Dr Thomas Smallman


Hello my name is Tom Smallman, and I am an ex-military orthopaedic surgeon practicing at the Auburn Community Hospital in Upstate New York.


Every orthopaedic surgeon, even in training, becomes aware of the difficulty of caring for patients with patellofemoral pain (PFP) or anterior knee pain (AKP); these terms represent the same condition. The pathophysiology of this common problem, and the nature of the pain itself, has remained unexplained, hence its moniker, 'the Black Hole of Orthopaedics'. The term, pathophysiology, by the way, simply means the functional changes that accompany a particular disorder.

As I started my career as a military orthopaedic surgeon I soon realized that AKP is common in soldiers, and subsequently as a generalist I found this characteristic set of complaints was present in a wide variety of clinical settings.

My personal goal, in this course, is to tell the story of how our team developed an effective surgical solution to AKP based upon a new paradigm.


What is 'Anterior Knee Pain'?

Anterior knee pain is a symptom complex, dominated by 'pain in the front of the knee'.

This characteristic pain tends to be associated with:

  • forced activities -- squatting, weight bearing activities, running.
  • prolonged sitting – producing stiffness, pain, or both, relieved by straightening (extending) the knee.
  • on getting up from sitting, the pain may be severe, then diminishes and even disappears as the individual keeps walking.
  • the “theatre sign” in some - where the individual seeks to sit at the end of any row of chairs, to allow the relief afforded by knee extension and even standing up.
  • problems with walking - where the person may exhibit weakness, giving way of the knee, and 'catching'.
  • stair climbing producing pain when weight is applied on the leg, when going up or down stairs.
  • snapping, popping, or crunching in the knee occurring with activity as simple as walking, that may be accompanied by pain, which may be so severe that the individual feels that the knee locks.


Objectives and outline of this course

Let me first provide introductory material.

  • What is the definition of the symptom complex of AKP?
  • When does AKP occur?
  • Why is AKP such a problem?

In order to understand AKP you will have to learn some basic anatomy, defining the structures involved, and physiology, the study of the way in which the knee functions.  The various anatomical terms as we go through the discussion may seem intimidating, but the concepts are straight forward.  I will try to simplify at every level.