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Physical Examination and Patellofemoral Pain Syndrome: an Updated Review

  • Non-Operative Management of Anterior Knee Pain (M Fredericson and T Besier, Section Editors)
  • Published:
Current Reviews in Musculoskeletal Medicine Aims and scope Submit manuscript

Abstract

Purpose of Review

Patellofemoral pain syndrome (PFPS) accounts for 25 to 40% of all knee disorders. Diagnosis of PFPS is primarily based on history and physical examination, but the findings on physical examination are often subtle and do not consistently correlate with symptoms described. Yoon and Fredericson published a review article in 2006 detailing the physical examination maneuvers most frequently used to assist clinicians in the accurate diagnosis and treatment of PFPS, and our aim in this review is to provide an update on this previous article focusing on the literature published over the past 15 years regarding the topic.

Recent Findings

Since publication of Fredericson’s original review article, there have been studies building on the literature specifically surrounding Q angle, patellar tilt, crepitus, strength and functional testing, and physical examination maneuver clustering. Additionally, multiple studies have been conducted on the use of musculoskeletal ultrasound (US) as a diagnostic tool for PFPS.

Summary

Recent literature has further supported Q angle (when measured utilizing a standardized protocol), crepitus, weakness of hip abductors and extensors, and weakness detected in functional testing as predictors of PFPS while finding inconsistent evidence behind lateral patellar tilt as a predictor of PFPS. The reliability of most physical examination tests alone remain low, but clustering physical examination findings may provide better sensitivities and specificities in diagnosing PFPS. Musculoskeletal US is rapidly gaining popularity, and decreased vastus medialis obliquus (VMO) volume, asymmetry in gluteus medius thickness, intra-articular effusions, and quadriceps and patellar tendon thicknesses have shown value in diagnosing those with PFPS. Additionally, US has the advantage of providing dynamic examination as well as evaluation of the patellofemoral joint in newborns and infants as a predictor of future patellofemoral instability. Further studies are needed to establish the gold standard for diagnosing PFPS and what US findings are truly predictive of PFPS.

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References

Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. •• Decary S, et al. Validity of combining history elements and physical examination tests to diagnose patellofemoral pain. Arch Phys Med Rehabil. 2018;99(4):607–614 e1. Identified two clusters of history elements and physical examination tests with high specificifities to diagnose PFPS and three clusters with high sensitivities to exlcude PFPS

    Article  PubMed  Google Scholar 

  2. Crossley KM, van Middelkoop M, Callaghan MJ, Collins NJ, Rathleff MS, Barton CJ. 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). Br J Sports Med. 2016;50(14):844–52.

    Article  PubMed  Google Scholar 

  3. Taunton JE, Ryan MB, Clement DB, McKenzie D, Lloyd-Smith DR, Zumbo BD. A retrospective case-control analysis of 2002 running injuries. Br J Sports Med. 2002;36(2):95–101.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  4. van Middelkoop M, van Linschoten R, Berger MY, Koes BW, Bierma-Zeinstra SMA. Knee complaints seen in general practice: active sport participants versus non-sport participants. BMC. 2008;9(36):9.

    Google Scholar 

  5. Witvrouw E, Crossley K, Davis I, McConnell J, Powers CM. The 3rd International Patellofemoral Research Retreat: an international expert consensus meeting to improve the scientific understanding and clinical management of patellofemoral pain. Br J Sports Med. 2014;48(6):408.

    Article  PubMed  Google Scholar 

  6. Outerbridge RE. The etiology of chondromalacia patellae. J Bone Joint Surg (Br). 1961;43-B:752–7.

    Article  CAS  Google Scholar 

  7. Outerbridge RE, Dunlop JA. The problem of chondromalacia patellae. Clin Orthop Relat Res. 1975;110:177–96.

    Article  Google Scholar 

  8. Nimon G, Murray D, Sandow M, Goodfellow J. Natural history of anterior knee pain: a 14- to 20-year follow-up of nonoperative management. J Pediatr Orthop. 1998;18(1):118–22.

    Article  CAS  PubMed  Google Scholar 

  9. Stathopulu E, Baildam E. Anterior knee pain: a long-term follow-up. Rheumatology (Oxford). 2003;42(2):380–2.

    Article  CAS  Google Scholar 

  10. Blond L, Hansen L. Patellofemoral pain syndrome in athletes: a 5.7-year retrospective follow-up study of 250 athletes. Acta Orthop Belg. 1998;64(4):393–400.

    CAS  PubMed  Google Scholar 

  11. Utting MR, Davies G, Newman JH. Is anterior knee pain a predisposing factor to patellofemoral osteoarthritis? Knee. 2005;12(5):362–5.

    Article  CAS  PubMed  Google Scholar 

  12. Lack S, Neal B, de Oliveira Silva D, Barton C. How to manage patellofemoral pain - understanding the multifactorial nature and treatment options. Phys Ther Sport. 2018;32:155–66.

    Article  PubMed  Google Scholar 

  13. Pohl MB, Patel C, Wiley JP, Ferber R. Gait biomechanics and hip muscular strength in patients with patellofemoral osteoarthritis. Gait Posture. 2013;37(3):440–4.

    Article  PubMed  Google Scholar 

  14. Eijkenboom JFA, Waarsing JH, Oei EHG, Bierma-Zeinstra SMA, van Middelkoop M. Is patellofemoral pain a precursor to osteoarthritis?: Patellofemoral osteoarthritis and patellofemoral pain patients share aberrant patellar shape compared with healthy controls. Bone Joint Res. 2018;7(9):541–7.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  15. Fredericson M. Patellofemoral pain syndrome. In: O’Conner FG WR, Nirchl R, editors. Textbook of Running Medicine. New York: McGraw-Hill; 2001. p. 169–79.

    Google Scholar 

  16. Messier SP, Davis SE, Curl WW, Lowery RB, Pack RJ. Etiologic factors associated with patellofemoral pain in runners. Med Sci Sports Exerc. 1991;23(9):1008–15.

    Article  CAS  PubMed  Google Scholar 

  17. Kannus P, et al. An outcome study of chronic patellofemoral pain syndrome. Seven-year follow-up of patients in a randomized, controlled trial. J Bone Joint Surg Am. 1999;81(3):355–63.

    Article  CAS  PubMed  Google Scholar 

  18. Thomee R, et al. Patellofemoral pain syndrome in young women. I. A clinical analysis of alignment, pain parameters, common symptoms and functional activity level. Scand J Med Sci Sports. 1995;5(4):237–44.

    Article  CAS  PubMed  Google Scholar 

  19. Fredericson M, Yoon K. Physical examination and patellofemoral pain syndrome. Am J Phys Med Rehabil. 2006;85(3):234–43.

    Article  PubMed  Google Scholar 

  20. Grelsamer RP, Dubey A, Weinstein CH. Men and women have similar Q angles: a clinical and trigonometric evaluation. J Bone Joint Surg (Br). 2005;87(11):1498–501.

    Article  CAS  Google Scholar 

  21. Smith TO, Hunt NJ, Donell ST. The reliability and validity of the Q-angle: a systematic review. Knee Surg Sports Traumatol Arthrosc. 2008;16(12):1068–79.

    Article  PubMed  Google Scholar 

  22. Boden BP, Pearsall AW, Garrett WE, Feagin JA. Patellofemoral instability: evaluation and management. J Am Acad Orthop Surg. 1997;5(1):47–57.

    Article  CAS  PubMed  Google Scholar 

  23. Kibler WB. Strength and flexibility findings in anterior knee pain syndrome in athletes. Am J Sports Med. 1987;15:410.

    Google Scholar 

  24. Thomee R, et al. Patellofemoral pain syndrome in young women. II. Muscle function in patients and healthy controls. Scand J Med Sci Sports. 1995;5(4):245–51.

    Article  CAS  PubMed  Google Scholar 

  25. Nunes GS, Barton CJ, Serrao FV. Hip rate of force development and strength are impaired in females with patellofemoral pain without signs of altered gluteus medius and maximus morphology. J Sci Med Sport. 2018;21(2):123–8.

    Article  PubMed  Google Scholar 

  26. Loudon JK, Wiesner D, Goist-Foley HL, Asjes C, Loudon KL. Intrarater reliability of functional performance tests for subjects with patellofemoral pain syndrome. J Athl Train. 2002;37(3):256–61.

    PubMed  PubMed Central  Google Scholar 

  27. Nunes GS, de Oliveira Silva D, Crossley KM, Serrão FV, Pizzari T, Barton CJ. People with patellofemoral pain have impaired functional performance, that is correlated to hip muscle capacity. Phys Ther Sport. 2019;40:85–90.

    Article  PubMed  Google Scholar 

  28. Merchant AC. Classification of patellofemoral disorders. Arthroscopy. 1988;4(4):235–40.

    Article  CAS  PubMed  Google Scholar 

  29. Brattstroem H. Shape of the intercondylar groove normally and in recurrent dislocation of patella. A clinical and x-ray-anatomical investigation. Acta Orthop Scand Suppl. 1964;35(SUPPL 68):1–148.

    Article  Google Scholar 

  30. Aglietti P, Insall JN, Cerulli G. Patellar pain and incongruence. I: Measurements of incongruence. Clin Orthop Relat Res. 1983;176:217–24.

    Article  Google Scholar 

  31. France L, Nester C. Effect of errors in the identification of anatomical landmarks on the accuracy of Q angle values. Clin Biomech (Bristol, Avon). 2001;16(8):710–3.

    Article  CAS  Google Scholar 

  32. Caylor D, Fites R, Worrell TW. The relationship between quadriceps angle and anterior knee pain syndrome. J Orthop Sports Phys Ther. 1993;17(1):11–6.

    Article  CAS  PubMed  Google Scholar 

  33. Post WR. Clinical evaluation of patients with patellofemoral disorders. Arthroscopy. 1999;15(8):841–51.

    Article  CAS  PubMed  Google Scholar 

  34. •• Merchant AC, et al. A reliable Q angle measurement using a standardized protocol. Knee. 2020;27(3):934–9. Validated a standardized protocol to measure the Q angle and provided a reliable reference for clinical comparison in the assessment of tubercle lateralalization without expensive imaging studies

    Article  PubMed  Google Scholar 

  35. Draper CE, Chew KTL, Wang R, Jennings F, Gold GE, Fredericson M. Comparison of quadriceps angle measurements using short-arm and long-arm goniometers: correlation with MRI. PM R. 2011;3(2):111–6.

    Article  PubMed  Google Scholar 

  36. Grelsamer R, McConnell J. The patella: a team approach. Gathersburg: Aspen Publishers; 1998. p. 109–18.

    Google Scholar 

  37. Nunes GS, Stapait EL, Kirsten MH, de Noronha M, Santos GM. Clinical test for diagnosis of patellofemoral pain syndrome: systematic review with meta-analysis. Phys Ther Sport. 2013;14(1):54–9.

    Article  PubMed  Google Scholar 

  38. Johnson LL, van Dyk G, Green JR III, Pittsley AW, Bays B, Gully SM, Phillips. Clinical assessment of asymptomatic knees: comparison of men and women. Arthroscopy. 1998;14(4):347–59.

    Article  CAS  PubMed  Google Scholar 

  39. de Oliveira Silva D, Barton C, Crossley K, Waiteman M, Taborda B, Ferreira AS, Azevedo FM. Implications of knee crepitus to the overall clinical presentation of women with and without patellofemoral pain. Physical Therapy in Sport. 2018;33:88–95.

    Article  Google Scholar 

  40. Callaghan MJ, Oldham JA. Quadriceps atrophy: to what extent does it exist in patellofemoral pain syndrome? Br J Sports Med. 2004;38(3):295–9.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  41. Ireland ML, Willson JD, Ballantyne BT, Davis IMC. Hip strength in females with and without patellofemoral pain. J Orthop Sports Phys Ther. 2003;33(11):671–6.

    Article  PubMed  Google Scholar 

  42. • Jan MH, et al. Differences in sonographic characteristics of the vastus medialis obliquus between patients with patellofemoral pain syndrome and healthy adults. Am J Sports Med. 2009;37(9):1743–9. First study to identify specific ultrasonography findings in those with PFPS

    Article  PubMed  Google Scholar 

  43. •• Payne K, Payne J, Larkin TA. Patellofemoral pain syndrome and pain severity is associated with asymmetry of gluteus medius muscle activation measured via ultrasound. Am J Phys Med Rehabil. 2020;99(7):595–601. Identified the importance of left-right asymmetries between gluteus medius muscle activation, rather than the actual values of gluteus medius muscle activation, in patients with PFPS

    Article  PubMed  Google Scholar 

  44. • Sier-Ner I, et al. Ultrasonography findings and physical examination outcomes in dancers with and without patellofemoral pain. Physician & Sports Medicine. 2018;46(1):48–55. Identified intra-articular effusions on US as a potential indicator for those with PFPS

    Article  Google Scholar 

  45. • Kizilkaya A, Ecesoy H. Ultrasonographic assessment of quadriceps and patellar tendon thickness in patients with patellofemoral pain syndrome. Acta Orthop Traumatol Turc. 2019;53(4):272–7. Established quadriceps tendon and patellar tendon thickness thresholds under US to help with diagnosis of PFPS

    Article  PubMed  PubMed Central  Google Scholar 

  46. •• Shih YF, et al. A technique for the measurement of patellar tracking during weight-bearing activities using ultrasound. Proc Inst Mech Eng H. 2003;217(6):449–57. Developed the most studied method to evaluate patellar tracking with musculoskeletal ultrasound

    Article  PubMed  Google Scholar 

  47. Shih YF, Bull AMJ, McGregor AH, Amis AA. Active patellar tracking measurement: a novel device using ultrasound. Am J Sports Med. 2004;32(5):1209–17.

    Article  PubMed  Google Scholar 

  48. Herrington L, Pearson S. The applicability of ultrasound imaging in the assessment of dynamic patella tracking: a preliminary investigation. Knee. 2008;15(2):125–7.

    Article  PubMed  Google Scholar 

  49. Herrington L, McEwan I, Thom J. Quantification of patella position by ultrasound scanning and its criterion validity. Ultrasound Med Biol. 2006;32(12):1833–6.

    Article  PubMed  Google Scholar 

  50. Chen CL, Lo CL, Huang KC, Huang CF. Intrarater reliability of measuring the patella position by ultrasonography in weight-bearing condition. J Phys Ther Sci. 2017;29(10):1865–8.

    Article  PubMed  PubMed Central  Google Scholar 

  51. •• Bailowitz Z, Papas I, Newman M, Ultrasonographic evaluation of patellar tracking: normative values in asymptomatic patients. 2018: Poster presentation at: AAPM&R Annual Assembly; September 26, 2018; Orlando, FL. Introduced a new ultrasound technique to evaluate patellar tracking in a convenient, accurate method.

  52. Oye CR, Holen KJ, Foss OA. Mapping of the femoral trochlea in a newborn population: an ultrasonographic study. Acta Radiol. 2015;56(2):234–43.

    Article  PubMed  Google Scholar 

  53. Kohlhof H, Heidt C, Bähler A, Kohl S, Gravius S, Friedrich MJ, Ziebarth K, Stranzinger E. Can 3D ultrasound identify trochlea dysplasia in newborns? Evaluation and applicability of a technique. Eur J Radiol. 2015;84(6):1159–64.

    Article  PubMed  Google Scholar 

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Authors and Affiliations

  1. Department of Orthopaedic Surgery, Stanford University School of Medicine, Stanford, CA, USA

    Donald Kasitinon, Wei-Xian Li, Eric Xue Song Wang & Michael Fredericson

  2. Department of Physical Medicine and Rehabilitation, University of Texas Southwestern Medical Center, Dallas, TX, USA

    Donald Kasitinon

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Correspondence to Donald Kasitinon.

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Donald Kasitinon, Wei-Xian Li, Eric Xue Song Wang, and Michael Fredericson declare that they have no conflicts of interest.

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This article is part of the Topical Collection on Non-Operative Management of Anterior Knee Pain

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Kasitinon, D., Li, WX., Wang, E.X.S. et al. Physical Examination and Patellofemoral Pain Syndrome: an Updated Review. Curr Rev Musculoskelet Med 14, 406–412 (2021). https://doi.org/10.1007/s12178-021-09730-7

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