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Adolescent patellofemoral pain: implicating the medial patellofemoral ligament as the main pain generator

  • Original Clinical Article
  • Published:
Journal of Children's Orthopaedics

Abstract

Purpose

The purpose of this study is to define the clinical presentation of adolescent patellofemoral pain.

Methods

A review was completed of all patients with patellofemoral pain at a children’s hospital sports clinic over a 3-year period.

Results

One hundred and one patients (91 female) with 136 symptomatic knees were identified. Mean age was 14.4 years. Knee pain was localized to the anteromedial or anterior region of the knee in 96% of patients and was typically produced with running (94%), jumping (92%) and stair use (69%). On physical examination there was usually a non antalgic gait (99%), no patellofemoral crepitation (98%), normal lower extremity angular (84%) and rotational alignment (94%), with no foot malalignment (>97%). The medial patellofemoral ligament (MPFL) was the most palpably tender area of the knee in 98% of patients. During “lateral apprehension” testing, 89% had pain at the MPFL, but not true apprehension. A “J-sign” was present at terminal knee extension in 65%. Mean Q-angle was 18.7°. Means of all radiographic measures were within normal ranges.

Conclusion

The prototypical patient had anterior/anteromedial knee pain of insidious onset during running and jumping. The most consistent physical findings were focal tenderness at the MPFL, positive terminal J-sign, and an elevated Q-angle. Most patients required only nonsurgical treatments, but 18% underwent surgical interventions for persistent pain.

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References

  1. Ficat RP, Philippe J, Hungerford DS (1979) Chondromalacia patellae: a system of classification. Clin Orthop 144:55–62

    Google Scholar 

  2. Fulkerson JP (1983) The etiology of patellofemoral pain in young, active patients: a prospective study. Clin Orthop 179:129–133

    Google Scholar 

  3. Henry JH, Goletz TH, Williamson B (1986) Lateral retinacular release in patellofemoral subluxation. Indications, results, and comparison to open patellofemoral reconstruction. Am J Sports Med 14:121–129

    Article  CAS  Google Scholar 

  4. Insall J, Falvo KA, Wise DW (1976) Chondromalacia patellae. A prospective study. J Bone Joint Surg [Am] 58:1–8

    CAS  Google Scholar 

  5. Johnson RP (1989) Lateral facet syndrome of the patella. Lateral restraint analysis and use of lateral resection. Clin Orthop 238:148–158

    Google Scholar 

  6. Yates CK, Grana WA (1986) Patellofemoral pain: a prospective study. Orthopaedics 9:663–667

    CAS  Google Scholar 

  7. Eilert RE (1993) Adolescent anterior knee pain. Instructional course lectures. AAOS 42:497–516

    CAS  Google Scholar 

  8. Fulkerson JP (2002) Diagnosis and treatment of patients with patellofemoral pain. Am J Sports Med 30:447–456

    Google Scholar 

  9. Fulkerson JP (1994) Patellofemoral pain disorders: evaluation and management. J Am Acad Orthop Surg 2:124–132

    Google Scholar 

  10. Post WR (2005) Anterior knee pain: diagnosis and treatment. J Am Acad Orthop Surg 13:534–543

    Google Scholar 

  11. Dye SF, Vaupel GL (1994) The pathophysiology of patellofemoral pain. Sports Med Arthros Rev 2:203–210

    Article  Google Scholar 

  12. Hoffa A (1904) The influence of the adipose tissue with regard to the pathology of the knee joint. JAMA 43:795–796

    Article  Google Scholar 

  13. Staheli LT, Corbett M, Wyss C, King H (1985) Lower-extremity rotational problems in children. Normal values to guide management. J Bone Joint Surg [Am] 67:39–47

    CAS  Google Scholar 

  14. Merchant AC, Mercer RL (1974) Lateral release of the patella: a preliminary report. Clin Orthop 103:40–45

    Article  Google Scholar 

  15. Walker P, Harris I, Leicester A (1998) Patellar tendon-to-patella ratio in children. J Pediatr Orthop 18:129–131

    CAS  Google Scholar 

  16. Kannus P (1992) Long patellar tendon: radiographic sign of patellofemoral pain syndrome-a prospective study. Radiology 185:859–863

    Article  CAS  Google Scholar 

  17. Merchant AC (1988) Classification of patellofemoral disorders. Arthroscopy 4:235–240

    Article  CAS  Google Scholar 

  18. Dye SF, Vaupel G, Dye CC (1998) Conscious neurosensory mapping of the internal structures of the human knee without intraarticular anesthesia. Am J Sports Med 26:773–777

    CAS  Google Scholar 

  19. Casscells SW (1982) Chondromalacia of the patella. J Pediatr Orthop 2:560–564

    Article  CAS  Google Scholar 

  20. Fulkerson JP, Tennant R, Jaivin JS, Grunnet M (1985) Histologic evidence of retinacular nerve injury associated with patellofemoral malalignment. Clin Orthop 197:196–205

    Google Scholar 

  21. Schwarz C, Blazina ME, Sisto DJ, Hirsh LC (1988) The results of operative treatment of osteochondritis dissecans of the patella. Am J Sports Med 16:522–529

    Article  CAS  Google Scholar 

  22. Royle SG, Noble J, Davies DRA, Kay PR (1991) The significance of chondromalacic changes on the patella. Arthroscopy 7:158–160

    Article  CAS  Google Scholar 

  23. Reider B, Marshall JL, Koslin B, Ring B, Girgis FG (1981) The anterior aspect of the knee joint: an anatomical study. J Bone Joint Surg [Am] 63:351–356

    CAS  Google Scholar 

  24. Schutzer SF, Ramsby GR, Fulkerson JP (1986) Computed tomographic classification of patellofemoral pain patients. Orthop Clin North Am 17:235–248

    CAS  Google Scholar 

  25. Wojtys EM, Beaman DN, Glover RA, Janda D (1990) Innervation of the human knee joint by substance-P fibers. Arthroscopy 6:254–263

    Article  CAS  Google Scholar 

  26. McGinty JB, McCarthy JC (1981) Endoscopic lateral retinacular release: a preliminary report. Clin Orthop 158:120–125

    Google Scholar 

  27. Fulkerson JP (1982) Awareness of the retinaculum in evaluating patellofemoral pain. Am J Sports Med 10:147–149

    Article  CAS  Google Scholar 

  28. Devereaux MD, Parr GR, Lachmann SM, Page Thomas DP, Hazleman BL (1986) Thermographic diagnosis in athletes with patellofemoral arthralgia. J Bone Joint Surg [Br] 68:42–44

    CAS  Google Scholar 

  29. Goodfellow J, Hungerford DS, Zindel M (1976) Patello-femoral joint mechanics and pathology: functional anatomy of the patello-femoral joint. J Bone Joint Surg [Br] 58:287–290

    CAS  Google Scholar 

  30. Goodfellow J, Hungerford DS, Woods C (1976) Patellofemoral joint mechanics and pathology: chondromalacia patellae. J Bone Joint Surg [Br] 58:291–299

    CAS  Google Scholar 

  31. Krompinger WJ, Fulkerson JP (1983) Lateral retinacular release for intractable lateral retinacular pain. Clin Orthop 179:191–193

    Google Scholar 

  32. Gerbino PG, Griffin ED, d’Hemecourt PA, Kim T, Kocher MS, Zurakowski D, Micheli LJ (2006) Patellofemoral pain syndrome: evaluation of location and intensity of pain. Clin J Pain 22:154–159

    Article  Google Scholar 

  33. Hungerford DS, Barry M (1979) Biomechanics of the patellofemoral joint. Clin Orthop 144:9–15

    Google Scholar 

  34. Conlan T, Garth WP, Lemons JE (1993) Evaluation of the medial soft-tissue restraints of the extensor mechanism of the knee. J Bone Joint Surg [Am] 75:682–693

    CAS  Google Scholar 

  35. Feller J, Feagin J, Garrett W (1993) The MPFL revisited: an anatomical study. Knee Surg Sports Traumatol Arthrosc 1:184–186

    Article  CAS  Google Scholar 

  36. Hautamaa PV, Fithian DC, Kaufman KR, Daniel DM, Pohlmeyer AM (1998) Medial soft tissue retraints in lateral patellar instability and repair. Clin Orthop 349:174–182

    Article  Google Scholar 

  37. Paulos LE, Rosenberg TD, Drawbert J, Manning J, Abbot P (1987) Infrapatellar contracture syndrome. An unrecognized cause of stiffness with patella entrapment and patella infera. Am J Sports Med 15:331–341

    Article  CAS  Google Scholar 

  38. Warren LF, Marshall JL (1979) The supporting structures and layers on the medial side of the knee: an anatomical analysis. J Bone Joint Surg [Am] 61:56–62

    CAS  Google Scholar 

  39. Heegaard J, Leyvraz PF, Van Kampen A, Rakotomanana L, Rubin PJ, Blankevoort L (1994) Influence of soft structures on patellar three-dimensional tracking. Clin Orthop 299:235–243

    Google Scholar 

  40. Sandmeier RH, Burks RT, Bachus KN, Billings A (2000) The effect of reconstruction of the medial patellofemoral ligament on patellar tracking. Am J Sports Med 28:345–349

    CAS  Google Scholar 

  41. Luo ZP, Sakai N, Rand JA et al (1997) Tensile strength of the lateral patellofemoral ligament during knee motion. Am J Knee Surg 10:139–144

    CAS  Google Scholar 

  42. Eilert RE (1993) Adolescent anterior knee pain. Inst Course Lect 42:497–516

    CAS  Google Scholar 

  43. Hehne HJ (1990) Biomechanics of the patellofemoral joint and its clinical relevance. Clin Orthop 258:73–85

    Google Scholar 

  44. Lieb FJ, Perry J (1971) Quadriceps function: an electromyographic study under isometric conditions. J Bone Joint Surg [Am] 53:749–758

    CAS  Google Scholar 

  45. Mariani PP, Caruso I (1979) An electromyographic investigation of subluxation of the patella. J Bone Joint Surg [Br] 61:6169–6171

    Google Scholar 

  46. Perry J, Antonelli D, Ford W (1975) Analysis of knee-joint forces during flexed-knee stance. J Bone Joint Surg [Am] 57:961–967

    CAS  Google Scholar 

  47. Voight ML, Wieder DL (1991) Comparative reflex response times of vastus medialis obliquus and vastus lateralis in normal subjects and subjects with extensor mechanism dysfunction: an electomyographic study. Am J Sport Med 19:131–137

    Article  CAS  Google Scholar 

  48. Boden BP, Pearsall AW, Garrett WE, Feagin JA (1997) Patellofemoral instability: evaluation and management. J Am Acad Orthop Surg 5:47–57

    Google Scholar 

  49. Kennedy JC, Alexander IJ, Hayes KC (1982) Nerve supply of the human knee and its functional importance. Am J Sports Med 10:329–335

    Article  CAS  Google Scholar 

  50. Biedert RM, stauffer E, Friederich NF (1992) Occurrence of free nerve endings in the soft tissue of the knee joint: A histologic investigation. Am J Sports Med 20:430–433

    Article  CAS  Google Scholar 

  51. Gardner E (1948) The innervation of the knee joint. Anat Rec 101:109–130

    Article  CAS  Google Scholar 

  52. Witonski D, Wagrowska-Danielewicz M (1999) Distribution of substance-P nerve fibers in the knee joint in patients with anterior knee pain syndrome: a preliminary report. Knee Surg Sports Traumatol Arthrosc 7:177–183

    Article  CAS  Google Scholar 

  53. Sanchis-Alfonso V, Rosello-Sastre E, Monteagudo-Castro C, Esquerdo J (1998) Quantitative analysis of nerve changes in the lateral retinaculum in patients with isolated symptomatic patellofemoral malalignment: a preliminary study. Am J Sports Med 26:703–709

    CAS  Google Scholar 

  54. Sandow MJ, Goodfellow JW (1985) The natural history of anterior knee pain in adolescents. JBJS (Br) 67(1):36–38

    CAS  Google Scholar 

  55. Fujimoto A, Mori Y, Kuroki Y, Yamamoto R, Hino H, Okumo H (1988) The natural history of anterior knee pain in japanese adolescents. Surgery and arthroscopy of the knee. 2nd Congress of the European Society. Springer, Berlin, pp 447–451

  56. Blond L, Hansen L (1998) Patellofemoral pain syndrome in athletes: a 5.7 year retrospective follow-up study of 250 athletes. Acta Orthop Belg 64:393–400

    CAS  Google Scholar 

  57. Crossley K, Bennell K, Green S et al (2002) Physical therapy for patellofemoral pain. A randomized, double-blinded, placebo-controlled trial. Am J Sports Med 30:857–865

    Google Scholar 

  58. DeHaven KE, Dolan WA, Mayer PJ (1979) Chondromalacia patellae in athletes: clinical presentation and conservative management. Am J Sports Med 7:5–14

    Article  CAS  Google Scholar 

  59. Singer KM, Henry J (1985) Knee problems in children and adolescents. Clin Sports Med 4:385–397

    CAS  Google Scholar 

  60. Thomee R (1997) A comprehensive treatment approach for patellofemoral pain syndrome in young women. Phys Therap 12:1690–1703

    Google Scholar 

  61. Doucette S, Goble EM (1992) The effect of exercise on patellar tracking in lateral patellar compression syndrome. Am J Sports Med 20:434–440

    Article  CAS  Google Scholar 

  62. Larson RL, Cabaud HE, Slocum DB, James SL, Keenan T, Hutchinson T (1978) The patellar compression syndrome: surgical treatment by lateral retinacular release. Clin Orthop 134:158–167

    Google Scholar 

  63. Fulkerson JP, Gossling HR (1980) Anatomy of the knee joint lateral retinaculum. Clin Orthop 153:183–188

    Google Scholar 

  64. Reider B, Marshall JL, Ring B et al (1981) Patellar tracking. Clin Orthop 157:143–148

    Google Scholar 

  65. Aglietti P, Pisaneschi A, Buzzi R, Gaudenzi A, Allegra A (1989) Arthroscopic lateral release for patellar pain or instability. Arthroscopy 5:176–183

    Article  CAS  Google Scholar 

  66. Aglietti P, Insall JN, Cerulli G (1983) Patellar pain and incongruence. I: Measurements of incongruence. Clin Orthop 176:217–224

    Google Scholar 

  67. Betz RR, Magill JT III, Lonergan RP (1987) The percutaneous lateral retinacular release. Am J Sports Med 15:477–482

    Article  CAS  Google Scholar 

  68. Bigos SJ, McBride GG (1984) The isolated lateral retinacular release in the treatment of patellofemoral disorders. Clin Orthop 186:75–80

    Google Scholar 

  69. Chen SC, Ramanathan EB (1984) The treatment of patellar instability by lateral release. J Bone Joint Surg [Br] 66:344–348

    CAS  Google Scholar 

  70. Christensen F, Soballe K, Snerum L (1988) Treatment of chondromalacia patellae by lateral retinacular release of the patella. Clin Orthop 234:145–147

    Google Scholar 

  71. Dzioba RB (1990) Diagnostic arthroscopy and longitudinal open lateral release. A four year follow-up study to determine predictors of surgical outcome. Am J Sports Med 18:343–348

    Article  CAS  Google Scholar 

  72. Kolowich PA, Paulos LE, Rosenberg TD, Farnsworth S (1990) Lateral release of the patella: indications and contraindications. Am J Sports Med 18:359–365

    Article  CAS  Google Scholar 

  73. LanKenner PA Jr, Micheli LJ, Clancy R, Gerbino PG (1986) Arthroscopic percutaneous lateral patellar retinacular release. Am J Sports Med 14:267–269

    Article  Google Scholar 

  74. Metcalf RW (1982) An arthroscopic method for lateral release for the subluxating or dislocating patella. Clin Orthop 167:9–18

    Google Scholar 

  75. Micheli LJ, Stanitski CL (1981) Lateral patellar retinacular release. Am J Sports Med 9:330–336

    Article  CAS  Google Scholar 

  76. Sherman OH, Fox JM, Sperling H, Del Pizzo W, Friedman MJ, Snyder SJ, Ferkel RD (1987) Patellar instability: treatment by arthroscopic electrosurgical lateral release. Arthroscopy 3:152–160

    Article  CAS  Google Scholar 

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Authors and Affiliations

  1. Department of Orthopaedic Surgery, Shriner’s Hospital for Children, St Louis Children’s Hospital, Washington University School of Medicine, 660 S. Euclid Ave., Campus Box 8233, St Louis, 63110, MO, USA

    Scott J. Luhmann, Perry L. Schoenecker, Matthew B. Dobbs & J. Eric Gordon

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  1. Scott J. Luhmann
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  2. Perry L. Schoenecker
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  3. Matthew B. Dobbs
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Correspondence to Scott J. Luhmann.

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Luhmann, S.J., Schoenecker, P.L., Dobbs, M.B. et al. Adolescent patellofemoral pain: implicating the medial patellofemoral ligament as the main pain generator. J Child Orthop 2, 269–277 (2008). https://doi.org/10.1007/s11832-008-0104-2

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