Patellar maltracking is prevalent among patellofemoral pain subjects with patella alta: An upright, weightbearing MRI study

The purpose of this study is to determine if patellar maltracking is more prevalent among patellofemoral (PF) pain subjects with patella alta compared to subjects with normal patella height. We imaged 37 PF pain and 15 pain free subjects in an open‐configuration magnetic resonance imaging scanner while they stood in a weightbearing posture. We measured patella height using the Caton–Deschamps, Blackburne–Peel, Insall–Salvati, Modified Insall–Salvati, and Patellotrochlear indices, and classified the subjects into patella alta and normal patella height groups. We measured patella tilt and bisect offset from oblique‐axial plane images, and classified the subjects into maltracking and normal tracking groups. Patellar maltracking was more prevalent among PF pain subjects with patella alta compared to PF pain subjects with normal patella height (two‐tailed Fisher's exact test, p < 0.050). Using the Caton–Deschamps index, 67% (8/12) of PF pain subjects with patella alta were maltrackers, whereas only 16% (4/25) of PF pain subjects with normal patella height were maltrackers. Patellofemoral pain subjects classified as maltrackers displayed a greater patella height compared to the pain free and PF pain subjects classified as normal trackers (two‐tailed unpaired t‐tests with Bonferroni correction, p < 0.017). This study adds to our understanding of PF pain in two ways—(1) we demonstrate that patellar maltracking is more prevalent in PF pain subjects with patella alta compared to subjects with normal patella height; and (2) we show greater patella height in PF pain subjects compared to pain free subjects using four indices commonly used in clinics. © 2012 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 31: 448–457, 2013

[1]  K. Bennell,et al.  Effects of vastus medialis oblique retraining versus general quadriceps strengthening on vasti onset. , 2010, Medicine and science in sports and exercise.

[2]  Nogah Shabshin,et al.  MRI criteria for patella alta and baja , 2004, Skeletal Radiology.

[3]  Scott L Delp,et al.  Weight‐bearing MRI of patellofemoral joint cartilage contact area , 2004, Journal of magnetic resonance imaging : JMRI.

[4]  P. Kannus.  Long patellar tendon: radiographic sign of patellofemoral pain syndrome--a prospective study. , 1992, Radiology.

[5]  D. Kohn,et al.  Comparison of five patellar height measurement methods in 90° knee flexion , 2011, International Orthopaedics.

[6]  H. Dejour,et al.  Factors of patellar instability: An anatomic radiographic study , 2005, Knee Surgery, Sports Traumatology, Arthroscopy.

[7]  Alexis Colvin,et al.  CURRENT CONCEYTS REVIEW Patellar Instability , 2008 .

[8]  D. Silver,et al.  The measurement of patellar height: a review of the methods of imaging. , 2010, The Journal of bone and joint surgery. British volume.

[9]  G. Cerulli,et al.  Patellar Pain and Incongruence , 1983 .

[10]  S. Dekel,et al.  Patellofemoral Pain Syndrome: Validity of Clinical and Radiological Features , 2006, Clinical orthopaedics and related research.

[11]  W C Hayes,et al.  Patellofemoral contact pressures. The influence of q-angle and tendofemoral contact. , 1984, The Journal of bone and joint surgery. American volume.

[12]  D. Felson,et al.  The effect of a patellar brace on three-dimensional patellar kinematics in patients with lateral patellofemoral osteoarthritis. , 2011, Osteoarthritis and cartilage.

[13]  P. G. Kramer.  Patella malalignment syndrome: rationale to reduce excessive lateral pressure. , 1986, The Journal of orthopaedic and sports physical therapy.

[14]  A. Jurik,et al.  Patellar height and patellofemoral congruence , 2004, Archives of orthopaedic and traumatic surgery.

[15]  L. Lin,et al.  A concordance correlation coefficient to evaluate reproducibility. , 1989, Biometrics.

[16]  S. Lachmann,et al.  Patello-femoral arthralgia in athletes attending a Sports Injury Clinic. , 1984, British journal of sports medicine.

[17]  L. Shepstone,et al.  The sulcus angle and malalignment of the extensor mechanism of the knee. , 2000, The Journal of bone and joint surgery. British volume.

[18]  J. Elias,et al.  Reducing the Lateral Force Acting on the Patella Does Not Consistently Decrease Patellofemoral Pressures , 2004, The American journal of sports medicine.

[19]  U. Kujala,et al.  Factors predisposing to patellar chondropathy and patellar apicitis in athletes , 2004, International Orthopaedics.

[20]  C. Powers,et al.  Association between patella alta and the prevalence and worsening of structural features of patellofemoral joint osteoarthritis: The multicenter osteoarthritis study , 2010, Arthritis care & research.

[21]  T J Koh,et al.  Neuromechanics of the patellofemoral joint. , 1994, Medicine and science in sports and exercise.

[22]  Andrea Baldini,et al.  Patellofemoral evaluation after total knee arthroplasty. Validation of a new weight-bearing axial radiographic view. , 2007, The Journal of bone and joint surgery. American volume.

[23]  R. Biedert,et al.  The patellotrochlear index: a new index for assessing patellar height , 2006, Knee Surgery, Sports Traumatology, Arthroscopy.

[24]  J. Karadimas,et al.  Patella Alta and chondromalacia , 1982, International Orthopaedics.

[25]  K. Jonsson,et al.  Radiography in osteoarthritis of the knee , 1999, Skeletal Radiology.

[26]  E. Strauss,et al.  Patellar instability. , 2014, Bulletin of the Hospital for Joint Disease.

[27]  Scott L. Delp,et al.  Patellar Maltracking Correlates With Vastus Medialis Activation Delay in Patellofemoral Pain Patients , 2011, The American journal of sports medicine.

[28]  T. Miller,et al.  Patellar height on sagittal MR imaging of the knee. , 1996, AJR. American journal of roentgenology.

[29]  Samuel R Ward,et al.  Patella alta: association with patellofemoral alignment and changes in contact area during weight-bearing. , 2007, The Journal of bone and joint surgery. American volume.

[30]  J. Caton.  [Method of measuring the height of the patella]. , 1989, Acta orthopaedica Belgica.

[31]  P. Chambat,et al.  [Patella infera. Apropos of 128 cases]. , 1982, Revue de chirurgie orthopedique et reparatrice de l'appareil moteur.

[32]  J. Caton.  Méthode de mesure de la hauteur de la rotule. , 1989 .

[33]  G. Ng,et al.  Biofeedback exercise improved the EMG activity ratio of the medial and lateral vasti muscles in subjects with patellofemoral pain syndrome. , 2008, Journal of electromyography and kinesiology : official journal of the International Society of Electrophysiological Kinesiology.

[34]  E. Culham,et al.  Radiographic Measures in Subjects Who Are Asymptomatic and Subjects With Patellofemoral Pain Syndrome , 2003, Clinical orthopaedics and related research.

[35]  R. Grelsamer,et al.  The modified Insall-Salvati ratio for assessment of patellar height. , 1992, Clinical orthopaedics and related research.

[36]  G. Cerulli,et al.  Patellar pain and incongruence. I: Measurements of incongruence. , 1983, Clinical orthopaedics and related research.

[37]  C. Nickerson.  A note on a concordance correlation coefficient to evaluate reproducibility , 1997 .

[38]  S. Koskinen,et al.  Scoring of patellofemoral disorders. , 1993, Arthroscopy : the journal of arthroscopic & related surgery : official publication of the Arthroscopy Association of North America and the International Arthroscopy Association.

[39]  M. Terk,et al.  Patella alta: lack of correlation between patellotrochlear cartilage congruence and commonly used patellar height ratios. , 2009, AJR. American journal of roentgenology.

[40]  J. S. Blackburne,et al.  A new method of measuring patellar height. , 1977, The Journal of bone and joint surgery. British volume.

[41]  Juan M. Santos,et al.  Differences in patellofemoral kinematics between weight‐bearing and non‐weight‐bearing conditions in patients with patellofemoral pain , 2011, Journal of orthopaedic research : official publication of the Orthopaedic Research Society.

[42]  Richard B. Chambers,et al.  Primer of Biostatistics, 5th ed , 2002 .

[43]  E. Salvati,et al.  Recurrent dislocation and the high-riding patella. , 1972, Clinical orthopaedics and related research.

[44]  S. Delp,et al.  Patellar tilt correlates with vastus lateralis: Vastus medialis activation ratio in maltracking patellofemoral pain patients , 2012, Journal of orthopaedic research : official publication of the Orthopaedic Research Society.

[45]  T. Helbich,et al.  3D Versus 2D Ultrasound: Accuracy of Volume Measurement in Human Cadaver Kidneys , 2002, Investigative radiology.

[46]  E. Salvati,et al.  Patella position in the normal knee joint. , 1971, Radiology.

[47]  E. Kinney.  Primer of Biostatistics , 1987 .

[48]  C. Powers,et al.  Patellofemoral joint stress during stair ascent and descent in persons with and without patellofemoral pain. , 2002, Gait & posture.

[49]  J. Fulkerson,et al.  Diagnosis and Treatment of Patients with Patellofemoral Pain , 2002, The American journal of sports medicine.

[50]  R. Mansour,et al.  The association of infrapatellar fat pad oedema with patellar maltracking: a case–control study , 2012, Skeletal Radiology.