A Biomechanical Basis for Rehabilitation Programs Involving the Patellofemoral Joint

Problems at the patellofemoral joint have long been recognized as a cause of dysfunction at the knee. This is true both when the patellofemoral joint is the primary site of involvement and when injury to other structures or aggressive activity/ rehabilitation causes the patellofemoral joint to become involved. The purpose of this article is to review the biomechanics of the patellofemoral joint to facilitate the design of safe, effective, rehabilitation programs. The review of normal patellofemoral biomechanics is followed by general rehabilitation guidelines based on those normal biomechanics. These guidelines can be used to design individualized rehabilitation programs for patients with patellofemoral joint dysfunction, in place of putting all patellofemoral patients on a straight leg program regardless of pathology. Two case studies are presented that incorporate the rehabilitation guidelines that were developed based on normal biomechanics of the patellofemoral joint. One case study reviews the rehabilitation of a patient whose recurrent patellar subluxation is treated with a proximal realignment of the extensor mechanism. The other case study involves a patient with an open reduction internal fixation of a fractured patella.

The patellofemoral joint is recognized as a major source of pain and dysfunction at the knee. Before one can treat a symptomatic knee, one must understand the normal structure and function of the patellofemoral joint. The major function of the patella is to increase the mechanical advantage of the quadriceps femoris by lengthening its lever arm (5, 10, 12). Also, by increasing the contact area on the femur, the patella helps distribute the compressive forces the femur must endure (12, 17). It has a minor function of offering protection to the anterior surface of the knee (21, 25). The patellar surface that articulates with the femur is formed by the medial, lateral, and odd facets (5). These facets are covered with thick articular cartilage. The function of articular cartilage on the underside of the patella is to spread the weight of contact over a large surface area and to prevent stress

' Department of Physical Therapy. School of Health Related Professions. University of Mississippi Medical Center. Jackson. MS 39216. 'The Physical and Athletic Rehabilitation Clinic, San Jose, CA 95125.
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TnE JOURNAL ORT~OPAEOIC SPORTS OF AND PHYSICAL THERAPY Copyright 0 1990 by The Orthopedic and Sports Physical Therapy Sections of the Amefican Physical Therapy Association

concentrations which can occur in bone-to-bone contact (3). The cartilage on different parts of the patella can react differently to stresses. These stresses include both increased and abnormal compressive forces and lack of motion at the patellofemoraljoint. Motion is necessary for articular cartilage to stay healthy (35). Specific articular cartilage lesions will be discussed later. The patella is stabilized in the patellofemoral joint by both static and dynamic supports. Statically, one of the main supports is the shape of the joint (16, 18, 30). The angle of the sulcus should be between 130' and 145O with the lateral ridge higher (2, 28). The center of the patella then fits into this sulcus. The various shapes of the patella and patellar groove will not be discussed. Those wishing specific classifications are referred to Wiberg (36) and Baumgartl (4). Other static stabilizers include the medial and lateral patellar retinacula (9,30). The medial retinaculum originates from the medial borders of the vastus medialis obliquus (VMO), quadriceps tendon, and patellar border. The lateral retinaculum runs between the distal portion of the iliotibial band and the lateral edge of the patella and extensor mechanism (10). The medial and lateral patellofemoral ligaments are also static stabilizers (Fig. 1). They are thickenings of the capsule that run from the middle

JOSPT 11:11 May 1990


18). Problems with the VMO can come from its attachment at the femoral condyle. until the extremes of flexion when the periphery of the patella comes into contact with the femur (Fig. Patellol~bial lig. and therefore significantly affect patellar tracking (21. Also. vastus intermedius. BIOMECHANICS Understanding the biomechanics of the patellofemoral joint is very important in order to know how rehabilitation exercises will affect the joint. The points on the femur contacted by the patella. 30). 2) (8. the patella centralizes in the sulcus (8. vastus medialis. Static and dynamic supports of the patellofemoral joint. The contact points on the femur also change as the angle of the knee changes. its dorsal surface contact point with femur actually moves proximally. The VMO is the part of the quadriceps most often involved in patellofemoral problems. 26. the patella 536 W u s rnediulis Patellofernoral lig. past 90' of flexion. and the compressive forces generated during activity all change with the angle of the knee joint.of the patellar borders to the medial and lateral femoral condyles (5. the main supports of the patella are the four parts of the quadriceps femoris muscle group-the vastus lateralis. From approximately 10-0°. and rectus femoris (5). The main function of the quadriceps. but rather deceleration (16).24. 30). especially when viewed in the context of patellofemoral joint involvement. the patellar tendon runs inferolaterally from the distal pole of the patella to the tibial tubercle (8. Past 90°. 30). They attach to the patella by the quadriceps tendon. Retinaculum Figure 1. 18. the lateral facet of the patella comes into contact with the lateral ridge of the femoral sulcus (17). The other dynamic structures that affect patellar stability are the pes anserine group and the biceps femoris. Figure 2. is not extension. The points on the patella that actually articulate with the femur change from distal to proximal as the knee goes from extension to flexion. 3). Patellar contact joints during range of motion. At approximately 20" of flexion. Its importance cannot be overstated because it offers the main dynamic restraint to the lateral forces that act upon the patella (10. Schematic illustration showing as patella slides distally. 21). JOSPT 11 11 May 1990 : WOODALL AND WELSH . These two structures control internal and external tibial rotation. The VMO attaches to the midportion of the medial border of the patella at an angle described by different authors as 65' (16) or from 50-55' (25. 23). Figure 3. 18. the quadriceps tendon begins to bear contact and the patellar contact area decreases as the amount of flexion increases. 13. Tears at this point can limit the effectiveness of the VMO's medial pull on the patella (22). 26). respectively. At approximately 30-4S0. the parts of the patella that make the contact with the femur. As the knee flexes the articulating points on the patella go from distal to proximal while the patella itself slides distally (12) (Fig. the patellar tendon contacts the femur and the patella contacts the supratrochlear fat pad (8.29). Also. 18. Dynamically.

e. Often these lesions do not progress to reach subchondral bone unless a lateral patellar facet lesion is involved as well (14). Pain from the patellofemoral joint is thought to be due either to synovial irritaJOSPT 11:11 May 1990 tion or to pressure on neural structures in the underlying subchondral bone (8. the Q angle increases. the forces are greatest at approximately 35 to 40° (1 1. and a line that runs from the tibial tubercle up through the middle of the patella (16. are often due to disuse (6. is applied more easily if one understands various lesions of the patella's articular cartilage. At the present time it is considered a less reliable physical finding than was previously believed. 12. 21). Peripheral lesions of articular cartilage are frequent. such as contact points at various angles. 15). and at approximately 135O comes into contact with the femoral condyles as well (12. Therefore. The actual compressive forces on the patellofemoral joint decrease from 30-O0 (34). During different exercises the compressive forces at the patellofemoral joint can vary. The quadriceps has to exert the most force in the last 15' of extension (12. if a patient is performing extension exercises at 45O. For example. the terminal ranges of extension) is not always the best approach. However. During stair climbing. which is most often affected with changes of the articular cartilage. 13. 34). The Q angle is the angle between a line that goes from the middle of the patella to the anterior superior iliac spine of the pelvis. The Q angle still should be observed during the static physical examination. when the person performs knee extension with resistance at a right angle to the ankle. the force can be three times one's body weight (9. Therefore these areas do not bear contact very often. the compressive forces are greatest at 90' and then decrease as the leg extends. A normal Q angle with the knee in full extension can be significantly different than the Q angle with the knee flexed to 45'. but its diagnostic limitations should be kept in mind until a more accurate method of measurement during activity can be devised. at full flexion the patella moves into the intercondylar groove. they are usually asymptomatic due to the fact that most people do not go into the extremes of flexion. It is not always along the line of the rectus femoris. as the tibia externally rotates. with knee flexion at 90°. as on various isotonic and isokinetic knee extension machines. If they do progress. biomechanical problems of the foot can cause abnormal amounts of tibial rotation and this can affect the tracking of the patella. 17. 4). The angle of pull of the quadriceps mechanism is determined by the total pull of all four muscles (18). 12). A final consideration is one must realize that the structure of the entire lower extremity can affect the patellofemoral joint. For example. a weak VMO will functionally increase the Q angle by allowing the direction of the pull of the quadriceps to be directed more laterally. but the presence of a normal static Q angle should not be interpreted as the absence of malalignment. Previous investigators have used the term "miserable malalignment" to describe patients with complete lower extremity malalignment of increased internal hip 537 REHABILITATING THE PATELLOFEMORAL JOINT . So exercising all patellofemoral patients in the same manner (i. Past 135' the odd facet of the patella contacts the medial femoral condyle (13.19). 32. However. The quadriceps force has to increase as the knee extends due to the muscle losing its mechanical advantage (1 1. The articular cartilage has no blood or nerve supply. where knee flexion is minimal. These lesions. 15). but usually do not progress to subchondral bone (13). 13. so it is able to tolerate extreme stresses and forces (8. the largest reaction force on the patellofemoral joint is approximately one-half the body weight of the subject. this area of the patella can be irritated. during ambulation. If there is definitely articular cartilage involvement. The biomechanical information discussed earlier. 27. Also. For example. and it usually does so with the development of no significant symptoms (1. Therefore. An abnormally large Q angle is reason for concern. Another important factor is that the midfacet region of the patella. For example. what might appear to be a normal Q angle during a static physical examination can become pathological during activities. especially at the odd facet. 18. Therefore. is the area that comes in contact with the femur at 45O. One reason is that the size of the angle can differ dramatically when measured during activity and when measured at rest. 26).contacts only the medial femoral facet. 33). 31). One final area of patellofemoral joint biomechanics that needs to be addressed is the Q angle. 34). weakness of the VMO can functionally increase the Q angle. having the patient perform knee extension-flexion exercises is usually counterproductive due to the fact that the cartilage lesion is being unnecessarily stressed and irritated. The amount of compressive force on the patella varies during dynamic activities. in a previous study it was found that a patella with significant arthrosis often centralizes at approximately 20° and both facets constantly stay in contact with the femur during the entire range of flexion (23). 30) (Fig.. However. The medial central area of the articular cartilage begins to soften in most people at a fairly young age. if a person performs knee extension while wearing a weight boot. lesions of the lateral central area are progressive and often eventually expose subchondral bone (7. 33). Exercises should be performed at angles that do not necessitate patellar contact of the involved sites.

patella compression syndromes or arthrosis of the joint). The treatment protocol is based upon a sound knowledge of the existing pathology. These are the patients whose complaints primarily are feelings of weakness or instability due to axial malalignment. With a proper understanding of the biomechanics of the patellofemoral joint.general and at the patellofemoral joint in particular. or soft tissue imbalance. These problems are occasionally overlooked. These patients may be helped by general strengthening of the muscles of the lower extremity. The most common would be increased femoral internal rotation that causes compensatory external tibial torsion (8. Crepitus without pain is not usually of significant importance in the management of patellofemoral dysfunction. It should be emphasized that limitations based on the pathology. Proximally.e. joint biomechanics. biomechanical deficits. Q angle determination. and the operative procedure. There are many patients who improve quickly on a conservative program. rotation. and compensatory pronation (20.. For the JOSPT 11:11 May 1990 Figure 4. if one was done. The rehabilitation process is individualized daily to assess the specific needs of the patient. Many patients with patellofemoral joint involvement have significant feelings of knee instability and painful crepitus on active knee motion. Excessive compensatory pronation can lead to significant overuse injuries at the knee in 538 WOODALL AND WELSH . one can appropriately and safely devise an individualized rehabilitation program for a patient. REHABILITATION OF THE PATELLOFEMORAL JOINT Patellofemoral problems are often referred to physical therapy. 18). The patients should be informed that a controlled. For those patients considering surgery. well supervised physical therapy rehabilitation program may benefit them. 21). Some patients will not be able to graduate through all the usual rehabilitation phases of the protocol. bilateral squinting patellae. patella alta. especially postoperatively. When rehabilitating any knee pathology. and the patient's own goals and effort have an influence on the ultimate result. Those patients experiencing knee dysfunction may be seen for either conservative nonoperative care or after a surgical procedure for correction of specific joint pathology (i. The optimum goal is 10O0/0 return of function. VMO dysplasia. tibial varum. the initial efforts are directed toward the patellofemoral joint. increased external tibial rotation. a conservative program often is suggested initially. The actual pathology of this crepitus is not fully understood. Comparisons with the opposite extremity or preoperative assessment of the extremity are helpful in directing the program. genu recurvatum. angulation abnormalities at the hip can affect patellar tracking as well. Those who improve on a conservative progressive resistive exercise program usually do not have significant intraarticular patellofemoral problems.

time must be allowed for the joint to convalesce before starting an aggressive program. Early.. These are the ones with a significant patellofemoral arthrosis. the VMO is adding dynamic medial support. etc.). The intermediate phase of the rehabilitation program begins when the joint is comfortable and the motion is approaching normal. Eccentric/concentric contractions e . In addition to the VMO-SLR-SA program. and nondestructive to the joint and muscles. The initial phase of the rehabilitation program is to increase joint motion. especially if pain or specific pathology is present. knee flexion/extension with weights) are also encouraged in the short arc of motion. Swelling can cause a reflex dystrophy with a decrease of quadriceps strength and limb function if allowed to continue. they are done in the upper ranges of motion and in a painfree.e. Full arc exercise may cause pain if malalignment persists. active. All exercises are performed with low resistance.e. If we use isokinetics at this point. Leg press activities. 539 JOSPT 1 lrl 1 May 1990 REHABILITATING THE PATELLOFEMORAL JOINT . 5). nonirritating.. i. We keep our patients off isokineticequipment that is set in the knee extension/flexion mode while the patient is in the earlier phases of rehabilitation. with some of the dynamometers today there is a sudden arrival at training speed. stretching and strengthening of the hamstrings. There is no place for heavy progressive resistive exercise (PREs) until patellar motion and joint stability have been restored.rest of the rehabilitation program to be effective the patellofemoral joint must be stabilized and functioning in the biomechanically correct fashion that was described earlier (i. use of isokinetics in the later phases of the reha- Figure 5. Isometric exercises may be started as tolerated in a painfree arc of motion. Figure 6. This is usually in the 60-45' range of motion. This can be done in conjunction with electrical stimulation for muscle reeducation (Fig. voluntary control and to decrease patellofemoral joint irritation. especially at slow speeds. full arc isolated concentric/eccentric contractions of the quadriceps (Figs. Time must also be allowed for the joint to dry out before moving to the intermediate and advanced stages of the rehabilitation program. Quadriceps re-education program using electrical stimulation. We feel pure extension/flexion is too stressful to the patellofemoral joint. Also. we set the machine in the leg press fashion. The angles of the patellofemoral joint are carefully selected. At 45O of knee flexion. Care must be taken with patellofemoral problems if arthrosis is present. and the major component of the program. hip musculature. pain is predictable and poor patient results are expected. These aid in regaining eccentric control and often times we have found them to be less irritating than activities in which the foot is not fixed. There can be a pinching of the synovium and irritation of the patella arthrosis in this zone. This is true only if the program is nonaggressive. For those patients with minimal or no patellofemoral pathology. If pathology is present. the main arthritic zones of the patella are present so this area is avoided. to get the VMO under good. noncrepitus position. leg press exercises or short squats can be instituted as is appropriate for the particular patient. There are some patients who should never be placed on it except possibly for testing purposes. If eccentric squats are done. Also. The patient has good control of his VMO and can complete the SLR-SA program. The initial exercise. If it is a postoperative condition. is the straight leg raise (SLR)-short arc (SA) program from 20° to full extension. The rehabilitation program requires supervision as well as a concentrated effort by the patient. and iliotibial band are suggested. It is suggested that isometrics be started at approximately 20° of knee flexion because the patella actively begins to centralize in the femoral sulcus at this position. This p e sition can be best determined by feeling the patient's knee during squatting and determining the proper range of motion. nonaggressive physical therapy is suggested using pain and swelling as a guide. 6 and 7). the patella is tracking correctly over the femur. at this time.

easy straight ahead jogging is encouraged. vastus medialis advancement. In addition. with 10-1 5% of the body weight as the goal. Close supervision and motivation of the patient are very important factors at this time in the rehabilitation program. At 85% of normal. He began having problems iri July when his right patella subluxed. His passive range of motion was 0-1 15'. On August 26. shotputting. He was full weightbearing with a slight limp. A patellar debridement. but no changes of the articular cartilage on his femur or tibia. This is the time when many patients will stop their rehabilitation program. he underwent surgery. He had only minimal complaints of pain and joint effusion present. Continued emphasis on the SLR and short arc exercises are recommendedwith up to 8-1 0 sets. three times a day. jogging. However. When the patient is 95%+. and activities such as racquetball are emphasized. In the terminal phases of the rehabilitation program and as the patient becomes more comfortable. stop and start drills. This can include increasing the intensity of the stationary biking program. Newer methods of exercise equipment and/ or adaptations to isokinetic machines are now available. Increases in activities can be based on the isokinetic scores. The isokinetic strength report. full return to sports activities is encouraged. On July 25. The patient was placed on a program to increase his VMO tone. CASE HISTORY 1 Diagnosis: Recurrent subluxation of the patella Surgery: Proximal realignment of the extensor mechanism The patient was a very active 19-year-old male who participated in weight lifting. the intensity of the program is increased. Our exercise mode of choice at this time is still to get the involved extremity. if available. may be helpful in gauging when the individual can exercise and participate in recreational and/or sports activities. 2 years later. lateral retinacular release. If it is used. the patient began to suffer from recurrent subluxations of his right patella. The patient began physical therapy on August 26. and medial capsular reefing were performed during surgery. more aggressive exercises are encouraged.the rehabilitation program and slowly increased in intensity. He had poor control of his VMO and a slight extensor lag was present. muscle strength. After 1 month of uneventful physical therapy. The endurance component is emphasized rather than the strengthlbulk components of the leg. and range of motion. if use of the machine is not contraindicated due to the patient's diagnosis. straight leg raises. Good isokinetic scores do not necessarily need to be achieved for the patient to have acceptable functional results. It is important to emphasize that the patient's functional goals and abilities are more important in assessing recovery than an isokinetic strength report. He was found to have significant lateralization of his patella. into functional. a moderate amount of chondromalacia over the midfacet region. terminal knee extension exerJOSPT 1 1 : 1 1 May 1 9 9 0 Figure 7. some cutting drills are introduced. Short squats to stress eccentric loading. The knee is not exercised or tested if it causes pain. If the patient has a painfree joint and isokinetic scores 50-60% of normal. closed kinetic chain exercises and activities as quickly as possible. bilitation may be indicated. lsokinetic equipment use and testing are considered. which usually is begun early in 540 WOODALL AND WELSH . Patients must be aware that they should now stay on a maintenance program as long as they remain active. he was able to return to sports with normal strength and no significant complaints of dysfunction. sharp cutting. and progressing to running activities as tolerated are encouraged. as well as more functional and aggressive exercises. At 75% of normal. after a short period of time. If there are no patellofemoral symptoms or pathology present. This was done with quad sets. initial testing or exercising is not done below 20 RPM. and therefore the patient. he had an arthroscopic loose body removal. and football. the mini tramp.

a third surgery was performed to remove the wires around the patella. an isokinetic test indicated 70%+ strength at all speeds and improving. No weights were used during this initial phase of treatment. He had medial patella pain and attempts to start a straight leg raise program produced increasing pain. On November 1. The patient was instructed to inform us of any patellofemoral pain. this resolved itself. his physician allowed him to start isometrics as tolerated. and electrical stimulation of the VMO. rubber tubing exercises with the knee fully extended. he had 50" of motion and poor control of the VMO. he was continued on the short arc program. The early phases of therapy were designed to decrease his swelling and increase the joint motion. The patient's orthopaedic surgeon fitted the patient with a patella stabilizing brace and allowed him to begin slow jogging in a straight line. The only time he worked full arc was for physician requested isokinetic tests. Early tests were taken which showed a 50% deficit at the 30 and 40 RPM level. On November 5. Approximately 6 weeks after surgery. He also began short squats to incorporate an eccentric component into his program. Until then. He had an extensor lag and poor control of his VMO. At this time. as tolerated. the patient's strength was tested isokinetically and he was found to have normal hamstring strength at both 10 and 30 RPM. He had no significant complaints of pain with this increase in his program. No physical therapy was prescribed after this second operation. Approximately 2 months after surgery. He had gradual increases in motion to approximately 90°. leg press exercises were included. He was started on physical therapy 1 week later. done both eccentrically and concentrically. His motion had stabilized at approximately 135" of 541 REHABILITATING THE PATELLOFEMORAL JOINT .cises. working in the 20-O0 range and a leg press program was started. At that time. he had some nonpainful crepitus. The physician wanted to wait an additional month to see how the patient's movement progressed. but over a 10 day period. Therapy was to continue until his strength was 90% of the uninvolved leg. and was provided with an electrical stimulator for the VMO. He has had no subsequent problems with his knee to this date. the patient's right quadriceps scores were 81% of the left at 10 RPM and 91% of the left at 30 RPM. electrical stimulation. Submaximal. the knee was very swollen with only 45' of motion. his motion had stabilized at 50°. Because the patient had some minimal complaints of pain when he performed a full arc isokinetic test. Treatment included ice. This was done with no complaints of increased pain or swelling at the joint. and he was in a brace set at 0-30°. He was unable to do a SLR and had no control of his VMO. he had only 0-20° of motion. 20 RPM efforts were started. He was seen a total of 3 weeks and then released from physical therapy. the patient's orthopaedic surgeon allowed him to begin a slow return to weight lifting and shot putting. nonaggressive stretching with 2-4 Ibs on a flexed knee was started with an initial early gain of flexion to approximately 1OOO. Lysis of the scar tissue and manipulation of the knee to 125' was performed. CASE HISTORY 2 Diagnosis: Fractured patella Surgery: Open reduction internal fixation This 33-year-old male fell on his right knee playing football and fractured his right patella on November 3. At that time. Initially. His right quadriceps at 10 RPM were 56% of his left and at 30 RPM were 82% of his left. On August 7. At that time. isometric extension exercises at 10 and 20" were added to the program. On October 21. Slow. An ORlF was performed on November 5. The patient began this in a short arc mode from approximately 40-0'. 3 months after surgery and 2 months after PT began. Through periodic isokinetic evaluations. light weights were added to the short arc program. He also performed passive and active assistive range of motion exercises and icing of the joint. This patient was able to return to his sporting activities 3l/2 months following the patella realignment procedure. He was instructed to mobilize the patella. but it was evident early that he was scarring down and that a manipulation might be considered. He progressed well through a physical therapy program that stressed increasingly quadriceps strength through the use of extension exercises in the range of 40-0°. The functional program was increased as well as his strengthening efforts. He was operated on again with fixation of the patella. he was bearing JOSPT 11:11 May 1 9 9 0 weight at 50% with crutches. and short arc exercises in the terminal ranges of extension. On September 9. utilize soft tissue massage. stationary bike. highspeed. as tested isokinetically. As his strength increased. The patient continued to improve with no complaints of significant pain. There were further increases in joint motion. The bike program for motion and SLR program with light weights were continued. and the initial physical therapy workup was on November 26. the patient's strength was shown to improve steadily. the patient fell and refractured the patella. Next. On January 5. the patient's orthopaedic surgeon prescribed a slow return to isokinetic extension and flexion exercises.

Wiberg G: Roentgenographic and anatomic studies on the feme ropatellar joint. Phys Ther 60:1556-1560. Portland. Acta Orthop Scand 12:319-409. Ficat RP. Early nonaggressive postoperative therapy was the key to rehabilitation. Berlin: Springer-Verlag. Akeson WH: Articular cart~lage-normal structure and function. Radin EL (eds). Clin Orthop 144:9-15. Radin EL (eds). Townsend PR. Nordin M: Biomechanics of the knee.1980 to 6. Portland. 0 REFERENCES 1. Funk FJ (eds). 1983 16. Ital J Orthop Traumatol5:187-190. Conference presented by the American Academy of Orthopaedic Surgeons. Baumgartl F: Das Knieglenk. In: The Patellofemoral Joint. Ceralli G: Chondromalacia and recurrent subluxation of the patella: a study of malalignment with some indications for radiography. Chondromalacia of the Patella. Jacobsen RH. In: Hunter LY. August 1985 4. Radin EL: Is chondromalcia patellae a separate clinical entity? J Bone Joint Surg (Br) 60:205-210. pp 1-10. We are well aware that this patient has experienced short-term success. Louis: CV Mosby. Rehabilitation of the lnjured Knee. 1980 31. Zindel M: Patello-femoral joint m e chanics and pathology: 1. August 1985 20. Much of the success of this program was due to a highly motivated and cooperative patient.1941 WOODALL AND WELSH JOSPT 1 1: 1 1 May 1990 . 1983 28. Aglietti P. J Bone Joint Surg (Am)50:15351548. In: Pickett JC. The intensity of the program was related to the motion available and pain/crepitus status of the patellofemoral joint. HungerfordDS. J Bone Joint Surg (Br) 58:291-299. HungerfordDS: Patellar subluxationand excessive lateral pressure as a cause of fibrillation. 1976 21. In: Pickett JC. OR. Funk FJ (4s). Phys Ther 60:1624-1632. J Bone Joint Surg (Am) 56:1391-1398. Radin EL: Chondromalacia: Treatment based on a more precise diagnosis. Merchant AC. St.1962 25. Portland. In: Picken JC. Baltimore: Williams 8 Wilkins. Fowler PJ: Functional anatomy of the knee. Baltimore: Williams 8 Wilkins. pp 68-82. Baltimore: Williams 8 Wilkins. Hungerford DS: Disorders of the Patellofemoral Joint. Significant individualwork was requiredto achieve this level of return. 1983 32. Cool CR: Roentgene graphic analysis of patellofemoral congruence. Baltimore: Williams & Wilkins. Baltimore: Williams 8 Wilkins. In: Kennedy JC (ed). 1979 18. functional activities (i. Radin EL (eds).1973 8. Acta Orthop Scand 43: 126-1 37. Johnson L: Arthroscopic examination of the patellofernoral joint. 1944 5. pp 24-42. 1979 3. August 1985 h 24. Woods C: Patelletemoral joint mechanics and pathology: 2. Chondromalacia of the Patella. Noyes F: Patellar protection after major knee ligament repair and reconstruction. pp 25-55. This information presented can help the therapist plan a safer and more effective treatment for patients with primary involvement of their patellofemoral joint and help prevent negatively involving the patellofemoral joint when rehabilitating other lower extremity pathologies. OR. Radin EL (eds). Functional anatomy of the patelle femoral joint. In: The Patellofemoral Joint. In: Hunter LY. As early as possible. Radin EL (eds). OR. All too often patients with patellofemoral joint involvement are treated the same regardless of their underlying pathology.1968 27. Bany M: Biomechanicsof the patellofemoraljoint. Hughston JC. Hungerford DS: Patellar mechanics. Chondromalada of the Patella. 1980 12. Frankel VH. Mercer RL. Perry J: Quadriceps function: an anatomical and mechanical study using amputated limbs. In: The Patellofemoral Joint. Lieb FJ. Martens M: Experimental analysis of the quadriceps muscle force and patello-femoral joint reaction force for various activities.e. A good understanding of normal structures and biomechanics of the patellofemoral joint are needed to design appropriate rehabilitation programs for the individual patient.flexion. pp 95-1 12. Baltimore: Williams 8 Wilkins. either when the patellofemoral joint is the primary site of pathology or when it is stressed by the rehabilitation of other pathologies. Goodfellow J. Falvo KA. James SL: Chondromalacia of the patella in the addescent. Louis: CV Mosby. Kaplan EG: Some aspects of functional anatomy of t e human knee joint. Conference presented by the American Academy of Orthopaedic Surgeons. J Bone Joint Surg (Br) 58:287-290. Nordin M: Basic Biomechanicsof the Skeletal System.. SUMMARY The patellofemoral joint is effected by all lower extremity rehabilitation. pp 161-204. OR. In: The PatellofemoralJoint. Radin EL (moderator): Panel discussion: Does chondromalacia patella exist? In: Pickett JC. Louis: CV Mosby. St. pp 205-251. Blackbum TA. Romash MM. 1974 29. pp 1-10. 1983 19. Baltimore: Williams 8 Wilkins. 1972 35. All ADL activities were comfortable and he was continuing to accelerate his program. Baltimore: Williams 8 Wilkins. Hungerford DS. Chondromalacia of the Patella. Philadelphla: Lea and Febiger. Conference presented by the American Academy of Orthopaedic Surgeons. In: The Patellofemoral Joint. Conference presented by the American Academy of Orthw paedic Surgeons. Craig E: Knee anatomy: a brief review. 1983 7. 1979 26. Goodfellow J: Cartilage lesions and chondromalacia. with special reference to chondromalacia patellae. Reilly DT. 1977 9. Meachim G: Cartilage lesions on the patella. Frankel VH. 1976 14. J Anat 116:103-120. OR. Chondromalacia patellae.1978 2. Philadelphla: WB Saunders Company. Rase RM. Casscells W: Chondromalaciapatella and its relationsh~p anterior femoral pain. He has been made aware of the potential problems for his patella and hopefully he will act accordingly. Chondromalacia of the Patella. August 1985 30. pp 134-143. In: The Patellofemoral Joint. Goodfellow J. Baltimore: Williams 8 Wilkins. Portland. Puddu G: Patellar Subluxation and Dislocation. Radin EL (eds). 1984 17. Motion and painfree exercise related to the patella protection program were advocated for the rehabilitation of this condition. 1984 36. In: Hunter LY. Meachim G: Surface morphology and topography of patello-femoral cartilage fibrillation in Liverpool necropsies. pp 11-24. short eccentric nonpainful squats) were encouraged which added strengthening tolerance. Larson RL: Subluxation-dislocation of the patella. Paulas L. 1983 33. Rehabilitation of lhe Injured Knee. 1983 10. Conference presented by the American Academy of Orthopaedic Surgeons. OR. pp 235-255. Emery IH. Walsh WM. 1979 22. Chondromalacia of the Patella. Noyes F: Patellar malalignment: a treatment rationale. Rusche K. Ficat RP: Lateral fascia release and lateral hyperpressure syndrome. Portland. 1984 13. Johnson C. In: Pickett JC. Funk FJ (eds). Portland. August 1985 23. The lnjured Adolescent Knee. Bassett FH: Protected motion and dynamic splintmg. Baltimore: WIIliarns 8 Wilkins. August 1985 34. 1984 11.In: Pickett JC. Radin EL (eds). In: Pickett JC. Abemethy PJ. Conference presented by the American Academy of Orthopaedic Surgeons. 1976 15. lnsall J. James SL: Extensor mechanism-Anatomy. In: Kennedy JC (ed). Clin Orthop 23:18-29. pp 43-48. St. The Injured Adolescent Knee. Hungerford DS. Chondromalacia of the Patella. Radin EL: Patellar bone stress patterns. We are not able to predict his future course of events. Wise DW: Chondromalaciapatellae: a prospective study. J Bone Joint Surg (Am) 58:l-8. Rehablitation of the Injured Knee.

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