculum leading to neural proliferation and pain.7,8 Patellar tendinitis
Patellar instability Psychiatric disorder (ie,
stress, depression, etc)
Patellar malalignment Meniscus tears
From the *Department of Orthopaedic Surgery, University of Texas at
Houston Medical School, Houston, TX; wTristate Orthopaedic
Osteochondritis dissecans Fracture
Treatment Center, Cincinnati; and zSports Health Center, Depart- Hip pathology (ie, SCFE, stress Ligamentous injury
ment of Orthopaedic Surgery, Cleveland Clinic Foundation, fracture, etc)
Cleveland, OH. Tumors (ie, osteosarcoma, Iliotibial band friction
Reprints: Jack Andrish, MD, Sports Health Center, Department of osteoid osteoma, etc) syndrome
Orthopaedic Surgery, Cleveland Clinic Foundation, Cleveland, OH
(e-mail: andrisj@ccf.org). SCFE indicates slipped capital femoral epiphysis.
Copyright r 2011 by Lippincott Williams & Wilkins

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Kodali et al Sports Med Arthrosc Rev  Volume 19, Number 1, March 2011

extension test in which pain is reproduced with quick active high signal consistent with irritation of the fat pad.18 Speci-
extension of the leg from a flexed knee position.14 A flexion fically, edema in the fat pad, fibrosis of fat pad, infrapa-
test can also be conducted by allowing the leg to flex with tellar bursitis, and calcifications on MRI has been shown to
gravity from an extended position, and the patient is asked be associated with impingement19 (Fig. 1). The described
to stop the flexion moment. This causes eccentric contrac- treatment options for anterior fat pad syndrome include
tion of the quadriceps that can cause pain if the plica is rest, avoidance of aggravating activities, and even mod-
pathologic.14 Radiographs are typically normal, and an alities such as transcutaneous electrical nerve stimulation,
magnetic resonance imaging (MRI) scan may identify a ultrasound, and cold therapy. In addition, taping has been
prominent plica though often times it will be inconclusive as used in order to try to decrease compression of the fat
to whether it is pathologic. Occasionally, this thickened pad.20 Surgery, consisting of debridement of the exuberant
cord can cause wear as it rubs or snaps over the medial fat pad has been used in refractory cases with good results
femoral condyle.3 Arthroscopically, more severe patholo- in small series.21,22
gical changes of the plicae have been associated with more
severe chondral changes.15 With the advent of stronger
magnets for MRI scans, it is theoretically possible to OSTEOCHONDROSES/PATELLAR TENDINITIS
identify wear in the medial femoral condyle consistent with AND TENDINOSIS
the area where a thickened medial plica may exist. Osgood-Schlatter (OS) disease and Sinding-Larsen-
Nonoperative management is the initial treatment, and Johannsen (SLJ) disease are extremely common in the
symptom resolution typically occurs with patients who have young athlete with the former being more common. They
had a shorter duration of symptoms. Nonoperative treat- were originally described in the early 1900s and represent
ment has been described in the literature to include a period pain at the tibial tuberosity (OS) or inferior pole of the
of activity limitation, anti-inflammatory medications, corti- patella (SLJ).23,24 OS is thought to be due to a traction
costeroid injections into the plica and physiotherapy to effect of the extensor mechanism on the tibial tuberosity
work on quadriceps, hamstring, and gastrocnemius stret- causing separation of the apophysis.25 Diagnosis is often
ching.9,13 Results of nonoperative management have had made by physical examination with tenderness, swelling, or
reported success rates as high as 60%.16 When conservative even a bony prominence in the area of the tibial tuberosity.
treatment fails, arthroscopy can be performed and should Plain radiographs are obtained and typically show irregu-
include a complete arthroscopic evaluation to rule out other larity with separation of the apophysis in the early stages
etiologies of knee pain, in addition to complete plica and fragmentation in the later stages.26 These radiographic
excision. findings, although commonly found, are not diagnostic of
The anterior fat pad of the knee is a collection of fatty OS disease as they may also occur without symptoms.
tissue posterior to the patellar tendon just distal to the Further imaging studies are usually not required unless
inferior edge of the patella. Hoffa in 190417 described irrita- patients present with atypical symptoms or to rule out other
tion of this structure leading to AKP. It has also been shown diagnoses. Treatment can consist of a long course of
that manipulation of the anterior fat pad under conscious conservative treatment involving cessation of aggravating
arthroscopy resulted in the most severe pain with high spatial activities, nonsteroidal anti-inflammatory drugs (NSAIDs),
localization.5 As a result of its high-density innervation, ice, and physical therapy.3,26,27 Physical therapy is initially
anterior fat pad syndrome can result in significant pain. focused on stretching of the quadriceps, hamstrings, and
Clinically, patients with Hoffa syndrome may present heel cords with progressive strengthening of the ham-
with swelling in the region of the fat pad and tenderness strings.26 Quadriceps strengthening is avoided in the initial
to palpation in this area. The Hoffa maneuver is performed stages of rehabilitation because this can increase stresses
by applying compression to the fat pad on each side of across the tibial tuberosity apophysis and thus aggravating
the patellar tendon while bringing the knee into extension. symptoms.26 In addition, a counter-force brace may
A test is considered to be positive if this maneuver produces provide some symptomatic relief. Although sport activity
pain or apprehension. The Hoffa syndrome is not evident is typically allowed unless pain is affecting performance
on plain radiography, but MRI can detect subtle areas of and quality of life and we think of OS disease as a benign,

FIGURE 1. Magentic resonance imaging increased signal (arrows) in fat pad on sagittal (A) and axial (B) views characteristic of Hoffa
syndrome.

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Sports Med Arthrosc Rev  Volume 19, Number 1, March 2011 Anterior Knee Pain in the Young Athlete

self-limiting condition, it should be recognized that an found lower success rates when surgical treatment involved
increased susceptibility to epiphyseal fracture has been bony debridement of the inferior pole, closure of the
described.28 Surgical treatment is reserved for patients who paratenon, and immobilization after surgery. Platelet-rich
fail conservative treatment and is typically carried out after plasma has been used for various tendinopathies but long-
skeletal maturity for the removal of a tender and painful term outcomes for patellar tendinosis is nonexistent.
intratendon ossicle.26
Patients with the SLJ disease present with AKP and a
physical examination that reveals tenderness to palpation PATELLAR INSTABILITY
near the inferior pole of the patella. Plain radiographs may Although AKP from an acute patellar dislocation is
be normal in the early stages with calcifications or an ossicle dramatic and easily diagnosed, AKP from recurrent
adjacent to the inferior pole in the later stages23 (Fig. 2). patellar subluxation can be insidious. The incidence of
Similar to OS disease, treatment consists of conservative both is not exactly known. However, one study,34 which
treatment with activity modification, NSAIDs, ice, and examined a managed care database consisting of 400,000
physical therapy. It is invariably self-limiting with surgery members, noted a first time dislocation rate of 5.0 per
being rarely indicated.23,29 100,000 yearly. The majority of these individuals were
Patellar tendinitis is another common source of AKP younger and female. Patellar instability can result from
in the young athlete. It causes pain at the inferior pole of an injury owing to a direct blow to the patella, or more
the patella that is exacerbated by activity. It is often related commonly by an indirect mechanism during athletic
to a period of increased activity that can be debilitating participation. In most cases, the patella reduces sponta-
during the athlete’s sport. Initially, symptoms may start neously as the knee is extended.
with activities only but as the disease progress, they can In evaluating these patients, the treatment is often
occur with activities of daily living.30 Physical examination dependant upon differentiating between patients with normal
demonstrates tenderness to palpation at the inferior pole and abnormal anatomy. Stability of the patella is conferred
overlying the proximal aspect of the patellar tendon. by both osseous and soft tissue structures. In recent times, the
A decline squat test can be performed by having the medial retinacular structures of the knee have been recog-
patient squat on a decline surface. This places increased nized for their importance. The medial patellofemoral liga-
stress on the patellar tendon and can illicit pain.31 Similar ment has been examined in detail and has been determined to
to OS and SLJ syndromes, treatment consists of rest, be the primary soft tissue restraint to lateral displacement of
NSAIDs, ice, physical therapy to work on stretching, and the patella.35–37 Numerous studies have demonstrated that in
strengthening the muscles around the knee as this has been acute lateral patellar dislocation, damage to the medial
seen as an overload problem.30 patellofemoral ligament ranges from partial disruption to the
If patients are refractory to these measures, an MRI more common complete disruption.38–40
study can be obtained to look for a thickened tendon or The examiner must pay attention to any malalignment
increased signal within the proximal end of the patellar including genu valgum, external torsion of the tibia, and
tendon consistent with tendinosis. Patellar tendinosis occurs femoral anteversion, which may be associated with subluxa-
owing to rapid acceleration and deceleration forces across tion or patellofemoral malalignment. Palpation of the
the tendon origin leading to microruptures.32 Over time, this structures of the patellofemoral articulation should be
leads to chronic degenerative changes in the tendon. undertaken. Patellar tilt can be assessed clinically by placing
Ultrasound can also be used as a diagnostic modality to the examiner’s thumb and index finger on the medial and
look for these chronic changes owing to the superficial lateral border of the patella with the knee in extension and
location of the tendon. If imaging studies are consistent with assessing the relationship of the fingers in the sagittal plane.
significant tendinosis, surgery may be performed for patellar If the medial border of the patella is anterior to the lateral
tendon debridement. Kaeding et al33 in a systematic review border, then the patient has lateral tilt. If the medial border is

FIGURE 2. An ossicle (arrow) at the inferior pole noted on both the plain radiograph (A) and MRI (B) with increased signal around the
ossicle noted on MRI. (Courtesy of Paul Saluan, MD, Cleveland Clinic Foundation). MRI indicates magentic resonance imaging.

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Kodali et al Sports Med Arthrosc Rev  Volume 19, Number 1, March 2011

posterior to the lateral border, then the patient has medial formed procedure. However, we should remember that
tilt.41 Lateral patellar tilt can indicate a tight lateral retina- biomechanical and clinical studies have shown that the
culum and increased contact forces in the lateral patella and lateral retinaculum may actually prevent lateral instabil-
trochlea.42 Patellar mobility is another test that can be used ity.52–55 Therefore, this procedure is best confined to the
to assess range of motion of the patella identifying any treatment of AKP associated with a tight lateral retinacu-
medial or lateral tightness.41 The apprehension test, perfor- lum and should be used with caution for patellar instability.
med by placing a laterally directed force on the patella with The surgical treatment for chronic patellar instability
the knee in approximately 30 degrees of flexion with involves the identification of the individual pathoanatomies
subjective feelings of impending dislocation, is the classic that contribute to the instability and organizing the surgical
examination finding of patellar instability. procedures to correct these pathoanatomies.56
Imaging of the patellofemoral instability patient should
include weightbearing anteroposterior (AP), 45 degree
posteroanterior flexion or tunnel view, lateral and axial OSTEOCHONDRITIS DISSECANS OF THE KNEE
views. Plain radiographs can provide information about It is important to consider osteochondritis dissecans
osteochondral fracture, patellar height, morphology of the (OCD) lesions in the differential for AKP in an athlete as
trochlear groove, patellar tilt, and the sulcus angle. The they are often missed. The exactly etiology is unclear and
single most important view may be the lateral projection as it seems to be a polyarticular problem.57 Repetitive micro-
has been shown to be very accurate in assessing patellar trauma, vascular insufficiency, and genetics have all been
malalignment.43 Computed tomography scanning can be proposed as potential explanations.58,59 Prevalence is high-
helpful in planning a realignment procedure once this has est in the 10 to 15 years age group with males being more
been determined necessary based on the patient’s clinical commonly affected with a 15% to 30% incidence of
findings. The distance between the tibial tuberosity and contralateral limb involvement.60 Because of this, it is
trochlear groove can be calculated on axial imaging to recommended that bilateral knee radiographs be obtained
determine the necessity for a distal realignment procedure once the diagnosis of OCD has been established.
once the decision for surgery has been made.44 A distance Patients often present with AKP, effusion, and if a
greater than 20 mm is considered to be sufficiently abnormal loose body is present, variable symptoms of catching,
to consider medialization.44 MRI has also gained acceptance locking, or giving way. Physical examination can demon-
in the imaging of patellofemoral instability, especially in the strate limited range of motion, an effusion, and a positive
case of acute dislocation. It can provide information regard- Wilson’s test, which is carried out by reproducing pain with
ing the integrity of the medial retinacular structures, chon- internal rotation of the tibia while passively extending the
dral damage, and possible cruciate or collateral ligament knee.61 Plain radiographs are extremely valuable, and it is
damage. In the case of an acute dislocation, Quinn et al45 important to get a full knee series consisting of a standard
described a triad of injuries detectable on MRI consisting weightbearing AP and lateral view in addition to a skyline
of focal impaction injuries of the lateral femoral condyle, or Merchant view for trochlear or patellar lesions and a
osteochondral injuries of the medial patellar facet, and injury “notch” view to identify posterior lesions. Classically, the
of the medial patellar retinaculum. Acute dislocation of the majority of the lesions are found in lateral aspect of the
patella is most commonly associated with osteochondral medial femoral condyle, followed by the lateral femoral
injuries with an incidence of 24%.46 Nomura et al47 noted condyle and least commonly the patella.60,62 The presence
that the most common site of chondral injury is the medial of open physes on plain radiographs has a favorable
patellar facet. However, one study showed that at the time of prognosis for eventual healing. However, this may be in
arthroscopy, only 32% of chondral injuries and 29% of loose part owing to errors in diagnosis in which normal variants
bodies were noted on plain radiographs.48 of ossification in the posterior femoral condyles are
The nonoperative treatment of chronic patellofemoral interpreted as OCD lesions.63 An MRI is also valuable in
instability focuses on regaining strength. The role of the hip diagnosing these lesions and may be able to characterize the
abductors (pelvic stabilizers) and quadriceps mechanism in stability of the fragment. The presence of homogenous,
stability of the patellofemoral articulation has been noted. high signal beneath the fragment of greater than 5 mm in
Patellofemoral contact pressures have been shown to be at diameter may represent an unstable lesion.64 Lesions are
their lowest levels from 0 to 30 degrees of flexion thus typically classified by Berndt and Harty’s system based on
leading to the use of short arc extension exercises in the talar dome lesions.65 The natural history, according to a
rehabilitation program. large multicenter trial by Hefti et al,60 showed that patients
Historically, for an acute dislocation, the knee was with pain and swelling indicative of unstable lesions, lesions
immobilized in a cylinder cast to allow for healing of the greater than 2 cm, skeletally mature patients, and lesions in
medial structures. However, studies by Noyes et al49 and atypical locations had a worse prognosis. Peters and
Woo et al50 have shown the negative impact of immobiliza- Mclean66 reported their series on patellofemoral lesions
tion on soft tissue structures and cartilage. Others prefer early and noted pain relief whether treated with or without
motion combined with lateral buttress bracing. The non- surgery. Surgical treatment was indicated in the presence of
operative treatment of this condition remains controversial. unstable lesions or loose bodies.
The role of operative treatment in patellar instability Treatment of these lesions is dependant on multiple
has expanded recently. In the setting of acute patellar factors including the stability of the lesion as assessed by
dislocation, surgery is indicated when there is an associated MRI and intraoperative findings. Fragmentation and the
osteochondral fracture for removal or repair. Surgery may presence and quality of bone in the fragment are important
also be indicated for the repair or reconstruction of the intraoperative factors that determine the reparability of
medial retinacular structures of the knee, although this OCD lesions. Nonsurgical management is primarily re-
remains controversial.51 Lateral release in the setting of served for stable lesions and consists of activity modifica-
recurrent lateral instability has been a commonly per- tion including cessation of running and jumping sports and

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Sports Med Arthrosc Rev  Volume 19, Number 1, March 2011 Anterior Knee Pain in the Young Athlete

pharmacological pain management modalities. In addition,

patients can be placed on crutches and kept nonweight
bearing until symptom resolution.58,67 However, if the OCD
lesion is in the patellofemoral compartment, then the patient
may be weightbearing as tolerated in a knee brace locked in
extension. Surgical management is reserved for unstable
lesions or those that have failed conservative treatment.
Stable lesions that fail conservative treatment may have
histological findings of instability in the deep layers of
cartilage. This is evidenced by the presence of fibrous tissue
or fibrocartilage indicating a delayed union or nonunion in
those deep layers.68 If arthroscopic findings show healthy
cartilage and a stable lesion, then our treatment of choice is
extra-articular drilling to stimulate bleeding and promote
subchondral bone healing. This has shown good results in
femoral condyle lesions clinically and radiographically with a
healing time of approximately 4 to 8.5 months in skeletally
immature patients.69,70 Transarticular or retrograde drilling
has also yielded good results with average healing time of
4.4 months for condyle lesions.71 For unstable lesions,
every effort should be made to salvage the fragment. An
assortment of fixation methods, which include headless
screws, K wires, bioabsorbable pins or screws, and osteo- FIGURE 3. Femoral neck stress fracture (arrows) of the left hip in
a patient who presented with knee pain.
chondral bone pegs, can be used to stabilize the fragment. If
the fragment is not salvageable, then treatment options
include simple excision, microfracture, osteochondral auto- immature individual that continues despite a reasonable
graft for smaller lesions, osteochondral allograft, or auto- period of nonoperative treatment mandates workup with
logous chondrocyte implantation for larger lesions. One radiographs. Tumors occurring around the knee include
recent study showed osteochondral autograft transplantation osteosarcoma, Ewing sarcoma, enchondroma, adamanti-
had better clinical results than microfracture for OCD lesions noma, and osteoid osteoma. Problematic lesions around the
in skeletally immature patients, though both treatment knee warrant referral to an orthopedic oncologist for
options had improved clinical outcomes.72 Excision is consultation.
generally reserved for older patients with small lesions away Infection should also be in the differential in a skele-
from the central weightbearing portion of the knee. With tally immature patient who presents with AKP. Clinical
autologous chondrocyte implantation, it is important to features of septic arthritis include pain with range of
recognize that with significant bone loss, bone grafting may motion, swelling, fever, and refusal to bear weight on the
also be required. affected extremity. Laboratory features include an elevated
white blood cell count, erythrocyte sedimentation rate, and
HIP ETIOLOGIES C-reactive protein. Diagnosis is made by history and
It is well know that pathologic entities of the hip can physical examination and confirmed with a knee aspiration.
refer pain to the knee. These include slipped capital femoral Typically, the bacterial isolate is Staphylococcus aureus.78
epiphysis (SCFE) and femoral neck stress fracture (Fig. 3). Treatment includes irrigation and debridement in addition
In regard to SCFE presenting as knee pain, it has been to antibiotics that the specific isolates are sensitive to.
shown that there is a delay in diagnosis in comparison to
patients who present with hip pain.73 Therefore, an IDIOPATHIC AKP
examination of the hip is always included in the evaluation If the history and physical examinations as well
of the patient with knee pain. Posterolateral displacement as diagnostic modalities have not conclusively established
of the femoral epiphysis relative to the metaphysis is the a diagnosis, then some would say that the patient has
hallmark of SCFE. The incidence of SCFE ranges from idiopathic AKP.3,79 An argument can be made that there is
0.2 per 100,000 in Japan to 10 per 100,000 in the United no such entity as idiopathic AKP, and most patients will at
States.74 Mean age at diagnosis is 12 years in females and least have subtle muscle imbalances or malalignment that
13.5 years in males.74 Bilateral SCFE has been reported to can subsequently alter patellofemoral contact forces caus-
be as high as 63% with bilateral involvement at initial ing pain.80,81 In these patients, physical therapy is extremely
presentation in the range of 50%.75,76 Obesity has been important to identify imbalances or deficiencies of core
implicated in the etiology of SCFE owing to increasing and/or lower extremity strength and flexibility and then to
shear forces across the femoral physis.77 AP and frog leg proceed to organize a rehabilitation regimen accordingly.
lateral imaging of the hip is performed and usually leads to Finally, interviewing the parents of the young athlete
the diagnosis. Once diagnosed, early treatment of SCFE is is critical. The athlete may have extraordinary pressure to
indicated and is most often accomplished with in situ succeed in their sport that originates from his or her
pinning. However, high degrees of deformity may require parents.3 In these scenarios, it is important to council the
corrective osteotomy after initial stabilization. parents and the athlete on having realistic expectations and
on the potential deleterious effects of overuse injuries with
TUMOR/INFECTION excessive training. In addition, a psychiatric profile to look
Another cause of knee pain that must be kept in mind for signs of depression, hostility, or passive attitude is
is the possibility of a tumor. Knee pain in the skeletally useful as these findings have been associated with AKP.82

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Kodali et al Sports Med Arthrosc Rev  Volume 19, Number 1, March 2011

In our practice, patients with normal objective findings with 17. Hoffa A. The influence of the adipose tissue with regard to the
chronic pain refractory to traditional treatment will be pathology of the knee joint. JAMA. 1904;43:795–796.
referred to a multidisciplinary clinic involving a pain medi- 18. Jacobson JA, Lenchik L, Ruhoy MK, et al. MR imaging of the
cine specialist and a clinical psychologist. infrapatellar fat pad of Hoffa. Radiographics. 1997;17:675–691.
19. Von Engelhardt LV, Tokmakidis E, Lahner M, et al. Hoffa’s
Fortunately, according to Nimon et al,83 the natural fat pad impingement treated arthroscopically: related findings
history of AKP managed nonoperatively is fairly good with on preoperative MRI in a case series of 62 patients. Arch
22% having no pain and 71% having an improvement in Orthop Trauma Surg. 2010;130:1041–1051.
pain at an average of 16-year follow-up. Though, 1 in 4 20. Crossley K, Cowan SM, Bennell KL, et al. Patellar taping: is
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necessary component of treatment. It is can be helpful to
26. Gholve PA, Scher DM, Khakharia S, et al. Osgood Schlatter
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28. Ogden JA, Tross RB, Murphy MJ. Fractures of the tibial
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