Bone Strength

Bone strength decreases as we age. Bones can become very weak and fragile — a condition called osteoporosis. Osteoporosis often develops in women after menopause, and in men in older age. This bone-thinning disorder puts people at greater risk for broken bones, particularly fractures of the hip, wrist, and spine.

Risk Factors

Many of the factors that put you at greater risk for a hip fracture are those that cause bone loss.

• Age. The risk for hip fractures increases as we age. In 2010, more than 80% of the people hospitalized for hip fractures were age 65 and older, according to the National Hospital Discharge Survey (NHDS).
• Gender. In 2010, 72% of hip fractures in people aged 65 and older occurred in women (NHDS).
• Heredity. A family history of osteoporosis or broken bones in later life puts you at greater risk for a hip fracture. People with small, thin builds are also at risk.
• Nutrition. Low body weight and poor nutrition, including a diet low in calcium and Vitamin D, can make you more prone to bone loss and hip fracture.
• Lifestyle. Smoking, excessive alcohol use, and lack of exercise can weaken bones.

In addition to factors that affect bone strength, things that put you at greater risk for falling can increase the possibility of hip fracture.

• Physical and mental impairments. Physical frailty, arthritis, unsteady balance, poor eyesight, senility, dementia and/or Alzheimer’s disease can increase the likelihood of falling.
• Medications. Many medicines can affect balance and strength. Side effects of some medications can also include drowsiness and dizziness.

Home Safety

Most hip fractures occur as a result of a fall, and most falls occur in the home. Many falls can be prevented by simple home safety improvements, such as removing clutter, providing enough lighting, and installing grab bars in bathrooms.

For more comprehensive information on preventing falls: Guidelines for Preventing FallsGuidelines for Preventing Falls (topic.cfm?topic=A00135)

Exercise

Moderate exercise can slow bone loss and maintain muscle strength. It can also improve balance and coordination. Good exercise options include climbing stairs, jogging, hiking, swimming, dancing, and weight training.

Balance training and tai chi have been shown to decrease falls and reduce the risk of hip fracture. Tai chi is a program of exercises, breathing, and movements based on ancient Chinese practices. These classes can also increase self-confidence and improve body balance.

Be sure to talk to your doctor if you are just beginning an exercise program.

Understand Your Health and Medications

Each year, be sure to have an eye examination, as well as a physical that includes an evaluation for cardiac and blood pressure problems. Talk with your doctor about the side effects of any medications and over-the-counter drugs you take. It is helpful to keep an up-to-date list of all medications you take so that you can provide it to any other doctors with whom you consult.

Maintain Your Bone Health As You Age

As we age, our bones are affected by genetics, nutrition, exercise, and hormonal loss. We cannot change our genes, but we can control our nutrition and activity level, and if necessary, take osteoporosis medications.

There are things you can do to maintain and even improve your bone strength.

• Understand your individual risk for fracture. This is based on any risk factors you have for fracture and your bone density. Ask your doctor if you need a bone density test.
• Understand your individual risk for bone loss. Genetics plays a role in bone health, and some people have genetically determined high rates of bone turnover after menopause or with aging. Talk to your doctor about bone metabolism testing. Bone metabolism testing can provide additional information about your risk for fracture.
• Make healthy lifestyle choices. Maintain a healthy weight and eat a diet rich in calcium and Vitamin D. Do not smoke and limit your alcohol intake.
• Consider bone-boosting medications. In addition to calcium and Vitamin D supplements, there are many drug options that slow bone loss and increase bone strength. Talk to your doctor about these methods for protecting your bones.

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Overuse

In many cases, patellofemoral pain syndrome is caused by vigorous physical activities that put repeated stress on the knee —such as jogging, squatting, and climbing stairs. It can also be caused by a sudden change in physical activity. This change can be in the frequency of activity—such as increasing the number of days you exercise each week. It can also be in the duration or intensity of activity—such as running longer distances.

Other factors that may contribute to patellofemoral pain include:

• Use of improper sports training techniques or equipment
• Changes in footwear or playing surface

Patellar Malalignment

Patellofemoral pain syndrome can also be caused by abnormal tracking of the kneecap in the trochlear groove. In this condition, the patella is pushed out to one side of the groove when the knee is bent. This abnormality may cause increased pressure between the back of the patella and the trochlea, irritating soft tissues.

Factors that contribute to poor tracking of the kneecap include:

• Problems with the alignment of the legs between the hips and the ankles. Problems in alignment may result in a kneecap that shifts too far toward the outside or inside of the leg, or one that rides too high in the trochlear groove—a condition called patella alta.
• Muscular imbalances or weaknesses, especially in the quadriceps muscles at the front of the thigh. When the knee bends and straightens, the quadriceps muscles and quadriceps tendon help to keep the kneecap within the trochlear groove. Weak or imbalanced quadriceps can cause poor tracking of the kneecap within the groove.

(Top) In these x-rays taken from above, both kneecaps are normally aligned within the trochlear groove. (Bottom) Here, both kneecaps have shifted out of the trochlear groove and are pulled toward the outside of the knee.

Reproduced with permission from JF Sarwark, ed: Essentials of Musculoskeletal Care, ed 4. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2010

Activity Changes

Stop doing the activities that make your knee hurt until your pain is resolved. This may mean changing your training routine or switching to low-impact activities that will place less stress on your knee joint. Biking and swimming are good low-impact options. If you are overweight, losing weight will also help to reduce pressure on your knee.

The RICE Method

RICE stands for rest, ice, compression, and elevation.

• Rest. Avoid putting weight on the painful knee.
• Ice. Use cold packs for 20 minutes at a time, several times a day. Do not apply ice directly on skin.
• Compression. To prevent additional swelling, lightly wrap the knee in an elastic bandage, leaving a hole in the area of the kneecap. Make sure that the bandage fits snugly and does not cause additional pain.
• Elevation. As often as possible, rest with your knee raised up higher than your heart.

Medication

Non-steroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen and naproxen can help reduce swelling and relieve pain.

If you pain persists or it becomes more difficult to move your knee, contact your doctor for a thorough evaluation.

Physical Examination

During the physical examination, your doctor will discuss your general health and the symptoms you are experiencing. He or she will ask when your knee pain started and about the severity and nature of the pain (dull vs. sharp). Your doctor will also ask you what activities cause the pain to worsen.

To determine the exact location of the pain, your doctor may gently press and pull on the front of your knees and kneecaps. He or she may also ask you to squat, jump, or lunge during the exam in order to test your knee and core body strength.

During the examination, your doctor will check your knee for problems in patellar tracking.

Reproduced with permission from JF Sarwark, ed: Essentials of Musculoskeletal Care, ed 4. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2010

To help diagnose the cause of your pain and to rule out any other physical problems, your doctor may also check:

• Alignment of the lower leg and the position of the kneecap
• Knee stability, hip rotation, and range of motion of knees and hips
• The kneecap for signs of tenderness
• The attachment of thigh muscles to the kneecap
• Strength, flexibility, firmness, and tone of the hips, front thigh muscles (quadriceps), and back thigh muscles (hamstrings)
• Tightness of the heel cord and flexibility of the feet

Finally, your doctor may ask you to walk back and forth in order to examine your gait (the way you walk). He or she will look for problems with your gait that may be contributing to your knee pain.

X-Rays

Usually, your doctor will be able to diagnose patellofemoral pain syndrome with just a physical examination. In most cases, however, he or she also will order an x-ray to rule out damage to the structure of the knee and to the tissues that connect to it.

Nonsurgical Treatment

In addition to activity changes, the RICE method, and anti-inflammatory medication, your doctor may recommend the following:

Shoe inserts take stress off your lower leg by aligning your foot and ankle.

Reproduced with permission from JF Sarwark, ed: Essentials of Musculoskeletal Care, ed 4. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2010

Physical therapy exercises. Specific exercises will help you improve range of motion, strength, and endurance. It is especially important to focus on strengthening and stretching your quadriceps since these muscles are the main stabilizers of your kneecap. Core exercises may also be recommended to strengthen the muscles in your abdomen and lower back.

Orthotics. Shoe inserts can help align and stabilize your foot and ankle, taking stress off of your lower leg. Orthotics can either be custom-made for your foot or purchased “off the shelf.”

Surgical Treatment

Surgical treatment for patellofemoral pain is very rarely needed and is done only for severe cases that do not respond to nonsurgical treatment. Surgical treatments may include:

Arthroscopy. During arthroscopy, your surgeon inserts a small camera, called an arthroscope, into your knee joint. The camera displays pictures on a television screen, and your surgeon uses these images to guide miniature surgical instruments.

If tightness in the lateral retinaculum is pulling your kneecap to the side, your doctor may recommend lateral release surgery to cut the ligament.

Reproduced with permission from JF Sarwark, ed: Essentials of Musculoskeletal Care, ed 4. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2010

• Debridement. In some cases, removing damaged articular cartilage from the surface of the patella can provide pain relief.
• Lateral release. If the lateral retinaculum tendon is tight enough to pull the patella out of the trochlear groove, a lateral release procedure can loosen the tissue and correct the patellar malalignment.

Tibial Tubercle Transfer. In some cases, it may be necessary to realign the kneecap by moving the patellar tendon along with a portion of the tibial tubercle—the bony prominence on the tibia (shinbone).

A traditional open surgical incision is required for this procedure. The doctor partially or totally detaches the tibial tubercle so that the bone and the tendon can be moved toward the inner side of the knee. The piece of bone is then reattached to the tibia using screws. In most cases, this transfer allows for better tracking of the kneecap in the trochlear groove.