11/3/2014 Professor Freih Abuhassan- University of Jordan 1 Patellofemoral Pain Syndrome
Patellofemoral Pain
Syndrome
Freih Odeh Abu Hassan
FRCS (Eng.), FRCS (Tr. & Orth.)
Professor of Orthopedics
Universit y of Jordan
11/3/2014 2Professor Freih Abuhassan-
University of Jordan
A- Anatomy B-Assessment
C-Acute dislocation
D-Breakdown of disorders
1-PF malalignment (e or e out articular
degeneration)
2-PF instability e out static malalignment
3-Articular degeneration e out malalign.
4- Unstable Patella after TKR
11/3/2014 3Professor Freih Abuhassan-
University of Jordan
• Thickest articular cartilage in the body
–Up to 5mm at central ridge
• Joint reaction forces ( X of B.Wt)
–0.5 level walking
–3.3 stair climbing
–7.8 squats
A-PF Basics and Anatomy
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University of Jordan
Passive stabilizers
–Patellar tendon
–Retinaculum(Med. & Lat.)
–MPFL +VMO
Dynamic stabi.
–Quadriceps
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University of Jordan
• Geometry of the patella &
trochlea.
– Hypoplastic trochlea (flat)
• Angle of pull of the
quadriceps (Q-angle)
Bony stabilizers
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University of Jordan
Proper assessment
1-Pain–Character, Location, Onset, Intensity,
Exacerbation, Remittance
2-Effusion
3-Trauma–Subluxation
–Dislocation11/3/2014 9Professor Freih Abuhassan-
University of Jordan
4-Previous treatment
5-Other joint involvement
6-Litigation
7-Worker’s compensation
8-Psychological components
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University of Jordan
Symptoms•Pain Anterior knee
•Pain after sitting (movie sign)
•Pain ascending stairs
•Popping & clicking
•Pseudo-locking
•Instability - Giving Way
The patellar pain are aggravated by flexed
knee activities as sitting, climbing, squatting
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University of Jordan
Physical Examination
• Alignment : Varus/valgus, Rotational(Ext. tibial torsion, Femoral anteversion)
• Patellofemoral crepitus
• Patellar tracking
–J-sign, Apprehension
• Lateral retinaculum
–Tenderness, Tilt, Patellar mobility
. Compression test chondromalacia11/3/2014 12Professor Freih Abuhassan-
University of Jordan
• Quad strength (VMO)
– IT band friction synd., Pes anserinus bursitis
• Q-angle: N – Male(10º) , Female(15º)
• Tubercle-sulcus angle
• Extensor mechanism: alta vs. baja
• Patellar/femoral dysplasia
• Hamstring tightness
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University of Jordan
Radiographic Evaluation
Weight-bearing=AP extension view
=AP 45° flexion (Rosemberg)
=Lateral view in 30° of flexion
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University of Jordan
• Merchant axial– 45 deg and 30 caudal tilt
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University of Jordan
• Sulcus angle– Angle formed by the trochlear ridges
= Sulcus angle 140° (+ 5)
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University of Jordan
• Congruence angle– Angle formed by bisecting the sulcus angle
and central patellar ridge
– Mean = -6º +/- 6º (central ridge should lie medial to the bisector)
11/3/2014 17Professor Freih Abuhassan-
University of Jordan
Dynamic CT Scan:
0°, 15°, 30° and 45° knee flexion
More accurate bec. the post. condyles
of femur are more precise reference.
=Tilt angle
=Subluxation
=Congruence angle11/3/2014 19Professor Freih Abuhassan-
University of Jordan
MRI scan = Status of the lateral retinaculum
(thickening), MPFL & cartilage
=Injuries in the PF joint.
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University of Jordan
Torn MPFL
Chondral inj.
lateral edema
Chondral inj.
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University of Jordan
• Subluxation Central patellar ridge is lateral to the bisector of the sulcus angle.
• Tilt Patella centered in the trochlea but the medial facet is elevated away from the trochlea
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University of Jordan
Arthroscopic evaluation1- Confirms the Dx of patellar subluxation
2- Classification of articular lesion
(size, severity and location)
3- Helps to quantify lateral malalignment -
tracking
°90°45°011/3/2014 24Professor Freih Abuhassan-
University of Jordan
4-Treatment of associated pathologies
Patellar fracture secondary to luxation
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University of Jordan
5-Reevaluation of patellar tracking after
open proximal realignment
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University of Jordan
• Usually presents to ED after twisting injury
• Often hemarthrosis, Fat !!
• 40% risk of osteochondral injury
• Most often underlying alignment issues
B-Acute Dislocation
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University of Jordan
Dislocation lesions
• Medial tear
• Medial patellar chondral injury
• Lateral femoral edema
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University of Jordan
• Acute Dislocation
Flex the hip & gradually extend the knee to
reduce If x-ray changes, fat in joint, or
crepitus Scope.
Conservative R/–Cast for 3 W in extension, brace for
6 W Brace at the 1st return to sport.
–Physical therapy (proprioception)
Treatment
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University of Jordan
SurgeryEarly !!!! chronic pain and arthrofibrosis
Late (50% will need surgery)
=In recurrent cases
=Correct malalignments
• Chronic– Treat pain, alignment or instability issues as needed
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University of Jordan
• C/O = Pain or Mechanical issues.
1-Patellofemoral Malalignment
–NSAIDS
–Physical therapy• Mainstay
• several months before aggressive measures
• Avoid aggressive quad strengthening.
Conservative treatment
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University of Jordan
–Patellar tracking braces
–Avoidance of offending activities
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University of Jordan
Patellar tilt
Surgical treatment
Lateral release–Patella should evert to 70-90°
–May need proximal or distal realignment as well
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University of Jordan
1-Hauser procedure.– Posteriomedial tibial tubercle transfer
– Increases DJD due to joint reaction forces
– Contraindicated
Distal Realignment
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University of Jordan
2-Elmslie-TrillatMedial and distal transfer
– Originally included medial tightening and
lateral release, but not necessary.
– Much better than Hauser
–Avoid if significant degenerative changes
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University of Jordan
=Increased “Q” angle
=Recurrent lateral subluxation
=Skeletally mature patients
Indications
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University of Jordan
3-Fulkerson
–Anteromedial transfer.
–Use for combination of chondralchanges and malalignment.
–Oblique cut.
–Large surface area for healing.
–Good for distal and lateral chondrosis.
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University of Jordan
• Usually indicative of soft tissue injury.
• Conservative treatment .=Overall limb strengthing, =VMO strength,
= avoidance of foot overpronation
• Examine arthroscopically
• Surgery proximal realignment
procedure with or without lateral release
2-Dynamic Instability without Static
Malalignment
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University of Jordan
Proximal realignment
=After dislocation for torn MPFL
=Patella fails to centralize after lateral release
=Skeletally imature patients
=Abnormal VMO
=Dynamic lateral subluxation without overall
malalignment
Indications
Severe OAContraindication11/3/2014 45Professor Freih Abuhassan-
University of Jordan
=Lateral release
=Imbrication of medial capsule
=Advancement of VMO (distal and laterally)
MPFL reconstruction
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University of Jordan
• Chondral changes on the patella correlate
poorly with pain
• Underlying bony changes are better indicator
• Assess location of chondral damage
• Check alignment carefully
3-Articular Degeneration without
Malalignment
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University of Jordan
–Avoid aggressive PT
–Stop offending activities
–Stay within “envelope of function”
Treatment
• Arthroscopic debridement/chondroplasty
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University of Jordan
Conclusion
1- Proper assessment and radiology.
2-Always conservative first.
3-Lateral release must be complete .
4-Documented patellar tilt and minimal
articular cartilage.
5-Check malalignments.
6- Fulkerson procedure more consistant
results
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University of Jordan
Unstable Patella after TKR
1-Component malpositioning,(internal malrotation of the femoral or
tibial components)
2- Limb malalignment,
3-Prosthetic design,
4-Improper patellar preparation,
5-Soft-tissue imbalance.
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University of Jordan
Major malposition of components
implant revision.
No malposition proximal
realignments
(lateral release with lateral advancement of
the vastus medialis obliquus muscle)
11/3/2014 56Professor Freih Abuhassan-
University of Jordan