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  1. The Inter-Rater Reliability and Diagnostic Accuracy of Patellar Mobility Tests in Patients with Anterior Knee Pain (The Physician and Sportsmedicine) by Brett A. Sweitzer, Chad Cook, et all 2010-10-24

41. Simon Bartold Podiatry:Anterior Knee Pain- Patello - Femoral Syndrome
Fact Sheets. anterior knee pain Patello - Femoral syndrome. anterior knee pain or knee pain arising from the front region of the
http://www.simonbartoldpodiatry.com.au/fact_sheets/anterior_knee.html
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Anterior Knee Pain- Patello - Femoral Syndrome
The structures most commonly affected are the undersurface of the kneecap (or patella) and the end of the femur or thigh bone which forms a groove in which the patella slides. There may also be some inflammation of the patella tendon which is the attachment point of the quadricep muscles and the kneecap is incorporated in this tendon. These problems can exist individually or may present together.
Patello - femoral Syndrome
Predisposing factors for this condition include tight muscles (quadriceps , hamstrings and iliotibial band), internal rotated femur and tibia which is often secondary to excessive pronation of the foot and poor postural stability at the level of the hips and pelvis. Training changes such as increased workload, intensity or slope can also have an effect on the knee. Quadricep muscle weakness also upsets the balance of forces around the knee joint. Clinically the patient often presents with a vague ache, often aggravated by activity and may have some degree of swelling, creaking/grinding behind the kneecap. Some people will have pain after periods of rest especially sitting. It is important to have the injury correctly diagnosed to rule out more serious structural damage and to accurately determine which factors are contributing to the ongoing problem.

42. Patellofemoral Pain Syndrome Homepage
Patellofemoral pain syndrome is known by other names such as Patellar Chondromalacia, Excessive Lateral Pressure syndrome and simply anterior knee pain.
http://www.emedx.com/emedx/diagnosis_information/knee_disorders/patellofemoral_p

Diagnosis
PATELLOFEMORAL PAIN SYNDROME For more Sports Medicine and Orthopedic Information Check out EMEDx.com Definition
Patellofemoral pain syndrome describes a variety of possible disorders that cause pain in the joint between the kneecap (Patella) and the thigh bone (Femur).
Model and X-ray of a Normal Knee
Details Patellofemoral pain syndrome is known by other names such as: Patellar Chondromalacia, Excessive Lateral Pressure Syndrome and simply Anterior Knee Pain. It is a very common problem especially in women.
The pain associated with this disorder may worsen with descending stairs climbing or deep squating. Sitting with your knees flexed for a long period of time in a car or movie theatre may also aggravate the symptoms. Causes A variety of underlying anatomic abnormalities may result in patellofemoral pain syndrome. It can be caused by softening or cracking of the articular cartilage under the kneecap. This is known as chondromalacia. A malalignment of the kneecap or tight tissue around the kneecap can also create tension that may lead to patellofemoral pain syndrome.
Usually, this disorder arises without a history of significant trauma. Occasionally, the pain may begin after a blow to the knee or a minor injury.

43. MedlinePlus Medical Encyclopedia: Chondromalacia Patellae
Alternative names Return to top. Patellofemoral syndrome; anterior knee pain Definition Return to top. Chondromalacia patellae is
http://www.nlm.nih.gov/medlineplus/ency/article/000452.htm
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Chondromalacia of the patella Runners knee Alternative names Return to top Patellofemoral syndrome; Anterior knee pain Definition Return to top Chondromalacia patellae is the softening and degeneration of the cartilage beneath the kneecap (patella). Causes, incidence, and risk factors Return to top Chondromalacia patella that occurs in adolescents and young adults is thought to be related to overuse, trauma, and/or abnormal forces on the knee. It is more common in females. Many affected adolescents have a mildly abnormal alignment of the kneecap. Chondromalacia patella may also reflect arthritis of the kneecap, which is usually seen in older individuals. People who have previously had a dislocation , a fracture , or other trauma to the kneecap may be more likely to get chondromalacia. Symptoms Return to top
  • Knee tenderness Knee pain in the front of the knee that worsens after sitting for prolonged time Knee pain that worsens with using stairs or getting out of a chair A grating or grinding sensation when the knee is extended
Signs and tests Return to top The doctor will perform a physical examination. The knee may be tender and mildly swollen, and the kneecap may not be perfectly lined up with the femur (thigh bone) underneath.

44. MedlinePlus: Knee Injuries And Disorders
Family Physicians); Patellofemoral pain syndrome (American Academy Water on the knee (Mayo Foundation Treatment; ACL (anterior Cruciate Ligament) Reconstruction
http://www.nlm.nih.gov/medlineplus/kneeinjuriesanddisorders.html
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Leg Injuries and Disorders

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Injuries and Wounds

45. ESPN.com: TRAININGROOM - Patellofemoral Pain Syndrome
This can result in anterior knee pain and that usually suggests an overuse syndrome where the physical demands were beyond what the knee could withstand.
http://espn.go.com/trainingroom/s/1999/0901/13988.html
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Patellofemoral pain syndrome

It's an inescapable fact that knee injuries are a part of sports. One of the most complex joints in the body, the knee must withstand and absorb an incredible assortment of forces, both natural and unnatural, in order for an athlete to jump, run or cut. One of the structures of the knee, the patella (or kneecap) is particularly prone to pain and discomfort primarily because it sits at the juncture of ligaments, tendons, cartilage and bone. These afflictions, collectively referred to as patellofemoral pain syndrome, may have many causes. Dr. Giles Scuderi, a member of the Association of Professional Team Physicians (PTP) and an attending orthopedic surgeon at Beth Israel Medical Center, joins us to discuss this syndrome the causes, treatments and prognosis.
What is patellofemoral pain syndrome?

46. Patellar Tracking Disorder -- Topic Overview
This kind of pain, called anterior knee pain or patellofemoral pain syndrome, is sometimes caused by a common kneecap problem known as patellar tracking
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Health Topics Symptoms ... Credits Patellar Tracking Disorder Topic Overview
What is patellar tracking disorder?
Patellar tracking disorder is a condition in which the kneecap (patella) shifts out of place as the leg bends or straightens. Your knee joint is a complex hinge joining the lower leg bones (tibia and fibula) with the upper thighbone (femur). The kneecap (patella) is anchored to the front of the knee joint by tendons on the top and bottom and by ligaments on the sides. A layer of cartilage lines the underside of the kneecap, helping it glide along the groove at the end of your thighbone. The kneecap can shift or rotate off track if the groove is too shallow or if the cartilage is damaged. Ligaments, tendons, or muscles that are too loose or too tight may also lead to a malaligned kneecap. See an illustration of the knee joint
What causes patellar tracking disorder?

47. Patellofemoral Syndrome
Causes of patellofemoral or anterior knee pain Soft tissue causes Osteochondritis Dissecans of the knee; Chondral fracture. Functional causes Hip pain; Ankle pain.
http://www.fpnotebook.com/ORT236.htm
Home About Links Index ... Editor's Choice document.write(code); Advertisement Orthopedics Knee Fracture ... Knee Osteochondritis Dissecans Assorted Pages Anatomy Pes Anserine Bursitis Prepatellar Bursitis Fabella Syndrome ... Knee Pain Patellofemoral Syndrome Chondromalacia Patellae Miserable Malalignment Syndrome Patellofemoral Pain Syndrome Runner's Knee Book Home Page Cardiovascular Medicine Dentistry Dermatology Emergency Medicine Endocrinology Gastroenterology General Medicine Geriatric Medicine Gynecology Hematology and Oncology HIV Infectious Disease Jokes Laboratory Neonatology Nephrology Neurology Obstetrics Ophthalmology Orthopedics Otolaryngology Pediatrics Pharmacology Prevention Psychiatry Pulmonology Radiology Rheumatology Sports Medicine Surgery Urology Chapter Orthopedics Index Ankle Brachial Cervical Spine Dermatology Elbow Examination Foot Forearm Fracture Hand Hematology and Oncology Hip Infectious Disease Knee General Pulmonology L-Spine Neurology Pediatrics Prevention Procedure Radiology Rheumatology Shoulder Sports Medicine Symptom Evaluation T-Spine Wrist Page Knee Index Anatomy Bursa Pes Anserine Bursa Prepatella Fabella Fracture OCD Iliotibial Band Ligament ACL Ligament Collateral Tear Ligament PCL Meniscus Patella Patella Chronic Injury Patella Dislocation Patella Osgood Schlatter Patella Tendon Rupture Plica Popliteal Cyst
  • Epidemiology Most common Running Injury Causes of patellofemoral or anterior Knee Pain Soft tissue causes Prepatella bursitis Patella tondonitis Meniscus Tear Articular causes Chondromalacia patellae Patella Osteoarthritis Osteochondritis Dissecans of the Knee Chondral fracture
  • 48. McConnell Treatment For Anterior Knee Pain - Physio-net
    Patellofemoral pain syndrome is characterised by anterior or peripatellar knee pain in the absence of other knee pathology. This
    http://physio-net.com/reference/treatmenttechniques/mcconnell.htm
    Home Reference Treatment Techniques McConnell Treatment for Anterior Knee Pain Patellofemoral pain, also referred to as anterior knee pain, is a common musculoskeletal condition in the general and sporting communities. It affects up to 25% of the population, 36% of adolescents and is more prevalent in females. Patellofemoral Pain Syndrome is characterised by anterior or peri-patellar knee pain in the absence of other knee pathology. This pain can be diffuse or sharp and is usually associated with at least two of the following activities:
    • squatting ascending or descending stairs kneeling sitting for long periods walking/running
    It may be associated with crepitus on knee movements, occasional swelling particularly after exercise, and pseudo locking or giving way. Role of physiotherapy Physiotherapy is the mainstay of conservative treatment for this condition and the Australian physiotherapy profession has received international recognition for anterior knee pain management. The most effective treatment for patellofemoral pain is a McConnell program, designed and monitored by a physiotherapist according to the patient's individual needs. This recognised anterior knee pain management program was first introduced by Jenny McConnell, an Australian physiotherapist (McConnell, 1986). The approach uses a specialised, functional exercise program to improve the muscle control around the knee and taping to reposition the patella.

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    50. Pediatric Sports Medicine - Anterior Knee Pain
    the patella is a common cause of anterior knee pain. the trochlear groove during normal knee range of factors that predisposes someone to malalignment syndrome?
    http://www.ucch.org/sections/sports/anteriorkneepain.html
    Sections/Specialties Palos Heights Merrillville La Rabida
    [Return to main] Pediatric Sports Medicine ANTERIOR KNEE PAIN Malalignment of the patella is a common cause of anterior knee pain What is a malaligned patella?
    It is a patella that subluxes laterally within the trochlear groove during normal knee range of motion. What are some factors that predisposes someone to malalignment syndrome?
    • Increased Q angle
    • Increased femoral anteversion
    • Genu recurvatum
    • Patella alta
    • Pes planus

    What are the signs and symptoms of malalignment syndrome?
    Knee cap cracking or popping when the knee is flexed
    Knee pain associated with activities that require knee flexion, for example stair climbing
    Knee stiffness with prolonged sitting What can be done to treat malalignment syndrome?
    Quadricep strengthening is the best course of conservative care. What are some quadriceps strengthening exercises that will not exacerbate my pain?
    Straight leg raises are the best exercises for strengthening without causing increased pain. Straight leg raise
    • This exercise is performed by lifting the affected leg off the floor approximately 6inches and contracting the quadriceps for 3-5 seconds, while keeping the knee fully extended.

    51. Knee Pain In Adolescents- TEMPLATE
    Common conditions OsgoodSchlatter syndrome; Chondromalacia patellae; anterior knee-pain syndrome (patellofemoral arthralgia); Meniscus tear.
    http://www.uicomp.uic.edu/intmedres/template/KneeAdol.htm
    Return to list of Templates Internal Medicine
    Residency Program
    Primary Care Template: Knee Pain in Adolescents and Young Adults
    Description:
    Active adolescents and young adults can develop chronic knee pain from the repetitive trauma of running, playing basketball, and jumping. The causes of this condition differ from the causes of acute knee pain that follow trauma to the knee, and also from the causes of chronic knee pain in the older adult
    Common conditions:
    • Osgood-Schlatter syndrome Chondromalacia patellae Anterior knee-pain syndrome (patellofemoral arthralgia) Meniscus tear
    Key historical information:
    • Young adolescent (Osgood-Schlatter, patellofemoral arthralgia) Young adult runner or basketball player (Chondromalacia) Rotational injury while knee flexed (meniscus tear). Aggravated by climbing or descending stairs (Chondromalacia, patellofemoral arthralgia) Relieved by activity (sometimes in patellofemoral arthralgia) Relieved by rest (Chondromalacia) Locking (meniscus tear, sometimes patellofemoral arthralgia)
    Key physical findings:
    • Effusion (meniscus tear, Chondromalacia)

    52. Welcome To AJC!
    anterior knee pain. Overview Symptoms Treatment Prevention. Alternative names knee pain runner s condition; Patellofemoral stress syndrome. Definition
    http://www.ajc.com/search/healthfd/shared/health/adam/ency/article/001259.html
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    ajc store Gifts Photos/pages Browser tip  Make ajc.com  your homepage: ajc guides Schools Visitors Illustrated Health Encyclopedia Important notice Ency. home Injury A Anterior knee pain Overview Symptoms Treatment Prevention Alternative names: Knee pain - runner's condition; Patellofemoral stress syndrome Definition: Knee pain caused by misalignment of the patello-femoral joint (where the kneecap articulates with the end of the thigh bone). Considerations A physical examination of the knee will confirm the presence of a painful joint. Tests that may be performed to rule out possible structural damage to the knee or connective tissue: Causes The most common cause of runner's knee is pronation and lateral (away from the middle) pulling of the patella. This causes misalignment with the connective tissues and muscles involved with knee movement.

    53. Acupuncture Relieves Knee Pain - Acupuncture Today
    anterior knee pain in adolescents. Clin J Sports Med 1994;4176181. Karlsson J, et al. Eleven year followup of patellofemoral pain syndrome.
    http://www.acupuncturetoday.com/archives2000/apr/04kneepain.html
    Acupuncture Today
    April, 2000, Volume 01, Issue 04
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    Acupuncture Relieves Knee Pain Study Finds "Clear, Durable Effect" in Reducing Pain and Improving Function
    By Michael Devitt, Managing Editor According to the National Institutes of Health, more than four million people seek medical care for a knee problem each year. A leading cause of chronic knee pain, particularly in young adults, is patellofemoral pain syndrome (PFPS). The condition occurs most frequently in adolescents who participate in sports, and is one of the most common diagnoses given at orthopedic centers and sports medicine clinics worldwide. Despite its prevalence, the contributing factors to patellofemoral pain syndrome are unclear. Although several studies have linked knee pain to certain physical activities, there seems to be no direct correlation between the level of pain and the degree of cartilage damage to one's knee, or to the amount of flexion or extension a person's knee experiences. To date, no single therapy has been shown to be completely effective in treating PFPS. However, acupuncture has shown promise in treating similar conditions such as gonarthrosis and osteoarthritis of the knee.

    54. The Physician And Sportsmedicine:
    and femoral trochlea, which may produce the characteristic anterior knee symptoms (1). Diagnosing and treating patellofemoral pain syndrome is challenging but
    http://www.physsportsmed.com/issues/1999/08_99/paluska.htm
    Using Patellofemoral Braces for Anterior Knee Pain
    Scott A. Paluska, MD; Douglas B. McKeag, MD, MS Department Editor: William O. Roberts, MD THE PHYSICIAN AND SPORTSMEDICINE - VOL 27 - NO. 8 - AUGUST 1999 D isorders of the patellofemoral joint are common in recreational and competitive athletes. The pathophysiology of these disorders is unclear but may be related to malalignment of the patella and femoral trochlea, which may produce the characteristic anterior knee symptoms (1). Diagnosing and treating patellofemoral pain syndrome is challenging but important, since patellofemoral abnormalities can result in substantial discomfort and disability. One treatment measure that many patients find helpful for anterior knee pain is the simple-to-fit, inexpensive patellofemoral knee brace (PFB). These braces are best used as an adjunct to other therapies.
    Benefits and Uses
    PFBs were designed to minimize lateral patellar subluxation and dislocation, improve patellofemoral tracking, and decrease anterior knee pain (2). They are also intended to provide proprioceptive feedback and warm the patellofemoral joint. PFB manufacturers have made many claims about the efficacy and benefits of their braces, but most assertions have not been supported by scientific investigation or analysis (3). As with other types of knee braces, however, patients who have worn PFBs report benefits that exceed the objective effects noted by researchers (3,4). While PFBs do not appear to alter underlying biomechanical dysfunction, they provide a static restraint that (in most cases) applies a medially directed force to the lateral patella, thereby decreasing abnormal patellofemoral tracking. The sleeve itself helps compress the tissues and limit excessive patellar movement.

    55. The Physician And Sportsmedicine: Knee Pain And Bicycling
    In Brief anterior knee pain and patellofemoral pain syndrome are among the most common leg overuse injuries in cyclists. Bicycle
    http://www.physsportsmed.com/issues/2004/0404/asplund.htm
    Knee Pain and Bicycling
    Fitting Concepts for Clinicians
    CPT Chad Asplund, MD; COL Patrick St Pierre, MD THE PHYSICIAN AND SPORTSMEDICINE - VOL 32 - NO. 4 - APRIL 2004 For CME accreditation information, instructions and learning objectives, click here In Brief: Anterior knee pain and patellofemoral pain syndrome are among the most common leg overuse injuries in cyclists. Bicycle fit, recent change in equipment, training distance and intensity, and individual anatomic factors are important evaluation considerations. Clinicians need a basic understanding of bicycle fitting and how anatomic factors and training errors contribute to repetitive stress injuries. After problems are addressed, a gradual return to activity is recommended to avoid further injury and improve performance. W ith Lance Armstrong's successes in the Tour de France and the increasing popularity of mountain biking, participation in bicycling has steadily increased over the past 10 years. Cycling is an excellent alternative for runners and other athletes seeking low-impact exercise. The Bureau of Transportation Statistics at the US Department of Transportation estimates that more than 49 million Americans ride bicycles at least monthly, with over 5 million people riding at least 20 days per month. The number of cycling-related injuries has also risen, with the majority caused by overuse. Injuries may also be related to improper bicycle fit or equipment, poor technique, or inappropriate training patterns. Cycling is very repetitive; during 1 hour of cycling, a rider may average up to 5,000 pedal revolutions. The smallest amount of malalignment, whether anatomic or equipment related, can lead to dysfunction, impaired performance, and pain.

    56. Injurytreatment.com.au > Injury Regions > Knee > Anterior (Front) Knee Pain
    Joint pain) anterior knee pain or what is commonly known as patellofemoral joint (PFJ) syndrome is a very common cause of pain at the front of the knee.
    http://www.injurytreatment.com.au/home/injuries/knee/141
    e: p: Not a member? Join now With a free membership you can access extra information and features that will help you get back on track faster. Home Injury Regions Knee Anterior (Front) Knee Pain
    Anterior (Front) Knee Pain
    Injury Information
    Patella Dislocation/Subluxation:
    The patella, or knee-cap as it is commonly known, is the round shaped bone at the front of the knee. It is used by the powerful leg muscles such as the quadriceps to provide the fulcrum for leverage and power.
    The patella tendon runs down from the knee-cap to connect to the lower leg bone, tibia.
    When bumped with force, the knee-cap can sometimes be moved from its place at the front of the knee to either side but most commonly to the outside. A dislocation has been sustained when it 'pops' out of its groove and stays there. If the patella only slides out part of the way this is known as a subluxation.
    Intense pain and patellofemoral joint swelling will be experienced.
    Patella tendonitis:
    Patella tendonitis usually is caused from excessive stress to the patella tendon. Jumpers knee is a term commonly used. It is not a sudden injury but a wear and tear soreness the you may notice over time during and after activity. Pain will be felt as a burning and will be worst following exercise. Quadriceps tightness and weakness may accompany patella tendon pain Kicking a ball regularly or constantly squatting or climbing stairs might trigger the soreness.

    57. Research + Anterior Knee Pain In Athletes: Surgical Management
    It is important to realise that anterior knee pain is a symptom and not a syndrome. Chondromalacia, like anterior knee pain, is not a syndrome.
    http://www.orthopaedics.co.uk/boc/v2rinfo6.htm
    home +research
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    Research Papers and Topics
    Anterior Knee Pain in Athletes: Surgical Management
    David P Johnson Optimum knee function is of vital importance in a wide variety of sports. Knee stability is important in runniing, twisting, jumping and pivoting. Injuries to the knee are very common because of the lack of bony congruity and its reliance on muscular and ligamentous support. Knee injuries are the most common serious injury during sporting activities. Anterior knee pain affects 29% of adolescent children (Fairbank 1984). This may be related to the increase in structured sporting activity which occurs at school during early adolescence. Anterior knee pain is particularly prevalent in certain sports which include basketball, netball, athletics, skiing and cyclling. In these sports activities are undertaken whilst the knee is in a flexed position, and or jumping is common. To understand the patho-mechanics of anterior knee pain, the anatony, clinical examination and mechanics of the knee must be well understood. Much of the confusion surrounding anterior knee pain has been produced by the inability of the practitioner to translate distinct clinical problems into a specific classification. This applies whether they be a general practitioner or hospital consultant (Ref).

    58. Knee Pain
    anterior knee pain anterior knee painPatella Femoral syndrome anterior knee pain (patella femoral syndrome) is very common in athletes.
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    Discuss Knee pain related topics with other users, in our forums centered around knee conditions or procedures, like knee replacement, osteoarthritis. ... COMMUNITY:Forums - Knee pain. You are in the Knee pain forum on Knee1 ... Mar. 21, 2004. Knee pain under knee cap. 1 ...
    Knee Pain

    Knee Pain and Problems. Brief anatomy of the knee: The knee is a vulnerable joint that bears a great deal of stress from everyday activities such as lifting and kneeling, and from high-impact activities such as jogging and aerobics.

    59. INTRODUCTION & DEFINITION
    any one of patellofemoral pain syndrome, chondromalacia patellae , recalcitrant anterior knee pain , patellofemoral stress syndrome , femoropatellar pain
    http://www.ucalgary.ca/~kneepain/Intro.htm
    Anterior Knee Pain (AKP) is a nonspecific diagnosis that refers to pain expressed in the anterior region of the knee. It is a common clinical problem seen in all age groups and presented to general practice, sport medicine, orthopaedic and emergency department settings. Previous studies by our research group have confirmed that a paucity of consensus exists in the following areas definition classification , assessment, diagnosis and management of anterior knee pain. This lack of consensus and the ambiguity of the term 'anterior knee pain' creates confusion and frustration for both the clinician and the patient. Anterior Knee Pain has been referred to as any one of ' patellofemoral pain syndrome chondromalacia patellae recalcitrant anterior knee pain patellofemoral stress syndrome femoropatellar pain syndrome patellofemoral arthralgia ' or ' patellalgia '. Without consensus on the definition, etiology and/or management of anterior knee pain, a symptom such as pain in the anterior region of the knee becomes accepted as a diagnosis. The treatment process then results in a subjective focus on the symptoms rather than individualizing treatment based upon causative and/or etiologic factors. The use of consensus statements in the assessment and management of knee disorders may assist in alleviating the confusion for patients and physicians, and may result in more efficient use of health care dollars. The AKP research group is undergoing a multi-phased approach to developing consensus statements in the areas of definition, assessment, diagnosis and management. Consensus that is based upon current scientific literature coupled with 'expert' opinion and review assists in providing a strong foundation for developing clinical guidelines.

    60. An Approach To Knee Pain
    Causes of anterior knee pain, ranging from quadriceps tendinopathy to patellar subluxation and patellofemoral syndrome, will elicit pain and/or weakness with
    http://www.patientcareonline.com/be_core/content/journals/p/data/2003/0415/0403k
    document.write('')
    April 2003
    An approach to knee pain
    EUGENE HONG, MD, Clinical Assistant Professor, Departments of Sports Medicine and Family Medicine; and Assistant Director, Primary Care Sports Medicine, Thomas Jefferson University, Philadelphia, Pa.
    The differential diagnosis of knee pain encompasses intra- and extra-articular causes, and the pathogenesis may be traumatic, biomechanical, or systemic. This article focuses on intra-articular knee problems.
    Jump to: Choose article section... Piecing together the story Overview of the differential diagnosis Knee examination Examination for anterior knee pain Role of knee biomechanics When to get an imaging study Principles of management Supplementation in knee osteoarthritis: Does it help? When to refer Basic palpation and stress testing of the knee
    Click here to view full-size graphic A thorough history is vital in understanding the possible causes in any complaint of knee pain. The patient's age, occupation, sports and other activities, and history of trauma should all be noted. Then gather the details about the pain itself, specifically when and how it started and whether trauma was involved (see Table 1).
    TABLE 1
    Key history components in knee pain
    Age of patient
    Skeletal maturity
    Occupation
    Activities
    Prior trauma
    Onset: acute, traumatic, or insidious

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