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Patellofemoral pain: an update on diagnostic and treatment options

  • Women's Issues (MA Goolsby, Section editor)
  • Published:
Current Reviews in Musculoskeletal Medicine Aims and scope Submit manuscript

Abstract

Patellofemoral pain is a frequent and often challenging clinical problem. It affects females more than males and includes many different pathologic entities that result in pain in the anterior aspect of the knee. Diagnosis of the specific cause of pain can be difficult and requires assessment of lower extremity strength, alignment, and range of motion, as well as specific patella alignment, tracking, and mobility. The treatment for patellofemoral pain is usually conservative with anti-inflammatory medications, activity modification, and a specific physical therapy program focusing on strengthening and flexibility. Infrequently, surgical treatment may be indicated after a non-operative program fails. The outcomes of surgical management may include debridement, lateral release, and realignment of the extensor mechanism to unload the patellofemoral articulation are favorable.

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References

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  1. Foss KB, Myer GD, Chen SS, et al. Expected prevalence from the differential diagnosis of anterior knee pain in adolescent female athletes during preparticipation screening. J Athl Train. 2012;47:519–24.

    Google Scholar 

  2. Roush JR, Curtis Bay R. Prevalence of anterior knee pain in 18–35 year-old females. Int J Sports Phys Ther. 2012;7:396–401.

    PubMed  Google Scholar 

  3. Hughston JC. Subluxation of the patella. J Bone Joint Surg Am. 1968;50:1003–26.

    PubMed  CAS  Google Scholar 

  4. Insall J, Falvo KA, Wise DW. Chondromalacia Patellae. A prospective study. J Bone Joint Surg Am. 1976;58:1–8.

    PubMed  CAS  Google Scholar 

  5. Stanitski CL. Anterior knee pain syndromes in the adolescent. Instr Course Lect. 1994;43:211–20.

    PubMed  CAS  Google Scholar 

  6. Post WR, Fulkerson J. Knee pain diagrams: correlation with physical examination findings in patients with anterior knee pain. Arthroscopy. 1994;10:618–23.

    Article  PubMed  CAS  Google Scholar 

  7. Brattstroem H. Shape of the intercondylar groove normally and in recurrent dislocation of patella. A clinical and X-ray-anatomical investigation. Acta Orthop Scand Suppl. 1964;68 Suppl 68:1–148.

    PubMed  Google Scholar 

  8. Kosashvili Y, Fridman T, Backstein D, et al. The correlation between pes planus and anterior knee or intermittent low back pain. Foot Ankle Int. 2008;29:910–3.

    Article  PubMed  Google Scholar 

  9. Staheli LT, Corbett M, Wyss C, et al. Lower-extremity rotational problems in children. Normal values to guide management. J Bone Joint Surg Am. 1985;67:39–47.

    PubMed  CAS  Google Scholar 

  10. Lee TQ, Anzel SH, Bennett KA, et al. The influence of fixed rotational deformities of the femur on the patellofemoral contact pressures in human cadaver knees. Clin Orthop Relat Res. 1994;302:69–74.

    Google Scholar 

  11. Eckhoff DG, Montgomery WK, Kilcoyne RF, et al. Femoral morphometry and anterior knee pain. Clin Orthop Relat Res. 1994;302:64–68.

    Google Scholar 

  12. Turner MS. The association between tibial torsion and knee joint pathology. Clin Orthop Relat Res. 1994;302:47–51.

    Google Scholar 

  13. Biedert RM, Stauffer E, Friederich NF. Occurrence of free nerve endings in the soft tissue of the knee joint. A histologic investigation. Am J Sports Med. 1992;20:430–3.

    Article  PubMed  CAS  Google Scholar 

  14. Dye SF, Vaupel GL, Dye CC. Conscious neurosensory mapping of the internal structures of the human knee without intra-articular anesthesia. Am J Sports Med. 1998;26:773–7.

    PubMed  CAS  Google Scholar 

  15. Witonski D, Wagrowska-Danielewicz M. Distribution of substance-P nerve fibers in the knee joint in patients with anterior knee pain syndrome. A preliminary report. Knee Surg Sports Traumatol Arthrosc. 1999;7:177–83.

    Article  PubMed  CAS  Google Scholar 

  16. Post WR, Teitge R, Amis A. Patellofemoral malalignment: looking beyond the view box. Clin Sports Med. 2002;21:521–46. x.

    Article  PubMed  Google Scholar 

  17. Ahmad CS, McCarthy M, Gomez JA, et al. The moving patellar apprehension test for lateral patellar instability. Am J Sports Med. 2009;37:791–6.

    Article  PubMed  Google Scholar 

  18. Rosenberg TD, Paulos LE, Parker RD, et al. The forty-five-degree posteroanterior flexion weight-bearing radiograph of the knee. J Bone Joint Surg Am. 1988;70:1479–83.

    PubMed  CAS  Google Scholar 

  19. •• Merchant AC, Mercer RL, Jacobsen RH, et al. Roentgenographic analysis of patellofemoral congruence. J Bone Joint Surg Am. 1974;56:1391–6. Seminal paper describing a reproducible technique for accurate visualization of the patellofemoral joint and measurement of congruence angle to determine degree of lateral subluxation.

    PubMed  CAS  Google Scholar 

  20. Insall J, Salvati E. Patella position in the normal knee joint. Radiology. 1971;101:101–4.

    PubMed  CAS  Google Scholar 

  21. •• Blackburne JS, Peel TE. A new method of measuring patellar height. J Bone Joint Surg Br. 1977;59:241–2. Original description of measurement to assess patellar height.

    PubMed  CAS  Google Scholar 

  22. Berg EE, Mason SL, Lucas MJ. Patellar height ratios. A comparison of 4 measurement methods. Am J Sports Med. 1996;24:218–21.

    Article  PubMed  CAS  Google Scholar 

  23. Laurin CA, Dussault R, Levesque HP. The tangential x-ray investigation of the patellofemoral joint: x-ray technique, diagnostic criteria and their interpretation. Clin Orthop Relat Res. 1979;144:16–26.

    Google Scholar 

  24. Pihlajamaki HK, Kuikka PI, Leppanen VV, et al. Reliability of clinical findings and magnetic resonance imaging for the diagnosis of chondromalacia patellae. J Bone Joint Surg Am. 2010;92:927–34.

    Article  PubMed  Google Scholar 

  25. •• Harris JD, Brophy RH, Jia G, et al. Sensitivity of magnetic resonance imaging for detection of patellofemoral articular cartilage defects. Arthroscopy. 2012;28:1728–37. Systematic review finds that MRI is a very sensitive (87 %), specific (86 %) modality for evaluation of patellar chondral defects with good intra-observer agreement. Similar findings were found in evaluation of MR imaging of the trochlea with sensitivity of 72 % and specificity of 89 %.

    Article  PubMed  Google Scholar 

  26. Bredella MA, Tirman PF, Peterfy CG, et al. Accuracy of T2-weighted fast spin-echo MR imaging with fat saturation in detecting cartilage defects in the knee: comparison with arthroscopy in 130 patients. Am J Roentgenol. 1999;172:1073–80.

    Article  CAS  Google Scholar 

  27. Disler DG, McCauley TR, Kelman CG, et al. Fat-suppressed 3-dimensional spoiled gradient-echo MR imaging of hyaline cartilage defects in the knee: comparison with standard MR imaging and arthroscopy. Am J Roentgenol. 1996;167:127–32.

    Article  CAS  Google Scholar 

  28. •• Potter HG, Linklater JM, Allen AA, et al. Magnetic resonance imaging of articular cartilage in the knee. An evaluation with use of fast-spin-echo imaging. J Bone Joint Surg Am. 1998;80:1276–84. 1998 study evaluated the sensitivity and specificity of MRI in visualizing cartilage lesions in 88 young (average 38 yrs) patients and comparing the findings with intra-operative findings.

    PubMed  CAS  Google Scholar 

  29. Bland JM, Altman DG. Statistical methods for assessing agreement between 2 methods of clinical measurement. Lancet. 1986;1:307–10.

    Article  PubMed  CAS  Google Scholar 

  30. Goutallier D, Bernageau J, Lecudonnec B. The measurement of the tibial tuberosity. Patella groove distanced technique and results (author’s translation). Rev Chir Orthop Reparatrice Appar Mot. 1978;64:423–8.

    PubMed  CAS  Google Scholar 

  31. Schoettle PB, Zanetti M, Seifert B, et al. The tibial tuberosity-trochlear groove distance; a comparative study between CT and MRI scanning. Knee. 2006;13:26–31.

    Article  PubMed  Google Scholar 

  32. Dejour H, Walch G, Nove-Josserand L, et al. Factors of patellar instability: an anatomic radiographic study. Knee Surg Sports Traumatol Arthrosc. 1994;2:19–26.

    Article  PubMed  CAS  Google Scholar 

  33. McConnell J. The management of chondromalacia patella: a longterm solution. Austral J Physiother. 1986;32:215–23.

    Google Scholar 

  34. Lan TY, Lin WP, Jiang CC, et al. Immediate effect and predictors of effectiveness of taping for patellofemoral pain syndrome: a prospective cohort study. Am J Sports Med. 2010;38:1626–30.

    Article  PubMed  Google Scholar 

  35. Wilson NA, Mazahery BT, Koh JL, et al. Effect of bracing on dynamic patellofemoral contact mechanics. J Rehabil Res Dev. 2010;47:531–41.

    Article  PubMed  Google Scholar 

  36. Hunter DJ, Harvey W, Gross KD, et al. A randomized trial of patellofemoral bracing for treatment of patellofemoral osteoarthritis. Osteoarthr Cartil. 2011;19:792–800.

    Article  PubMed  CAS  Google Scholar 

  37. • Crossley K, Bennell K, Green S, et al. Physical therapy for patellofemoral pain: a randomized, double-blinded, placebo-controlled trial. Am J Sports Med. 2002;30:857–65. Multicenter, randomized, double-blinded, placebo-controlled trial demonstrates that physical therapy results in a greater reduction in average pain, worst pain, and disability scores compared with the placebo group.

    PubMed  Google Scholar 

  38. Witvrouw E, Lysens R, Bellemans J, et al. Intrinsic risk factors for the development of anterior knee pain in an athletic population. A 2-year prospective study. Am J Sports Med. 2000;28:480–9.

    PubMed  CAS  Google Scholar 

  39. Van Tiggelen D, Cowan S, Coorevits P, et al. Delayed vastus medialis obliquus to vastus lateralis onset timing contributes to the development of patellofemoral pain in previously healthy men: a prospective study. Am J Sports Med. 2009;37:1099–105.

    Article  PubMed  Google Scholar 

  40. Zhang SN, Bates BT, Dufek JS. Contributions of lower extremity joints to energy dissipation during landings. Med Sci Sports Exerc. 2000;32:812–9.

    Article  PubMed  CAS  Google Scholar 

  41. Fukuda TY, Rossetto FM, Magalhaes E, et al. Short-term effects of hip abductors and lateral rotators strengthening in females with patellofemoral pain syndrome: a randomized controlled clinical trial. J Orthop Sports Phys Ther. 2010;40:736–42.

    PubMed  Google Scholar 

  42. •• Earl JE, Hoch AZ. A proximal strengthening program improves pain, function, and biomechanics in women with patellofemoral pain syndrome. Am J Sports Med. 2011;39:154–63. A case series study shows that an 8-week rehabilitation program focusing on strengthening and improving neuromuscular control of the hip and core musculature improves patient outcomes, increases hip and core muscle strength, and decreases the knee abduction moment.

    Article  PubMed  Google Scholar 

  43. Clarke S, Lock V, Duddy J, et al. Intra-articular hylan G-F 20 (Synvisc) in the management of patellofemoral osteoarthritis of the knee (POAK). Knee. 2005;12:57–62.

    Article  PubMed  Google Scholar 

  44. Fulkerson JP, Shea KP. Disorders of patellofemoral alignment. J Bone Joint Surg Am. 1990;72:1424–9.

    PubMed  CAS  Google Scholar 

  45. Cox JS. An evaluation of the Elmslie-Trillat procedure for management of patellar dislocations and subluxations: a preliminary report. Am J Sports Med. 1976;4:72–7.

    Article  PubMed  CAS  Google Scholar 

  46. Barber FA, McGarry JE. Elmslie-Trillat procedure for the treatment of recurrent patellar instability. Arthroscopy. 2008;24:77–81.

    Article  PubMed  Google Scholar 

  47. •• Fulkerson JP, Becker GJ, Meaney JA, et al. Anteromedial tibial tubercle transfer without bone graft. Am J Sports Med. 1990;18:490–6. discussion 496–7. Follow-up study of patients 2 plus years status post anteromedial tibial tubercle transfer for patellofemoral pain with patellar chondromalacia reports 93 % good and excellent results subjectively and 89 % good and excellent results objectively. In addition, this surgical procedure was shown to allow many patients to resume increased levels of activity with substantially diminished pain.

    Article  PubMed  CAS  Google Scholar 

  48. Ferguson Jr AB. Elevation of the insertion of the patellar ligament for patellofemoral pain. J Bone Joint Surg Am. 1982;64:766–71.

    PubMed  Google Scholar 

  49. Maquet P. Considerations biomecaniques sur l’arthrose du genou. Un traitment biomecanique de l’arthrose femoro-patellaire. L’avancement du tendon rotulien. Rev Rhum Mal Osteoartic. 1963;30:779–783.

    Google Scholar 

  50. Ostermeier S, Holst M, Hurschler C, et al. Dynamic measurement of patellofemoral kinematics and contact pressure after lateral retinacular release: an in vitro study. Knee Surg Sports Traumatol Arthrosc. 2007;15:547–54.

    Article  PubMed  Google Scholar 

  51. Vaatainen U, Kiviranta I, Jaroma H, et al. Lateral release in chondromalacia patellae using clinical, radiologic, electromyographic, and muscle force testing evaluation. Arch Phys Med Rehabil. 1994;75:1127–31.

    Article  PubMed  CAS  Google Scholar 

  52. Shea KP, Fulkerson JP. Preoperative computed tomography scanning and arthroscopy in predicting outcome after lateral retinacular release. Arthroscopy. 1992;8:327–34.

    Article  PubMed  CAS  Google Scholar 

  53. Davies AP, Vince AS, Shepstone L, et al. The radiologic prevalence of patellofemoral osteoarthritis. Clin Orthop Relat Res. 2002;402:206–12.

    Article  PubMed  Google Scholar 

  54. Dy CJ, Franco N, Ma Y, et al. Complications after patello-femoral vs total knee replacement in the treatment of isolated patello-femoral osteoarthritis. A meta-analysis. Knee Surg Sports Traumatol Arthrosc. 2012;20:2174–90.

    Article  PubMed  CAS  Google Scholar 

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Correspondence to Sabrina M. Strickland.

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McCarthy, M.M., Strickland, S.M. Patellofemoral pain: an update on diagnostic and treatment options. Curr Rev Musculoskelet Med 6, 188–194 (2013). https://doi.org/10.1007/s12178-013-9159-x

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