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1
Evidence – Based Examination
and Treatment of the
Sports/Orthopedic Knee and
Patellofemoral Joint
@robptatcscs
Robert Manske, PT, DPT, SCS, ATC, CSCS
Wichita State University Department of
Physical Therapy
Via Christi Health
Wichita, KS
Anatomy and Biomechanics of
the Patellofemoral Joint
Robert C. Manske PT, DPT, MEd, SCS, ATC, CSCS
Professor
Wichita State Department of Physical Therapy
Via Christi Health
Wichita, KS
Knee Injuries
• 14-16% of all musculoskeletal injuries at
the high school level.
• 9000 knee surgeries performed on high
school athletes alone
National high school injury survey. Natl Athl Train Assoc News. April
1996:17-23.
Rice SG. Risks of injury during sports participation. In: Sullivan JA,
Anderson SJ, (eds). Care of the Young Athlete. Rosemont, IL: American
Academy of Orthopaedic Surgeons and the American Academy of
Pediatrics; 2000:9-18.
PFP• General practitioner sees an average of 5-6 new cases
per year, actual incidence in general population is
unknown.
• Higher incidence in females.
• Incidence rates of 25-43% in military and sports
medicine.
Callaghan M, Selfe J. Has the incidence of prevalence of patellofemoral pain in
the general population in the UK been properly evaluated. Phys Ther Sport.
2007;8:37-43.
Devereaux MD, Lachmann SM. Patello-femoral arthralgia in athletes attending
a Sports Injury Clinic. Br J Sports Med. 1984;18:18-21.
Thijs Y, Van Tiggelen D, Roosen P, De Clercq D, Witvrouw E. A prospective
study on gait-related intrinsic factors for patellofemoral pain. Clin J Sports
Med. 2007;17:437-445.
PFP• Investigate 2-year prognosis of knee pain among
adolescents with and without knee pain.
• 2200 aged 15-19 yrs old.
• 55% of those with knee pain continued to have
knee pain after 2 years
• 12% of those without knee pain at baseline had
pain after 2 years
• Those with pain more likely to decrease activity
Rathleff MS, Rathleff CR, Olesen JL, Rsmussen S, Roos WM. Is knee pain
during adolescence a self-limiting condition? Prognosis of patellofemoral pain
and other types of knee pain. Am J Sport Med. 2016;44(5):1165-1171.
Patellofemoral Anatomy
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The Patella: The “little plate”
Primary role in promoting efficient
load transmission
Acts as bony shield to underlying
structures
Patella
• Embedded within
quadriceps
• Largest sesmoid in
body
• Inverted triangle with
apex directed inferior
Patella
• Anterior Surface
• Convex all directions
• Rough superior third
– Quadriceps tendon
• V-shaped point
– Patellar tendon
Patella
• Posterior Surface
• Central portion of patella has thickest cartilage ~ 5 mm
• < 1 mm in periphery of surfaces
• Up to 7 mm mid-patellar – Thickest in human body
Fulkerson JP. Disorders of the Patellofemoral Joint, 3rd ed. Williams
&Wilkins, Baltimore, MD, 1997.
Heegaard J, et al. The biomechanics of the human patella during passive knee
flexion. J Biomech. 1995;28:1265-1279.
Grelsamer RP, Weinstein CH. Applied biomechanics of the patella. Clin
Orthop Rel Res 2001;389:9-14.
Patella• Posterior Surface
• Bone mineral density greater in lateral portion of patella – Increased loads
• Inferior pole– Non articulating
• Vertical ridge
• Articular cartilage
• Divided equally
• Medial and lateral facets
Fulkerson JP. Disorders of the Patellofemoral Joint, 3rd ed. Williams
&Wilkins, Baltimore, MD, 1997.
Leppala J, et al. Bone mineral density in the chronic patellofemoral pain
syndrome. Calcif Tissue Int 1998;62:548-553.
Patella
• Posterior Surface
• Facets flat to biconvex
sup/inf and med/lat
• Second vertical ridge
• Odd facet
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Distal Femur
• Distal Femur
– Femoral sulcus
– Patellar groove
– trochlea
• Ridge corresponds to that of posterior patella
• Lateral facet of sulcus higher than medial
Distal Femur
• Trochlear displasia
PFJ
• Attached from quads
to tibial tuberosity
• Patellar surface much
smaller than femoral
surface
• One of the most
incongruent joints in
body
Four – Quadrant Force Equality
PF Medial Side Restraints
• Dynamic
– VMO fibers
– Originates from adductor magnus and adductor longus tendon
– Inserts on superomedial half of patella
– Results in oblique pull
PF Medial Side Restraints
• Dynamic
– VMO fibers do not extend the knee
– VML fibers extend the knee
– VMO fibers provide medial dynamic stability to patella
– VMO dysplasia predisposes the patient to lateral subluxation
– Selective atrophy of VMO post Sx
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PF Medial Side Restraints
• VMO
• “Key to the knee”
• Normal inserts 1/3 to ½ way down medial border of patella
• Pathologically may barely reach patella
• Only medial side dynamic restraint
Quadriceps
• Lieb and Perry
• VML 15-18° from
long axis of femur
• VMO 50-55° from
long axis of femur
Lieb FJ, Perry J: Quadriceps function: an anatomical and mechanical study
using amputated limbs. J Bone Joint Surg 1968;50A:1535-1548.
PF Medial Side Restraints
• Static
– Medial Retinaculum
– Medial capusle
– Medial PFL
Medial Patellofemoral Ligament
• Primary static restraint to lateral patellar
displacement at 20° of knee flexion,
contributing 60% of total restraining force.
• Medial retinaculum and patellotibial
ligaments minimal contributions at 11% and
5% respectively
Desio SM, Burks RT, Bachus KN. Soft tissue restraints to lateral
patellar translation in the human knee. Am J Sports Med 1998;26:59-65.
Medial Patellofemoral Ligament
• 55% of passive soft tissue restraint to lateral
patellar subluxation
Amis AA. Current concepts on anatomy and biomechanics of patellar
stability. Sports Med Arthrosc. 2007;15:48-56.
Medial Patellofemoral Ligament
• 20 limbs from 17
cadavers
• MPFL identified in
66.7%
• More commonly
found than LPFL
Waligora AC, Johanson NA, Hirsch BE. Clinical anatomy of the
quadriceps femoris and extensor apparatus of the knee. Clin Orthop Rel
Res 2009;467:3297-3306.
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Dynamic Medial Restraints PF Lateral Side Restraints
• Dynamic
– Vastus lateralis
• Static
– Lateral retinaculum
• Superficial – IT
band to patella
• Deep
– ITB
– TFL
Dynamic Lateral Restraints
Patellofemoral Biomechanics
Patellar Function
• Facilitating extension of the knee by increasing the distance of the extensor apparatus
• Moment arm produces greatest quadriceps torque at 20-60°flexion
• Neutral position 0°
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Patellar Function
• Guide for the quadriceps tendon
• Changes direction of quadriceps force –acting as a pulley
PF Joint Reaction Forces
(PFJRF)
• The measurement of compression of patella
against femur
• Greatest force occurs between 60-30°
– Values approaching 3000 Newtons
Huberti HH, et al. Force ratios in the quadriceps tendon and ligamentum
patella. J Orthop Res 1984;21:49-54.
PF Joint Reaction Forces
(PFJRF)
• PFJRF are equal and
opposite to R of
quadriceps tension and
patellar tendon tension
PFJRF• Increase as knee flexion increases
– Angle becomes more acute
– Lever arms of femur and tibia increase
PF Joint Reaction Forces
(PFJRF)
• OKC knee extension requires greater
amount of quad force
– Active insufficiency of quads
– Full effects of gravity
– Decreased biomechanical advantage
PFJRF
• Imbalance of quadriceps muscle that
produces a decrease in magnitude or
direction of tension of VMO may result in
significant displacement of patella laterally
placing the PFJRF almost entirely on the
lateral facet
Rand JA. The patellofemoral joint in total knee arthroplasty. J Bone
Joint Surg 1994; 76A:612-620.
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Forces on the patella
• Walking 0.5-1.5x BW
• Stairs 3.0x BW
• Squatting 7-8x BW
Percy EC, Strother RT. Patellalgia. Phys SportsMed 1985;13:43-59.
Huberti HH, Hayes WC. Patellofemoral contact pressures. The incidence of
Q-angle and tendofemoral contact. J Bone Joint Surg 1984;66A:715-724.
Reilly DT, Martens M. Experimental analysis of the quadriceps muscle force
and patello-femoral joint reaction force for various activities. Acta Orthop
Scand 1972;43:126-137.
Contact Stress
One part or another of patellar cartilage is
loaded throughout the entire flexion-
extension cycle
Except the earliest degrees of knee flexion
Grelsamer RP, Weinstein CH. Applied biomechanics of the patella.
Clin Orthop Rel Res 2001;389:9-14.
CKC Exercises
Contact Pressures and PFJ
• CKC Exercises
• As knee extends PFJ
contact stress decreases
despite”
– decreased contact area
– May be due to decreased
torque of gravity
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OCK Exercises
Contact Pressures and PFJ
• OKC Exercises
• As knee extends PFJ
contact stress increases
due to:
– Increased PFJR force and
decreased contact area
Contact Pressures and PFJ
• High contact pressure
activities
• Loaded OKC knee
extension exercise
• CKC knee extension
activities in > 50° of
knee flexion
Contact Pressures and PFJ
• Low contact pressure
activities
• Loaded OKC knee
extension exercise from
90°-50° & 20°-0°
• CKC knee extension
activities in < 50° of
knee flexion
PF Contact Surface Area
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PF Contact Surface AreaDegree of
Flexion
Patella Articulation Femoral
Articulation
0° Femoral Sulcus Min. bony
contact
20°-30° Inf. facets Mid. fem.sulcus
60° mid. facets Superior femoral
notch
90° mid/sup lat facets Sup fem notch
120° Lat mid and sup
facet
Sup fem notch/
LFC
135° Lat mid facet/lat
sup facet/ odd
LFC/lat surface
of MFC
Contact Stress
Distal portion of patella loaded as knee flexes
and contact area migrates proximally with
progressive flexion
At 90° the contact area is located proximally,
after which contact area moves back toward
central aspect of patella
Grelsamer RP, Weinstein CH. Applied biomechanics of the patella.
Clin Orthop Rel Res 2001;389:9-14.
Articular Surface Of The Patella
Quadriceps Angle
“THE LAW of VALGUS”
Fulkerson JP and Hungerford DS:
Disorders of the Patellofemoral Joint.
2nd ed. Baltimore, MD: Williams and
Wilkins
PF Signs
• Increased Q-angle
– More significant
for females
• Normal
Males: 8°-14°
• Females: 15°-
17°
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Q-Angle • Originally described
by Brattstrom
• “the angle formed by
the resultant vector of
the quadriceps force
and the patellar tendon
with the knee in an
“extended, end-
rotated” position.”
Brattstrom H. Shapre of the intercondylar groove normally and in recurrent
dislocation of the patella. Acta Orthop Scand Suppl 1964;68:1-48.
Q-Angle • Angle formed by the
intersection of a line drawn from the anterior superior iliac spine to the midpoint of the patella
• Proximal extension of the line from the tibial tubercle to the midpoint of the patella
Neuman DA. Kinesiology of the Musculoskeletal System: Foundations
for Physical Rehabilitation. Philadelphia, PA: Mosby, Inc., 2002.
Q-Angle
• Theory centers around
this measurement
• Offset in force vectors
from the quadriceps
force and force from
patellar tendon
Q-Angle
• A larger Q-angle may
create a larger lateral
vector and potentially a
greater predisposition to
lateral patellar tracking
when compared to a
smaller Q-angle
Schulthies SS et al: Does the Q angle reflect the force on the patella in the
frontal plane? Phys Ther 1995;75:24-30.
Measuring Q angle
• Standing
Caylor D, Fites R, Worrell TW: The relationship between
quadriceps angle and anterior knee pain syndrome. J Orthop
Sports Phys Ther 17(1):11-16, 1993.
Cowan DN, et al: Lower limb morphology and risk of
overuse injury among male infantry trainees. Med Sci Sports
Exerc 28(8):945-952, 1996
Roy S, Irvin R: Sports Medicine: Prevention, Evaluation,
Management, and Rehabilitation, Englewood Cliffs:
Prentice-Hall, Inc., 1983.
Measuring Q angle
• Dynamically
Caylor D, Fites R, Worrell TW: The relationship between
quadriceps angle and anterior knee pain syndrome. J Orthop
Sports Phys Ther 17(1):11-16, 1993.
Kernozek TW, Greer NL: Quadriceps angle and rear-foot
motion: Relationships in walking. Arch Phys Med Rehabil
74(4):407-410, 1993
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Measuring Q angle
• With Quadriceps Contracted
Fairbank JCT, et al: Mechanical factors in the incidence of
knee pain in adolescents and young adults. J Bone Joint Surg
66B(5):685-693, 1984.
Guerra JP, Arnold MJ, Gajdokik RL: Q-angle: Effects of
isometric quadriceps contraction and body position. J Orthop
Sports Phys Ther 19(4):200-204, 1994.
Measuring Q angle
• With Standardized Foot Positions
Cowan DN, et al: Lower limb morphology and risk of
overuse injury among male infantry trainees. Med Sci Sports
Exerc 28(8):945-952, 1996.
Guerra JP, Arnold MJ, Gajdokik RL: Q-angle: Effects of
isometric quadriceps contraction and body position. J Orthop
Sports Phys Ther 19(4):200-204, 1994.
Reider B, Marshall JL, Warren RF: Clinical characteristics of
patellar disorders in young athletes. Am J Sports Med
9(4):270-274, 1981.
Lack of
standardization of a
measurement
technique still a
problem!
Q-Angle
• Relationship between Q-
angle and clinical signs
and symptoms has not
always been consistent
Livingston LA: The Quadriceps angle: a review of the literature. J
Orthop Sports Phys Ther 1998;28:105-109.
Q-Angle
• May be problematic in subpopulation of
those with PFP
• Etiologic factors unrelated to Q-angle may
be more dominant in certain individuals
• Remember: Q-Angle is “static”
measurement that measures dynamic
function!
Femoral Anteversion and
Retroversion Effects on Q-Angle
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Q-Angle
• Can vary significantly when measurement
taken standing due to foot position.
• Supine measurement taken as static position
• Standing can be taken as a more
“functional” measurement.
Q-Angle
• Although and increased Q-angle is
traditionally associated with a valgus knee,
some of the highest Q angles are found in
patients with a combination of genu varus
and proximal tibial torsion.
Hughston JC, Walsh WM, Puddu G. Patellar subluxation and
dislocation. In: Saunders Monographs in Clinical Orthopeadics,
Philadelphia. Saunders, 1984.
Olerud C, Berg P. The variation of the quadriceps angle with
different positions of the foot. Clin Orthop 1984;191:162-165.
Patellar OrientationClinical Assessment of PF
Alignment
Patellar Position
• Assess medio-lateral
glide and patellar tilt
with MRI
• 24 subjects; 16 males;
8 females
• * Examiner -15 years
of experience
McEwan I, et al. The validity of clinical measures of patella position.
Man Ther 2007;12:226-230.
Patellar Position
• Good correlation
between findings of
clinical test of
medio-lateral
position and MRI
(r=0.611, p=0.002)
McEwan I, et al. The validity of clinical measures of patella position.
Man Ther 2007;12:226-230.
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Patellar Position
• If found lateral
patellar tilt, patellar
tilt angle via MRI
was > 5°
McEwan I, et al. The validity of clinical measures of patella position.
Man Ther 2007;12:226-230.
• 30 patients with tilt
• 51 patients without tilt
• Found patients with significant tilt on PE can be
expected to have >10° tilt on MR
Grelsamer RP, Weinstein CH, Gould J, Dubey A. Patellar tilt: The
physical examination correlates with MR imaging. Knee. 2008;15:3-8.
Grelsamer RP, Weinstein CH, Gould J, Dubey A. Patellar tilt: The
physical examination correlates with MR imaging. Knee. 2008;15:3-8.
• Any MR angle <10° is associated with the absence
of significant tilt on MR
• *This study should not imply abnormal tilt in any
given patient automatically implies pathology
• Patients with any tilt on PE can be expected to
have an MRI tilt angle that is 10° or >.
Grelsamer RP, Weinstein CH, Gould J, Dubey A. Patellar tilt: The
physical examination correlates with MR imaging. Knee. 2008;15:3-8.
Assessment of Patellar Position?
14
Clinical examination and
measurement of patellofemoral
alignment with visual
examination, using calipers or
goniometer’s may be unreliable
when performed within or
between testers
Intratester Kappa’s displayed
questionable reliability for:
• Mediolateral tilt 0.57
• Superior/inferior tilt 0.50
• Rotation 0.41
• Mediolateral position 0.40
Tomsich DA, Nitz AJ, Threlkeld AJ, Shapiro R. Patellofemoral
Alignment: Reliability. J Orthop Sports Phys Ther 1996;23(3):200-208
Intertester Kappa’s displayed
questionable reliability for:
• Mediolateral tilt 0.18
• Superior/inferior tilt 0.03
• Rotation 0.30
• Mediolateral position 0.03
Tomsich DA, Nitz AJ, Threlkeld AJ, Shapiro R. Patellofemoral
Alignment: Reliability. J Orthop Sports Phys Ther 1996;23(3):200-
208
The low intratester and intertester
agreement coefficients were
clinically unacceptable and
suggest that treatment decisions
based on these measurements
should not be made!
What passes for PF malalignment
at one clinic or with one therapist
may not be the deemed the same
problem at another clinic because
clinicians cannot agree on basic
physical examination data.
Reliability of Tests for PF
Alignment (Intertester)
• Medial/lateral displacement 0.10
• Medial/lateral tilt 0.21
• Anterior/posterior tilt 0.24
• Medial/lateral rotation 0.36
Fitzgerald GK, McClure PW. Reliability of measurements obtained with
four tests of patellofemoral alignment. Phys Ther 1995;75(2):84-92.
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Smith TO, et al. An evaluation of the clinical tests and outcome
measures used to assess patellar instability. The Knee. 2008;15:255-262
Smith TO, et al. The reliability and validity of assessing medio-lateral
patellar position: a systematic review. Man Ther. 2008;:1-8.
Medial/lateral Position
AUTHOR Inter-Tester Intra-Tester
Fitzgerald and McClure, 1995 0.10 NA
Herrington, 2008 NA 0.86
Herrington, 2002 M-.91; L-.94 NA
Herrington, 2006 NA 0.99
Herrington and Nester, 2004 NA 0.99
McEwan et al, 2007 NA 0.86
Powers et al, 1999 NA 0.91
Tomsich et al, 1996 0.14 0.70
Watson et al, 1999 0.02 0.11-0.35
Fitzgerald GK, McClure PW. Reliability of measurements obtained with four tests
for patellofemoral alignment. Phys Ther. 1995;75:84-92.
Herrington LC. The inter-tester reliability of a clinical measurement used to
determine the medial/lateral orientation of the patella. Man Ther. 2002;7:163-167.
Herrington LC et al. the relationship between patella position and length of
iliotibial band as assessed using Ober’s test. Man Ther. 2006;11:182-186.
Herrington LC. The difference in a clinical measure of patella lateral position
between individuals with patellofemoral pain and matched controls. J Orthop
Sports Phys Ther. 2008;38:59-62.
Herrington LC, Nester C. Q-angle undervalued? The relationship between Q-angle
and medio-lateral position of the patella. Clin Biomech. 2004;19:1070-1072.
McEwan I, Herrington L, Thom J. The validity of clinical measures of patella
position. Man Ther. 2007;12:226-230.
Powers C et al. Criterion-related validity of a clinical measurement to determine
the medial/lateral component of patellar orientation. J Orthop Sports Phys Ther.
1999;29:372-377.
Tomsich DA, Nitz AJ, Threlkeld AJ, Shapiro R. Patellofemoral Alignment:
Reliability. J Orthop Sports Phys Ther 1996;23(3):200-208.
Watson CJ et al. Reliability of McConnell’s classification of patellar orientation in
symptomatic and asymptomatic subjects. J Orthopedic Sports Phys Ther.
1999;29:378-385.
Thank You!Robert C. Manske, PT, DPT, MEd, SCS,
ATC, LAT, SCS, CSCS
Professor
Wichita State University Dept. Physical Therapy
1845 North Fairmount
Wichita, Kansas 67260-0043
316-978-3702