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Patellofemoral Online Education

A new online educational resource created by the Yale Medical Library for scientists, caregivers and patients with a particular interest in patellofemoral disorders.

Healio Blog-Orthopedics

A Healio Patellofemoral Update sponsored by the Patellofemoral Foundation with the mission of improving care of individuals with anterior knee pain through targeted education and research.

International Society of Arthroscopy, Knee Surgery, and Orthopaedic Sports Medicine (ISAKOS)

Patellofemoral Foundation Partner Organization

Patellofemoral Study Group

Patellofemoral Foundation Partner Organization

Arthroscopy Association of North America

Patellofemoral Foundation Partner Organization

Patellofemoral Videos

Not all patients with patellar dislocation need more than MPFL reconstruction

In this video, Beth E. Shubin Stein, MD, discusses when surgeons should perform more than a medial patellofemoral ligament reconstruction in patients with patellar dislocation.

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Speaker advises MPFL reconstruction for first-time patellar instability

Whenever addressing a kid with patellar instability, you have to look at all factors, including the way the patellar tracks, the alignment, the rotation and the dysplasia of both the patella and the trochlea …
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MPFL reconstruction should be anatomic, without over tensioning the ligament

At the Arthroscopy Association of North America Annual Meeting, Miho J. Tanaka, MD, discussed acceptable variations and surgical techniques for medial patellofemoral complex reconstruction…

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Tibial tubercle osteotomy evolves for patellofemoral joint preservation

In this video from the American Orthopaedic Society for Sports Medicine and Arthroscopy Association of North America Combined Meeting, Seth L. Sherman, MD, discussed the evolution of tibial tubercle osteotomy…

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Patellofemoral Knowledge

Patellofemoral Online Education has been created to present important information that will be helpful to physicians,scientists, caregivers and patients with a particular interest in patellofemoral disorders. All funding has been provided by the Patellofemoral Foundation (PFF), a non profit organization dedicated to education and research pertaining to patellofemoral disorders www.patellofemoral.org.

With the help of Peter Jokl (Professor of Orthopedic Surgery and Director of Sports Medicine at Yale) and website design and bibliographic support of librarians at the Cushing/Whitney Medical Library, the website obtains information from scientists with an understanding of patellofemoral dysfunction and will provide ongoing and updated information in an effort to help doctors, therapists, trainers, patients and athletes understand these problems better and thereby help them make informed decisions regarding patellofemoral care.

Patellofemoral pain can be perplexing at times and is disabling for many people, usually short term, but sometimes chronically and progressing to the point of causing permanent disability, loss of recreational sport participation, and loss of employment in more extreme cases. Some people with minimal findings on clinical examination have dramatic, disabling pain, confounding caregivers at all levels.

Patellofemoral instability (in which one experiences displacement of the patella) can also be incapacitating with apprehension and activities limitations commonly noted in those afflicted.

One important feature of this website is its free online access to John Fulkerson’s Disorders of the Patellofemoral Joint, thanks to the generosity of the original publisher, Lippincott, Williams and Wilkins and particularly the efforts of Eileen Wolfberg. The book will be updated as needed so that its information will be current at all times.

Major unrestricted grant contributions from Smith and Nephew Endoscopy, DJ Ortho, Arthrex, EBI, Kinamed, Bledsoe, Centre Albert Trillat (Lyon, France), Jack Farr, John Fulkerson, Ronald Grelsamer, and Hartman newspapers(Rosenberg, Texas) to the Patellofemoral Foundation have made this effort possible.

  • American Academy of Orthopedic Surgeons (AAOS)
  • National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS)
  • American Orthopaedic Society for Sports Medicine (AOSSM)
  • American Orthopaedic Association (AOA)
  • American Orthopaedic Foot and Ankle Society (AOFAS)
  • American Association of Hip and Knee Surgeons (AAHKS)
  • Arthroscopy Association of North America (AANA)
  • European Society of Sports Traumatology Knee Surgery and Arthroscopy (ESSKA)
  • International Society of Arthroscopy, Knee Surgery & Orthopaedic Sports Medicine (ISAKOS)
  • International Patellofemoral Study Group (IPSG)
  • The Knee Society
  • Effect of Patella Alta on the Native Anatomometricity of the Medial Patellofemoral Complex: A Cadaveric Study
  • Relationship of the Medial Patellofemoral Ligament Origin on the Distal Femur to the Distal Femoral Physis: A Systematic Review
  • Patellar Instability and Dislocation: Optimizing Surgical Treatment and How to Avoid Complications
  • Generalized joint hypermobility does not influence clinical outcomes following isolated MPFL reconstruction for patellofemoral instability.
  • Anteromedial Tibial Tubercle Osteotomy Improves Results of Medial Patellofemoral Ligament Reconstruction for Recurrent Patellar Instability in Patients With Tibial Tuberosity–Trochlear Groove Distance of 17 to 20 mm
  • The Recurrent Instability of the Patella (RIP) Score: A Statistically Based Model for Prediction of Long-Term Recurrence Risk After First-Time Dislocation
  • Clinical Outcomes After Isolated Medial Patellofemoral Ligament Reconstruction for Patellar Instability Among Patients With Trochlear Dysplasia.
  • Examination under Anesthesia in Patients with Recurrent Patellar Dislocation: Prognostic Study.
  • Short lateral posterior condyle is associated with trochlea dysplasia and patellar dislocation.
  • Femoral trochlea does not remodel after patellar stabilization in children older than 10 years of age.
  • Are Patellofemoral Joint Alignment and Shape Associated With Structural Magnetic Resonance Imaging Abnormalities and Symptoms Among People With Patellofemoral Pain?
  • Derotational Osteotomy of the Distal Femur for the Treatment of Patellofemoral Instability Simultaneously Leads to the Correction of Frontal Alignment: A Laboratory Cadaveric Study.
  • Periosteal autologous chondrocyte implantation for patellar chondral defect in patients with normal and abnormal patellar tracking.
  • Allowing one quadrant of patellar lateral translation during medial patellofemoral ligament reconstruction successfully limits maltracking without overconstraining the patella
  • Clinical Outcomes After Isolated Medial Patellofemoral Ligament Reconstruction for Patellar Instability Among Patients With Trochlear Dysplasia
  • The Relationship of Static Tibial Tubercle–Trochlear Groove Measurement and Dynamic Patellar Tracking
  • Complications of medial patellofemoral ligament reconstruction using two transverse patellar tunnels
  • The Tibial Tubercle-Trochlear Groove Distance Is Greater in Patients With Patellofemoral Pain
  • Patellar Resurfacing Versus Circumferential Denervation of the Patella in Total Knee Arthroplasty
  • Anteromedialisation tibial tubercle osteotomy for recurrent patellar instability in young active patients: A retrospective case series
  • Sulcus deepening trochleoplasty for patellofemoral instability: A series of 34 cases after 15 years postoperative follow-up
  • Radiographic Reference Points Are Inaccurate With and Without a True Lateral Radiograph: The Importance of Anatomy in Medial Patellofemoral Ligament Reconstruction.
  • Outcomes after Trochleoplasty
  • Medial Quadriceps Tendon–Femoral Ligament: Surgical Anatomy and Reconstruction Technique to Prevent Patella Instability
  • The Prevalence and Combined Prevalences of Anatomic Factors Associated With Recurrent Patellar Dislocation: A Magnetic Resonance Imaging Study.
  • Tibial Tubercle Osteotomy: Indication and Techniques.
  • Re-evaluating the functional implications of the Q-angle and its relationship to in-vivo patellofemoralkinematics.
  • Minimally invasive reconstruction of the medial patellofemoral ligament using quadriceps tendon.
  • Shape and size of the medial patellofemoral ligament for the best surgical reconstruction: a human cadaveric study.
  • Lateral patellofemoral ligament reconstruction using a free gracilis autograft
  • Guidelines for medial patellofemoral ligament reconstruction in chronic lateral patellar instability
  • Arthroscopic Evaluation of Patellofemoral Congruence With Rotation of the Knee Joint and Electrical Stimulation of the Quadriceps
  • Medial quadriceps tendon-femoral ligament: surgical anatomy and reconstruction technique to prevent patella instability
  • Running-induced patellofemoral pain fluctuates with changes in patella water content
  • Patellofemoral osteoarthritis treated by partial lateral facetectomy: results at long-term follow up
  • Quantitative and Qualitative Assessment of Bone Perfusion and Arterial Contributions in a Patellar Fracture Model Using Gadolinium-Enhanced Magnetic Resonance Imaging: A Cadaveric Study
  • Southwick-fulkerson osteotomy with intraoperative femoral nerve guidance
  • Trochleoplasty in major trochlear dysplasia: current concepts
  • The basic science of the patella: structure, composition, and function
  • Influence of kinesiophobia and catastrophizing on pain and disability in anterior knee pain patients
  • Familial association of femoral trochlear dysplasia with recurrent bilateral patellar dislocation
  • Does knee joint proprioception alter following medial patellofemoral ligament reconstruction?
  • Towards a Better Understanding of Anterior Knee Pain: Don´t Forget to Look Up
  • Patellofemoral pain syndrome: pain, coping strategies and degree of well-being.
  • Open Lateral Patellar Retinacular Lengthening Versus Open Retinacular Release in Lateral Patellar Hypercompression Syndrome: A Prospective Double-Blinded Comparative Study on Complications and Outcome.
  • Editor: Vicente Sanchis-Alfonso, MD, PhD
  • About Patellofemoral Pain
  • Patellofemoral Pain [From the International Cartilage Repair Society]
  • International PF Study Group (IPSG) consensus regarding PF Pain
  • Sanchis-Alfonso Book now available. Anterior knee pain and patellar instability. 2nd Ed. London: Springer-Verlag.

Editor: Miho Tanaka

Overview and treatment algorithm

    • Patellofemoral Instability [From the International Cartilge Repair Society]
    • Acute Patella Dislocation (ISAKOS 2011 Presentation)
    • Adult Recurrent PF Instability (ISAKOS 2011 Presentation)
    • Patellar Instability Management: A Survey of the International Patellofemoral Study Group
    • Predictors of recurrent first time dislocation
    • ISAKOS Symposium on Patellofemoral Instability: Patella Alta (The Lyon Experience)

Anatomy and biomechanics

TTO

Trochleoplasty

  • Sulcus deepening trochleoplasty for patellofemoral instability: A series of 34 cases after 15 years postoperative follow-up.
  • https://www.ncbi.nlm.nih.gov/pubmed/29951262

Avoiding complications in PF instability surgery

Patellofemoral Arthritis (PF Chondrosis)

Editors: Jack Farr

      • Mechanisms Underlying Patellofemoral Pain: Lessons Learned over the Past 20 Years
      • The Effects of Isolated Hip Abductor and External Rotator Muscle Strengthening on Pain, Health Status, and Hip Strength in Females With Patellofemoral Pain: A Randomized Controlled Trial
      • Management of Patellofemoral Pain Targeting Hip, Pelvis, and Trunk Muscle Function: 2 Case Reports
      • Rehabilitation of the Knee After Medial Patellofemoral Ligament Reconstruction

Editor: Dan Green and Shital Parikh

  • Epidemiology — Matthew Ellington, MD; Albert Pendelton, MD
  • Developmental Anatomy — Sean Keyes, DO; Shital Parikh, MD
  • Pathophysiology of Pediatric Patellar Dislocation — Nicole A. Friel, MD, MS
  • Types of Instability — Jason Rhodes, MD, MS; Alex Tagawa, BA
  • Imaging — John A. Schlechter, DO, FAOAO; Richard Michelin, DO
  • Conservative Management and Outcomes — Daniel W. Green, MD, MS, FACS; Linsday Schlichte, MS
  • Pediatric MPFL reconstruction and Outcomes — Eric Wall, MD
  • Pediatric Patellar Stabilization (besides MPFLR) and outcomes — Lee Page, MD
  • Complications after surgical stabilization and how to prevent them — Drew E. Warnick, MD
  • Rehabilitation and Prevention — Joseph T. Molony, Jr., PT, MS, SCS, CSCS

Editor: Christopher Powers

  • Mechanisms Underlying Patellofemoral Pain: Lessons Learned over the Past 20 Years
  • The Effects of Isolated Hip Abductor and External Rotator Muscle Strengthening on Pain, Health Status, and Hip Strength in Females With Patellofemoral Pain: A Randomized Controlled Trial
  • Management of Patellofemoral Pain Targeting Hip, Pelvis, and Trunk Muscle Function: 2 Case Reports
  • Rehabilitation of the Knee After Medial Patellofemoral Ligament Reconstruction

Recommended Articles

Editor: Robert Magnussen, MD

The following articles have been recommended by members of the International Patellofemoral Study Group.

Patellar nomenclature: The tower of babel revisited.
Grelsamer R P.
Clinical orthopaedics and related research, 2005, (436), 60-65.

Anatomy

Biomechanics

Pathophysiology

Diagnosis and Treatment

Is Knee Pain During Adolescence a Self-limiting Condition? Prognosis of Patellofemoral Pain and Other Types of Knee Pain.

Rathleff MS, Rathleff CR, Olesen JL, Rasmussen S, Roos EM. Am J Sports Med. 2016 Jan 20. pii: 0363546515622456. [Epub ahead of print]

2016 Patellofemoral pain consensus statement from the 4th International Patellofemoral Pain Research Retreat, Manchester. Part 2: recommended physical interventions (exercise, taping, bracing, foot orthoses and combined interventions).

Crossley KM, van Middelkoop M, Callaghan MJ, Collins NJ, Rathleff MS, Barton CJ. Br J Sports Med. 2016;50(14):844-852.

Factors that predict a poor outcome 5-8 years after the diagnosis of patellofemoral pain: a multicentre observational analysis.

Lankhorst NE, van Middelkoop M, Crossley KM, Bierma-Zeinstra SM, Oei EH, Vicenzino B, Collins NJ. Br J Sports Med. 2015 Oct 13. pii: bjsports-2015-094664. doi: 10.1136/bjsports-2015-094664.

Hip posterolateral musculature strengthening in sedentary women with patellofemoral pain syndrome: a randomized controlled clinical trial with 1-year follow-up.

Fukuda TY, Melo WP, Zaffalon BM, Rossetto FM, Magalhães E, Bryk FF, Martin RL. J Orthop Sports Phys Ther. 2012 Oct;42(10):823-30.

Hip strengthening prior to functional exercises reduces pain sooner than quadriceps strengthening in females with patellofemoral pain syndrome: a randomized clinical trial.

Dolak KL, Silkman C, Medina McKeon J, Hosey RG, Lattermann C, Uhl TL. J Orthop Sports Phys Ther. 2011 Aug;41(8):560-70. doi: 10.2519/jospt.2011.3499. Epub 2011 Jun 7.

Immediate effect and predictors of effectiveness of taping for patellofemoral pain syndrome: a prospective cohort study.

Lan TY, Lin WP, Jiang CC, Chiang H. Am J Sports Med. 2010 Aug;38(8):1626-30. Epub 2010 May 26.

Diagnosis and treatment of patients with patellofemoral pain.

Fulkerson JP. Am J Sports Med. 2002 May-Jun;30(3):447-56. Review.

Resection of clinically localized segments of painful retinaculum in the treatment of selected patients with anterior knee pain.

Kasim N, & Fulkerson JP. American Journal of Sports Medicine. 2000, 28(6), 811-814.

Pathophysiology

Imaging

Non-operative Management and Recurrence

Surgical Techniques

MPFL Reconstruction

Tibial Tubercle Osteotomy

Trochleoplasty

Biomechanical Effects of Surgery

MPFL Reconstruction

Tibial Tubercle Osteotomy

Other Procedures

Surgical Outcomes

Medial Reefing and Lateral Release

MPFL Reconstruction

MPFL Reconstruction

Trochleoplasty

More Learning Opportunities

Comments from an MD Radiologist with Patellofemoral Pain

A TESTIMONIAL

I am satisfied with the progress of my patellofemoral issues. It has been 18 months now, and overall, I am doing well.

My local physical therapist had a slightly different philosophy than most I had worked with. His instructions were to work through discomfort, provided it did not go over my baseline pain. His focus was strengthening the muscles, at almost any cost (except new pain)!

Moreover, the focus was hip strengthening—as opposed to years of focused VMO strengthening–with the goal of overall lower extremity alignment improvement, so the femur did not collapse into the patella. I worked both legs equally to achieve symmetry.

In the end, the combination of effective muscle strength, and the mechanical advantage of the tibial tubercle transfer, helped a lot. I still have minor pain with certain activities, and will never run again….but the big thing is I no longer have discomfort with walking!! I had 8 years of damage prior to getting the tibial tubercle transfer, so any expectations to ever be back to 100% are unrealistic. However, the key thing is that I am now back to good lower extremity alignment with reduced contact pressure on the patella, so at least the daily deterioration has halted. I no longer have synovitis–that aggravating warmth in my knee.

For years my treatment had focused only on sampling new and stiffer arch supports, having certain surgeries (VMO advancement and lateral release) without adequate focus on therapy, PT programs that had me stop as I felt any discomfort, and targeted VMO strengthening…all with no success.

I think that with an aggressive PT program, +/- a correctly-timed surgery, success is possible. I hope that my story can help anyone else who may also have experience with patellofemoral issues.

Sincerely, Matthew

Computational Comparison of Tibial Tuberosity Anteromedialization vs. MPFL Reconstruction for Patellofemoral Instability John J. Elias, M.D., Andrew J. Cosgarea, M.D. Medical Education and Research Institute of Colorado, Colorado Springs, CO. Orthapaedic Surgery, Johns Hopkins University, Baltimore, MD.

Striving to improve the quality of life for individuals of all ages affected by anterior knee problems.

Contact info

Eric F Dahlinger, Executive Director

  • 847-309-0222
  • info@patellofemoral.org

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