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The Patellofemoral Articulation

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... or subluxate within 20 to 30 degrees of knee flexion or after valgus blow to knee ... Surgical intervention within 7 to 10 days ... – PowerPoint PPT presentation

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Title: The Patellofemoral Articulation


1
Chapter 7
  • The Patellofemoral Articulation

2
Introduction
  • Separated from the knee chapter because of
    differences in the mechanisms and onset of injury
  • Injury is usually due to overuse, congenital
    malalignment, or structural insufficiency

3
Clinical Anatomy
  • Patella is largest sesamoid bone in body
  • Anatomical design allows for
  • Increased efficiency of quadriceps muscle group
  • Protection of anterior portion of knee joint
  • Absorption and transmission of patellofemoral
    joint reaction forces (forces transmitted through
    articular surfaces)
  • Shape of patella
  • Figure 7-1, page 244

4
Clinical Anatomy
  • Articular surface of patella
  • Figure 7-2, page 244
  • Patella tracks medially during range of 45o to
    18o as knee moves from flexion to extension
  • During final 18o of extension, patella tracks
    laterally
  • During flexion and extension patella tracks
    within femoral trochlear groove (between the 2
    femoral condyles lined with articular cartilage)

5
Clinical Anatomy
  • Articulation of patellofemoral joint
  • Table 7-1, page 245
  • Compressive forces
  • Walking .5 times body weight
  • Walking up/down stairs or running hills 3.3
    times body weight
  • Lateral retinaculum
  • From vastus lateralis and IT band to lateral
    border

6
Clinical Anatomy
  • Medial retinaculum
  • Vastus medialis and adductor magnus to medial
    border
  • Medial and lateral patellofemoral ligaments
  • Superior portion on fibrous capsule thickens and
    inserts on patellas superior border

7
Muscular Anatomy and Related Soft Tissue
  • Quadriceps muscles
  • Flexion patella is pulled inferiorly by patella
    tendons attachment to tibial tuberosity
  • Extension quadriceps femoris and its tendon
    pull patella superiorly
  • Length of patella is approximately same length as
    the long axis of the patella
  • Figure 7-4, page 245

8
Muscular Anatomy and Related Soft Tissue
  • Vastus lateralis pulls patella laterally
  • Vastus medialis (VMO) guides patella medially
    and prevents lateral patellar subluxation
  • Tight IT band can accentuate the lateral tracking
    of patella, resulting in subluxations or patellar
    malalignment

9
Muscular Anatomy and Related Soft Tissue
  • Alignment of foot and normal flexibility of
    triceps surae and hamstring muscles are needed
    for adequate knee ROM and normal patellofemoral
    mechanics
  • Example increased foot pronation increased
    internal tibial rotation rotation of tibial
    tuberosity toward midline

10
Bursa of the Extensor Mechanism
  • Varying numbers of bursa being directly involved
    with extensor mechanism
  • 4 found consistently in population
  • Suprapatellar bursa
  • Prepatellar bursa
  • Subcutaneous infrapatellar bursa
  • Deep infrapatellar bursa
  • Figure 7-5, page 246

11
Clinical Evaluation of the Patellofemoral
Articulation
  • Dysfunction of joints superior to or inferior to
    knee may manifest themselves as patellofemoral
    pain
  • Patient preparedness
  • Clinician preparedness

12
History
  • Mechanism and onset of injury
  • Acute vs. chronic or insidious onset
  • Chondromalacia Patella
  • Softening and wearing away of patellas hyaline
    cartilage grinding
  • Box 7-1, page 247
  • Clarkes sign - Box 7-5, page 253
  • When pain occurs
  • Location of pain

13
History
  • Level of activity
  • Prior surgery
  • Relevant past history

14
Inspection
  • Patella alignment
  • Patellar alignment
  • Figure 7-6, page 247
  • Patellar malalignment
  • Box 7-2, page 248
  • Figure 7-7, page 247
  • Posture of knee
  • Genu varum, valgum, recurvatum

15
Inspection
  • Q angle
  • Relationship between line of pull of quadriceps
    and the patellar tendon
  • Box 7-3, page 250
  • Box 7-4, page 251
  • Tubercle sulcus angle
  • Relationship between tibial tuberosity and
    inferior patellar pole
  • Leg length difference
  • Foot posture
  • Areas of scars

16
Palpation
  • Refer to clinical proficiencies
  • Utilize pages 249 253

17
Range of Motion Testing
  • AROM
  • Flexion to extension patella glides superiorly
    and somewhat laterally
  • Tightness of lateral structures may accentuate
    lateral displacement
  • Flexion patella glides inferiorly and medially
  • RROM
  • Pain during movement may indicate malalignment
  • Open and closed kinetic chain

18
Range of Motion Testing
  • Lower extremity flexibility
  • Quadriceps, hamstrings, IT band, triceps surae
  • Tightness may
  • Result in decreased functional ROM
  • Force the quadriceps to exert more pressure on
    patella
  • Cause patellar tracking deficits

19
Ligamentous Testing
  • Evaluate knee ligaments
  • Laxity in knee joint can result in abnormal
    patellar tracking, secondary to uniplanar or
    rotatory shifting of tibia or femur, causing
    patellofemoral pain
  • Ligamentous and capsular stability of patella is
    based on presence of patellar tilt and amount of
    glide available to patella

20
Ligamentous Testing
  • Patellar Glide
  • Figure 7-9, page 254
  • Box 7-6, page 255
  • Patellar Tilt
  • Box 7-7, page 256
  • Synthesis of Findings
  • Relationship between patellar glide and tilt

21
Neurologic Testing
  • Same as described in Chapter 6

22
Pathologies and Related Special Tests
  • patellofemoral dysfunction and patellofemoral
    pain syndrome used to describe wide range of
    symptoms
  • Onset may occur during inactivity (theater knee)
    and/or during or after activity
  • Differentiation between meniscal and patellar
    pain
  • Table 7-2, page 257
  • Evaluation Map page 257

23
Patellofemoral Pain Syndrome
  • All-inclusive diagnosis for pain in and around
    the joint that cannot be explained by a specific
    pathology
  • Signs and symptoms
  • Insidious onset occasionally caused by trauma
  • Primary complaint of anterior knee pain caused by
    activity, pain may be constant
  • Stair climbing, sitting for long periods
  • swelling

24
Patellofemoral Pain Syndrome
  • Signs and symptoms continued
  • Pain increased with AROM and RROM
  • Surrounding tissues evaluate for tightness and
    hyperlaxity by assessing patellar glide and tilt
  • Assess subtalar joint
  • Treatment
  • Modify activity, NSAIDs, ice, patellar
    mobilization and passive stretching, flexibility
    and strength training
  • Orthotics, patellar taping

25
Patellar Maltracking
  • Normal tracking depends on relationships between
  • Alignment of femur on tibia
  • Q angle
  • Integrity of soft tissue restraints
  • Foot mechanics
  • Flexibility of triceps surae, quads, hamstrings,
    IT band
  • Table 7-3, page 258

26
Patellar Maltracking
  • Predisposing factors
  • Congenital dysfunction
  • Injury to patella or knee
  • Increased body weight
  • Gait mechanics
  • Gradual onset of symptoms
  • Redistribution of forces along patellar facets
  • Pain during ADLs

27
Patellar Subluxation and Dislocation
  • Acute, chronic, or congenital laxity of medial
    patellar restraints or abnormal tightness of
    lateral retinaculum results in increased lateral
    glide of patella
  • Predisposes patient to subluxation or dislocation
  • Subluxations can occur without patient knowing it
  • Dislocations shift patella laterally and lock out
    of place, obvious deformity and quadriceps spasm
  • Figure 7-10, page 259

28
Patellar Subluxation and Dislocation
  • Most apt to dislocate or subluxate within 20 to
    30 degrees of knee flexion or after valgus blow
    to knee
  • May result in fractured patella, osteochondral
    damage, bone bruises, osteochondritis dissecans
  • Multiple incidences result in wearing of
    articular cartilage

29
Patellar Subluxation and Dislocation
  • Predisposing factors
  • Hypomobile medial glide
  • Flattened posterior articulating surface
  • External tibial rotation and hyperpronated feet
    increase Q angle
  • Family history

30
Patellar Subluxation and Dislocation
  • Evaluative Findings
  • Table 7-4, page 260
  • Apprehension Test
  • Box 7-8, page 261
  • Radiographic examination
  • Rule out MCL sprain
  • Treatment
  • Conservative vs. surgical

31
Patellar Tendinitis
  • Insidious onset
  • Jumping activities, running sports, weight
    lifting
  • Acute onset
  • Blow to tendon
  • Repetitive motions on a biomechanically
    malaligned extensor mechanism can result in
    unequal loads on the extensor mechanism
  • Microtearing of fibers

32
Patellar Tendinitis
  • Most common site of pain inferior pole
  • Pain at superior pole quadriceps tendinitis
    (jumpers knee)
  • Evaluative Findings
  • Table 7-5, page 262
  • MRI may be useful
  • Conservative vs. surgical treatment

33
Patellar Tendon Rupture
  • Predisposing factors
  • Rheumatoid arthritis, diabetes, lupus, chronic
    renal disease, gout
  • Chronic inflammation of tendon
  • Corticosteroid medications
  • Tension developed within quadriceps unit
    overloads the patellar tendon, resulting in
    rupture in midsubstance or avulsion from patella
    or patellar tuberosity

34
Patellar Tendon Rupture
  • Evaluative Findings
  • Table 7-6, page 262
  • No ligamentous stability tests should be
    performed until examined by physician
  • Treatment
  • Immediate immobilization and transport
  • Surgical intervention within 7 to 10 days
  • Rehabilitation to restore knee function full
    return to activity in 12 months

35
Patellar Bursitis
  • Bursa inflamed secondary to
  • Single traumatic blow
  • Repeated low-intensity blows
  • Overuse
  • Infection (redness, warmth, refer to physician)
  • Evaluative Findings
  • Table 7-7, page 264
  • Figure 7-11, page 263
  • Treatment modify activity control inflammation

36
Synovial Plica
  • Fold of the fibrous membrane that projects into
    joint cavity
  • During maturation, folds are absorbed into
    capsule however, in majority of population, a
    thickened area or crease remains
  • Remains asymptomatic until area is traumatized
  • Most commonly affects medial joint capsule

37
Synovial Plica
  • When symptomatic, plica loses elastic properties
    and alters biomechanics of patellar gliding
    mechanism
  • Evaluative Findings
  • Table 7-8, page 264
  • Test for medial plica syndrome
  • Box 7-9, page 265
  • Stutter Test
  • Box 7-10, page 266

38
Synovial Plica
  • Confirmed through MRI
  • Treatment
  • Modify activity
  • Control inflammatory response
  • Strengthen VMO to lessen symptoms by reducing
    tensile forces placed on plica

39
Osgood-Schlatter Disease
  • Adolescent inflammatory condition that strikes
    the tibial tuberositys growth plate where
    patellar tendon attached
  • Onset due to repeated avulsion fractures of
    tendon from its attachment caused by rapid
    growth and/or increased quad strength
  • Results in osteochondritis of tubercle

40
Osgood-Schlatter Disease
  • Evaluative Findings
  • Table 7-9, page 267
  • Figure 7-12 page 266
  • Conservative treatment by reducing activity,
    controlling inflammation
  • Surgical intervention if conservative treatment
    fails

41
Sinding-Larsen-Johansson Disease
  • Found at attachment of tendon into inferior
    patellar pole (or quad tendon at proximal pole)
  • Caused by stress fracture or avulsion because of
    repetitive forces associated with running and
    jumping
  • Affects males more often, ages 10-14 yrs

42
Sinding-Larsen-Johansson Disease
  • Evaluative Findings
  • Table 7-10, page 268
  • Treatment
  • Rest, immobilization
  • Decrease inflammation
  • Modalities, NSAIDs
  • Stretching and strengthening
  • May be symptomatic until maturation

43
Patellar Fracture
  • Blunt trauma
  • May rupture of bursa palpation reveals crepitus
    or false joint
  • Figure 7-13, page 268
  • Active knee extension and passive knee flexion
    produce severe pain
  • Resisted knee extension cannot be performed due
    to pain

44
On-Field Evaluation of Patellofemoral Injuries
  • Equipment considerations
  • On-field History
  • On-field Palpation
  • On-field Functional Tests
  • Willingness to move the involved limb
  • Willingness to bear weight

45
Initial Management of On-Field Injuries
  • Patellar Tendon Rupture
  • Gross deformity, immediate loss of function
  • Splint in extension and transport
  • Patellar Dislocation
  • Obvious deformity
  • Reduction should not be attempted spontaneous
    reduction may occur
  • Splint in position if not reduced, in extension
    if reduced transport
  • Figure 7-14, page 270
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