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The contemporary management of anterior knee pain and
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S4 T O Smith et al The Knee 20 S1 2013 S3 S15,6 Outcome measurement for PFJT pathology 11. 7 Authors preferred management 12,8 Conclusions 12. 9 Conflict of interest 12,References 12, 1 Introduction However when patellar lateralisation is severe and the medial. soft tissues are unable to maintain the patella within the. The management of the patellofemoral joint disorders of femoral trochlea patellar subluxation and dislocation can occur. anterior knee pain and patellofemoral instability is complex Thus both anterior knee pain and patellofemoral instability. In part the difficulties in management can be attributed to the can be seen as manifestations along a spectrum of the same. multifactorial nature of patellofemoral disorders where osseous pathology The assessment and treatment of the two conditions. and non osseous structures influence the biomechanical can therefore be conducted in the same manner with alterations. interaction between the patella and the femoral trochlea Factors according to the proportion of each in the presentation. that have been implicated in the presentation of patellofemoral. disease include abnormal quadriceps and hamstring muscle 3 Assessment of the patellofemoral joint. recruitment and timing compromised medial patellar soft. tissue restraints reduced lateral patellar soft tissue length 3 1 Patient history. and flexibility abnormal control and stability from the hip. aberrations of foot posture and abnormalities in the bony As with any musculoskeletal assessment a thorough patient. morphology of the trochlea Additional factors such as peri history and clinical assessment are the fundamentals to accurate. articular connective or soft tissue irritation intra articular diagnosis In assessing patellofemoral instability the single most. cartilage damage nerve mediated pain syndromes systemic important question to answer is whether the patient can describe. conditions and psychosocial issues have all been implicated in a convincing report of a dislocation 6 7 A classic history of. the presentation of anterior knee pain 1 2 However few patients patellar dislocation is one of a sudden palpable and visual bony. present with just anterior knee pain or pure patellar instability protuberance on the lateral aspect of the knee with a feeling of. but lie on a spectrum between these two extremes see Fig 1 In the patella popping out 6 often followed by a spontaneous. managing these patients it is better not to think of these as two reduction of the patella on knee extension 8. separate disorders although operative procedures have better In addition to the history surrounding the dislocation event. outcomes for pure instability rather than anterior knee pain and patients should be asked about a family history of patellar. the latter is best managed non operatively However all these instability 9 A positive family history of patellar instability. patients need to undergo an exercise programme to rehabilitate can often be attributed to hypermobility syndrome or trochlear. their muscles benefit from losing weight if obese and need dysplasia 10 14 and may be an important prognostic indicator. pain adequately controlled by medication They also need to be for recurrent dislocation in certain subsets of patients 10. assessed for hypermobility By comparison patients describing a history of anterior knee. This review discusses the current understanding on the pain attributable to the patellofemoral joint classically report. assessment and treatment of patients presenting with anterior retropatellar pain during stair ascent and descent sitting for. knee pain or patellofemoral instability The management of any period of time with the knees at 90 such as during driving. patellofemoral arthritis and other patellar pathologies are at the cinema or theatre and squatting running or jumping. beyond the remit of this review particularly from a flexed position It is important to note that. patients with significant anterior knee pain may describe their. 2 Pathology of anterior knee pain and patellofemoral knee including the patella as unstable and giving way secondary. instability to poor muscle control This is described as functional instability. compared to mechanical instability which is due to anatomical. There are multiple causes of anterior knee pain and abnormalities e g trochlear dysplasia. patellofemoral instability with not all individuals displaying the Due to the overlap of symptoms between patients with anterior. same underlying pathology Some patients have an underlying knee pain and patellofemoral instability for patients presenting. biomechanical cause for their poor patellar tracking This with anterior knee pain it is important to ask whether there have. biomechanical cause can be an underlying rotational profile been any previous episodes of dislocation Questions relating to. that makes them more prone to lateral tracking of the patella aggravating activities can be most insightful for this population. in the trochlear groove which in turn can be driven by either e g multi directional higher energy activities such as turning. proximal hip and pelvis or distal foot and tibial rotational during a football game or pushing a shopping trolley around a. abnormalities Alternatively other patients may have a normal shopping aisle corner are typical for patellofemoral instability. femoral or tibial rotational profile and present with central 15 Nevertheless individuals with more severe instability may. tibiofemoral patellofemoral joint anatomical features Finally report activities such as putting tights or socks on turning in bed. in a subset of patients the underlying diagnosis may not be a or looking over their shoulder as activities leading to dislocation. physical cause but a presentation of knee symptoms that are They may report either subluxation without frank dislocation all. secondary to anxiety and depression with associated poor coping the way up to recurrent dislocation Distinguishing the different. strategies 3 4 presentations is important as it may provide an indication of the. It is widely acknowledged that both anterior knee pain severity of the instability or malalignment driving the underlying. and patellar instability are associated with lateral tracking of anterior knee pain. the patella within the femoral trochlea 5 In cases where the Questions on previous episodes of anterior knee pain or. lateralised patella remains constrained within the femoral patellofemoral instability are important as they can provide an. trochlea the patient may present with anterior knee pain indication of the patient s perceptions of their management. T O Smith et al The Knee 20 S1 2013 S3 S15 S5, obvious effusion 28 Other findings may include a palpable. defect in the medial retinaculum due to disruption to the medial. capsule and retinaculum following lateral patellar dislocation. 7 22 29 30, In the assessment of chronic patellofemoral instability.
five studies have assessed the diagnostic accuracy of physical. examination tests Of the available tests the apprehension test is. the most frequently cited test in textbook and review papers to. assess patellar dislocation 19 30 33 Bassett s sign is a patellar. Fig 1 Schematic of the spectrum between anterior knee pain. and patellar dislocation dislocation specific test devised for the assessment of MPFL. injury 28 and is essentially pain on palpation of the medial. retinaculum 12 34 35, It is not uncommon for patients with patellofemoral disorders Sallay et al compared the apprehension test and Bassett s. to see numerous clinicians with varying degrees of success sign index tests to MRI and surgical findings reference test on. Patients have reported reduced confidence self efficacy in their 23 people following an acute patellar dislocation They reported. treatment or clinicians following previous failed interventions the sensitivity of the apprehension test and Bassett s sign and for. 15 It is important to be aware whether previous treatments patellar dislocation was 70 and 39 respectively 36. have failed or which were considered beneficial or successful by One study has assessed the intra and inter rater reliability. the patient thus managing patient expectation as well as their of various physical examination tests between five orthopaedic. clinical presentation surgeons specialising in patients presenting with recurrent. An integral part of patient assessment is acknowledging the dislocations The results indicated that there was moderate to. importance of psychosocial factors along with physical tests 16 substantial intra rater reliability for each of the orthopaedic. Patients presenting with anterior knee pain reported that anxiety surgeons The physical tests that demonstrated high agreement. and fear avoidance beliefs about work and physical activity were between the surgeon s first and second assessments included. significantly associated with poorer functional outcomes Fear the assessment of tibial torsion Kappa 0 84 95 confidence. avoidance beliefs about work and physical activity were also interval CI 0 68 0 97 popliteal angle Kappa 0 80 95 CI. associated with a higher severity of pain However whilst their 0 61 0 93 and the Bassett s sign Kappa 0 79 95 CI 0 60. importance has been emphasised it remains unclear as to the 0 90 However the inter rater reliability between surgeons was. optimal instruments to assess these domains consistently poor. Finally for any patient presenting with knee pathology it is. 3 2 Clinical assessment important to rule out the hip joint as a source of the pathology. By clearly assessing hip range of motion actively and passively. A wide variety of clinical tests focussing on assessing the any potential hip pathology such as acetabular labral tears. patellofemoral joint have been described The principal tests are chondral pathology or Perthes disease in children would present. widely summarised in texts by Smith et al 17 Fredericson and as a differential diagnosis of knee pain. Yoon 18 Malanga et al 19 and Lubowitz et al 20 and such. tests include the VMO capability test hamstring quadriceps 3 3 Stability of the patellofemoral joint. and calf muscle length patellar tilt and glide apprehension tests. iliotibial band ITB flexibility tests Thomas test hypermobility The stability of the patellofemoral joint is dependent upon. joint assessments Q angle patellar mobility J sign foot arch a combination of soft tissue and bony structures with both the. position tibial torsion hip version standing posture pain on soft tissue and bony structures contributing a variable amount. palpation of the patellar retinaculum pain on palpation of the of stability the degree of which is dependent upon the degree. retropatellar surface crepitus Bassett s sign and Clark s grind of knee flexion. test have been recommended In addition functional tests such Due to the shape of the patella and trochlea the bony. as squatting hopping and agility tests and joint position sense congruency of the patellofemoral joint is poor in the initial. testing have all been recognised as useful in the evaluation of the phase of flexion Stability of the patellofemoral joint in the. global capabilities of these patients 18 21 22 first 30 of flexion is therefore predominantly provided by. In an assessment of the commonest clinical examination tests the balance of tension between static and dynamic soft tissue. for anterior knee pain Cook et al 23 reported that a combination structures 37 The static soft tissue stabilizer on the lateral. of functional assessment and joint specific tests were the most side of the patella is the lateral retinaculum whereas on the. help in elucidating the underlying diagnosis but assessment of medial side the medial restraints are the medial retinaculum. individual tests were unrelated to patient reported disability the medial patellofemoral ligament MPFL and the medial. scores In an assessment of 76 participants with anterior knee patello tibial ligament The dynamic restraints acting on the. pain Cook et al concluded that the strongest diagnostic test medial side are the quadriceps muscle in particular the vastus. was pain during resisted knee extension Positive Predictive medialis obliquus portion 38. Value 82 Positive Likelihood Ratio 2 2 95 CI 0 99 5 2 Arguably the most important medial soft tissue stabiliser is. However a number of authors have concluded that the the MPFL The MPFL is a thickening of the medial patellofemoral. diagnosis of anterior knee pain should be based on a positive retinaculum Anatomically it originates from the groove between. history in conjunction with positive findings on clinical the adductor tubercle and the medial epicondyle and inserts. examination but that no single test is sufficiently accurate to into the superior two thirds of the medial border of the patella. diagnose this condition 24 25 A number of review papers and a In full knee extension during active quadriceps contraction the. systematic review on this topic have concluded that the evidence ligament is at its most taut In this state it is reported to contribute. base was in general insufficient to produce any strong conclusions an average of 53 of the force resisting lateral displacement of. as to the most useful physical test for diagnosis 18 24 27 the patella 39 During passive motion of the knee joint the. In the clinical assessment of a recent patellar dislocation ligament is the longest at approximately 30 degrees of knee. the examiner may find diffuse parapatellar tenderness and an flexion at which point the patella engages in the trochlea. S6 T O Smith et al The Knee 20 S1 2013 S3 S15, After the patella has engaged in the trochlea the congruency. of the patella and the trochlea is the major contributor to patellar. stability throughout the remainder of knee flexion 37 With. increasing degrees of knee flexion the importance of the MPFL. diminishes and the ligament becomes more lax, Malalignment of the extensor mechanism of the knee. causes both objective and subjective instability From a surgical. perspective the challenge is to identify those patients with. abnormalities of the patellofemoral joint that are amenable to. surgical intervention The anatomical dysplasias of the extensor Fig 2 Lateral radiographs of a normal trochlear groove right hand one shows a. mechanism that contribute to malalignment of the extensor shallow groove. mechanism include patella alta patellar tilt sulcus angle the. distance between the trochlear groove and the tibial tuberosity. TTTG and trochlear dysplasia 40 Secondary factors that surface of the patella and the anterosuperior corner of the tibial. contribute to patellar instability are excessive external femoral plateau to the length of the patella on a true lateral radiograph. rotation excessive external tibial rotation genu recurvatum and A ratio of greater than 1 2 is defined as patella alta and less than. genu valgum 0 6 is defined as patella infera, Blackburne Peel ratio 51 The Blackburne Peel ratio is the. 3 4 Radiological assessment of the patellofemoral joint ratio of the articular length of the patella to the perpendicular. distance from lower articular margin of patella to tibial plateau. Radiological assessment of the anatomical factors contributing Normal values for the ratio lie between 0 54 and 1 06. to objective patellar instability is essential in guiding further All three of the above measurements discriminate between. management 41 Radiological assessments include plain radio patients with patellar instability and healthy controls 49 51. graphs anteroposterior lateral and skyline views magnetic A recent meta analysis has reported that the measurement of. resonance imaging MRI computed tomography CT and patellar height on plain radiographs and MRI using both the. ultrasound US 42 45 Various radiological features occur Insall Savati and the Caton Deschamps ratios demonstrated. following an acute dislocation possibly on the background of good discrimination validity with a statistically significant. morphological features that make patellar dislocations more difference in the values measured between the healthy controls. likely The lateral radiograph is important for defining a normal and patellar instability cohorts p 0 0001 52 However it. groove Fig 2 in contrast to a dysplastic groove see below and can be difficult to measure patellar height on MRI if the tibial. Fig 3 tubercle is significantly offset laterally resulting in the sagittal. slice through the extensor mechanism being essentially oblique. 3 5 Assessment of acute dislocations, 3 7 Patellar tilt lateral patellofemoral tilt angle and patellar.
In the assessment of an acute patellofemoral dislocation subluxation. plain radiographs can be used It is unusual to find the patella. dislocated as relocation typically occurs immediately or when The medio lateral relationship of the patella to the trochlea. the knee is straightened to allow transfer to hospital The images is described in terms of patellar tilt and subluxation Patellar. allow assessment of any anatomical abnormalities e g trochlear tilt is defined as the angle formed between a line adjoining the. dysplasia and to look for osteochondral loose bodies Avulsion most medial and lateral edges of the patella and a reference line. fractures on the medial aspect of the patella are pathognomic of such as the horizontal or a line along the most posterior aspect. a patellar dislocation In those cases where an MRI is performed of the posterior femoral condyles measured with the knee. after an acute dislocation a number of findings may be observed flexed 53 In normal knees the angle subtended between the. These include osteochondral fractures or bone bruising of the reference points should be more open laterally Abnormally large. lateral femoral condyle or the medial aspect of the patella a degrees of patellar tilt are believed to be secondary to a number. disruption of the MPFL disruption of the medial patellofemoral of factors contributing to instability Those factors include shape. retinaculum and a joint effusion 46 47 of the patella and trochlea and the relationship between the. As mentioned earlier the anatomical features that can be tightness of the medial and lateral static restraints As well as. assessed reliably radiologically include patellar height patellar being measurable by plain radiographs the patellar tilt angle can. tilt and subluxation sulcus angle tibial tubercle trochlear be reliably determined by both CT and MRI measurement 52. groove TTTG distance and trochlear dysplasia Patellar subluxation is an abnormal medio lateral displace. ment of the patella compared to the trochlea Measurements of. 3 6 Assessment of patellar height patellar tilt and patellar subluxation are statistically significantly. different between patients with patellar instability and. Patella alta is recognised as a risk factor for patellar dislocation healthy controls and have been reported to demonstrate good. 48 Patellar height is normally evaluated by measurements discrimination validity 52. obtained from a true lateral plain radiograph There are a. number of different methods for measuring the height of the 3 8 Sulcus angle. patella as detailed below, Insall Salvati ratio 49 The Insall Salvati ratio is defined The sulcus angle is observed on skyline radiographs and is a. as the ratio between the length of the patellar tendon and the reflection of the shape of the trochlea It is measured with the. length of the patella as measured on a true lateral radiograph knee flexed at 45 degrees with a normal sulcus angle defined. A ratio of greater than 1 2 defines patella alta and less than 0 8 as 138 SD 6 Davies et al 54 reported a highly significant. defines patella infera relationship between the sulcus angle and the degree of. Caton Deschamps ratio 50 The Caton Deschamps ratio is the trochlear dysplasia with an increasing sulcus angle also being. ratio between the distance from the lower edge of the articular related to the increasing severity of many of the other features. T O Smith et al The Knee 20 S1 2013 S3 S15 S7, Fig 3 Lateral radiographs showing the three types of trochlear dysplasia using the Dejour classification. of dysplasia such as patella alta Davies et al 40 reported that 3 12 The reliability of different radiological modalities in the. while there was good intra and inter observer reliability in the assessment of dysplasia of the extensor mechanism. assessment of sulcus angle on plain radiographs MRI and CT. MRI failed to demonstrate a significant difference in the value of In determining which of the morphological features associated. measurements between normal controls and those patients with with patellar dislocation can be reliably measured radiologically. patellar dislocation 52 a recent meta analysis demonstrated a reasonable level of inter. observer and intra observer reliability and discrimination validity. 3 9 Q angle for measurements of patellar height by Caton Deschamps and. Insall Salvati on plain radiographs the Insall Salvati ratio assessed. The Q angle is the angle subtended between a line taken by MRI the sulcus angle as assessed with radiographic MRI and. from the anterior superior iliac spine ASIS and the middle CT methods and the TTTG assessed using CT 52. of the patella and another between the tibial tubercle and the Smith et al 52 reported that a number of different radiological. midpoint of the patella It has been proposed that an increased measures have been described to assess the patellofemoral joint. Q angle is a risk factor for patellar dislocation as there is a These included the Blackburn Peel method to assess patellar. relative lateralising force on the patella 55 However Ando et height 51 congruence angle on MRI 43 boss height 48. al 56 assessed the Q angle in individuals following patellar trochlear depth 48 lateral patellar tilt angle 43 48 lateral. dislocation and reported no statistically significant difference in patellar displacement on MRI 43 femoral anteversion on CT. either the clinical or CT assessment of the Q angle between the 48 patellar morphology 63 patella lateral condyle index on. patellar dislocation or an asymptomatic cohort p 0 05 The MRI 43 ventral trochlear prominence patella tibia distance. Q angle is therefore not recommended as a useful measurement cranio caudal patellar facet patellar tendon length patellar. in the assessment of patients presenting with patellar instability nose patellar nose ratio morphology ratio and lateral trochlear. due to its inability to distinguish between pathological and non inclination 64 All have been reported to have statistically. pathological knees significant discrimination validity between patellar instability. and healthy controls 52 However as each of the above methods. 3 10 Tibial tubercle trochlear groove distance TTTG involved a single researcher a meta analysis could not be used to. assess the robustness of the findings, The TTTG is a measure of the relative lateralisation of the tibial Conversely Smith et al 52 also reported that a number of. tubercle in relation to the trochlear groove 57 A lateralised tibial radiological measurements fail to discriminate between patients. tubercle increases the lateral force on the patella enhancing the presenting with a patellar dislocation and normal controls. risk of dislocation 58 The TTTG is measured radiologically as the These included the assessment of the sulcus angle with MRI 43. distance between the lowest part of the trochlear groove and the trochlear depth 64 Wiberg patellar shape classification 63. highest part of the tibial tubercle on superimposed CT axial images mean medial lateral condyle height ratio 65 intercondylar. taken at the level of the proximal trochlea and the proximal portion distance ventral trochlear prominence ratio cranio. of the tibial tubercle 41 48 The TTTG for a control population is caudal patellar distance patellofemoral contacting surface. 12 mm but reported to be greater than 20 mm in 56 of patients patellofemoral contacting surface ratio lateral and medial. presenting with a patellar dislocation While clinical assessment is condylar distance and trochlear groove distance 64. unreliable 59 both MRI and CT have been reported to determine. accurately the TTTG with both modalities demonstrating good 4 Non surgical interventions for anterior knee pain and. inter and intra observer reliability 60 patellar dislocation. 3 11 Trochlear dysplasia The vast majority of the literature has investigated different. interventions in the management of anterior knee pain. The anatomy of the femoral trochlea is reported to be one rather than patellofemoral instability The evidence for such. of the principal causes of patellar instability Dejour et al 48 interventions for each population is discussed below. classified trochlear dysplasia by features visible on a lateral plain. radiograph see Fig 3 The key feature of the classification is the 4 1 Exercise. radiological representation of the sulcus floor with respect to. the anterior border of the superimposed femoral condyles the Quadriceps exercise is considered the cornerstone inter. crossing sign Trochlear dysplasia is classified into four grades vention for the management of patellofemoral pathologies. depending upon the shape of the trochlea 48 61 The elements given the intimate relationship between the patella within the. that present within trochlear dysplasia are quadriceps complex 66 68 Van Linschoten et al 69 reported. 1 Trochlear boss at the entry into the trochlear groove that exercise addressing the quadriceps muscle significantly. 2 The morphology of the lateral trochlear facet improved outcomes in terms of decreased pain and improved. 3 The morphology of the medial trochlear facet 61 62 function at short and long term follow up compared with the. S8 T O Smith et al The Knee 20 S1 2013 S3 S15, usual care of advice and analgesia in primary care in patients 4 2 Taping. with patellofemoral pain syndrome, A variety of exercises have been advocated to address Patellar taping during exercise to assist in correcting patellar.
imbalances in the recruitment timing or general strength maltracking and tilt to promote vastus medialis function through. of the vastus medialis obliquus over the vastus lateralis in enhanced proprioceptive feedback and to decrease pain has. patients with anterior knee pain 70 Whilst there is evidence been reported 6 87 89 However Gigante et al suggested that. that specific vastus medialis obliquus VMO exercises taping does not medialise the patella and that a biomechanical. when used in collaboration with taping and biofeedback mechanism for any change in symptoms is unclear 90. may reduce symptoms and improve function over general The use of taping with exercise and in isolation for the. quadriceps exercises 2 71 there is also conflicting evidence management of pain and improved function for people with. suggesting that the VMO cannot be preferentially activated anterior knee pain is controversial Whilst Paoloni et al 91. and there is limited difference in outcome between these Aminaka and Gribble 92 Whittingham et al 93 Mason. two exercise programmes 66 72 Nonetheless exercise is a et al 94 and Ng and Cheng 95 suggest that taping may be. valued intervention for recruiting the quadriceps complex a valuable adjunct to improve symptoms and correct VMO. However exercise compliance and effectiveness is reduced in to vastus lateralis imbalance a recent Cochrane review 96. the presence of pain Based on this decreased effectiveness concluded that there was limited evidence to suggest that taping. strategies for managing pain should be considered prior to can significantly improve outcomes compared to other exercise. prescribing exercise Alternatively exercises performed in a based interventions not incorporating taping Similarly Akba et. pain free range of motion should be prescribed first to avoid al 97 who assessed the addition of Kinesio tape techniques. the potential of flaring a patient s symptoms 73 Heintjes to a conventional exercise programme reported no significant. et al s Cochrane review 74 on exercise for anterior knee improvement in the results of participants with anterior knee. pain concluded that whilst there is evidence that exercise is pain However Lan et al 98 concluded that taping may be. beneficial in reducing pain and disability for anterior knee pain less effective in certain subgroups of the anterior knee pain. there is strong evidence that open and closed kinetic chain population including those with a higher body mass index larger. exercises are equally effective lateral patellofemoral angle and smaller Q angle Stratifying this. Whilst the current literature suggests that quadriceps intervention may therefore be important in the clinical decision. strengthening exercises are paramount both following patellar making process. dislocation and patellofemoral instability 75 no studies have Whilst the majority of the literature has focused on anterior. assessed whether there is a difference in clinical outcome knee pain no studies have specifically assessed the use of taping. or recurrent symptoms between different types of exercises following patellar dislocation or in instability Two case series. Therefore whilst it is recommended that strengthening incorporated the use of taping following patellar dislocation. exercises are prescribed to provide greater dynamic stability 99 100 However the clinical effectiveness remains unknown. for patellofemoral joint stability it is unclear whether general. quadriceps are superior to VMO exercises and what dosage in 4 3 Electrotherapy. terms of frequency rate intensity or loading should be prescribed. Two randomised controlled trials RCTs have compared the Whilst the use of electric biofeedback systems in collaboration. outcomes of prescribing VMO specific versus general quadriceps with VMO specific training regimes has been discussed a. strengthening exercises for people with anterior knee pain number of other electrotherapy modalities have been described. 76 77 Both reported that there was no significant difference in in the literature These have included the use of ultrasound. outcome between either exercise regime p 0 05 laser interferential and transcutaneous nerve stimulation Based. Whilst patients following patellar dislocation have been on the current evidence which presents a number of major. reported to exhibit a proprioceptive deficit largely through methodological limitations there remains inconclusive evidence. injury to the medial retinaculum and the MPFL 78 79 no that such electrotherapy modalities provide benefit when used in. evidence is currently available to support or refute the inclusion isolation but may be useful adjuncts when used in combination. of proprioceptive exercises in physiotherapy rehabilitation for with other treatments such as exercise 101 103. this population Such proprioceptive deficits have also been Whilst the use of electrotherapy within physiotherapy. demonstrated in anterior knee pain populations 80 81 and regimes for patellar dislocation has been suggested no studies. as with the patellar instability literature no specific exercise have assessed the use of specific modalities in a clinical trial. regimes have been investigated to determine whether this can Three studies which detailed the rehabilitation programme of. be modified through exercise Only Hazneci et al 82 have their patients following first time patellar dislocation included. investigated the effect of exercise specifically on joint position muscle stimulation in their physiotherapy programmes 104. sense in this population and have reported that isokinetic 106 However since these specific interventions were not. exercise in general demonstrated improvement in proprioception investigated there is insufficient evidence to support or refute. in those with anterior knee pain the use of electrotherapy treatments such as muscle stimulation. As acknowledged earlier the biomechanics of the patello for the management of people following patellar dislocation or. femoral joint is dependent on proximal hip and core stability with instability. and distal foot and lower limb factors in addition to the. biomechanics of the knee 83 Consequently the prescription of 4 4 Bracing and splinting. glutei muscle strengthening exercises to improve femoral control. in order to limit excessive femoral internal rotation during As with taping the principle of bracing or knee orthoses is to. activities which can induce patellar lateralisation and increase centralise the patella to reduce abnormal tracking between the. symptoms has been advocated 84 85 Current understanding retropatellar surface and the femoral trochlea 107 Whilst this. would suggest that combined exercise programmes of hip would appear logical there is limited research to support their. abductors hip external rotators and quadriceps strengthening use in anterior knee pain 108. programmes combined provide superior outcomes to quadriceps Two studies have assessed the use of knee orthoses for the. strengthening alone 85 86 prevention of anterior knee pain in populations who are at high. T O Smith et al The Knee 20 S1 2013 S3 S15 S9, risk Van Tiggelen et al s 109 cohort of military recruits and effectiveness of NSAIDs has been recently questioned in a. BenGal et al s 110 cohort of young athletes both concluded recent review by Dixit et al who considered educating patients. that the use of a patellofemoral brace significantly reduced the about activity modification of risk factors is more important in. incidence of developing anterior knee pain in strenuous physical preventing recurrence and managing symptoms compared to. activity regimes Therefore knee orthoses may be valuable for pharmacological interventions 27. those individuals identified as at risk, Knee orthoses and braces have been used in the management 5 Surgical management of patellofemoral instability. following patellar dislocation in order to limit range of motion. whilst the surrounding soft tissues recover post dislocation The treatment of a patient who has sustained a first time. There is limited evidence to support the use of immobilisation dislocation of the patellofemoral joint still remains controversial. or restriction of range of motion with knee orthoses or casting Whilst a variety of different conservative and surgical manage. techniques compared to permitting range of motion without ment strategies have been proposed the findings of both a recent. a brace on clinical outcomes or recurrent dislocation events Cochrane review and separate meta analysis concluded that. 111 No studies have assessed the effectiveness of bracing or there was insufficient evidence to determine whether operative. knee orthoses during activities or sports for preventing patellar management of patients after a first time patellofemoral disloca. instability or dislocation tion confers any benefit over non operative management 124 125. An evaluation of the literature reporting the operative. 4 5 Foot orthoses treatment of patients with recurrent patellar dislocation. showed a diversity of techniques indications and interventions. In the anterior knee pain literature a number of studies 10 104 124 126 In general whilst older studies were. have provided favourable evidence for the use of foot orthoses retrospective case series reporting particular techniques many. to correct biomechanical abnormalities which may predispose used non anatomical methods to improve patellar stability. anterior knee pain Whilst some have reported limited These have been superseded by more recent anatomical. effectiveness in prescribing these interventions 112 pain and approaches designed to reconstruct the MPFL 10 104 126. function both significantly improved with those prescribed Anatomical MPFL reconstruction is reported as having a better. foot orthoses in studies by Barton et al 113 114 Barton et outcome than historic techniques 127. al s systematic review 115 also reported that the use of The following sections detail a variety of techniques that are. foot orthoses in addition to exercise demonstrated superior still in the mainstream orthopaedic armamentarium for the. outcomes for people with anterior knee pain compared to the surgical treatment of patellofemoral instability. sole use of orthoses The clinical efficacy of this intervention was. also demonstrated to be specifically higher for individuals aged 5 1 Medial patellofemoral ligament repair. over 25 years under 165 cm in height whose worst pain visual. analogue scale was less than 53 3 mm and who had a difference During a patellar dislocation the medial patellar soft tissue. in mid foot width from non weight bearing to weight bearing of restraints in particular the MPFL are torn or stretched in such. greater than 11 mm 116 a manner to render them incompetent Repair of the MPFL as. No studies have investigated the effectiveness of lower limb opposed to reconstruction would seem to be an attractive option. biomechanical interventions such as foot orthoses for people As such the role and outcomes of primary surgical repair of the. following patellar dislocation This is in contrast with textbook MPFL in children and adults has been evaluated by a number of. recommendations by Howell 117 Cherf and Paulos 118 different authors. Post et al 119 King 120 and Woo and Busch 6 who have For the paediatric population Palmu et al 10 compared. acknowledged that foot orthoses are important adjuncts to surgical repair of the medial structures with concomitant. correct leg length discrepancy or excessive foot pronation thereby lateral release to conservative treatment When comparing. improving excessive Q angle which may predispose individuals surgery to conservative treatment they found no difference. to instability However since these recommendations are either subjectively or functionally in terms of rate of recurrent. made on non empirical evidence the role of orthoses remains dislocation They concluded that routine repair of the torn. unproven for their use in patients following patellar dislocation medial stabilizing soft tissues is not advocated for the treatment. of acute patellar dislocation in children and adolescents 10. 4 6 Acupuncture In adults the literature is divided over the outcomes of. MPFL or medial retinacular repair Sillanp et al 104 reported. A small number of trials have investigated the use of that although the rate of redislocation was significantly lower. acupuncture to reduce pain in people with anterior knee pain in adults that had received surgery there was no difference. 121 They have reported that acupuncture may be a beneficial in subjective outcomes between groups that were either. adjunct to other interventions particularly in the management of treated surgically or non surgically Conversely Camanho et al. pain 121 122 Given this in those people where pain has failed 127 reported superior subjective results and a lower rate of. to improve causing poor exercise compliance acupuncture dislocation for patients undergoing MPFL reattachment to its. may be an appropriate intervention to reduce pain to facilitate site of avulsion either femoral or patellar insertion compared. exercise to non operative treatment However others using a mixture. of techniques to repair the medial structures have reported no. 4 7 Non steroidal anti inflammatory drugs difference in the rate of dislocation between operative and non. operative treatment 126, Heintjes et al s Cochrane review 123 concluded that only Following patellar dislocation the MPFL can be disrupted. non steroidal anti inflammatory drugs NSAIDs demonstrated at three anatomical locations the insertion on the patella the. the effectiveness in the pharmacological management of femoral insertion and the ligament midsubstance 47 128 The. short term symptoms Simple analgesics such as aspirin site of damage appears to be related to the rate of recurrent. produced no significant differences in clinical symptoms and dislocation In those patients in whom the femoral insertion has. signs compared to a placebo However the evidence for the been avulsed non surgical treatment has been reported to confer. S10 T O Smith et al The Knee 20 S1 2013 S3 S15, a greater risk of subsequent instability and lower functional in the contact pressure on the medial patellofemoral joint. scores than in those patients where the MPFL has been avulsed the medial tibiofemoral joint and tibiofemoral kinematics. from either the patella or sustained a midsubstance tear 129 140 141 However in a comparison of the two procedures only. If the site of avulsion is known one prospective RCT medialisation of the TT had the effect of decreasing the total. comparing conservative treatment to MPFL reattachment back force carried by the lateral facet of the patella induced by an. to its avulsion site either the patella or the femur using a suture increased Q angle whereas anteromedialisation of the TT had. anchor technique and showed a significant decrease in the rate no effect on the force distributions between medial and lateral. of dislocation in the operative group 127 However in contrast patellar facets 143 Clinically pure medialisation of the TT in. surgical repair of the MPFL back to the adductor tubercle using patients with recurrent instability with lateral positioning of the. a suture anchor technique confers no benefit over conservative TT either assessed clinically or by an abnormally large TTTG back. treatment 130 Mid substance damage to the MPFL commonly to normal values has been associated with good results 144 145. occurs in conjunction with avulsion from either the patella or The importance of patella alta in recurrent patellar instability. the femoral insertion site 47 However the rate of dislocation has been examined and the effect of surgical correction using tibial. following conservative treatment appears to be low and repair is tubercle transfer 48 50 146 147 Many authors have reported. generally not indicated 129 that in those patients defined as having patella alta Insall. Secondary damage to articular cartilage in patients presenting Salvati ratio 1 2 and excessive medial laxity distalisation of the. with a first time dislocation is up to 50 129 The surgical tubercle to correct the patella alta in conjunction with possible. treatment of areas of cartilage damage is dependent upon the site TT medialisation to correct an increased TTTG led to significant. and size of the cartilage fragment If the area of cartilage loss is improvements in patellar instability 50 146 148 150. large and the injury acute an attempt at reduction and fixation of. the fragment should be attempted In those patients with smaller 5 5 Trochleoplasty. defects or chronic cartilage loss microfracture of the defect with. excision of the cartilage fragment may be preferable 131 132 Severe trochlear dysplasia is a rare condition occurring. in approximately 15 of patients presenting to a specialist. 5 2 Medial patellofemoral ligament reconstruction patellofemoral clinic 151 152 It is defined and classified. radiologically by the presence of decreased height of the medial. The indications for MPFL reconstruction are based upon femoral condyle a decreased trochlear depth an increased. history clinical examination findings and imaging MPFL sulcus angle and a lateral trochlear facet which is shallow or. reconstruction as a stand alone procedure is indicated for those sometimes elevated or dome shaped 14 48 62. patients with recurrent patellofemoral instability in the context The principal indication for trochleoplasty is for those. of normal anatomy mechanical alignment and laxity of the patients with functional deficits from patellar instability who. medial patellar restraints A number of different graft materials have a severe trochlear dysplasia after the failure of conservative. including the adductor magnus tendon 133 134 quadriceps management 153 Trochleoplasty is designed to address the. tendon 135 semitendinosus tendon 136 137 and a mesh type morphological features of trochlear dysplasia by forming a. artificial ligament have all been used 138 Despite the variety of neo trochlea to facilitate patellar tracking While the surgical. graft materials the fundamental features of MPFL reconstruction techniques that are employed are beyond the scope of this article. remain those of anatomical reconstruction and the avoidance of all of the procedures involve removal of the trochlear boss or. over tensioning of the reconstructed ligament bump combined with a groove deepening procedure 154 157. In a large proportion of patients undergoing trochleoplasty. 5 3 Outcomes of MPFL reconstruction additional secondary procedures such as MPFL reconstruction. tibial tubercle transfer and lateral release are performed. Smith et al 139 recently analysed the literature reporting simultaneously 158. the clinical and radiological outcomes of MPFL reconstruction. for patellar instability concluding that MPFL reconstruction does 5 6 Surgical outcomes of trochleoplasty. provide favourable clinical and radiological outcomes However. the methodological limitations of the papers reviewed meant There are relatively few reports of the outcomes of. that the conclusions need to be interpreted with caution trochleoplasty but the majority of authors report good outcomes. in terms of improvement in patellofemoral instability and. 5 4 Tibial tubercle transfer TTT radiological indices 151 156 159 However subjectively in. terms of pain and satisfaction the procedure has mixed reports. There has been interest in the position of the tibial tubercle While most patients report that they are satisfied with the. TT relative to the trochlear groove and the effect of that distance outcomes of the procedure a large proportion of patients report. upon the stability of the patellofemoral joint In trying to reduce that they have a degree of residual pain following the procedure. the lateralising forces on the patella one approach is to medialise with a small proportion reporting that their pain is increased. the TT thereby decreasing the TTTG distance and improve patellar 157 160 In a recent systematic review Smith et al 153. tracking In attempting to do this as with operative interventions evaluated the clinical and radiological outcomes of patients after. addressing the soft tissue restraints in the proximal portion of the trochleoplasty and concluded that despite the poor quality of. knee multiple techniques have been described the evidence surrounding trochleoplasty the procedure appears. A number of cadaveric studies examining the effect of mediali to be successful in addressing instability and safe at mid term. sation of the tibial tubercle upon patellofemoral biomechanics follow up However longer term prospective studies are required. have reported conflicting results on the effect of patellar stability to fully evaluate the outcomes of the procedure. and subsequent patellofemoral and femorotibial joint contact. pressures 140 143 In summary while medialisation of the 5 7 Surgical decision making. TT would appear to improve patellar stability by decreasing the. force needed to resist lateral subluxation a number of studies The decisions regarding the surgical approach to patello. have reported the potentially deleterious effect of increases femoral instability remains contentious and challenging Most. T O Smith et al The Knee 20 S1 2013 S3 S15 S11, orthopaedic surgeons will tailor their operative approach on Table 1.
a patient by patient basis depending upon the individual Outcome measurements commonly used in the patellofemoral literature. anatomical morphology of the patient s extensor mechanism Functional outcome score Original Referenced Source. The goal of any intervention is to create a stable patellofemoral. Kujala patellofemoral disorder score Kujala et al 1993. joint throughout the full range of motion without creating long. Tegner level of activity score Tegner and Lysholm 1985. term harm in terms of abnormal loading or joint kinematics. Hughston VAS knee score Flandry et al 1991, Patients presenting with recurrent episodes of instability Lysholm knee score Lysholm and Gillquist 1982. or subluxation who have failed conservative treatment can be Crosby and Insall assessment tool Crosby and Insall 1976. classified into different groups for treatment After a patellar Heywood 1961. dislocation the MPFL is almost always either disrupted or Musculoskeletal Function Assessment injury Martin et al 1996. and arthritis survey, rendered incompetent In those patients that have a normal. Fulkerson knee instability scale Fulkerson and Shea 1990. morphology of the patellofemoral joint normal patellar height. Short Form 36 Ware and Sherbourne 1992, and normal TTTG MPFL reconstruction alone gives good results Lower Extremity Functional Scale LEFS Binkley et al 1999. However in the presence of abnormal morphology of the Hall assessment Hall et al 1979. extensor mechanism creating a laterally directed force an MPFL Knee Injury and Osteoarthritis Score Roos et al 1998. reconstruction alone may fail In such cases surgery to realign. the tibial tubercle may well be indicated, The indications for tibial tubercle transfer TTT are very. 6 Outcome measurement for PFJT pathology, much open to debate and as yet are not subject to a consensus in.
agreement In addition there is no systematic review evaluating. A variety of functional and patient reported outcome. the literature surrounding the outcomes of patients who have measurements have been used to assess clinical outcomes. undergone the different types of tubercle transfer following patellar dislocation or anterior knee pain 164 These. The use of tibial tubercle transfer is indicated in those are summarised in Table 1 Whilst the majority were originally. patients that have recurrent instability in conjunction with designed for non patellofemoral joint disorder populations the. an increased TTTG and or patella alta In patients with patella Kujala Patellofemoral Disorder Score was specifically designed. alta and a normal TTTG MPFL reconstruction in conjunction to assess people with anterior knee pain and patellofemoral. with tibial tubercle distalisation may be performed In patients disorders 165 This outcome measure has subsequently. with an increased TTTG greater than 20mm medialisation of demonstrated good reliability validity and responsiveness of. the tibial tubercle with MPFL reconstruction may be indicated anterior knee pain and patellar instability populations 164 166. In patients with increased TTTG and patella alta medialisation Watson et al 167 reported good reliability with acceptable. and distalisation of the tibial tubercle in conjunction with MPFL responsiveness of the Lower Extremity Functional Scale LEFS. reconstruction may be performed and for people with anterior knee pain whilst Crossley et. Some surgeons advocate performing a simultaneous TTT and al 168 reported that the VAS pain score was a reliable valid. MPFL reconstruction in those patients with an increased TTTG in and responsive instrument for this population Finally this. the absence of patella alta While simultaneous medial TTT and outcome has also been extensively evaluated for cross cultural. MPFL reconstruction have both been reported as being beneficial translations and validated in Chinese 169 Persian 170 and. Turkish 171, in improving stability in patients with an abnormally large TTTG. Whilst these outcomes provide an indication on the functional. 144 145 there are concerns that such a combined approach. outcomes of people with patellofemoral disorders until. might lead to excessive loads on the medial patellofemoral. recently no instrument existed to assess people s perceptions. compartment if performed on patients with a normal Q angle. of patellar instability The Norwich Patellar Instability NPI. score has been developed based on patient reported activities. Ostermeier et al 161 compared MPFL reconstruction to. which cause symptoms of instability 15 Consequently the. TT medialisation in cadavers with normal Q angle and MPFL NPI score was assessed in relation to validity and internal. deficient knee They reported that medial transfer of the tibial consistency demonstrating good psychometric properties for. tubercle showed no significant stabilising effect on patellar both evaluations 172. movement whereas reconstruction of the MPFL showed a A number of physical tests have been evaluated as outcome. significant stabilising effect on patellar movement In addition indicators for people with anterior knee pain These include the. Watanabe et al 162 reported equivalent clinical results of MPFL assessment of joint reaction force 173 and patellar mobility. reconstruction to TT medialisation in conjunction with MPFL tests 25 Loudon et al 174 assessed five functional tests for. reconstruction in patients with recurrent dislocation of the people with anterior knee pain anteromedial lunge step down. patellofemoral joint in patients with a normal Q angle single leg press bilateral squat balance and reach reporting. Despite the interest in trochleoplasty at present there is good intra rater reliability and were related to changes in pain. no consensus upon whom and at what point to perform a Following Jensen et al 3 and Carlsson et al 175 studies. trochleoplasty In a recent systematic review Bollier et al 163 suggesting psychological outcomes were important for people. advised that trochleopasty should be reserved for patients only with anterior knee pain only Thome et al 4 has assessed. after other pathologies have been corrected and that it is a salvage the reliability of psychological outcomes of anterior knee pain. operation for extreme dysplasia However it is recognised by symptoms In their study of 50 people with anterior knee pain. those who regularly perform trochleoplasty that the outcomes they reported good reliability for the multidimensional pain. are better when it is performed as a primary procedure and not inventory MPI coping strategies questionnaire CSQ and. for salvage For those who do not advocate trochleoplasty the Spielberger state trait anxiety inventory STAI in this population. Fulkerson anteromedialisation of the TT is the preferred option They also reported some concerns regarding the high proportion. to avoid increasing the patellofemoral joint reaction force in of participants who were catastrophizing their pain responses. the presence of trochlear dysplasia It should also be noted that when assessed about coping strategies suggesting further. severe trochlear dysplasia is rare evaluation in this field is required. S12 T O Smith et al The Knee 20 S1 2013 S3 S15, Through the use of patient reported outcome measures in methodological limitations including imprecise randomisation. addition to functional tests such as timed shuttle runs hop tests procedures duration of follow up control of co interventions. dynamometry muscle testing and knee range of motion pain and assurance of blinding accountability and proper analysis of. subsequent instability episodes it is possible to assess the global dropouts number of subjects and the relevance of outcomes. outcomes of people with anterior knee pain and patellofemoral Therefore current management is based on expert opinion. instability Paxton et al 166 concluded that multiple outcome rather than a strong evidence base. instruments are required to assess knee specific general health. and activity level domains to truly evaluate the outcomes of 9 Conflict of interest. people with such patellofemoral disorders, The authors have no conflict of interest to report. 7 Authors preferred management, From the history it is important to understand the patient s References. expectations Most can be managed non operatively with 1 Atanda A Ruiz D Dodson CC Frederick RW Approach to the active patient. advice on losing weight proper diet and regular exercise and with chronic anterior knee pain The Physician and Sports Medicine. a rehabilitation programme aimed at building up quadriceps 2012 40 41 50. 2 LaBella C Patellofemoral pain syndrome evaluation and treatment. strength and VMOs if present It is also important to build up. 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