Evidence – Based Examination

and Treatment of the

Sports/Orthopedic Knee and
Patellofemoral Joint

Anatomy and Biomechanics of

@robptatcscs
the Patellofemoral Joint
Robert Manske, PT, DPT, SCS, ATC, CSCS Robert C. Manske PT, DPT, MEd, SCS, ATC, CSCS
Wichita State University Department of Professor
Physical Therapy Wichita State Department of Physical Therapy
Via Christi Health Via Christi Health
Wichita, KS 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 Patellofemoral Anatomy
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.

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 The Patella: The “little plate” Patella
• Embedded within
quadriceps
Primary role in promoting efficient
• Largest sesmoid in
load transmission
body
• Inverted triangle with
Acts as bony shield to underlying apex directed inferior
structures

Patella
Patella
• Posterior Surface
• Anterior Surface • Central portion of patella
has thickest cartilage ~ 5
• Convex all directions mm
• < 1 mm in periphery of
• Rough superior third surfaces
– Quadriceps tendon • Up to 7 mm mid-patellar
– Thickest in human body
• V-shaped point
– Patellar tendon 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
Patella
• Bone mineral density
greater in lateral portion of • Posterior Surface
patella
– Increased loads • Facets flat to biconvex
• Inferior pole sup/inf and med/lat
– Non articulating
• Vertical ridge • Second vertical ridge
• Articular cartilage • Odd facet
• 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.

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 Distal Femur Distal Femur
• Distal Femur • Trochlear displasia
– Femoral sulcus
– Patellar groove
– trochlea
• Ridge corresponds to
that of posterior
patella
• Lateral facet of sulcus
higher than medial

PFJ Four – Quadrant Force Equality

• Attached from quads
to tibial tuberosity
• Patellar surface much
smaller than femoral
surface
• One of the most
incongruent joints in
body

PF Medial Side Restraints 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
• 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 Quadriceps
• VMO
• “Key to the knee” • Lieb and Perry
• Normal inserts 1/3 to ½ • VML 15-18° from
way down medial border long axis of femur
of patella
• Pathologically may barely • VMO 50-55° from
reach patella long axis of femur
• Only medial side dynamic
restraint

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 Medial Patellofemoral Ligament

• Static
– Medial Retinaculum • Primary static restraint to lateral patellar
– Medial capusle displacement at 20° of knee flexion,
– Medial PFL 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 Medial Patellofemoral Ligament

• 20 limbs from 17
• 55% of passive soft tissue restraint to lateral cadavers
patellar subluxation
• MPFL identified in
66.7%
• More commonly
found than LPFL

Amis AA. Current concepts on anatomy and biomechanics of patellar Waligora AC, Johanson NA, Hirsch BE. Clinical anatomy of the
stability. Sports Med Arthrosc. 2007;15:48-56. 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

Patellar Function
• Facilitating extension
of the knee by
increasing the distance
of the extensor
Patellofemoral Biomechanics 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)
• PFJRF are equal and
opposite to R of
quadriceps tension and
patellar tendon tension
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
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.
PFJRF
• Increase as knee flexion increases
– Angle becomes more acute
– Lever arms of femur and tibia increase
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 Contact Stress
• Walking 0.5-1.5x BW One part or another of patellar cartilage is
• Stairs 3.0x BW loaded throughout the entire flexion-
• Squatting 7-8x BW extension cycle
Except the earliest degrees of knee flexion
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. Grelsamer RP, Weinstein CH. Applied biomechanics of the patella.
Clin Orthop Rel Res 2001;389:9-14.
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 Pressures and PFJ

• CKC Exercises
• As knee extends PFJ
CKC Exercises contact stress decreases
despite”
– decreased contact area
– May be due to decreased
torque of gravity

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 Contact Pressures and PFJ
• OKC Exercises
• As knee extends PFJ
OCK Exercises 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
PF Contact Surface Area
extension exercise from
90°-50° & 20°-0°
• CKC knee extension
activities in < 50° of
knee flexion

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 PF Contact Surface Area
Degree of Patella Articulation Femoral Contact Stress
Flexion Articulation
0° Femoral Sulcus Min. bony Distal portion of patella loaded as knee flexes
contact
and contact area migrates proximally with
20°-30° Inf. facets Mid. fem.sulcus
progressive flexion
60° mid. facets Superior femoral
notch At 90° the contact area is located proximally,
90° mid/sup lat facets Sup fem notch after which contact area moves back toward
central aspect of patella
120° Lat mid and sup Sup fem notch/
facet LFC
Grelsamer RP, Weinstein CH. Applied biomechanics of the patella.
135° Lat mid facet/lat LFC/lat surface Clin Orthop Rel Res 2001;389:9-14.
sup facet/ odd of MFC

Articular Surface Of The Patella

Quadriceps Angle

“THE LAW of VALGUS” PF Signs

• Increased Q-angle
– More significant
for females
• Normal
Males: 8°-14°
Fulkerson JP and Hungerford DS: • Females: 15°-
Disorders of the Patellofemoral Joint. 17°
2nd ed. Baltimore, MD: Williams and
Wilkins

9
 Q-Angle Q-Angle
• Originally described • Angle formed by the
by Brattstrom intersection of a line
drawn from the
• “the angle formed by anterior superior iliac
the resultant vector of spine to the midpoint
the quadriceps force of the patella
and the patellar tendon • Proximal extension of
with the knee in an the line from the tibial
“extended, end- tubercle to the
rotated” position.” midpoint of the patella

Brattstrom H. Shapre of the intercondylar groove normally and in recurrent Neuman DA. Kinesiology of the Musculoskeletal System: Foundations
dislocation of the patella. Acta Orthop Scand Suppl 1964;68:1-48. for Physical Rehabilitation. Philadelphia, PA: Mosby, Inc., 2002.

Q-Angle
Q-Angle
• Theory centers around • A larger Q-angle may
this measurement create a larger lateral
• Offset in force vectors vector and potentially a
from the quadriceps greater predisposition to
force and force from lateral patellar tracking
patellar tendon 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 Measuring Q angle

• Standing • Dynamically
Caylor D, Fites R, Worrell TW: The relationship between Caylor D, Fites R, Worrell TW: The relationship between
quadriceps angle and anterior knee pain syndrome. J Orthop quadriceps angle and anterior knee pain syndrome. J Orthop
Sports Phys Ther 17(1):11-16, 1993. Sports Phys Ther 17(1):11-16, 1993.

Cowan DN, et al: Lower limb morphology and risk of Kernozek TW, Greer NL: Quadriceps angle and rear-foot
overuse injury among male infantry trainees. Med Sci Sports motion: Relationships in walking. Arch Phys Med Rehabil
Exerc 28(8):945-952, 1996 74(4):407-410, 1993

Roy S, Irvin R: Sports Medicine: Prevention, Evaluation,

Management, and Rehabilitation, Englewood Cliffs:
Prentice-Hall, Inc., 1983.

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 Measuring Q angle Measuring Q angle
• With Quadriceps Contracted • With Standardized Foot Positions
Fairbank JCT, et al: Mechanical factors in the incidence of Cowan DN, et al: Lower limb morphology and risk of
knee pain in adolescents and young adults. J Bone Joint Surg overuse injury among male infantry trainees. Med Sci Sports
66B(5):685-693, 1984. Exerc 28(8):945-952, 1996.

Guerra JP, Arnold MJ, Gajdokik RL: Q-angle: Effects of Guerra JP, Arnold MJ, Gajdokik RL: Q-angle: Effects of
isometric quadriceps contraction and body position. J Orthop isometric quadriceps contraction and body position. J Orthop
Sports Phys Ther 19(4):200-204, 1994. 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.

Q-Angle
Lack of
• Relationship between Q-
standardization of a angle and clinical signs
and symptoms has not
measurement always been consistent

technique still a
problem! Livingston LA: The Quadriceps angle: a review of the literature. J
Orthop Sports Phys Ther 1998;28:105-109.

Femoral Anteversion and

Q-Angle Retroversion Effects on 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!

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 Q-Angle Q-Angle
• Can vary significantly when measurement • Although and increased Q-angle is
taken standing due to foot position. traditionally associated with a valgus knee,
• Supine measurement taken as static position some of the highest Q angles are found in
• Standing can be taken as a more patients with a combination of genu varus
“functional” measurement. 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.

Clinical Assessment of PF
Patellar Orientation
Alignment

Patellar Position Patellar Position

• Assess medio-lateral • Good correlation
glide and patellar tilt between findings of
with MRI clinical test of
• 24 subjects; 16 males; medio-lateral
8 females
position and MRI
• * Examiner -15 years
(r=0.611, p=0.002)
of experience

McEwan I, et al. The validity of clinical measures of patella position. McEwan I, et al. The validity of clinical measures of patella position.
Man Ther 2007;12:226-230. Man Ther 2007;12:226-230.

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 Patellar Position
• If found lateral
patellar tilt, patellar
tilt angle via MRI
was > 5°
• 30 patients with tilt
• 51 patients without tilt
• Found patients with significant tilt on PE can be
expected to have >10° tilt on MR

McEwan I, et al. The validity of clinical measures of patella position. Grelsamer RP, Weinstein CH, Gould J, Dubey A. Patellar tilt: The
Man Ther 2007;12:226-230. 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 Grelsamer RP, Weinstein CH, Gould J, Dubey A. Patellar tilt: The
physical examination correlates with MR imaging. Knee. 2008;15:3-8. physical examination correlates with MR imaging. Knee. 2008;15:3-8.

Assessment of Patellar Position?

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 Clinical examination and Intratester Kappa’s displayed
measurement of patellofemoral questionable reliability for:
alignment with visual • Mediolateral tilt 0.57
examination, using calipers or • Superior/inferior tilt 0.50
goniometer’s may be unreliable • Rotation 0.41
• Mediolateral position 0.40
when performed within or
between testers
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

The low intratester and intertester
questionable reliability for:
agreement coefficients were
• Mediolateral tilt 0.18
• Superior/inferior tilt 0.03
clinically unacceptable and
• Rotation 0.30 suggest that treatment decisions
• Mediolateral position 0.03 based on these measurements
should not be made!
Tomsich DA, Nitz AJ, Threlkeld AJ, Shapiro R. Patellofemoral
Alignment: Reliability. J Orthop Sports Phys Ther 1996;23(3):200-
208

Reliability of Tests for PF

What passes for PF malalignment Alignment (Intertester)
at one clinic or with one therapist • Medial/lateral displacement 0.10
may not be the deemed the same • Medial/lateral tilt 0.21
problem at another clinic because • Anterior/posterior tilt 0.24
clinicians cannot agree on basic • Medial/lateral rotation 0.36

physical examination data.

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 Smith TO, et al. The reliability and validity of assessing medio-lateral
measures used to assess patellar instability. The Knee. 2008;15:255-262 patellar position: a systematic review. Man Ther. 2008;:1-8.

Medial/lateral Position Fitzgerald GK, McClure PW. Reliability of measurements obtained with four tests
for patellofemoral alignment. Phys Ther. 1995;75:84-92.
AUTHOR Inter-Tester Intra-Tester Herrington LC. The inter-tester reliability of a clinical measurement used to
Fitzgerald and McClure, 1995 determine the medial/lateral orientation of the patella. Man Ther. 2002;7:163-167.
0.10 NA
Herrington LC et al. the relationship between patella position and length of
Herrington, 2008 NA 0.86 iliotibial band as assessed using Ober’s test. Man Ther. 2006;11:182-186.
Herrington, 2002 M-.91; L-.94 NA Herrington LC. The difference in a clinical measure of patella lateral position
Herrington, 2006 between individuals with patellofemoral pain and matched controls. J Orthop
NA 0.99 Sports Phys Ther. 2008;38:59-62.
Herrington and Nester, 2004 NA 0.99 Herrington LC, Nester C. Q-angle undervalued? The relationship between Q-angle
McEwan et al, 2007 and medio-lateral position of the patella. Clin Biomech. 2004;19:1070-1072.
NA 0.86
McEwan I, Herrington L, Thom J. The validity of clinical measures of patella
Powers et al, 1999 NA 0.91 position. Man Ther. 2007;12:226-230.
Tomsich et al, 1996 0.14 0.70
Watson et al, 1999 0.02 0.11-0.35

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.
Thank You!
Watson CJ et al. Reliability of McConnell’s classification of patellar orientation in
symptomatic and asymptomatic subjects. J Orthopedic Sports Phys Ther. Robert C. Manske, PT, DPT, MEd, SCS,
1999;29:378-385.
ATC, LAT, SCS, CSCS
Professor
Wichita State University Dept. Physical Therapy
1845 North Fairmount
Wichita, Kansas 67260-0043
316-978-3702
robert.manske@wichita.edu

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