This pain corresponds to a tendino-bursitis of the posterior edge of the very thick ilio-tibial fibrous band which comes into conflict with the external condyle of the lower end of the femur.
This fibrous strip positioned forwards when the knee is extended, slides backwards like a windshield wiper, knee flexed and the repetition of the movement will create painful friction against the external condylar relief.
Windshield wiper syndrome preferentially affects runners and tri-athletes
Intrinsic contributing factors:excessive protrusion of the external femoral condyle genu varum unequal length of the lower limbs
hyper-pronator foot.
Extrinsic contributing factors- technological: unsuitable or worn shoes for long-distance runners, particular ground (curved road), poor adjustment of the pedals. - dystraining: excess and above all sudden increase in weekly mileage , training uphill and downhill, neglected stretching.
The diagnosis is essentially clinical. The pains of effort are localized on the level of the external part of the knee and radiate along the external face of the thigh. They are of progressive installation only appearing after a few kilometres, favored by hilly terrain or flat, non-hard surfaces. The pain increases when the effort intensifies and the mileage increases. Once installed, the pain does not disappear when the effort is stopped (stage 3 of Blazina).
Palpation of the posterior surface of the external condyle produces exquisite pain . Knee examination is normal: patella, menisci, external collateral ligament, pivot; no patellar shock, no pain on palpation of the joint spaces in search of chondropathy, no laxity in varus, no abnormal mobility.
The upper fibula-tibial joint is free. Two clinical tests confirm the diagnosis: - the Renne test: weight-bearing and mono-pedal support: appearance of pain when performing flexion/extension movements of the knee.
- the Noble test: subject in dorsal or lateral decubitus:
if digital pressure is exerted, knee flexed at 90°, at the level of the top of the external condyle, 2 to 3 cm above the joint space and passively extending the knee while maintaining the tibia in varus and internal rotation by the mobilizing hand; a sharp pain appears around 30° of flexion, indicating the positivity of the test.
departure
arrival
Imaging is useless and the differential diagnosis is easy (strictly normal knee examination) with external meniscal syndrome, blockage of the upper fibula-tibial joint, stress fracture of the neck of the fibula in runners, femoral chondropathy -external tibial.
Treatment in the acute phase: essentiallymedical: relative rest, ice, analgesics, NSAIDstransversemassage and stretching), physiotherapy.
Treatment in the chronic phase (stage 3 of Blazina), total rest and 1 to 2 tendinobursitis infiltrations can solve the problem.
Exceptional surgical treatment (Jager, Lutz), in the event of failure of medical treatment : excision of the bursitis, regularization of the posterior face of the external condyle, lengthening plasties of the ilio-tibial band.
Prevention: stretching, running shoes adapted and replaced regularly, adjustment of the pedals... , plantar orthosis if the foot pronator.
For runners, you have to pay attention to the nature of the terrain and training can be resumed gradually when the stretching of the strip has become painless.
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