ANTERIOR KNEE PAIN – SORTING OUT THE CAUSES

ANTERIOR KNEE PAIN – SORTING OUT THE CAUSES

Disclaimer

The information contained in “ANTERIOR KNEE PAIN – SORTING OUT THE

CAUSES” is not meant to replace any specific advice you may have been given by
a medical doctor. The information is not intended as a substitute for professional
input or action.

All interventions involve some inherent risk. If you are unfamiliar with anything
covered in this text, seek opinion from a qualified practitioner.

Jacked Athlete LLC disclaims any liability or loss in connection with the use of this
text or any advice herein.
 ANTERIOR KNEE PAIN – SORTING OUT THE CAUSES

Step One
Pain in the front of the knee. What is it? Here’s a list of potential diagnoses:

Patellar Tendinopathy, Quadriceps Tendinopathy, Distal Patellar Tendinopathy, Osgood-

Schlatter Disease, Sinding-Larsen-Johansson Syndrome, Tendon Rupture, Whole Tendon Pain,
Tendon Graft, Partial Tendon Tear, Patellofemoral Pain, Bipartite/Tripartite Patella, Patella
Fracture, Patella Instability, Fat Pad Impingement, Bursitis, Synovial Plica Syndrome, etc.

The bad news: There’s a lot that can be wrong.

The good news: Most of these conditions can be distinguished based on obvious
signs and symptoms.

Another Disclaimer
I am not a doctor. I am a meathead who knows a bit about pain at the front of
the knee. If you are experiencing symptoms, you should seek care and advice
from a medical professional. You may need an x-ray, MRI, ultrasound, blood
work, physical exam, or a bunch of other tests that you can’t get by reading a
book. You want to exclude all other conditions and that’s done with a doctor.

The 7 Structures
When it comes to pain in the front of the knee, we’re looking at these areas:

1) The Tendon
2) The Patellofemoral Joint
3) The Patella
4) The Fat Pad
5) The Bursa
6) The Plica
7) The Other Guys

Let’s get started.

ANTERIOR KNEE PAIN – SORTING OUT THE CAUSES

The
Tendon
 ANTERIOR KNEE PAIN – SORTING OUT THE CAUSES

The Tendon
Pain in your tendon can be a few different things:
- Tendinopathy (Patellar, Quadriceps, and Distal Patellar)
- Apophysitis (Osgood-Schlatter Disease and Sinding-Larsen-Johansson
Syndrome)
- Tendon Rupture
- Whole Tendon Pain
- Tendon Graft Pain

Let’s run down the list.

Tendinopathy

Tendinopathy is a disease or disorder of the tendon that

causes pain. Historically, it has been called Tendonitis (-itis
meaning that it’s inflammatory) or Tendinosis (-osis
meaning that it’s degenerative). Because tendon pain is
still poorly understood, it’s safer to just call it
Tendinopathy.

It hurts and the exact cause (inflammation, degeneration,

something else) is still unknown.

Tendinopathies occur at the enthesis (where the tendon

meets bone). There are three possible locations it can
occur (images from this study):

F) At the superior border of the patella (Quadriceps

Tendinopathy)

G) At the inferior pole of the patella (Patellar

Tendinopathy)

H) At the tibial tubercle (Distal Patellar Tendinopathy)

 ANTERIOR KNEE PAIN – SORTING OUT THE CAUSES

These three are disorders of the same tendon, so they are all very similar with just
a few differences. I cover them below.

Signs you should be thinking Tendinopathy:

- It’s pinpoint, sharp pain that stays localized.

- Pain comes about in high tendon stress activities (e.g., jumping, landing,
changing direction, explosive lifting).
- The pain gets better as you warmup and you can often do high tendon
stress activities with less or no pain (Warmup Effect).
- The pain flares up the next morning or 24-48 hours after high tendon stress
activities (Delayed Pain Response).
- A quick glance at your training history will show a big change in levels of
tendon stress over the past days and weeks from where you were before
(Exceeding your Tendon’s Capacity).
- Prolonged sitting (e.g., bus, car, plane) can cause pain.
- Levels of Knee Flexion: Patellar Tendinopathy is likely to be aggravated in
early knee flexion (0- to 60-degrees knee bend) whereas Quadriceps
Tendinopathy is likely to be aggravated in later knee flexion (90-degrees to
full bend).
- The different types of Tendinopathy can happen to anyone who stresses
the tendon, but there are a few differences:
• Patellar Tendinopathy is common in basketball and soccer players
(think explosive athletes who spend more time in early knee flexion).
• Quadriceps Tendinopathy is common in Olympic weightlifters and
volleyball players (think explosive athletes who reach deeper levels
of knee flexion).
• Distal Patellar Tendinopathy is common in distance runners. I’m
unsure the reason for this.

If these signs match up with your pain, you should be thinking Tendinopathy.
 ANTERIOR KNEE PAIN – SORTING OUT THE CAUSES

Apophysitis

Tendon issues are uncommon in kids. They are more

likely to get an injury to the apophyses (growing centers
around the tendon-bone interface). Apophysitis is
defined as an inflammation or stress injury to the areas
on or around growth plates in adolescents. There are
two conditions (Image from here):

1) Osgood-Schlatter Disease. Apophysitis at the

tibial tubercle.
2) Sinding-Larsen-Johansson Disease. Apophysitis at
the inferior pole of the patella.

These conditions will likely present with similar signs of a Tendinopathy (pinpoint
pain, high tendon stress=more likely to provoke pain, warmup effect, delayed
pain response, etc.).

Here are a few other signs you should be thinking Apophysitis:

- Kids. Apophysitis injuries happen in kids aged 9-15. At this stage, their
ossification centers are still forming. They are soft and cartilaginous,
making them a weak point in the muscle-tendon-bone chain.
- Kids in sports. The apophyses must be overloaded to get this injury. This
can happen from most sports (e.g., basketball, volleyball, football).
- Although not something that can diagnose pain, kids will present with
thickening at the area of pain (think the Osgood-Schlatter bump or a similar
feature at the inferior pole of the patella).

If these signs match up with your pain, you should be thinking Apophysitis.
 ANTERIOR KNEE PAIN – SORTING OUT THE CAUSES

Tendon Rupture

This one is straightforward. An event happened where

the patellar (below the kneecap) or the quadriceps
(above the kneecap) tendon has completely torn. This
can be picked up easily on MRI or ultrasound.

Image of a quadriceps tendon tear from this study.

Whole Tendon Pain

The tendinopathies and apophysitis injuries occur at the

connection points. When there is whole tendon pain, it is
usually the result from a direct blow or fall on to that
area.

Image of tendon pain that occurs along the tendon (not at

an enthesis).

Tendon Graft Pain

Patellar and quadricep tendons can be used to replace

ligaments elsewhere in your body. This runs a similar
healing course to a tendinopathy, it just takes a while to heal
(~6-12 months).

Image of a bone-patellar-bone graft from this study.

 ANTERIOR KNEE PAIN – SORTING OUT THE CAUSES

Partial Tendon Tears

This is a debated topic. Healthy tendon and tendon rupture are easy to pick up on
imaging. The issue lies in the middle where partial tears are suspected. It seems
that most experts recommend looking at partial tears as regular tendinopathy
because it’s difficult to distinguish between partial tear and tendinopathy. Here is
from Sean Docking on this podcast:

“There is no one criteria or set of guidelines of how you diagnose a partial tear… so it really
questions how reliable we are at subjectively looking at an imaging and subjectively reporting
whether there’s a partial tear… we are really good at picking up the complete tendon tears… we
are really good at telling you whether the tendon is normal… where we get lost is this
continuum or spectrum in between. Our ability to differentiate tendon pathology from partial
thickness tears is basically about a flip of a coin… 50%… we are no better than chance in terms
of determining whether it’s tendon pathology or whether it’s a partial tear.”

Because imaging can’t reliably distinguish between the two, a partial tear might
be something that needs to be determined by asking how the tendon was injured.
If you had a specific jump, land, cut, etc. where you felt a pop or tear in the
tendon (without it being a full rupture),
then the partial tear might be suspected.

MRI images of PPTT (Partial Patellar

Tendon Tear) classification from this
study. This grading system shows
severity of tendon pathology, but it
doesn’t do much to say whether it is a
partial tear or just degeneration of the
tendon, which is still something that is
not agreed upon.

Regardless of the debate, the consensus

among experts is to look at partial tears
just like normal tendinopathy.

That’s it for tendon issues. Up next, the patellofemoral joint.

ANTERIOR KNEE PAIN – SORTING OUT THE CAUSES

The
Patello-
femoral
Joint
 ANTERIOR KNEE PAIN – SORTING OUT THE CAUSES

The Patellofemoral Joint

We’re looking at one pain here: Patellofemoral Pain. Annoying, flares up from
the simplest things, and seems to stick around for years. Here we go:

Patellofemoral Pain

Patello- (kneecap) -femoral (femur).

When the knee bends, the patella glides

through the femoral groove. This stresses
the patellofemoral joint. This is normal
but sometimes it can lead to pain.

Image of pain drawings from this study.

Here are the signs you should be thinking Patellofemoral Pain:

- Pain that is retropatellar (behind the kneecap) or peripatellar (around the

kneecap).
- Pain that is more dull, widespread, and can “jump around” the retro- and
peri-patellar regions.
- Insidious onset. The pain came about in a gradual and subtle way.

- Pain that is reproduced with knee flexion (Box 3 from this study):

o PFP has been called Moviegoer’s Knee because prolonged sitting can
cause pain.
o PFP has also been called Runner’s
Knee because running can cause
pain. Especially downhill.
o Stair ascent/descent can cause pain.
o Squatting can cause pain.
o Jumping can cause pain.
 ANTERIOR KNEE PAIN – SORTING OUT THE CAUSES

- This study by Richard Willy et al., covered four subcategories of people who
have patellofemoral pain:
1) Overuse/overload without other impairment. You’ve just toasted
your PF joint with too much stress in a short window of time.
2) Muscle performance deficits. You have “weaker” hip and knee
muscles.
3) Movement coordination deficits. You have “excessive” and poorly
controlled knee valgus during movement.
4) Mobility impairments. You have either hypermobile or hypomobile
structures at the lower body.

If these signs and symptoms match up with your pain, you should be thinking
Patellofemoral Pain.

Up next is the patella.

ANTERIOR KNEE PAIN – SORTING OUT THE CAUSES

The
Patella
 ANTERIOR KNEE PAIN – SORTING OUT THE CAUSES

The Patella
I thought about lumping Patellofemoral Pain into the Patella section, but I didn’t.
PFP is its own complex beast. The Patella, one the other hand, is as simple as it
gets. Here’s what can be going on:

Bipartite/Tripartite Patella

The patella should form into one bone. This is a

case where it has developed into two (bipartite)
or three (tripartite) fragments. This can be
picked up on an x-ray. The most common
complaint is pain at the separated fragments.

Image shows bipartite patella (with arthritis),

from this study.

Patella Fracture

This is when the patella has broken. It can happen for a few reasons:
- A direct blow or fall on the patella.
- A person is prone for fracture because of low bone mineral density.
- A person is prone for fracture because of severe knee extensor
deconditioning (e.g., post-surgery).

Image of a transverse patella fracture from this

study.
 ANTERIOR KNEE PAIN – SORTING OUT THE CAUSES

Patella Instability

A normal patella should glide nicely in the trochlear groove. Some people have
issues with this tracking. It can happen for a few reasons, many unavoidable:
patella alta (high riding patella), trochlear dysplasia (a more flat trochlear groove),
acute trauma, chronic ligamentous laxity, bony malalignment, connective tissue
disorder, and/or anatomical pathology.

This instability can lead to two things:

- Subluxation where the kneecap briefly slides out
of its normal place in the groove.
- Dislocation where the kneecap pops sideways,
usually laterally, out of its groove.

Image of a patella dislocation from this study.

Images of a patella dislocation that is not apparent when in extension but is

severely shifted laterally at 90 and 120 degrees of flexion. From this study.

That wraps it up for issues with the kneecap. Next in line is the fat pad.
ANTERIOR KNEE PAIN – SORTING OUT THE CAUSES

The
Fat
Pad
 ANTERIOR KNEE PAIN – SORTING OUT THE CAUSES

The Fat Pad

There are actually a few fat pads, but I don’t want to give all of them the same
level of attention as the major player: the infrapatellar fat pad.

Infrapatellar Fat Pad Syndrome

It’s been called the airbag of the knee, meant for cushioning and protection. It
also stores stem cells so maybe it’s helping with regeneration of the structures
around it. Who knows. But when it’s aggravated, it’s a terrible thing.

Here are the signs that you should be thinking IFP:

- Intense pain on either side of the

patella. The IFP is highly
vascularized and richly innervated.
It is thought to be the most
painful structure in the anterior
knee when provoked. Image from
this study.
- Worse in extension. The fat pad can be impinged (and aggravated) when
the knee extends. Standing and walking can cause this.
- It can be swollen. Hoffa initially described IFP as inflammatory
hypertrophy. There is localized edema. The fat pad gets bigger, which
probably makes it more likely to get
impinged in extension.
- Palpation (Hoffa’s Test). The test is positive
for impingement if pain and discomfort is felt
during the last 10 degrees of knee extension.
Image of the test from this study.
- There are a few reasons why it gets aggravated:
o Acute trauma from a direct blow or surgery (arthroscopy portals)
o Chronic aggravation from classic impingement
o Inflammatory from obesity or osteoarthritis
- Anyone can get IFP from sport, surgery, or general poor health but it
usually affects middle-aged adults and is more common in females.
 ANTERIOR KNEE PAIN – SORTING OUT THE CAUSES

That’s it for the infrapatellar fat pad.

There are two other fat pads located above the patella. Image from this study.

The first is the anterior suprapatellar (quadriceps). People report tenderness at

the superior pole of the patella with pain getting worse in deep knee flexion.

The other one is the posterior prepatellar (prefemoral). People report pain
worsened by hyperextension.

Done with the fat pad. The next one is the bursa.
ANTERIOR KNEE PAIN – SORTING OUT THE CAUSES

The
Bursa
 ANTERIOR KNEE PAIN – SORTING OUT THE CAUSES

The Bursa
Bursa are fluid-filled structures that reduce friction between bones, muscles,
tendons, and ligaments. There are four of them, with the prepatellar being the
most commonly problematic. Bursa conditions are simple, they just get inflamed.

Bursitis

-itis means inflammation. That’s it.

Here are the signs that you’re thinking bursitis:

- Swelling over the patella (kneecap).

- It would occur in the location where you
kneel on your knee. It has been given the
names: housemaids, carpet layers, and
carpenters knee.
- It can present a couple of ways:
o Acute cases will usually present red,
warm, tender, and possibly decreased range-of-motion.
o Chronic cases will usually be painless because the bursa has had time
to accommodate for the increased fluid.
- It can get inflamed for a few reasons:
o Repetitive trauma from kneeling (Most common)
o Acute direct trauma
o Gout, rheumatoid arthritis, and infections (Least common)
- It’s difficult to know how common bursitis is because most people don’t
seek care for them unless it’s from an infection (which is serious and
requires medical attention).

As for the other, less affected bursa: superficial infrapatellar, deep infrapatellar,
and pes anserine. There doesn’t seem to be anything special for these.

That’s it for the bursa.

Up next: The sneaky plica.

ANTERIOR KNEE PAIN – SORTING OUT THE CAUSES

The
Plica
 ANTERIOR KNEE PAIN – SORTING OUT THE CAUSES

The Plica
Plica are a bit weird. Historically, they’ve been wrongly blamed for a lot of knee
pains. They happen, but there are probably more likely things to rule out first.
Because of this, they’ve been termed the dustbin diagnosis.

Synovial Plica Syndrome

First, what is plica? It’s an inward

fold of tissue, a shelf-like membrane
between the synovium of the patella
and the tibiofemoral joint. Studies
indicate that 90% of adults have one
or more plica in their knees but they
rarely cause symptoms.

A lot of people have plica but not a

lot of people get pain from them
because they never set them off.

There are 4 plica, but one is more commonly an issue: The medial plica.

Here are the signs that you should be thinking synovial plica syndrome (most of
these referring to the medial plica):

- Anteriomedial knee pain. Pain in the front but more

towards the inner part of the knee. Image showing
the location and how it can progressively damage
cartilage of the patella. From this study.
- Snapping, clicking, catching, grinding, “giving away”,
or a popping sensation along the inside of the knee
during flexion and extension.
- The medial plica may impinge between the quadriceps
tendon and femoral trochlea in knee flexion, which
causes these symptoms.
- The area may be tender to the touch, swollen, and
stiff.
 ANTERIOR KNEE PAIN – SORTING OUT THE CAUSES

- It can hurt during stairs, squatting, bending, biking, and arising from a
chair after sitting for an extended time. Pain tends to worsen during
activity.
- Prolonged flexion can cause pain. This could be the case when sleeping at
night if the knees are bent.
- Upon physical exam, a taut band may be palpable under the skin.
- Two tests, when both are positive, can confirm plica syndrome. They are
the Stutter Test and the Hughston Test.
- It can be difficult to distinguish between a plica and something else
(meniscal tears, articular cartilage injuries, or osteochondritic lesions). A
meniscus will be locking and sharp, which would rule out the plica.

Stutter Test (top left), Hughston Test (bottom left), and Medial Plica Palpation
(right). Images from this study.

The other plica are the: suprapatellar, infrapatellar, and lateral. They can all fall
into the category of synovial plica syndrome, just differing by location.

That’s it for the plica. A sneaky bugger. If it’s confirmed to be the source of pain,
and if conservative management doesn’t do the trick, arthroscopy is usually done
to cut it.

That’s it for the more in-depth explanations of anterior knee pain.

Up next: all the conditions that only deserve a quick rundown.

 ANTERIOR KNEE PAIN – SORTING OUT THE CAUSES

The Other Guys

For most cases of anterior knee pain, you’re thinking tendon, patellofemoral joint,
patella, fat pad, bursa, or plica. But there are other issues too. I’ll briefly cover
them.

Retinacular Pain

The retinaculum is a thin ligamentous structure that provides stability around the
patella.

Pain that occurs on the inside (medial retinacular complex) is thought to result
from patella instability. Patella dislocation can injure the MPFL.

Pain that occurs on the outside (lateral retinacular complex) is thought to be from
a more stable patella, but increased pressure felt laterally when going into flexion.

Image of lateral and medial retinaculum as well as MPFL and LPFL. All of which
can be sources of pain. From this study.
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Chondromalacia Patellae

Chondros means cartilage and malakia means softening. This is “sick cartilage” of
the surfaces between the patella and femur. It is often used interchangeably with
patellofemoral pain, but that is not completely accurate. Research does not
confirm the idea that more wear-and-tear on the cartilage is associated or
predictive of patellofemoral pain symptoms. A study in 56 young adults found
“no correlation between the severity of chondromalacia patellae and the clinical
symptoms of anterior knee pain syndrome” (this study).

Also, because articular cartilage is aneural, it cannot be the pain generator in

patellofemoral pain.

The usefulness of Chondromalacia Patellae comes when discussing Patellofemoral

Osteoarthritis. Covered below.
 ANTERIOR KNEE PAIN – SORTING OUT THE CAUSES

Patellofemoral Osteoarthritis

This generally affects older people. It’s the wearing down of the shock-absorbing
articular cartilage. Risk factors include previous connective tissue injuries,
obesity, old age, and systemic inflammatory disorders.

It’s not just an overuse issue but a general health issue.

Advanced chondromalacia patellae is thought to progress into patellofemoral

osteoarthritis.

Image from this study.

Here are some more knee pains that I will just put in a list because I’m done
explaining things in detail.

These are less common anyway and some fall more into the medial/lateral knee
pain category than they do anterior:

- Tumor. Patella, femur, tibia, patellar tendon, fat pad.

- Septic Arthritis. Can come as a rare complication after ACL surgery.
- Arthrofibrosis. Abnormal proliferation of fibrous tissue (joint trauma or
surgery).
- Hip Osteoarthritis. Can cause referral pain to the anterior knee.
 ANTERIOR KNEE PAIN – SORTING OUT THE CAUSES

- Hip Fracture. Same type of referral pain to the upper knee.

- Slipped Capital Femoral Epiphysis (SCFE) in children or adolescents.
Referral pain can be felt in the knee.
- Lumbar Radiculopathy. Herniated disc or spinal stenosis can refer pain to
the knee.
- Peripheral Nerve Entrapment. Happens in the infrapatellar branch of the
saphenous nerve, can cause anterior/medial pain.
- Ligamentous (Cruciate and Collateral) Injuries. MCL pain would be more
medial. LCL more lateral. Cruciate deeper.
- Osteonecrosis of the Knee. Bone death due to lack of blood supply.
Commonly seen in the medial femoral condyle.
- Parameniscal Cyst. Fluid leak from a meniscus tear causing a cyst.
- ACL Ganglion Cyst and Mucoid Degeneration. Rare. Can cause
anteromedial knee pain.
- Infrapatellar Contracture Syndrome (IPCS). Fibrous hyperplasia. Can
happen post-surgery (ACL).
- Osteochondritis Dissecans. Mostly in teenagers. Usually, a lesion at the
bottom of the femur and can break off to form a loose body.
- Patellar Hypertension Syndrome. Pain from increased intrapatellar
pressure. Can be seen in adolescent population.
- Infrapatellar Pain Syndrome (IPS). Nerve injury from trauma to the knee.
- Subchondral Bone Cyst. Common in the knee.
- Meniscus Injuries. This would be more lateral or medial knee pain.
- Articular Cartilage Injuries. From trauma, instability, or progressive
degeneration.
- Distal Iliotibial Band Syndrome (ITBS). This would be pain on the outside
of the knee.
- Trochlear Dysplasia. The trochlear groove (where the patella glides) is
deformed and can lead to increased patella instability.
- Ankylosing Spondylitis (AS) causing Patellar Tendon Enthesopathy. AS is a
disorder that causes inflammatory arthritis and enthesopathy (disorder of
entheses – this time being the patellar enthesis).
- Quadriceps Insertional Calcific Tendinopathy. Calcific tendinopathy is
common around the rotator cuff (potentially progressing to frozen
shoulder), but it can also occur at the inferior pole of the patella.
- Deep Vein Thrombosis (DVT). Blood clot formation. Leg may swell, be red,
warm.
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That’s All
Hopefully this has shed some light on the different conditions of the anterior
knee. If you’re not satisfied because I didn’t explain how to rehab each condition,
that’s okay. This was not the intention of the book.

As for diagnosis, best case scenario, you are only dealing with one issue and can
rehab accordingly. It can be more difficult when you’re dealing with multiple
things.

If you require more knowledge, here’s links to studies, videos, podcasts, and
experts that you should study:

GENERAL ANTERIOR KNEE DIAGNOSIS

Study: Layered Approach to the Anterior Knee: Normal Anatomy and Disorders
Associated with Anterior Knee Pain

Study: Diagnosis and Treatment of Anterior Knee Pain

Study: Narrative: Review of Anterior Knee Pain Differential Diagnosis (Other than
Patellofemoral Pain)

Study: Adolescent Anterior Knee Pain

Article: Uncommon Causes of Anterior Knee Pain

Article: Differential Diagnosis of Anterior Knee Pain

Article: Anterior Knee Pain

Video: The Enigma of the Patellofemoral Joint

Twitter: James Noake

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TENDON DIAGNOSIS

Study: Patellar Tendinopathy: Clinical Diagnosis, Load Management, and Advice

for Challenging Case Presentations

Study: Distinguishing Quadriceps and Patellar Tendinopathy: Semantics or

Signficant?

Study: Self-reported jumpers’ knee is common in elite basketball athletes – But is

it all patellar tendinopathy?

Study: Activity Modification and Knee Strengthening for Osgood-Schlatter

Disease: A Prospective Cohort Study

Podcast: Osgood-Schlatter Disease w/ Professor Michael Rathleef

Twitter: Jill Cook

PATELLOFEMORAL DIAGNOSIS

Study: Clinical Practice Guidelines: Patellofemoral Pain

Podcast: How to Treat Patellofemoral Pain with Dr. Richard Willy

Video: JOSPT Asks Rich Willy

Twitter: Rich Willy

Twitter: Brad Neal

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PATELLA DIAGNOSIS

Study: Clinical features and classification of bipartite and tripartite patella

Study: Patella Fractures

Study: Patellar Instability

FAT PAD DIAGNOSIS

Study: Hoffa’s fat pad abnormalities, knee pain, and magnetic resonance imaging
in daily practice

Video: Discussing Hoffa’s Fat Pad with Claire Robertson

Twitter: Claire Robertson

BURSA DIAGNOSIS

Study: Prepatellar Bursitis

Study: Bursae around the knee joints

PLICA DIAGNOSIS

Study: Synovial Plica Syndrome of the Knee: A Commonly Overlooked Cause of

Anterior Knee Pain

Article: Plica Syndrome

Podcast (towards the end): How to treat anterior knee pain with Kurt Lisle