clinical evaluation of the patellofemoral joint · patella:indications and contraindications am j...

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Clinical Evaluation of the

Patellofemoral Joint

Robert C. Manske, MPT, MEd, SCS, ATC, CSCS

Wichita State University Department of Physical Therapy

Via Christi Health – Wichita, Kansas

Common Condition

• 25-40% of all knee problems presenting to

sports medicine centers

Bizzini M, et al. Systematic review of the quality of randomized controlled

trails for patellofemoral pain syndrome. J Orthop Sports Phys Ther.

2003;33:4-20.

Chesworth BM, et al. Validation of outcome measures in patients with

patellofemoral pain syndrome. J Orthop Sports Phys Ther. 1989;10:302-

308.

Rubin B, Collins R. Runner’s knee. Phys Sportsmed. 1980. 8:49-58.

Common Terms

• PF Arthrosis: true wear and tear

• PF Chondrosis: wear of the chondrocytes

• PF Arthralgia: PF pain

• Anterior Knee Pain Syndrome

• Excessive Lateral Pressure Syndrome (ELPS): articular cartilage on lateral region causing pain

• Extension subluxation: VMO imbalance

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Common Terms

• PF Maltracking

• PF Malalignment

• PF Compression

Non Operative Treatment Successful

in 75-90% of Patients

• Busch MT et al., Clin Sports Med, 8:279-290, 1989

• DeHaven KE et al, Chondromalacia patella in athletes: Clinical presentation and conservative management. Am J Sports Med, 1979;7:5-11.

• Fulkerson J and Hungerford DS. Disorders of the Patellofemoral Joint, 1990

• Insall J. Current concepts review: Patellar pain. J Bone Joint Surg, 1982;64A:147-152.

• Micheli LJ et al., Am J Sports Med, 9:330-336, 1981

• Radin EL, A rational approach to the treatment of patellofemoral pain. Clin Orthop, 1979; 144:107-109.

• Sandow MJ et al, The natural history of anterior knee pain in adolescents. J Bone Joint Surg, 1985;67B:36-38.

• Stougard J, Acta Orthop Scand, 46:685-694, 1975

• Yates C et al., Orthopedics, 9:663-667, 1986

What About the Other

10-25%?

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The Key to Treating PFP is to

treat the CAUSE not the

SYMPTOM(S)

Patellofemoral Pain Syndrome is

Very Vague!

• There needs

to be a

classification

system for

patients with

PF problems

Wilk KE, Davies GJ, Mangine

RE, Malone TR. Patellofemoral

Disorders: A Classification

System and Clinical Guidelines

for Non-Operative Rehabilitation.

Journal of Orthopedic and

Sports Physical Therapy

1998; 28:307-322.

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Classification System

• Patellar Compressive Syndromes

• Patellar Instability

• Biomechanical Dysfunction

• Direct patella Trauma

• Soft Tissue Lesions

• Overuse Syndromes

• Osteochondritis Dissecans

• Neurologic Disorders

PF Pain Symptoms

• Primary c/o pain

• Complain of giving way, due to reflex

inhibition, swelling or weakness

• Crepitus – snap/crackles/pops

• Pain with stairs

• Very slight effusion from synovial response

PAIN

Pain at rest

Nerve-related pain

Neuroma

RSD/CRPS

Radiculopathy

Tumor

Infection

Stress fracture

Grelsamer RP, Stein DA. Patellofemoral Arthritis. J Bone Joint Surg

2006;88A(8):1849-1860.

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Activities that increase loading

across the PF joint

• Ascending or descending stairs

• Squatting

• Jumping

• Sitting with knee flexed for long periods of

time (+ Movie goers sign)

PF Signs

• Passive patellar hypo mobility (global)

• Passive patellar hypermobility

– Primarily lateral glide

• Patellar Malposition

– Patella Alta, patella baja, patellar tilt

VMO Atrophy

• VMO atrophy or

dysplasia

– Measure for VMO

atrophy 10cm proximal

to joint line

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PF Signs

• Patella Alta

– High riding patella

– Length of infrapatellar tendon > height of patella

– Hypermobility

– Usually a congenital problem

– Predisposition to subluxation

– “grasshopper eyes” – sup/lat deviation

– Rx – lateral subluxation brace

– VMO rehab

PF Signs

• Patella baja (infera)

– Congenital or iatrogenically produced

secondary to PT autograph ACL reconstruction

– Scarring down of IPT

– Hypomobility

– Development of chondromalicia secondary to

increased PFJRF

PF Signs

• Insall and Salvati

• Normal

– Height of superior

pole of patella and

length of the IPT

should have 1:1

relationship

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PF Signs

• Positive Apprehension

Test/Fairbanks Sign

• Facet tenderness upon

palpation

Facet Tenderness

PF Signs

• Muscular imbalances

– Flexibility deficits

• Quadriceps

tightness

• Hamstring

Tightness

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PF Signs

• Hypertrophied VL

• VL:VMO timing

• LE malalignment

Patellar Compression Test

Clark’s Patellar Grind

(Compression) Test

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Clark’s Patellar Grind

(Compression) Test

The Diagnostic Value of the

Clarke Sign in Assessing

Chondromalacia PatellaeDoberstein ST, Romeyn RL. J Athlet

Train. 43(2):190-196, 2008.

Doberstein and Romeyn

• Purpose to evaluate CS ability to detect CP in patients undergoing arthroscopic knee surgery

• 106 patients; none with complaints of PFP

Doberstein ST, Romeyn RL. The Diagnostic Value of the Clark Sign in

Assessing Chondromalacia Patellae. J Athl Train. 2008;43(2):190-196.

http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=2267328&rendertype=figure&id=i1062-6050-43-2-190-f02




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• In 106 patients (36) had + CS; only 23 actually had significant CP

• (27) false positives




• 67.5% specific meaning only (56 of 83)

who were tested - actually did not have

pathology.

• 9 patients actually had CP, thus 39% (9 of

23) sensitive meaning only 9 patients + CS

actually had CP

• Clarke’s Sign is an invalid and unreliable

method to detect CP



PF Crepitus

• Grading of crepitus will only evaluate the PF joint

• Position in 90/90

• Grade most severe sounds

• Loudest ROM should be documented

• If present is it painful or painless

– 1+ Mildly palpable

– 2+ Moderately palpable

– 3+ Severely palpable and audible





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PF Crepitus

• Tactile Friction Sound• Grading scale

• None

– Smooth motion – no sound

• Mild

– Fine grade sandpaper - no sound

• Moderate

– Medium grade sandpaper – squeaky floorboard

• Severe

– Bone-on-bone grinding – popping-cracking-crunching

Lancaster AR, Nyland J, Roberts CS. The validity of the motion

palpation test for determining patellofemoral joint articular cartilage

damage. Phys Ther Sport 2007;8:59-65.

PF Crepitus

• 188 consecutive patients with suspected PF joint articular cartilage damage.

• Clinical examination followed by arthroscopic surgery

• Motion Palpation Test

– Patient edge of table, knee at 90º, passively moving knee between 100-0º while applying ~5 lb compression force with index finger distal to inferior patellar pole




PF Crepitus

• Motion palpation test:

– sensitive (87%)

– positive predictive value (97%)

– Accuracy (85%)




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PF Crepitus

• Low in:

– Specificity (33%)

– Negative predictive value (10%)

– This indicates a large number of people without pathology tested positive

– **Findings indicate that MPT is only useful as PE tool for identifying PF joint articular cartilage damage when crepitation grade is listed as severe!




Muscle Flexibility

Specific Flexibility Tests

• Hamstrings in 90/90

– Tight hamstrings may pull tibia posterior

– Pulls IPT inferior/posterior

– Increase PFJRF secondary to adaptive shortening of the retinaculum

– Creates “hamstrung knee”

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• Gastrocnemius/Soleus

• Lumbar spine

• Hip flexors

– Thomas Test


• Quadriceps Femoris

– Ely’s Test


• ITB/TFL

– Obers Test (knee extended)

– Modified Obers (knee

flexed) isolates TFL

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• Hip IR/ER

The primary goal in treating

patients with anterior knee pain is

identifying the cause and treating

the causative factors

PF Orientation: Glide

Component

• Normal position

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Component

• Lateral glide: midline

of the patella is lateral

to the midline of the

femur


Component

• Lateral glide: midline

of the patella is lateral


femur


Component

• Medial glide: midline

of the patella is medial


femur. Medial glide is

very rare and may be

present with an over-

extensive post-op

lateral release.

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Passive Mobility of PFJ

• Has been described in full extension

• And 30° knee flexion.

Fulkerson JP, Hungerford DS. Disorders of the patellofemoral joint.

2nd ed. Baltimore, MD: Williams and Wilkins; 1990.

Kujala UM, Kvist M, Osterman K, et al. Factors predisposing army

conscripts to knee exertion injuries incurred in a physical training

program. Clin Orthop 1986;210:203-212.

Fithian DC, Mishra DK, Balen, et al. Instrumented measurement of

patellar mobility. Am J Sports Med 199523(5):607-615.

Skalley TC, Terry GC, Teitge RA. The quantitative measurement of

normal passive medial and lateral patellar motion limits Am J Sports

Med 1993;21:728-732.

Patellar Passive Mobility

• When done in full extension is more purely

a test of peripatellar soft-tissue compliance

because there is less resistance from

engagement of patella in trochlea

Passive Medial and Lateral Glide

Test

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• Measurement done by dividing the knee into quadrants

• 3 quadrants of lateral glide suggest incompetent medial restraint

• Medial glide of 1 or less tight lateral retinaculum

• Medial glide greater than 3 quadrants indicates hyper mobility

Kolowich PA, Paulos LE, Rosenberg TD, et al. Lateral release of the

patella:Indications and contraindications Am J Sports Med

1990;18(4):359-365.


• Medial translation 9.5 mm

• Lateral translation 5.4 mm

• Ranges for each direction 3-15 mm

• Must therefore examine for bilateral

symmetry not just overall mobility

Skalley TC, Terry GC, Teitge RA. The quantitative measurement of

normal passive medial and lateral patellar motion limits Am J Sports

Med 1993;21:728-732.


• Lateral passive patellar displacement with

6# force

• 14 +/- 1.8 mm

• Range of 8-20 mm

Joshi RP, Heatley FW. Measurement of coronal plane patellar

mobility in normal subjects. Knee Sports Surg Tramatol Arthrosc

2000;8:40-45.

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• 22 females with PFP

• 22 females without

• Measured with

special apparatus

Ota S, et al. Comparison of patellar mobility in female adults with

and without patellofemoral pain. J Orthop Sports Phys Ther

2008;38(7):396-402.



2008;38(7):396-402.

Passive Patellar Mobility

• No significant

differences in lateral

or medial patellar

mobility in females

with and without

PFP



2008;38(7):396-402.

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Apprehension Test

Image from: Stanitski CL: Patellofemoral Mechanism, in: Stanitski et al.

Pediatric and Adolescent Sports Medicine, Vol 3. W.B. Saunders,

Philadelphia, 1994.

Patellar Maltracking

• Continues to be the subject of much debate!

• Usually patella follows a Concave Lateral

C-Shaped curve moving from flexion to

extension.

PF Orientation: Passive Tracking

Component

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PF Orientation: Active Tracking

Component

Active Resisted Range of Motion

PF Orientation: Active CKC

Tracking Component

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PF Orientation: Tilt Component

• Normal position Lateral tilt: lateral border

is lower than medial border.


• Lateral tilt: lateral

border is lower than

medial border.


• Medial tilt: medial

border is lower than

lateral border. Rare.

Usually only present

after post-op lateral

release.

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Patellar Tilt Test

• Should be done in full extension with quads

relaxed so that soft tissues are in their most

relaxed position

• Push posteriorly on the medial border of the

patella while lifting on the lateral side

Patellar Tilt Test

• Patella should correct

to at least neutral or

beyond by about 15°

PF Orientation: Rotation

Component

• Normal position.

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Component

• External Rotation:

inferior pole lateral to

superior pole or most

medial point is inferior

to the most lateral

point.


Component

• Internal Rotation:

inferior pole medial to

superior pole or most

medial point is

superior to the most

lateral point.

PF Orientation: Anteroposterior

Component

• Normal

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Component

• Depression: inferior

pole to superior pole


Component

• Elevation: inferior

pole anterior to

superior pole.

Leg Length Measurements

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Leg Length Differences

• Result in abnormal gait and may be

associated with either short or long leg

• Short limb results in pelvic drop on

ipsilateral side causing a increased valgus

force at knee in terminal swing

Perry J. Gait Analysis, Normal and Pathological Gait.

Thorofare, NJ: Slack; 1992.

Leg Length

• No studies yet have implicated direct

relationship between leg length differences

and PF pain

• Clinically seems relevant.

Pelvic Symmetry

• Assess iliac crest

height

• ASIS

• PSIS

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Supine to Long Sitting Test

• Supine to long sit leg

length test

Direct Measurements

• Measure from ASIS to

medial malleolus

• Anatomical

– Supine non weight

bearing

• Functional

– Standing weight

bearing

Knee Ligament Instability

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Knee ligament Instability

• Always rule out each of the four major knee

ligaments for instability

• Parolie and Bergfeld reported that 48% of

their chronic PCL deficient patients had

stiffness following prolonged sitting (+

movie sign).

Parolie JM, Bergfeld JA. Long-term results of nonoperative

treatment of isolated posterior cruciate ligament injuries in the

athlete. Am J Sports Med 1986;14:35-38.

Knee ligament Instability

• Posterior cruciate ligament tears increase

patellofemoral joint reaction forces by

posterior displacement of the tibial

tuberosity.

Kinetic Chain Exercises

• Need to monitored very carefully.

• Limited ankle dorsiflexion

• Excessive subtalar pronation

• Hip external rotator weakness

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Limited Ankle Dorsiflexion

• Tibiofemoral joint required to extend during

mid-stance of gait.

• Excessive pronation (causing tibial internal

rotation) may prevent knee from fully

extending.

• This can ultimately affect patellar tracking.

Reid DC. Anterior knee pain and the patellofemoral pain syndrome. In: Reid

DC ed. Sports Injury Assessment and Rehabilitation, NY Churchill

Livingstone; 1992:345-398.

Lack of Ankle Dorsi Flexion

• Squat requires hip and knee flexion and

ankle dorsiflexion.

• If dorsiflexion limited the subtalar joint will

pronate to compensate for this lack of

motion.

Irrgang JJ, Rivera J. Closed Kinetic Chain Exercises for the Lower Extremity:

Theory and Application. Sports Physical Therapy Section Home Study

Course: Current Concepts in Rehabilitation of the Knee. LaCrosse WI: SPTS;

1994.

Tiberio D. The effect of excessive subtalar joint pronation on patellofemoral

mechanics: a theoretical model. J Orthop Sports Phys Ther 1987;9:160-165.

Ankle Joint Pronation

• This increased pronation, coupled with

internal tibial rotation will increase the

functional Q-angle and may contribute to

patellofemoral pain.

Irrgang JJ, Rivera J. Closed Kinetic Chain Exercises for the Lower Extremity:

Theory and Application. Sports Physical Therapy Section Home Study

Course: Current Concepts in Rehabilitation of the Knee. LaCrosse WI: SPTS;

1994.

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Hip External Rotator Weakness

• Hip weakness may allow uncontrolled hip

internal rotation, allowing excessive foot

pronation, both of which contribute to

increased Q-angle

Pease BJ, Cortese M. Anterior knee pain: Differential diagnosis and physical

therapy management. In Orthopedic Physical Therapy Home Study Course

92-1. LaCrosse WI: Orthopedic Section, American Physical Therapy

Association; 1992.

Thank You!Robert C. Manske, PT, DPT, MEd, SCS, ATC,

LAT, SCS, CSCS

Wichita State University Dept. Physical Therapy

1845 North Fairmount

Wichita, Kansas 67260-0043

316-978-3702

[email protected]

mailto:[email protected]

clinical evaluation of the patellofemoral joint · patella:indications and contraindications am j...

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