Mystery of Knee pain Black Hole of Orthopedics- Patellofemoral joint dr.sandeep c agrawal agrasen hospital gondia india

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Knee Pain. Patellofemoral pain syndrome,Chondromalacia patellae,Iliotibial Band fRICTION Syndrome,Patella Alta,Patellofemoral Arthritis, Patellar Tilt,Patellar Displacement,Anterior Knee Pain,Lateral Retinaculum,VMO Dysplasia.Excessive Lateral Patellar Pressure Syndrome,Patella Malalignment,Patellar Instabilty,Patella Maltracking,Patella Subluxation,Patella Dislocation,Synovial Plica,Tendinitis,Jumpers Knee,Congruence Angle,Malalignment of Extensor Mechanism,Patella Arthritis,Patella Fracture. Mystery of knee pain black hole of orthopedics- patellofemoral joint dr.sandeep c agrawal agrasen hospital gondia india

Health & Medicine

MYSTERY OF KNEE PAIN:
Black Hole Of Orthopedics:
Patellofemoral Joint
Dr.Sandeep Agrawal
Consultant Orthopedic Surgeon
MS,DNB
Agrasen Hospital
Gondia
Maharashtra
India
drsandeep123@gmail.com

Patella contact area
• At full extension, the distal
portion of the patella is in
contact with the superior
portion of the trochlea
• As knee flexion, the contact
area moves proximately
• Contact area increases from
0.8 cm2 at knee full
extension to 4 cm2 at 90º of
flexion (Hehne, 1990)

Patella contact area
Goodfellow J, Hungerford DS, Zindel M. Patellofemoral joint mechanics and pathology
J Bone Joint Surg (Br) 1976; 58-B: 287-290
20° 45° 90° 135°

• Lateral tilt and displacement of
patella: considered characteristic
features of patellofemoral pain
syndrome
• Suggested that : abnormal
patellar tilt and displacement
…detected best with the knee
near full extension, before the
patella becomes engaged in the
trochlear groove. which
requires CT or MRI
Patellofemoral Disorders

Common Causes of Patellofemoral
Pain
1. Muscular
• Excessive muscle tightness (inflexibility),
rapid teenage growth or poor conditioning
• Fatigue or tearing(strain) of quadriceps or
hamstring muscles ,
• Muscular strength imbalances,
• Overuse/disuse :
bending overuse,
too aggressive in starting a fitness program
runners and athletes that over train

$Common Causes of Patellofemoral Pain 2. Structural damage patella arthritis, stress fracture, direct traumatic injury$

Common Causes of Patellofemoral
Pain
3. Congenital dysplasia
patella alta(high patella), facet or
trochlear dysplasia

Common Causes of Patellofemoral
Pain
4. Malalignment
tilted patella, intoeing rotation of
the legs(persistent femoral
anteversion) knock knee
(excessive valgus deformity)

Common Causes of Patellofemoral
Pain
5. Instability of the patella :
Maltracking with subluxation(partial) or
complete dislocation of the knee cap:
Damaged or stretched ligament support
Acute dislocation After repair

Common Causes of Patellofemoral
Pain
6. Inflammatory : Bursitis,Tendinitis
Jumper’s knee: Patella tendinitis results from
excessive overload or overuse of the extensor
mechanism of the knee
7. Synovial plica

Radiographic Measures in
Subjects Who Are Asymptomatic and
Subjects With Patellofemoral Pain Syndrome
CORR (414) 2003,p172
lateral patellar angle congruence angle Caton’s ratio B/A
35° knee flexion
unloaded or loaded

There is no significant abnormal patellar alignment
detectable in subjects with patellofemoral pain
syndrome at 35° knee flexion
It is possible that the patellar malpositioning in
subjects with patellofemoral pain syndrome is too
subtle to be measured at one static imaging angle

Lateral
tubercle
deviation
Tibial tubercle lateralization
greater than 10 mm and a
lateral patellofemoral angle
less than 8° were predictive
of anterior knee pain with a
specificity of 95% and a
sensitivity of 64%
Arthroscopy June 2006 • Volume 22 • Number 6

Patellofemoral Pain Syndrome
• Overuse ????
• Neurogenic factors ???
• To think of anterior knee pain or patellar
instability as somehow being necessarily
tied to PFM [patellofemoral
malalignment] is an oversimplification
that has positively stultified progress
toward better diagnosis and treatment

Patellofemoral Pain Syndrome
• Malalignment of the extensor mechanism
:probably has a role in the multifactorial
pathogenesis of patellofemoral pain and
altered patellofemoral biomechanics.
• Contribution of extensor mechanism
malalignment to patellofemoral pain and
altered biomechanics may change on the
basis of the frequency and magnitude of
physiological weight-bearing and non-weight-
bearing loading conditions

Medial patellofemoral ligament. stabilizer of patella during initial 30 degree of flexion. More than 18 techniques of reconstruction described. Runs in layer 2 on medial aspect of the knee. Origin- 1.9mm anterior/3.8 mm distal to adductor tubercle.(Laparade JBJS- Am.07) Insertion – proximal 2/3 of patella Along Distal edge of VMO Broad insertion over 28.2+_ 5.6 mm over proximal 2/3 patella. Average length 59.8mm +_ 4.8mm. Passive- Trochlear constraints Depth ,length(Height) Patellar engagement Capsular ligamentous tethers, especially MPFL (Hautamaa, Fithian et al. 1998) Dynamic elements Simulated muscle tension has little effect on patellar mobility. Regardless of flexion angle (Scnavongers, Farahmand et al 2003

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