DIFFERENTIAL DIAGNOSIS

Patella Alta
• A high riding patella
• The patella may not articulate with the sulcus until higher
degrees of knee flexion.
• Ratio > 1,2
• Differential diagnosis :
– Recurrent lateral dislocation or subluxation of patella
– Chondro-malacia of patella
– Sinding-Larsen-Johansson disease & Osgood-Schlatter
disease
– Patellar and quadriceps tendonitis

(Insal-Salvati , Miller)
 Recurrent Lateral Dislocation or
Subluxation of Patella
• a result of direct trauma to the
knee, or just as frequently by
indirect trauma
• A patient will present
complaining of anterior knee
pain and may report hearing a
pop or snap at the time of injury;
the patient may describe feeling
as if the knee itself dis-located.

Hong, Eugene. Evaluating Anterior Knee Pain.

Division of Sports Medicine, Drexel University
College of Medicine. USA. 2014
Chondro-malacia of patella
• A softening of the patellofemoral
cartilage.
• A degenerative joint disease
• Leslie and Bentley found retro
patellar crepitus, effusion, and
quadriceps wasting greater than
2 cm as the most important
findings for detection of
chondromalacia of the patella.

Hong, Eugene. Evaluating Anterior Knee

Pain. Division of Sports Medicine, Drexel
University College of Medicine. USA. 2014
 Sinding-Larsen-Johansson disease

• A traction apophysitis of the inferior pole of the

patella caused by repetitive stress on the patella at
the prox-imal insertion of the patellar tendon.
• On physical examination, there is focal tenderness at
the patella’s inferior pole; there also may be
localized soft tissue swelling.
• It is typically seen in boys 10 to 13 years of age;
however, active girls also may present with this.
• Patients will usually be involved in sports or exercise
that requires a fair amount of running or jumping
Hong, Eugene. Evaluating Anterior Knee Pain.
Division of Sports Medicine, Drexel University
College of Medicine. USA. 2014
 Osgood-Schlatter disease
• An apophysitis of the tibial tubercle caused
by undergoing repetitive stress from the
patellar tendon constantly pulling on it, thus
found only in the skeletally immature in
acute cases.
• In boys, this tends to be 10 to 15 years of
age and in girls, 8 to 13 years of age.
• Most adolescents are patients who are
active in sports with running and cutting
involved
Hong, Eugene. Evaluating Anterior Knee Pain.
Division of Sports Medicine, Drexel University
College of Medicine. USA. 2014
 Patellar and Quadriceps Tendonitis
• Quadriceps and patellar
tendinopathy (also known as
Jumper’s Knee)
• These conditions are most often
a result of overuse: repetitive
stresses on the tendon
overwhelm the tissue’s ability to
heal itself, resulting in symptoms
and dysfunction.
• Ask the patient if he or she can
put a finger on the location of
the anterior knee pain and may
be able to localize the source as
below or above the patella.
Hong, Eugene. Evaluating Anterior Knee Pain.
Division of Sports Medicine, Drexel University
College of Medicine. USA. 2014
 Insall-Salvati Ratio
• A low-riding patella
• Often the result of fat pad and tendon fibrosis,
and proximal transfer of the tubercle may be
required in refractory cases.
• Ratio < 0,8
• Differential diagnosis :
– Quadriceps tendon rupture
– Neuromuscular disorders
– Achondroplasia
QUADRICEPS TENDON RUPTURE
• A quadriceps tendon rupture is
a tear of the tendonof the major
leg extensors (quadriceps), usually
close to its insertion at the
superior pole of the patella.
• Often occurs when the foot is
planted and knee is slightly bend
(extensor mechanism).
• Quadriceps tendon ruptures are
fairly rare, as the occur six times
less often than patellar fractures.
• These ruptures mainly occur in
patients above 40 years of age
affected by a systemic disorder
(diabetes, gout, renal failure,
floroquinolones or corticosteroid
treatment)
• In younger patients the mechanism
is usually direct trauma.
 NEUROMUSCULAR DISORDERS
• Arthrogryposis multiplex congenita (amyoplasia)
Nonprogressive disorder with multiple joints that are
congenitally rigid. Can be myopathic, neuropathic, or both.
Evaluation should include neurologic studies, enzyme test,
and muscle biopsy (at 3 to 4 months of age)
Lower extremity involvement, especially knee is knee
contractures (extended is classical, flexed is more common).
Knee contractures are treated with early (age 6-9 months)
soft tissue releases (especially hamstrings)

Miller
• Larsen Syndrome
Similar to arthrogryposis in clinical
appearance, but joints are less rigid.
Characterized primarily by multiple joint
dislocations (including bilateral congenital
knee dislocations), flattened facies, scoliosis,
and clubfeet.
Knee reduction may necessitate femoral
shirtening and excision of collateral ligaments.

Miller
• Myelodysplasia (Spina Bifida)
On the knee problems usually include
quadriceps weakness (usually treated with
knee-ankle-foot orthoses)
• Myopathies (Muscular Dystrophies)
These noninflammatory inherited disordes are
characterized by progressive muscle weakness

Miller
 ACHONDROPLASIA
• Achondroplasia is categorized
as a physeal dysplasia
(cartilaginous proliferative
zone).
• Most common form of
disproportionate short-
limbed dwarfism.
• Autosomal dominant
condition; 80% of cases
caused by a spontaneous
mutation in the fibroblast
growth factor receptor 3
(FGFR3)
Miller • May be associated with
advaced paternal age