![]() ![]() The patient’s gait should be assessed with respect to patella tracking, position (such as excessive patella lateralization), and femoral rotation that can identify increased femoral anteversion. ![]() The described Q-angle is difficult to measure clinically, so a surrogate is used from the anterior superior iliac spine to the center of the patella and from the center of the patella to the tibial tubercle. The Q-angle, or quadriceps angle, is the angle formed between the patellar tendon and the resultant line of force of the quadriceps muscle. ![]() In this position a rough measurement of the Q-angle can also be made. Lower extremity alignment is assessed with the patient standing to determine coronal alignment. A complete medical and prior surgical history is essential in addition to a complete musculoskeletal history. Full evaluation of the problem includes assessment of duration of pain, associated symptoms such as swelling and erythema, and disability caused by the pain. One should inquire as to when and with what motions of the knee the pain occurs a positive “theater sign” or pain beginning after prolonged knee flexion and pain with stairs may indicate patellofemoral pathology. A history of instability is particularly important. Prior history of any specific trauma is essential, even if remote. A pain diagram can be useful to localize the symptoms and focus the physical examination. Sometimes the patient will be able to point to a specific location of the pain, but often times the pain cannot be isolated as easily. Important details to elucidate are association with injury or activity at onset, location, quality, aggravating activities such as stairs, prolonged sitting, wearing high heels, or playing sports, and alleviating factors. The patient’s description of pain is a critical component in identification of the etiology. A full clinical evaluation including history and physical examination supplemented by imaging studies is essential to define the specific pathology in each patient. While Hughston focused attention on extensor mechanism malalignment as the predominant source of anterior knee pain, other common causes of anterior knee pain include quadriceps and patellar tendonitis, Osgood-Schlatter disease, multipartite patella, synovial and fat pad impingement, plica syndrome, patellar instability, loose bodies, and articular cartilage defects or degeneration known as chondromalacia patella. Foss evaluated adolescent females during pre-participation basketball screening and found that anterior knee pain was present in 26.6 % of athletes, with patellofemoral dysfunction the most common diagnosis with an overall prevalence of 7.3 %. The prevalence of anterior knee pain is higher in females and ranges between 13 % and 27 %. Recently, improved magnetic resonance imaging (MRI) of cartilage has significantly increased the ability to detect early changes in articular cartilage that may explain pain in some patients. Often the radiologic studies are fairly inconclusive. It is a term commonly used for knee pain that cannot be attributed to a specific anatomic pathology. Several terms, including “anterior knee pain” and “patellofemoral pain syndrome,” are used to describe the group of related pathologic entities resulting in pain in the anterior aspect of the knee. The diagnosis and treatment of patellofemoral pain is a challenging but common clinical problem. ![]()
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