Patellofemoral Disorders, A Classification System and Clinical Guidelines For Nonoperative Rehabilitation

C L I N I C A L C O M M E N T A R Y
Patellofemoral Disorders: A Classification

System and Clinical Guidelines for
~ o n o ~ e r a t i vRehabilitation
e
Kevin E. Wilk, PT'
George ). Davies, MEd, PT, SCS, ATC, CSCS '
Robert E. Mangine, MEd, PT, ATC3
Terry R. Malone, EdD, PT, A T C ~
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atients with patellofemoral Patellofemoral disorders are among the most common clinical conditions managed in the
pain symptoms remain orthopaedic and sports medicine setting. Nonoperative intervention is typicallv the initial form of
one of the most vexatious treatment for patellofemoral disorders; however, there is no consensus on the most effective
clinical challenges in reha- method of treatment. Although numerous treatment options exist for patellofemoral patients, the
bilitative medicine despite indications and contraindications of each approach have not been well established. Additionallv,
Copyright 1998 Journal of Orthopaedic & Sports Physical Therapy. All rights reserved.
thc. recent advancements in the un- there is no generallv accepted classification scheme for patellofemoral disorders. In this paper, we
derstanding and treatment of other will discuss a classification svstem to be used as the foundation for developing treatment strategies
knee conditions. Dve (21) has re- and interventions in the nonsurgical management of patients with patellofemoral pain and/or
ferred to this clinical conundrum as dvsfunction. The classification svstem divides the patellofemoral disorders into eight groups,
the "Black Hole of Orthopaedics," including: 1 ) patellar compression svndromes, 2) patellar instability, 31 biomechanical dysfunction,
stating that n o single explanation o r 4 ) direct patellar trauma, 5 ) soft tissue lesions, 6) overuse svndromes, 71 osteochondritis diseases,
therapeutic approach has yet fully and 8 ) neurologic disorders. Treatment suggestions for each of the eight patellofemoral dvsfunction
clarified this problem. This lack of categories will be brieflv discussed.
understanding of patellofemoral pain Key Words: patellofemoral dvsfunction, rehabilitation, classification
Journal of Orthopaedic & Sports Physical Therapy
and dysfunction is reflected in the ' National Director, Research and Clinical Education, Associate Clinical Director, HealthSouth Rehabilitation
vast number of different surgical pro- and Spom Medicine, 1201 1 lth Avenue South, :loo, Birmingham, A1 35205; Director oi Rehabilitation
cedures devised for the patellofemo- Research, American Sports Medicine Institute, Birmingham, AL; Adjunct Assistant Professor, Marquette
ral joint ( 2 2 ) . Universitv, Phvsical Therapv Program, Milwaukee, W
Patellofemoral disorders are ' Proiessor, Department oi Phvsical Therapv, Universitv oi Wisconsin-la Crosse, la Crosse, WI; Director,
Clinical Services and Research, Cundersen Lutheran Sports Medicine, la Crosse, WI
prohablv the most common knee pa- Director, Kentuckv Rehabilitation Services, Fort Mitchell, KY
thology encountered bv the ortho- Proiessor and Director, Phvsical Therapv Division, Universitv of Kentuckv, lexington, KY
paedic and sports medicine clinician.
Several studies (31,63,98,110,121,123, nal therapy for these patients is an The purpose of this article is to
124) have demonstrated that patel- understanding of the genesis and introduce a classification system that
lofemoral pain is o n e of the most pathophysiology of patellofemoral may be used as the foundation for
common clinical conditions present- pain. Furthermore, it would appear treatment strategies and interventions
ing to clinicians who treat musculo- that the ability to evaluate and differ- for nonsurgical management of pa-
skeletal conditions. Unfortunately, entiate these subtle variations and tient.. with patellofemoral pain. This
there appears to be n o consensus in the differences in the pathophysiol- proposed classification system has
the management of these conditions. ogy of these patellofemoral disorders been formulated from previously
There are certainly many reasons for would enable the clinician to formu- published research and the clinical
this vacuousness of information, but late effective treatment interventions obsemations of the authors of this
perhaps one of the reasons is because based on the findings from the his- paper. In addition, this classification
of the manv subtle variations of tory, subjective examination, phvsical svstem was developed in an attempt
"patellofemoral pain." Additionally, examination, and functional assess- to organize and offer suggestions on
central to the development of a ratio- ment. the application of the vast number of
CLINICAL COMMENTARY
treatment programs available to the tion schemes vary depending on the repetitive (overuse) syndromes, patel-
clinician. This classification system is author's background and purpose of lofemoral dvsplasias, idiopathic chon-
predicated on a thorough and com- the system. Most often, the groupings dromalacia patellae, osteochondritis
prehensive examination. Treatment. were designed to determine if the dissecans, and synovial plicae. Each
are thus individualized to the specific patient was a surgical candidate and of these categories were then divided
patient depending on the particular which surgical technique was most into two to four subgroups to further
unique characteristics and classifica- appropriate. Larsen et al, in 1978. differentiate the various disorders.
tion of the patient. proposed a structural classification Merchant emphasized the need for a
based on either congenital anoma- universally accepted classification sys-
lies, soft tissue pathology, o r mal- tem for patellofemoral disorders.
The Classification of Patellofernoral
alignment. of the lower extremity Although most authors agree that
Dysfunction (79). the initial treatment for the majority
In reviewing the literature per- Insall, in 1972, devised a classifi- of patients with patellofemoral pain
taining to patellofemoral pain and cation scheme based on the presence and/or dysfunction is a "wellde-
dysfunction, it becomes evident that of patellofemoral articular cartilage signedn rehabilitation program (2,5,
the huge variability in reported out- damage (62). Patients were chided 10,18,24,26,31,34,47,52,58,59,68,77,
comes, treatment techniques, and into three groups: I) presence of ar- 82,91,103,107,113,122,126,133,139),
rehabilitative interventions is related ticular cartilage damage, 2) variable to date, n o author has developed a
cartilage damage, and 3) normal ar- nonoperative rehabilitation classifica-
to a lack of consensus in the proper
ticular cartilage. These categories tion system for patellofemoral disor-
diagnosis and classification (1-3.8-
were then subdivided into eight ders. Authors typically describe o r
13,18,23,27,40-42,48,50,51,53,61,69,
groups based on malalignment syn- emphasize a particular treatment
70,72,73,75,78,81-86,88,93,100,105,
dromes, patellar subluxation, and technique o r approach, such as patel-
112,114,118,119,122,126-128,132,135,
dislocations. Fulkerson and Schutzer, lar taping (40,93),vastus rnedialis

136). Furthermore, there appears to
in 1986, suggested a classification sys- oblique retraining (9,20,29,50,81,108,
be a lack of standardized terminology
tem based on clinical and radiologic 128), foot orthotic intervention (23,
related to most effective rehabilitative
examination, utilizing computerized 72,l32), using biofeedback (81,l36),
approaches. Merchant (94) stated,
tomography scan studies (36). These o r knee bracing ( 1 3,83,84,lOO).
until an accepted classification system
authors defined four groups of patel- These techniques are generalized to
is in common use, it will remain diffl-
lofemoral dysfunction based on evi- all patient. with patellofemoral dvs-
cult to understand, diagnose, and dence of subluxation and/or patellar function, and there appears to be a
treat patellofemoral disorders. Diag- tilt. They emphasized the use of etio- lack of agreement regarding both the
noses such as "anterior knee pain" logic evidence and objective findings specific treatment interventions that
have become accepted by some clini- to determine surgical guidelines for should be utilized and when they
cians, adding to the confusion and patellofemoral procedures such as a should be employed. A consensus
nonspecific classification of patel- lateral retinicular release, proximal does exist that not one surgical pro-
lofemoral dysfunctions (45). Addi- realignment, and anteromedialization cedure is appropriate for all patel-
tionally, utilizing vague, nonspecific of the tibia1 tubercle. lofemoral patient.. The authors be-
diagnoses like "anterior knee pain" Later, Fulkerson et al (35) em- lieve that there is also not one
o r "patellofemoral pain" does not phasized the importance of a diagno- nonoperatiw treatment program a p
allow clinicians to effectively commu- sis based on the etiology of the disor- propriate for every patellofemoral
nicate, critically analyze, o r appropri- der. The authors proposed patient. While some common treat-
ately compare treatment approaches categorizing the etiology of patel- ment goals and techniques exist,
and result.. lofemoral pain from either arthral- each type of patellofemoral disorder
A comprehensive patellofemoral gias o r instability. Categories were necessitates specific treatment a p
classification scheme should: then established based on whether o r proaches which are more appropriate
I) clearly define diagnostic catego- not patellar malposition existed, and based on the etiology, structural in-
ries, 2) aid in the selection of appro- the appropriate surgical procedure tegrity, and a patient's response to
priate intenrentions, and 3) allow the was then chosen. the specific treatment.
comparison of treatment approaches In 1988, Merchant developed Hence, the goal in developing
for a specific diagnosis. perhaps the most thorough classifica- this classification system is to provide
Several authors have developed tion system based on the etiology of the clinician with guidelines that will
classification systems for patellofemo- the dysfunction (94). This scheme assist in the classification and treat-
ral disorders (25,35,36,43,45,46,62,79, was divided into five groups which ment of patellofemoral dysfunction.
94,111). The focus of these classifica- included acute traumatic disorders. The system presented uses the clini-
\'olume 28 Number 3 November 1W8 JOSPT

CLINICAL COMMENTARY
Loose pressure syndrome exhibit dimin-

1. Patellar compression syndromes
Excessive lateral pressure syndrome ished medial patellar displacement,
Global patellar pressure syndrome which results in a tilting of the me-
2. Patellar instability dial border. Patients with excessive
Chronic patellar subluxation lateral pressure syndrome may or
Acute patellar dislocation may not exhibit associated patellar
Recurrent patellar dislocation
3. Biomechanical dysfunction subluxation (24).
4. Direct patella trauma Frequently, the patient exhibits
Articular cartilage lesion (isolated) FIGURE 1. With excessive lateral pressure syndrome, muscular atrophy of the vastus media-
Fracture the lateral retinaculum is excessively tight and pulls
the patella laterally, usually resulting in a lateral tilt
lis oblique muscle fibers. This mav be
Fractureldislocation
Articular cartilage lesion with associated and a gradual stretching out of the medial retinacu- related to patellar position, associated
malalignment lum. pain, and inflammation, causing re-
5. Soft tissue lesions flexive inhibition, or dvsplasia of the
Suprapatellar plica vastus medialis oblique. Fulkerson et
Fat pad syndrome tients with excessive lateral pressure al have reported that the small nerve
Medial patellofemoral ligament pain branches which innervate the retinac-
lliotibial band friction syndrome
syndrome usually complain of lateral
Bursitis retinaculum pain (36,38), particularly ulum may become inflamed and in-
6. Overuse syndromes where the vastus lateralis inserts into jured in patients with chronic retinac-
Tendinitis the proximal lateral retinaculum, and ulum tightness (33,38). This may
Apophysitis occasionally of medial peripatellar contribute to reflexive inhibition of
7. Osteochondritisdissecans the quadriceps muscle and may also
pain, due to soft tissue stretching.
8. Neurologic disorders
Reflex sympathetic dystrophy Pain is frequently noted with stair explain the wide variations in pain
Sympathetically maintained pain climbing, squatting, or stooping intensity reported by patellofemoral
patients with relatively minor abnor-
down. As the condition worsens and

TABLE 1. Classification of patellofemoral disorders. articular cartilage erosion and degen- malities. Radiologic examination is
eration occurs, crepitation with pas- extremely helpful in the diagnosis of
cal examination to determine a diag- sive and active motion develops (36). this condition (80,95,111).
nostic category for the patient and, The most critical finding on physical The major long-term problem
thus, an appropriate treatment pro- examination is that the patella is with excessive lateral pressure syn-
gram. Therefore, the treatment pro- tilted laterally, and there is excessive drome is a deliterious effect on the
gram is based on the unique and spe- tightness of the lateral retinacular articular cartilage and surrounding
cific presentation of the patient. This structures when compared with the soft tissue. Fulkerson and Hunger-
classification system for patellofemo- medial side. Excessive lateral pressure ford (34) stated that excessive lateral
ral disorders is outlined in Table 1. syndromes may develop due to con- pressure syndrome is primarily the
genital lateral tilting of the patella result of chronic lateral patellar tilt,
which may be subtle initially. With
Patellar Compression Syndromes
time and bone growth, the magni-
Patellar compression syndromes tude of stress on a chronically tilted
manifest clinically via a patella that is patella may become substantial
overconstrained by the surrounding (36.38). When the patella is chroni-
soft tissue, grossly restricting patellar cally tilted (laterally), even to a mild
mobility. These may occur on one degree, adaptive shortening of the
side (usually laterally) or on both lateral retinaculum will occur (34).
sides of the patella and can have del- Additionally, the medial retinacular
eterious effects on the articular carti- structures, which have been placed
lage. on constant stretch, can become at-
tenuated. This condition is character-
ized by a loss of normal patellar mo-
Excessive Lateral Pressure Syndrome
bility. In the normal knee when fully
Ficat and Hungerford (24) in extended and relaxed, the patella
1977 first described a clinical condi- can be passively displaced mediallv
FIGURE 2. Assessment of patellar mobility. Gliding
tion they termed excessive lateral and laterallv approximately 1 cm in
the patella mediallv and laterally and determining the
pressure syndrome, which is unilat- each direction or approximately 25% amount of patella displacing over the medial and lat-
eral (lateral) compression or an over- of the width of the patella (31) (Fig- eral femoral condvle. This mav be pedormed in full
constrained patella (Figure 1). Pa- ure 2). Patients with excessive lateral extension and with the knee flexed to 25-30".
JOSPT Volume 28 Number 5 November 1938

CLINICAL COMMENTARY
adaptive deep lateral retinacular others. First, the treatment should RF

shortening, and a resultant chronic primarily focus on stretching the VL
-
30 400
-
5 70
VML
imbalance of facet loads (34). XI-
though it is more commonly seen in
tight lateral retinacular structures.
This may be attempted through joint
-
15 170
older patients, particularly females mobilization techniques, including
with a long histon of anterior knee medial glides and medial tilts of the
pain, excessive lateral pressirre syn- patella. Patellar taping to correct the
drome has been seen to de\.elop r a p excessive lateral tilt may also be benc-
idly in young patients (34). It should ficial. T h e authors have utilized patel-
be noted that chronic lateral facet lar taping to produce ;I low load,
overload can lead to a loss of lateral long duration stretch on the tight
patellar facet articular cartilage. lateral retinaculum structures. This
A nonoperative treatment pro- technique has been shown to elon-
gram for this condition can be suc- gate collagen more effectively than
cessful. Kramer (76) reported 31 of other stretching techniques (74.88.
33 patients returned to full unre- 129,130). The second area of rehabil-
stricted function following nonopera- itative focus is on m~rsculotendinosis
tive treatment for excessive lateral stretching, p;irtictrlarly the ham-

patellar pressure syndrome. An indi- strings, quadriceps, and iliotibial
\idualized rehabilitative program for band. Tightness of the iliotibial band,
excessive lateral pressure syndrome particularly the iliopatellar band, may A
patient5 and the specific patellofemo- contribute to lateral tilting of the pa-
ral condition must be implemented tella. The third goal of treatmcnt is
to ensure clinical success. T h e follow- improving quadriceps mr~sclc

ing rehabilitation guidelines are
based on the authors' clinical experi-
ences. The rehabilitation specialist
strength, particularly of the wstus
medialis oblique, in an attempt to
enhance patellar stabilization (8,12).
-
should consider the chronicity of the T h e vastus medialis oblique muscle
disorder, level of pain and inflamma- should only be focused on if the fi-
tion, patient's tissue type, a c t h i p lev- bers of the vastus medialis oblique
el, and lower extremip alignment attach onto the patella in a position
when designing the rehabilitation which can prevent lateralization of
program. For example, if the condi- the patella dynamically (Figure 3). If
tion has been present for a long pe- the patient exhibits vastus medialis
riod of time, the surrounding soft oblique dysplasia o r the attachment
tissue has adapted to the changes of angle of the vastus medialis oblique is
patellar position, motion, etc. Thus, more superior than preferred (Figure
the therapist may consider nontradi- 3). the vastus medialis oblique mus-
tional forms of stretching, such as cle fibers will exhibit a less effective
low load long duration stretching. medial stabilizing effect. In this case,
Additionally, if the patient's pain the clinician may not choose to focus
complaint o r level of inflammation is
significant, a more mild to moderate
entirely on wstos medialis oblique
muscle training. T h e use of biofeed-
I
form of rehabilitation and a c t i ~ i p back o r muscular stimulation mav
level should be utilized until these assist in reeducation of the n e w &
conditions are reduced. T h e patient's mtrscular unit. T h e fourth area of
tissue type o r degree of joint mobility focus is anti-inflalnmaton FIGURE 3. A J The quadricrps musclr's insrrtion an-
should also be carefully considered. gles are illustrated. The vastus medialis ohlique
for any syno\itis secondan to articu-
IVMOJ should insert at approximatelv 50-55' and
Patient5 with generalized congenital Iar cartilage degeneration. Modalities onlo the superior and aspect oj the pate//a,
hypermobilit\. are usually able to re- such as cnotherapy. high vol rage gal- BJClinicall\: this can he estimated throu,qhpalpation.
gain motion more readily than p;~- \.anic stimlllation, and anti-infli1mma- The patient's knee IS positioned at 60' ot knee tlexion
tient.5 who exhibit hypomobilip of tonmedication may also be benefi- andrmisted knee evtension is periormed against the
other.joint5 in the body. T h e n o n o p clinician's hand as the clinician's other hand palpates
cial, particularly if the patient
the insertion oithe VMO into the patella. VL = Vastus
erative rehabilitation program should exhi bits moderate to severe retinacu- late,ljs, RF = ~~t~~ iernorjs, VML = Vastusmed;'l/;s
focus on five areas and avoid several lum pain. Additionally, the patient lateralis.
must he educated regarding finding a latcr;d presstire syndrome is patellar pli;~siso n the niost rcstrictcd dir-cc-
suit;~hlclevel of activity and excrcisc mobility. In global patcll;w pressure tions) to provide ;I stretch to thr soft
intensity which will not cause a signif- svndrome, mobility is rcstrictcd in tissue. The ar~tliorssuggest that when
icant increase in symptoms. 110th tlie medial and lateral direc- performing patella mol~ilizationsan
T h e nonoperativc trcatmcnt tions. Additionally. patellar mobility attempt to hold tlic glide for a long
should include specific arcas of is ofien rcstrictcd superiorly d u e to duration (for at least 1-2 minutes
avoidance, especially during early in- im~nobilizationof the knee in a and as long ;IS 10-12 minutcs) c;ui
t e ~ ~ e n t i o Recause
n. of cxccssivc com- flexed position. Mc<:onncll (93) has 11c used to cnli;~ncc. rcniotlcling of
pression and an increase in patel- rccommended ;I scrics of tests to de- tlic soft tissue ( 137). Addition;tlly,
lofemoral joint reaction forces, as termine patcllofe~nor;dalignment on soft tissuc niobiliz;~tionto the qu;~dri-
well as a concentration of contact resting position. Fitzgcrald and Mc- ccps mi~scle,rspcci;dly ;it its insertion
stresses laterally (56). the authors <:lure (28) have r c p r t e d that tlie into the patcll;~;mtl the rctin;~cril;~r
strongly discourage the use of the reliabilitv of these tests is poor and tissuc, niay also bc beneficial. The
bicycle o r any rr.sistrd open kinetic suggcstcd ;dternative assessment tech- patient is ;dso instructcd to perfor-ni
chain kncc extension exercises dur- niques. T h e authors of this paper III~,-rrit/rrlkncc joint motion periotli-
ing the initial phase of the rehabilita- rccornmcnd assessing patellar mohil- c;dly thror~ghorittlic day to improvc
tion program. This shoidd he re- ity, medial, lateral, superior, and infix- and maintain soft tissue mobility. It is
stricted until normal patellar mobility rior. Frequently, tihiofemoral joint impcrativc for- the clinician to restore
is restored. Tlie patient is instructed motion is also restricted bccarisc of full passive kncc cxtcnsion to prc-
to minimize stair amhulation and the gloh;d loss of patellar motion. As scr\.e the integrity of the ~;itcIIoknio-
deep knee squats until the condition ;I result, patients may exhibit a slight ral ;~rticularc;~rtil;lgc.Stretching prr-
improves. Once the position of the flexion contractilre which can con- forriictl lix the hamstrings, hip
pitella has hccn normalized, the pa- tribute to o r result in patella infera flexors, q ~ ~ ; ~ d r i c cgastrocnemius,
ps,
and iliotibi;d h;uid is also cxtr-cnicly
tient may gradually increase their syndrome ( 102).

xtivities and may hcgin bicycle and The p t i c n t risually presents with hcncfici;~l,p;wticul;uly stl-etching of
othcr repetitive activities. disuse atrophy of the qu;~driceps.Tlie the qri;itlriccps nir~sculati~rc. \lrisclc
most pro~iorlncedchanges occrlr strcngtlicning sliould focus o n the
Global Patellar Pressure Syndrome within the stus us medi;dis oblique. quadriccps niusclc group. 1niti;dly.
Imss of flexibility can typically be clue to patcllok~iio~-al joint pain and
Another type of patellar compres- noted within tlie hamstrings, quadri- thc restriction in motion, the quadri-
sion syndrome is o n e where both the ccps, and iliotibial b;lnd. This loss of ccps strc.ngthcning program slior~ld
lateral and ~nedialrctinacr~lrimare flexibility usu;~llyworsens ;IS the con- be conscmxtivc in nature. Excrciscs
excessively tight. The authors of this dition progresses into a chronic such ;IS qu;~dricc*psmulti-angle istr
piper refer to this as global patellar stage. Plain r;~diograplis,p;~rtic~ila~-lyrnctric contr;~ctions,straight Icg rais-
pressure syndrome. This condition the axial or \lcrcli;int \iews, can bc rs, and mini-squats (0-40") have
usually devclops secondan to local uscful in idcntifying this condition been fhund t o hc most efTectivc by
trauma such as a blow to thc patella, and its extent. the authors. Oncc thc patella niohil-
whicli may lead to the formation of T h e nonoperativc approach for ity iniprovcs, the rchahilit;itiv~pro-
fibrosis within the sr~rroundingrcti- global patell;~rprcssurc s!~ndronic is gr;trii may I,c ;~d\;~nccd to inclridc
naculum. Global patellar pressure similar to the treatment of csccssivc other- exercises sucli as the Icg PI-css,
syndrome can also develop secondary lateral pressure syndronic with a few lunges, \ \ a l l sqriats, ctc.
to immobilization for fracture treat- important diffcwnccs. First and Sol-e- There ;we spccific ;ictivitics, cxcr-
ment, ctc. During extended immobi- most, patellar mohilit!. must hc im- ciscs, and trc;itmcnt tccliniqrics
lization, the patellofc~moral.joint he- proved before any qgl-essivc thera- which ;we contraindicated for this
comes hypomohilc, and the soft pcritic excrcisc may be initi;ltcd. This type of patient. R C C ~ I I the S ~ ptcII;1
tissuc srlrrounding tlie patella a d a p is critical to the trcatmcnt program rrtinacrilrim is gloh;dl\ tight, causing
tively shortens. in order to prevent the a d v a n c c ~ n ~ n t cxccssivc patellar compression into
Patients with global patellar pres- of articular cartilage degeneration tlic trochlcar groovr ;uid condyle.
sure syndrornc most often complain and increasing inflammation. T o pr-e- which incrcascs patcllofi.rnor;~ljoint
of diffi~seanterior knee pain globally pare the soft tissuc that surrorlnds contact pressrircs (.56,60),;~ctivitics
about the patclla, which may he d u r the pat ell;^ for strctcliing, mod;ditirs sucli as bicycling, rcsistcd knee cxtcn-
to inflammation of the rctinac~ilar such as ;I w;wm whirlpool and ultra- sions, dccp kncc Iwnds. or tlccp
structures. T h c most critical clinical sound ni;~!. hc Ixwcficial. Following sqriats (hcyond 60") arc strongl!. dis-
finding d i f k r e n t i a t i n global patellar moclality application, the patcll;~is cor~raged until p;itcll;w riiohility is
presslire syndrome from cxccssivc mobilized in a11 directions (with cni- I-cstol-cd. .i\dtlition;dly, patellar- taping
CLINICAL COMMENTARY
o r bracing, which may restrict or sation of instability. Often the patient performed with the knee flexed to
compress the patella, is discouraged. reports catching o r a pseudolocking 20-80". If greater than 50% of the
The primary goal of rehabilitation is feeling of the patella as the patella total patella width can be displaced
to improve patellar mobility and, un- gets "hung up" on the trochlea laterally over the edge of the lateral
til this occurs, the exercise program groove. Pain is usually localized to femoral condvle, the clinician should
and functional activities must be lim- the medial aspect of the patella o r be suspicious of patellar instability
ited to a conservative level. the distal pole but is often difficult to (31). This finding is an important
localize. Patient5 frequently report clinical assessment. Tracking of the
Patellar Instability snapping and popping of the patella. patella during passive knee extension
Episodes of gi\ing way are common, should also be noted for asymmetric
Patellar subluxation generally
and effusion will frequentlv accom- lateralization of the patella. The clini-
describes the transient lateral move-
pany such episodes. Often patients cian should carefully observe the
ment of the patella during early knee
are limited in sports participation course of tracking of the patella from
flexion (57). The degree of lateral
because of complaints of apprehen- the fully extended knee with the
movement of the patella can v a n dra-
sion, insecurity, and/or instability. quadriceps contracted to full flexion
matically from patient to patient. Of-
Upon palpation, medial retinacu- and back again. It is particularly im-
ten patients may experience pain
lar and distal patellar pole tenderness portant to observe the entrance and
(32) and/or instability (17,92). In
may be elicited. Occasionally, tender- exit into the trochlea during early
some cases, the patient may exhibit
ness may be elicited along the distal flexion between 10 and 25". Fre-
pathologic lateral tracking of the pa-
quadriceps. Patient apprehension quently, an abrupt lateral movement
tella. The patella normally tracks lat-
(positive Fairbanks sign) is common of the patella at terminal knee exten-
erally at the extremes of the range of
on displacing the patella in a lateral sion is observed and is referred to as
motion (full extension and flexion)
direction. Patellar hypermobility is an extension subluxation. An in-
(31). It has been the observation of
creased Q angle is also a common
often present, and patella alta may be

the authors that many individuals
noted. Muscular atrophy o r dvsplasia finding.
exhibit significant lateral tracking
of the quadriceps, particularly in the Radiologic examination is ex-
and are asymptomatic.
vastus medialis oblique, is common. tremely helpful in diagnosis of patel-
During the clinical examination, lar subluxation. Standard tangential
Chronic Subluxation it is critical to evaluate patella mobil- radiographs may readily demonstrate
Most patients with chronic patel- ity (28,125). Lateral and medial dis- subluxation (24,80,94). Merchant has
lar subluxation demonstrate extensor placement of the patella should be advocated an initial screening view
mechanism imbalance and some
form of patellofemoral joint dysplasia
(29). Subluxation may result from

congenital deficiency of the femoral
trochlea, malalignment of the lower
extremity, excessive hip anteversion, Med~al( ) Lateral ( + )
external tibia1 torsion, excessive pro-
nation of the foot, o r soft tissue and
muscular imbalances between the
vastus medialis oblique and lateralis
(28-30,37). Connective tissue laxity
may aggravate any preexisting exten-
sor mechanism malalignment condi-
tion (34,94). Most patients complain
of giving way and a feeling of instabil-
ity and/or pain. Subluxation is often
accompanied by a patellar tilt; thus,
many patient5 will complain of tight-
ness o r discomfort around the pa-
tella. Frequentlv, patient5 are unable
to be specific in describing episodes FIGURE 4. Congruenceangle: The sulcus angle E' TI' is bisected by a neutral reference line TO. The apex of the
patella is then connected to the lowest point on the sulcus. When this line, RT, is medial to the neutral reference
of subluxation but report that "some- line, the angle is given a negative value; when lateral, a positive value. (FromMerchant AC, Mercer RL, lacobsen
thing jumps" and "it feels like some- RH, Cool CR: Roentgenographic analvsis bv patello-femoral congruence. I Bone joint Surg 56A: 1391-1396,
thing is out of place," causing a sen- 1974, reprinted with permission,.
31? h l u m e 28 Number .iNovember 1 9 8 JOSPT

CLINICAL COMMENTARY
taken at 45" of flexion for easier ex- the Genutrain P3 brace (Bauerfeind aware that their patella has gone out
posure and clarity (94). T h e congnl- Inc. USA, Kennesaw, GA) minimized of place. Acutely, the knee is signifi-
ence angle provides useful informa- lateral displacement of the patella. cantly swollen and painful and mo-
tion in determining patellar position. An exercise brace, such as the Pro- tion is limited. Often the examina-
Merchant (94) has reported a con- tonics brace (Protonics Corp., Lin- tion is difficult d u e to pain and
+
gruence angle of -6 SD 6" as nor- coln, NE), which produces resistance swelling. Upon palpation, often pain
mal (Figure 4). during functional activities, may he o r a tear may be noted along the me-
T h e nonoperative treatment for beneficial when the brace is adjusted dial retinacular structures. A patho-
patients with chronic patellar sublux- to resist knee extension (117). Thus, gnomonic finding of patellar disloca-
ation emphasizes maintaining patella the primary treatment goal is enhanc- tion is pain at the adductor tubercle
stability, enhancing dynamic stabiliza- ing patellar stability, either by dy- where the medial patellar ligament
tion ( 19,20), correcting the malalign- namic stabilization o r by passive originates from. The clinician should
ment (79), while minimizing s y m p mechanisms. As the condition im- carefully examine the vastus medialis
toms and diminishing r i s h for proves, the exercise program may be oblique to determine whether this
dislocation (34,36). T h e use of patel- progressed and sports may be gradu- structure is intact. Additionally, the
lar bracing o r taping the patella me- ally initiated. clinician should examine for con-
dially to enhance patella stability may cominant anterior cruciate ligament,
be helpful during exercise and func- Patellar Dislocation medial collateral ligament, o r menis-
tional activities ( 15,49). Pain-free cal injury. Assessment of patella mo-
Patellar dislocation is defined as
quadriceps strengthening should be bility usually produces significant a p
complete patella displacement out of
performed to assist on improving dy- prehension. Knee joint motion is
the femoral trochlea. Patellar disloca-
namic stability, with the goal of en- often limited because of pain, swell-
tion may occur as a direct traumatic
hancing vastus medialis oblique effi- ing, and muscle guarding.
event to the patient with normal pa-
ciency. Again, an evaluation of the The nonoperative treatment ini-

tellar alignment o r may occur in the
insertion angle of the vastus medialis tially begins with immobilization of
patient with malalignment (31). Nor-
oblique onto the patella will deter- the knee in extension for a period of
mally, the patella has a tendency to
mine the usefulness of vastus medialis time to permit healing of the medial
displace laterally. There are several
oblique training (Figure 3). In the retinaculum and/or vastus medialis
structures which tend to restrict o r
authors' opinion, although there are oblique to the patella (31). T h e au-
control this lateral patellar displace-
n o exercises that "isolate" the vastus thors have found it beneficial to uti-
ment. These structures include the
medialis oblique, muscle exercises lize a lateral doughnut pad, which is
medial patellar ligaments (patel-
such as the leg press, lateral step-ups, constructed and applied to assist in
lofemoral and patellomeniscal liga-
terminal knee extension, isometric the medialization of the patella dur-
ments), the buttress effect of the lat-

quadriceps setting exercises, and hip ing the period of immobilization.
eral femoral touchlea, and muscle
adductions have heen reported as During the immobilization phase,
activity by the vastus medialis oblique.
excellent exercises to produce high quadriceps muscular reeducation ex-
For the purpose of this paper, we will
levels of electromyographic activity of ercises are performed. Exercises to
briefly discuss acute and recurrent
the vastus medialis oblique in rela- activate the quadriceps muscle with
patellar dislocation only.
tionship to the vastus lateralis (12, the knee fullv extended are per-
114,l 18,154-136). However, d u e to formed during the early stages. Addi-
Acute Patellar Dislocation
lateral tracking of the patella at ter- tionally, electrical muscle stimulation
minal knee extension, in some pa- Acute dislocation occurs as a sud- may be beneficial in the activation of
tients, knee extensions from 90-40" den event, whether related to trauma the quadriceps (1 l 6 ) , and modalities
may be necessary to enhance osseous o r to preexisting malalignment. Of- such as ice and high voltage galvanic
stability. Orthotics may be used to ten patients express that a torsional stimulation should be used as well as
minimize excessive foot pronation stress was imparted onto the extensor compression and elevation to reduce
and improve lower extremity align- mechanism, which caused the com- inflammation. Once the initial in-
ment, thus diminishing valgus thrust- plete displacement of the patella out flammation has subsided and early
ing at the knee. Additionally, the sta- of the trochlea. Hawkins et al (51) healing has occurred, the patient's
tionary bicycle, stair climbing reported that 30-50% of the patients range of motion is gradually in-
machine, and swimming can all be who have suffered a dislocated pa- creased, and strengthening exercises
helpful in improving quadriceps tella will continue to experience pain are gradually progressed. A patellar
strength. Some braces may assist in and instability. stabilization brace may he utilized
controlling lateral patellar displace- Patients who have experienced during this phase as functional activi-
ment. Shellock et al (1 12) reported an acute dislocation of the patella are ties are advanced ( 12,15,44,112).
JOSPT Volume 28 Number 5 November 1998

Recurrent Patellar Dislocation for the lower extremity should also position of the patella during static
be performed. Any malalignment of weight-bearing radiographs. Addition-
Fulkerson and Hungerford and the lower extremity shordd be appro- ally, Eng and Piernnowski (23)
Fulkerson et a1 have reported that priately addressed with stretching, noted orthotics in conjunction with
the natural histon of patients follow- orthotics, etc. Often, patients must an exercise program were more effec-
ing dislocation of the patella can be modifv their activities for a period of tive in diminishing patellofemoral
quite variable (34,36). Occasionally, a symptoms than an exercise program
time to prevent recurrent disloca-
patient presents with a single disloca- alone. Wallace (132) has noted the
tions; frequently, i t may be necessary
tion in their lifetime; however, this is most common intrinsic foot imbal-
to limit participation in specific
unusual. Others present with two to ance is forefoot varils with compensa-
sports.
three recurrent dislocations over a t o n rearfoot valgus. This results in
period of several years and often may excessive pronation which affects the
avoid s i ~ r g e n O
. n the other hand, Lower Extremity Biomechanical entire lower extremity kinetic chain.
some patients present with frequent Dysfunction A thorough evaluation of the foot
recurrent dislocations, even during and ankle is necessan when examin-
activities which are not too stressful, Patellofemoral pain may develop ing a patient with patellofemoral
such as walking, descending stairs, in individuals with wrious activity pain. If intrinsic imbalances of the
getting into and out of a car, etc. levels d u e to biomechanical factors
foot are found, orthotics may be indi-

Crosby and Insall ( I 7) reported that which affect the patellofemoral joint cated.
the frequency of dislocations de- (.i6,60). These biomechanical factors A lower extremity limb length
creased with age in a series of pa- can often be subtle and can gradi~ally discrepancy can have a significant
tients who were treated nonopera- lead to significant patellofemoral effect on lower extremity mechanics
tively. pain and dysfunction. Abnormal bio- and the patellofemoral joint. Com-
Recurrent patellar dislocation mechanics affect the patient during
pensations for limb length discrepan-

most frequently affects females more everyday activities, such as working, cies include excessive foot pronation,
than males; the predominance varies amhulation on stairs, and during toeing-out (forefoot abduction), and
from 1.5:l to as high as .i:l (30,Fi.i. strenuous actkities such as exercise a flexed knee gait and/or stance
90). Additionallv, it has been docu- o r sports (89,96,97). T h e arlthors ( 131,132). All of these compensaton
mented that this disorder occurs in have clinicallv noted that a subtle mechanisms have a direct affect on
adolescents with a mean age of alteration in normal mechanics may the patellofrmoral joint and patellar
14-15 years (24). Peak incident5 oc- have a profound effect on the patel- mobility. T h e evaluation of the lower
cur during puberty, which may re- lofemoral articulation over a period extremity limb lengths should be per-
flect changes in acti\ity level and skel- formed both anatomic;dly and fimc-
of time related to repetitive move-

etal alignment. T h e initial dislocation ments. Common areas of lower ex- tionally. Functional limh length dif-
occurs without warning and often is tremiw biomechanical factors to be ferences can occur at the foot, knee,
d u e to a twisting movement. A com- hip, and sacroiliac articulations. T h e
euluated are imbalances of the foot,
mon mechanism in athletics o r daily authors also recommend limb length
limb length deficiency, and flexibility
function is when external rotation measurements be taken in a weight-
deficiencies.
and valgus stress is applied to the bearing position to identifi any fi~nc-
Intrinsic imbalances of the foot
knee joint. tional limb length discrepancy and in
may change the lower extremity me-
T h e nonoperative treatment for supine for anatomical limh length
recurrent patellar dislocations is simi- chanics, which can either cause o r
differences.
lar to that for chronic patellar sub- aggravate patellofemoral pain and/or
A loss of flexibility of the lower
luxation syndrome. However, the cli- dysfunction. O n e frequently pro- extremity musci~latureor soft tissue
nician should become more posed abnormality is excessive subta- can cause a variety of disorders and
suspicious of articular surface injury. lar joint pronation resulting in lateral can contribrlte to patellofemoral dys-
T h e mainstay of the treatment is to displacement of the patella. Excessive function. Flexibility deficiencies of
enhance patella stability during acti\i- subtalar joint pronation results in the gastrocnemii~s/soleus, ham-
ties of daily living and/or sporu. This increased medial tibia1 rotation strings, iliotibial band, quadriceps,
can be accomplished through the use through the talocrural joint articula- and hip rotators can have a profound
of a patellofemoral brace o r patellar tion. Thus, medial tibia1 rotation effect on patellofemoral joint biome-
taping. Additionally, aggressive efforts forces the patella to displace laterally chanics ( 132). If normal talocrural
must be made to reestablish dynamic (109,138). Klingman et al (72) have joint dorsiflexion range of motion is
stability through quadriceps muscular shown that medial rearfoot-posted not available, it will be obtained dur-
strengthening. Endurance exercises orthotics resulted in a more medial ing ambillation and weight bearing
CI.INICXL COMMENTARY
through excessive compensator). pro- sports. Any direct blow to the patella Soft Tissue Lesions
nation (106). which can contribute to may result in an articular cartilage
injun. The authors have noted that There are numerous soft tissue
lateral tracking of the patella. Tight-
structures about the patellofemoral
ness of the lateral hamstrings may associated in.juries such as a fracture
joint which may become inflamed
cause the patient to toe-out and/or or dislocation may occur at the time
and be a source of pain and inflam-
pronate. Hughston et al (-59) stated of the i n j u n and should be treated
mation. These structures inclirde the
that hamstring tightness necessitates promptly.
plica, infrapatellar fat pad, medial
greater force being generated by the Following the initial in-jun, the
patellofemoral ligament, bursa, and
extensor mechanism. Additionally, it patient often complains of diffuse distal iliotibial band.
has been the clinical experience of anterior knee pain, occasionally feel- During embryonic life, the syno-
the authors that a loss of hamstring ing retropatellar pain, especially with \ial ca\ity of the human kneejoint
flexibilih decreases stride length, motion. Often patients will notice forms by fusion of three separate cilv-
causing the quadriceps to contract crepitation, particularly at one point ities (59). Such fusion may provide
more f'orcefully to overcome the pas- in the range of motion. Pain and dys- seams (junctions o r overlappings),
sive resistance of the tight hamstring function are exacerbated with activi- lea\ing a crescent-shaped fold of sy-
muscles and may often lead to quad- ties in which the quadriceps contract no\ium which attaches in the region
riceps fatigue. Tight hamstrings may
significantly, such as stair ambillation, of the vastus lateralis tendon inser-

also cause an increase in patellofemo- sqiiatting, and resisted knee exten- tion onto the patella, passes medially
ral joint reaction forces and/or a pos- sions. As the condition worsens, some beneath the deep surface of the
terior rotation of the sacroiliac joint. patients will develop erosion of the quadriceps tendon, attaches to it, and
Loss of mobilih of the patellofemoral articular cartilage to srrbchondral then passes around the medial femo-
joint can result in a flexed knee gait bone, and significant pain and/or ral condyle to the infrapatellar fat
pattern and increased patellofemoral
dysfunction will develop. pad (Figirre 3 ) . This synovial fold is

joint reaction force. Also, posterior T h e treatment for direct patellar referred to as the suprapatellar plica
capsular tightness of the tibiofemoral trauma withorrt associated fracture o r (6,64,66,101). Pain may develop as a
joint results in a flexed knee (knee restilt of direct i r l j ~ r nto the plica
malalignment is a consenative non-
flexion contracture), which results in folds with secondan inflammation or
operative rehabilitation program. T h e
a functional limb length difference, fibrosis. As the inflammato? re-
program should include range of mo-
an increase in patellofemoral pres- sponse progresses, varying degrees of
tion exercises to enhance articular
sure, and diminished patellar mobil-
cartilage healing, exercises which d o
ity. Tightness of the iliotibial band,
not produce excessive patellofemoral
especially distally at the insertion in
contact force, and a flexibility pro-

the lateral retinaculum, may contrib-
gram for the lower extremip muscles.
ute to lateral displacement of the pa-
The motion exercises should be per-
tella. T h e clinician should carefully
evaluate the f l e x i b i l i ~and mobilip of
formed repeatedly throughout the
day. Other activities such as swim-
Patella ;! '
the lower extremih musculature and
soft tissue and treat the specific disor- ming and bicycling with mild resis-
tance are beneficial. Limiting weight
der o r deficiency exhibited. It is im-
bearing may be indicated for a short
b', - /?&Fat Pad
portant for the clinician to determine
the reason for the compensaton me- period of time to control patel- -Patellar Tendon
chanics. lofemoral forces. A quadriceps I
strengthening program should be

performed which is nonpainfiil. Ini-
Direct Patellar Trauma tially, short arc exercises shoilld be
Frequently, patients will report a performed on either side of the pain-
mechanism of i n j u n that includes a ful area. Any exercises o r functional
direct blow to the patella, either dur- actkities that produce crepitation
ing evenday activities o r during and pain should be avoided. As the
sports participation. Often patients patient's symptoms gradually abate, FIGURE 5. Suprapatellar plica. The svnovial iold in its
the acti\ities may be gradually in- usual intra-articular location. Note the size and loca-
report they hit their patella on a
tion o i the intrapatellar iat pad. f r o m Hughston lC,
picce of furniture o r the dashboard creased. Symptoms associated with Mfalsh \VM, Puddu G: Patella Suhluxation and Dislo-
of a car. In sports, a blow to the pa- this condition may persist for several cation, p 29. Philadelphia, PA: M1.B. Saunders Com-
tella mav occur in collision o r contact months. panv, 1984, reprinted with permission).
CLINICAL COMMENTARY
fibrosis develop, ranging from mild a patient does not regain full passive abnormal lateral patellar tracking but
thickening to a significantly scarred extension because of scar tissue for- also a friction syndrome, where the
svno\ial tissue (59). Because of the mation in the fat pad area. This can iliotibial band passes over the lateral
thickening of the plica, two different result in pain and functional limita- femoral condyle. This friction may
areas of associated pathology are of- tions which are referred to as an in- produce inflammation, popping, and
ten seen. Erosion of the medial femo- frapatellar contraction syndrome. associated patellofemoral dysfunction.
ral condyle is due to impingement by Once injured, the fat pad exhibits Pain that worsens with activity and is
the thick and tight plica. Secondarily, tightness due to inflammation, ten- relieved by rest may radiate toward
the tethering connection with the derness upon palpation, and symp the lateral joint line and proximal
quadriceps tendon produces path* toms with direct pressure o r pressure tibia. It is beyond the scope of this
logic changes in the plica, causing from the patellar tendon. In the ad- paper to discuss these disorders in
abnormal tracking and pain in the vanced stages, the fat pad can be- detail, but the clinician should care-
extensor mechanism. come severely swollen and painful. fully consider each of them when
Often, the plica becomes in- Successful nonoperative treatment is evaluating a patient with a patel-
flamed due to a direct blow o r usually expeditious if initiated early. lofemoral problem.
trauma. It may also develop gradually The treatment focus is on avoidance
in individuals who perform excessive of direct pressure o r compression to Overuse Syndromes
squatting o r kneeling activities, run the fat pad, reduction of inflamma-
with excessive compensatory prona- tory reaction, and prevention of asso- A common ovenlse injury that
tion, o r increased tihiofemoral inter- ciated atrophy and loss of motion. occurs at the knee joint is tendinitis.
nal rotation. Characteristic symptoms The authors have found the use of Tendinitis, in general, denotes an
of a pathologic supratellar plica in- phonophoresis followed by ice bene- inflammatory reaction involving the
clude aching of the knee when held ficial for this condition. Additional tendon sheath and contained ten-
in a flexed posture, as in a n automo- soft tissue injuries include inflamma- don. The term tendinitis seems to
bile o r theater seat (59) (positive tion to the medial patellofemoral lig- imply that the entire tendon is in-
movie sign). Extending the knee is ament secondary to lateral patellar flamed in all cases; however, this is
often accompanied by a definite snap subluxation o r dislocation. The evalu- not tnle. Specific stnictures of the
o r pop that the patient associates ation and treatment of this should tendon may be individually involved
with relief of symptoms (59). Crepita- follow the patellar instability pro- without pathologic changes in the
tion and mild effusion are also com- gram. others. Clancy ( 14) advocates classifi-
mon. Atrophy of the quadriceps mus- Bursitis about the patellofemoral cation of these different pathologic
cle is commonlv present, which may joint can also occur. Prepatellar bur- conditions based on the involved ana-
be related to pain inhibition and dis- sitis is somewhat common and can tomic structures.
use atrophy. Hamstring muscle tight- occur due to a direct blow o r fall Paratendinitis is inflammation of
ness can also be present. T h e n o n o p onto the patella. In the acute phase, the outer layer of the tendon o r
erative treatment of the suprapatellar the prepatellar bursae is very swollen paratenon. Tendinitis is a condition
plica is directed toward reducing the and tender, allowing a relatively easy in which the site of injury is the ten-
inflammation of the plica and reduc- diagnosis. Pes anserine bursitis can don itself with an inflammatory re-
ing the fibrotic scarring of the plica. also develop. This bursae lies under- sponse and is usually accompanied
Contributing and associated factors, neath the combined insertion of the with inflammation of the paratenon.
such as muscle tightness and weak- sartorius, gracilis, and semitendinosus Tendinosis is tendon degeneration
ness, should also be addressed. Pa- into the proximal medial tibia. Palpa- with a limited inflammatory response.
tient education and avoidance of tion of the bursae and resisted man- The most common tendinitis
squatting, kneeling, and resisted knee ual muscle testing are the most effec- seen at the knee joint related to the
extension is beneficial. tive clinical tests to establish a patellofemoral joint is patellar tendi-
Fat pad syndrome (Hoffa's syn- differential diagnosis. A contusion is nitis. Patellar tendinitis is the most
drome) (54) usually develops second- often the precipitating o r causative common form of "jumper's knee"
arily to some form of trauma to the event. The iliotibial band also plays a and results from repetitive loading of
infrapatellar fat pads. The trauma significant role in extensor mecha- the knee extensor mechanism and is
may be a direct blow o r mechanical nism function. The distal portion of considered ovenae tendinitis. Patel-
in nature. Mechanically, the fat pad the iliotibial band is thick and e x h i h lar tendinitis is characterized by pain
can be caught between the femoral its significant attachments to the pa- felt anteriorly near the inferior pole
condvles and the tibia1 plateaus with tella and reinforcement to the lateral of the patella. T h e subjective history
extension, particularly hyperexten- retinaculum. Tightness of the ili- typically includes the insidious onset
sion. Occasionally following surgery, otibial band may be involved with of pain, initially presenting as an
\'olume 28 Numher i November 1W8 .JOSPT

CLINICAL COMMENTARY
Phase I Pain only after participation pation. Anti-inflammatoly medication tion of the tendon. Although nlp
Phase II Some pain/discomfort during practice may be beneficial. Modalities such as tures of the extensor mechanism in
but not sufficient enough to interfere warm whirlpool and ultrasound can the knee are not common in young
with participation be helpful. Exercises to restore flexi- athletes, the incidence increases with
Phase Ill Pain during and after participation, bility should be addressed, especially
sufficient enough to interfere with age (115,135).
performance for the hamstrings, calf, and quadri-
Phase IV Complete tendon disruption ceps. Muscular strengthening exer-
cises should begin with isometrics
Apophysitis
TABLE 2. Classiiication oipatellar tendinitis (71. and light resistance isotonics in a Two types of traction apophysitis
shortened muscle length tension po- seen at the patellofemoral joint are
ache o r discomfort following nmning sition to minimize stress to the ten- Osgood-Schlatter's disease and Sind-
o r jumping. The pain usually sub- don. Eccentric strengthening has ing-Larsen-Johansson syndrome (59).
sides with rest but returns as the ath- been advocated by several authors to Osgood-Schlatter's disease is a trac-
lete resumes activities that stress the speed the recoven for tendon over- tion apophvsitis of the tibial tuberos-
extensor mechanism. T h e pain may use injuries and may be considered
ity (59). This is characterized by an
progress to severely limit sports par- as a significant component of the
enlargement of the tibial tuberosity
ticipation and activities, such as walk- rehabilitation process (4,39,65,120).
(Figure 6). A similar traction phe-
ing u p and down stairs. T h e condi- A patella-restraining brace o r strap

nomenon can occur on the inferior
tion is generally worsened with across the patellar tendon may be
pole of the patella, referred to as
sudden quick jumps o r extreme beneficial; however, the authors of
Sinding-Larsen-Johansson syndrome
quadriceps force. Blazina et al (7) this manuscript have observed mixed
based a classification scheme on the results The clinician should acijust (Figure 7) (66).
relationship of the pain to athletic the patient's activity level to a point The usual symptoms and physical
findings of Osgood-Schlatter's disease
participation. This classification is at which improvement continues

helpful in formulating a treatment gradually. Often, symptoms from pa- is pain around the region of the tib-
program (Table 2). tellar tendinitis (Phases I and 11) may ial tuberosity with use of the knee,
O n physical examination, these require several months to resolve. such as athletics, bike riding, o r re-
patients often exhibit swelling along Some patients, however, continue to sisted knee extension. Localized ten-
the inferior pole of the patella. have symptoms and advance into the derness over the tibial tuberosity is
Range of motion of the knee is nor- more chronic stages. Phase 111 patel- usually the prominent complaint. Pa-
mal, except when the knee is flexed lar tendinitis is generally treated tella aha posture is frequently present
with the hip extended; this often pro- more conservatively initially than as well as hamstring tightness. Radio-
Phase I o r 11. Phase IV of patellar logic changes are easily seen, with an
duces pain at the patellar attach-

ments and limb knee flexion range tendinitis represents complete d i s n ~ p enlarged tibial tuberosity, as well as
of motion. A key clinical examination
finding is palpable pain at the infe-
rior pole of the patella. Another key
finding in the sensitivity of the lesion
is an increase in pain with resistance
applied during knee extension. Often
patients will exhibit tightness of the
quadriceps and hamstrings. Radio-
graphic examination may reveal calci-
fication along the inferior pole of the
patella. Kajala et al (67) reported a
40% incidence of tendinous calcifica-
tions in volleyball players. Further-
more, the tendon may develop a ne-
crotic region in some patients.
The nonoperative treatment is
determined by the stage of the condi-
tion. Treatment for patellar tendinitis
FIGURE 6. Oyood-Schbtter's dise've as seen on radiograph. A) Earlv enlqement of the tibial tuberosity,
for patients in the first two phases of B1 C~lciiicationanterior to the tibial tuberositv apophvsis, Cj Loose ossicles within patellar tendon. (From
the condition include an adequate Hughston/C, Walsh WM, Puddu G: Patella Subluxation and Dislocation, p 55. Philadelphia, PA: W.B. Saunders
warm-up followed by ice after partici- Companv, 1984, reprinted with permissionl.
JOSPT Volume 28 Number 5 Novrmher 1998 Sli

Osteochondritis Dissecans of the i n j u n o r srlrgen (24,31,71,104). Al-
Patella though there exists numerous treat-
ment approaches, Cooper et al (16)
T h e e t i o l o p of this condition and Ogihie-Harris and Roscoe (99)
contini~esto bc a n area of disagree- havc reported higher success rates
ment (.59), rcg;wdlcss of the location when the diagnosis and treatment is
of the osteochondritis dissecans le- established within the first 6 months
sion in the knee. Some authors be- of onset. This stresses the importance
licvc a ~ ~ s c u l necrosis
ar of the seg- of early detection and treatment.
ment of the bone exists, which leads The e;u-liest symptom associated
to secondan changes in the overlying with reflex sympathetic dystrophy is
;~rticul;~rc;~rtil;lge.Others believe pain disproportionate to the pathol-
some type of traumatic episode local- OF. Often, pain is manifested within
ized t o that part of the articular sur- the medial compartment of the knee
face produces an osteochondral lesion. and associated with the saphenous
Keg;~rdlessof the true etiolop, n e n e . T h e pain is often intense and
ccrt;lin cases d o present difTerently, can occur for prolonged periods of
with h p i c d changes on both radiw time. During the early stages, night
graphic and visual cxamination re- pain is a frequent complaint which
sembling a true osteochondritis disse- can awaken the patient with a sharp
cans. T h e patient complains of pain burning sensation. Patients often ex-
on the retrosurface of the patella, hibit cold intolerance and h!persensi-
ofien worse during squatting, s t o o p ti\ih, which may interfere with ther-
ing, ;~mbr~l;~tion. and descending apy techniques.

steps. 0cc;isionally. patients note giv- O n physical examination, the
ing way of the knee. Some patients most salient findings are sensitkit\.
report the knee feels 21s though i t and discomfort, which can be elicited
\ \ r~rirorw.The
FIGURE i. Sinding-Larsen-/oll,~ri~i~o~~ locks o r gets caught and is difficult to at the medial compartment near the
infenor pole of the patelh e~h~hits ci~ronicchanges
bend o r straighten. Plain radio- s;lphenous n e n e . .is the pathology
due to traction applied. (From Hughston /C, 12'alth
IZ'M, Puddu G: Patella Suhluvation and Dislocation, p graphs, especially the lateral of the progresses, tenderness may become
55. Phibdelphia, PA: llf.B. bunrlers Companv, 1984, tihiofernoral view, can reveal osteo- more diffuse through the entire me-
reprinted w t h permission^. chondritis dissecans of the patella dial compartment of the lower ex-
and/or anv loose bodies within the
trcmih, radiating both proximally

knee joint. and distally. In addition, persistent
c;dcific;~tionor- sep;iratc loose ossicles The prcfcrred treatment of osteo pain and discomfort often forces the
within the tendon. chondritis dissec;lns of the patella is patient to avoid knee motion, weight
In the past, ofien the treatment somewhat controversial (31.59). bearing, and some fr~nctionalactivi-
of Osgood-Schlatter's diseasc in- Some authors have suggested replac- ties. Cross muscular atrophy and
cluded the avoidance of sports, run- ing the fragment back onto the pa- weakness are common. Often pa-
ning, ;ind bicycling, and, in some cas- tella. Others advocate a simple exci- tients become frustrated and de-
es, cylindcr casts were ;ipplied to sion of the fragment with correction pressed related to the functional limi-
irnmohilize the patellofemoral and of any coexisting extensor mecha- tations. Plain radiographs are usually
tihiofemoral joints. However, the cur- nism malalignment. Prior to srlrgen, norm;d unless an underlying i ~ l j u nis
rent trends in treatment should focus the nonoperative treatment is conser- present. As the disorder progresses,
on hamstring flcxihility, moderate \.;~tive,with low level quadriceps osteoporosis may develop. Skin tem-
intensity quadriceps strcngthcning, strengthening exercises performed peraturc tomography may be helpful
and pain relief mod;llitics (icc) fhr along with gentle range of motion in the diagnostic process, especially
the painful tibia1 titberosity. Often, and flexibilih exercises. during the middle to end stages with
local padding o r ;I donut pad is used significant alterations in temperature
for comfort if the patient is returning Reflex Sympathetic Dystrophy being present.
to sports activities. \lost patients T h e treatment of rcflcx sympa-
1c;lrn t o adjust their acti\it!. level. Reflex sympathctic dystrophy of thetic dystrophy may be difficult and
and. rvcntu;dly, the pain sulwidcs the kncc oftell occurs secondarily to often fi-ustrating to both the clinician
lwc;lr~sethese arc somewh;~tsclf4imit- ;I wricty of rncchanisms but most and patient. If reflex sympathctic dys-
ing conditions. commonly bccarlse of patellofemoral trophy is suspected, an ;ippropriate
CLINICAL COMMENTARY
referral for pain control is crucial. Combined Pathologies FUTURE RESEARCH

T h e most common diagnostic tech-
nique is a sympathetic block with the Occasionally, patients will present The following issues shorild be
use of local anesthetics. Following the with physical examination findings, addressed in future research:
block, the patient's response is care- which will place the patient in more 1 ) Determine the validity and
fully monitored. If the blockade re- than one classification. This most fre- reproducibility of the pre-
sults in a unilateral limb temperature quently occurs with patients with sented patellofemoral classifi-
rise but n o change in pain intensit?., lower extremit\. biomechanical factors cation system, including the
and associated pathologies such as reliability of specific clinical
a sympathetically maintained pain
patellar instability o r soft tissue le- test5 used to categorize pa-
syndrome is suspected. If pain is re-
sions, etc. In these case scenarios, the tients
lieved along with a rise in tempera-
authors recommend that the clini- 2) Determine why some indi\idu-
ture, reflex sympathetic dystrophy is
cian treat d l the physical findings als experience patellofemoral
suspected and the length of pain re-
which contribute directly to the disor- pain and dysfunction while
lief is carefully monitored. If the pa- other indi\iduals with similar
tient's pain returns, even with oral der. T h e patient may he classified as
anatomic structures, align-
pain medication treatments, further "patellar instabilih with lower extrem-
ment, etc., are asymptomatic.
blocks are considered. ity hiomechanical dysfunction." A
3) Determine the most effective
T h e treatment of reflex sympa- careful and thorough clinical exami-

treatment program for each of
thetic dvstrophy and sympathetically nation will enable the clinician to the patellofemoral disorders
maintained pain appears inconclusive sricccssfully place the patient in the listed in this manuscript. ,IOSI'T
in techniques to control symptoms most appropriate classification (s).
and progress of the patient. Ficat and
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Volume 28 Number 5 November 1W8 JOSPT

CLINICAL COMMENTARY
55. Horwitz T: Recurrent or habitual dis- patellofemoral pain syndrome. Phys 86. Lieb FJ, Perry J: Quadriceps function:
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IOSPT Volume 28 Number 5 November 1998

CLINICAL COMMENTARY
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\'olume 28 Number 3 November 1998 *JOSPT

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Patellofemoral Disorders, A Classification System and Clinical Guidelines For Nonoperative Rehabilitation

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C L I N I C A L C O M M E N T A R Y

Patellofemoral Disorders: A Classification

dislocations. Fulkerson and Schutzer, lar taping (40,93),vastus rnedialis

\'olume 28 Number 3 November 1W8 JOSPT

Loose pressure syndrome exhibit dimin-

down. As the condition worsens and

JOSPT Volume 28 Number 5 November 1938

adaptive deep lateral retinacular others. First, the treatment should RF

tive treatment for excessive lateral stretching, p;irtictrlarly the ham-

to ensure clinical success. T h e follow- improving quadriceps mr~sclc

tient may gradually increase their syndrome ( 102).

often present, and patella alta may be

(29). Subluxation may result from

31? h l u m e 28 Number .iNovember 1 9 8 JOSPT

ciency. Again, an evaluation of the The nonoperative treatment ini-

ments), the buttress effect of the lat-

JOSPT Volume 28 Number 5 November 1998

foot are found, orthotics may be indi-

pensations for limb length discrepan-

of time related to repetitive move-

significantly, such as stair ambillation, of the vastus lateralis tendon inser-

dysfunction will develop. pad (Figirre 3 ) . This synovial fold is

contact force, and a flexibility pro-

strengthening program should be

\'olume 28 Numher i November 1W8 .JOSPT

ing u p and down stairs. T h e condi- A patella-restraining brace o r strap

participation. This classification is at which improvement continues

duces pain at the patellar attach-

JOSPT Volume 28 Number 5 Novrmher 1998 Sli

ing, ;~mbr~l;~tion. and descending apy techniques.

trcmih, radiating both proximally

referral for pain control is crucial. Combined Pathologies FUTURE RESEARCH

T h e treatment of reflex sympa- careful and thorough clinical exami-

Sports Med 25(2):207-2 12, 1997

Volume 28 Number 5 November 1W8 JOSPT

tellar tendinitis. Phys Ther 69(3):27 7-

IOSPT Volume 28 Number 5 November 1998

Radin EL: A rational approach to the /is muscle integrated electromyo-

\'olume 28 Number 3 November 1998 *JOSPT

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