Overview of Patellofemoral Joint Instability

Original Editor - Jess Bell based on the course by Claire Robertson
Top Contributors - Jess Bell, Kim Jackson, Wanda van Niekerk and Ewa Jaraczewska

Introduction

Patellofemoral instability is a complex orthopaedic condition that frequently affects children and adolescents. It is estimated that the incidence of patellofemoral instability in paediatric patients ranges from 23 to 43 per 100,000 person-years. The highest rates are in teenagers aged between 14 and 18 years, with the first episode of dislocation typically occurring at the age of 15.

The management of patellofemoral instability is complex. Vellios et al. note that first-time dislocation may be managed conservatively (i.e. through rehabilitation, bracing, and activity modification), but as many as 36 percent of patients will have recurrent instability on the same leg.

Definitions

Patellofemoral stability is defined as “constraint by passive soft tissue tethers and chondral/bony geometry that, with muscular forces, guide the patella into the trochlear groove and keep it engaged within the trochlear groove as the knee flexes and extends.”

Patellofemoral instability is defined as “symptomatic deficiency of the aforementioned passive constraint (patholaxity) such that the patella may escape partially or completely from its asymptomatic position with respect to the femoral trochlea under the influence of displacing force.”

Comparison of a patella in situ, subluxed and dislocated.

Dislocation - the patella comes completely out of the trochlea (see image). Dislocation might be caused by a:

• Traumatic event (e.g. rugby tackle)
  • In these cases, the knee has been structurally intact prior to injury
  • These individuals tend to have a better prognosis as there are no underlying structural morphological elements to predispose them to instability
• Minor trauma - a slight tap / knock to the knee causes dislocation
  • These individuals tend to have a structural element which predisposes them to instability

Subluxation - a “halfway" point between a patella in situ and dislocation (see image). Patients with a subluxing patella may complain of a painful knee / anterior knee pain.

Recurrent Patellofemoral Instability

Recurrent patellofemoral instability is relatively common. Individuals who experience recurrent patellofemoral instability often have specific pathoanatomical features which predispose them to patellar dislocation. Migliorini et al. note the following risk factors:

• Bony conformation abnormalities (e.g. trochlear dysplasia)
• Lower limb mal-alignment syndromes
• Soft tissue abnormalities (e.g. patella alta)

Jaquith and Parikh found that the following are risk factors for multiple dislocations in children and adolescents:

1. Aged under 14 years at first dislocation
2. History of contralateral dislocation
3. Any type of trochlear dysplasia
4. Skeletal immaturity (i.e. the physis in the distal femur or proximal tibia are still partially / fully open)
5. Long patellar tendon

The number of risk factors a child / adolescent has impacts their risk of recurrent dislocations:

• Children who have risk factors 2-5 are 88 percent likely to have recurrent dislocations
• Having any three risk factors is associated with a 75 percent risk of recurrent dislocations
• Having any two risk factors is associated with a predicted risk of around 55 percent
• 97 percent of recurrences occur within three years

Jaquith and Parikh found that the mean age of first dislocation for children who experienced re-dislocation was 12.9 years and for those who did not re-dislocate, the mean age of first dislocation was 13.8 years. Thus, 13 years is an important milestone when considering patellofemoral dislocation.

Morphology and Instability

This is an area of growth:

• Imaging is improving
• More sophisticated surgeries are available
• Our understanding of the subtleties associated with this condition is improving
• There is an awareness that individuals with patellofemoral instability are more likely to have accelerated wear leading to premature patellofemoral arthritis

Dysplasia Assessment

The following are important features to consider when assessing individuals with potential / confirmed patellofemoral instability:

• Morphology of the trochlea
• Position of the tibial tubercle
• Length of the patellar tendon

Morphology of the Trochlea

The patella is essentially a floating bone which needs to stay in the trochlea (i.e. the groove of the distal femur). It is well recognised that trochlear dysplasia is associated with patellofemoral instability.

Trochlear Depth

Ideally, the trochlea will be deep, with a sharp inclination on the lateral side. It is important to look out for a “shallow trochlea” on an MRI report. Patients may also have a long lateral facet and / or shallow inclination.

If imaging is not available, you can assess the following:

• Feel for passive glide, especially laterally (see video on left below)
• Look for J sign (see video on right below) for subluxation (i.e. increased lateral patellar deviation when moving from flexion to extension) and poor engagement at the entrance to the trochlea

There is a spectrum of trochlear dysplasia. Ideally, a trochlea will be shaped liked a soup bowl. Individuals who have a saucer-shaped trochlea (i.e. shallow) are more likely to experience subluxation or dislocation. They may report that it feels like their patella is “skidding around” or “slipping”. At the more extreme end of the spectrum, patients can have a domed trochlea. These persons are most likely to dislocate and are unlikely to stabilise without surgery (e.g. trochleoplasty).

“High-grade trochlear dysplasia is characterized by the combination of a flat and/or prominent trochlea proud of the anterior femoral cortex, which offers inadequate tracking during flexion and leads to patellar subluxation.”

Trochleoplasty - Prevention of Rapid Wear

• Addresses trochlear morphology, Q angle and TT-TG distance (see below)
• Addresses a long patellar tendon (see below)
• Addresses the over-stretching of medial structures (see below)

Please note that trochleoplasty is major surgery and outcomes are better when this procedure is performed on pristine chondral surfaces (i.e. on individuals in their late teens).

Non-Operative Rehabilitation

Individuals with patellofemoral instability may have multi-directional instability, but they may not always dislocate:

• Look out for patients using descriptors such as ‘slipping’
• Robertson notes that patellofemoral instability is often associated with small patellae and hypermobility
• It is important to try to establish if the individual is subluxing, dislocating or has general excess mobility
• If the problem is with engagement, look at rehabilitating in the early range of motion, avoiding pain
• Isometrics are very useful
• Robertson also notes that individuals with multi-directional instability are often very puffy in their parapatellar soft tissues
• They often have medial and lateral fat pad oedema
• Can consider bracing (see below)
• Not always isolated to terminal extension instability

Bracing

It is essential to use clinical reasoning when considering bracing. Ask the following questions:

• Is there any chondral damage or bone oedema? If yes where?
  • Lateral facet / lateral trochlea, then consider Q brace
  • If no damage, then consider a patellar stabilising brace

Q Brace

Callaghan et al. explored the use of a Bioskin Patellar Tracking Q Brace on patients with painful patellofemoral joint osteoarthritis (PFJOA):

• MRI was used to monitor bone marrow lesions in lateral PFJOA
• Participants either wore a brace or had no brace (control)
• Participants in the brace group wore their braces for a mean of 7.4 hours per day
• At the six-week follow-up, Callaghan et al. found that subjects using the Q brace had decreased pain, as well as a reduction in the volume of patellofemoral bone marrow lesions

Taping

• McConnell taping can be useful for lateral pathology (see video below)
• K tape can be used to stabilise the knee

Position of the Tibial Tubercle

Ideally, the tibial tubercle will be positioned directly under the trochlea. However, some people present with a lateralised tibial tuberosity. When the quadriceps works, the position of the tibial tubercle creates an overall lateralising force, which can have an impact on stability.

TT-TG distance (tibial tuberosity-trochlear groove) is measured on MRI to accurately determine the position of the tibial tubercle in relation to the trochlea. The greater the distance, the more lateralised the tibial tuberosity.

To measure TT-TG distance:

• A line is made through the trochlea and tibial tuberosity
• The distance between these two lines is measured
  • Up to 15 mm is considered normal
  • 15-20 mm may start to affect stability and potentially create pain
  • ≥20 mm indicates individuals at risk for future instability

When MRI is not available, it is possible to conduct a visual examination. You can then ask the patient to perform a static quadriceps hold and look to see if the patella moves laterally. While this is not an accurate measure, it can be useful when considered alongside the overall clinical picture.

Non-Operative Management of a Large TT-TG

A lateralised tibial tuberosity causes a lateral valgus movement, which overloads the lateral facet and provides a lateral force. Thus, it is important for patients to avoid the following femoral positions:

• Adduction
• Internal rotation
• Adduction with internal rotation

Check also if the patient is anteverted (using Craig's test - see video below). Other points to consider include:

• Are patients aware of any issues with dynamic control (i.e. do they knock their knees when running?)

• Do they have weakness or poor neuromusculoskeletal (NMS) control?
• Can they correct this? What cues work best?
• Consider at what angle of hip flexion the rotation problem occurs
• Is the “medial collapse” driven from the foot?
  • Care with orthotics is required for this group

The following exercises can be useful in the rehabilitation of individuals with a large TT-TG:

• 

  Rotational control in standing.

• 

  Eccentric control in sitting.

Length of the Patellar Tendon

A patella alta is essentially a “high-riding” patella. It can occur when individuals are born with long patellar tendons and it is known to be associated with patellofemoral instability.

The Insall-Salvati ratio is most often used to measure the height of the patella. It compares patellar tendon length with patellar length. An ideal ratio is 1:1. This can also be informally assessed in the clinic.

Non-Operative Management of Patella Alta

In individuals with patella alta, the patella takes longer to enter the trochlea. Typically, the patella will engage in the trochlea at around 15 degrees of knee flexion. But this is delayed in individuals with patella alta. Thus, their knee is relatively more unstable for the first 30 degrees of knee flexion.

It is, therefore, important to target 0-30 degrees of knee flexion with dynamic stability. Conservative management should focus on making the Vastus Medialis Oblique (VMO) architecturally favourable - i.e. increase the fibre angle and the insertion ratio.

Medial Patellofemoral Ligament

The medial patellofemoral ligament (MPFL) is the primary restraint to the patella, so it can have a significant impact on stability. While people do not tend to have a congenital problem with this ligament, it is disrupted after dislocation (either very stretched or ruptured).

If a patient presents after a confirmed or potential dislocating event, look for:

• Bruising
• Swelling
• Medial tenderness (just medial to the patella)

These will increase your suspicion of a MPFL injury.

Outcome Measures

The following outcome measures can be useful in this client group:

• Norwich Instability Score: highlights degree of instability and impact on life
• Tampa Score of Kinesiophobia: highlights level of kinesiophobia (i.e. the fear of movement)