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Patellofemoral Syndrome Workup

  • Author: Patrick J Potter, MD, FRCSC; Chief Editor: Consuelo T Lorenzo, MD  more...
 
Updated: May 23, 2016
 

Laboratory Studies

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  • Laboratory studies generally are not indicated for the diagnosis of patellofemoral syndrome.
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Imaging Studies

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  • Imaging studies usually are not necessary in order for a physician to diagnose or recommend treatment for patellofemoral syndrome (PFS). Imaging studies should be considered for unusual presentations and for persons in whom the syndrome is refractory to conservative management.
    • Skyline views should be included with anterior-posterior (AP) and lateral radiographic imaging of the knee. Limited positions of flexion are available for such viewing. These radiographs provide more of an indirect observation of what is happening within the articulation.
    • Lateral patellar tilt and a high-riding patella (patella alta) may be observed.
    • Osteophytes or joint space narrowing may be identified, suggesting arthritic changes in the articular cartilage.[5]
  • Nuclear scans are less likely to be of value in defining PFS and are more useful in helping to identify other, less common conditions that may mimic PFS, as outlined in the differential diagnoses. When changes have occurred in the retropatellar cartilage, mild increases in uptake of radionucleotide may be observed. Increased uptake of radionucleotide is not limited to the patella; it may be seen in the proximal tibia, distal femur, or patella.[6]
  • Computed tomography (CT) scanning and magnetic resonance imaging (MRI)
    • CT scanning and MRI allow for imaging at various angles of flexion.
    • CT scanning with the knee in full extension has been demonstrated to more accurately detect patellar subluxation.
    • Cross-sectional viewing allows more direct visualization of the articulation between the patella and femur.
    • Schutzer et al identified 3 patterns of malalignment using CT scanning[7] :
      • Type 1 includes patellar subluxation without tilt.
      • Type 2 is described as patellar subluxation with tilt.
      • Type 3 is patellar tilt without subluxation.
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Other Tests

Serology, joint aspiration, and related tests are indicated only when alternative diagnoses are suspected. Such investigations are not likely to provide useful information in this syndrome, as it is not a disease entity but rather a group of symptoms occurring sometimes in association with multiple factors (intrinsic and extrinsic).[8]

A study by Ferrari et al indicated that surface electromyography (sEMG) can be used in patients with referred anterior knee pain to diagnose PFS. In the study, which involved 22 persons with PFS and 29 persons without pain, the investigators found that by using the medium frequency ̶ band parameter, it was possible to differentiate between the two groups. They concluded that EMG signals from the vastus lateralis and vastus medialis muscles with referred anterior knee pain can be used in the diagnosis of PFS.[9]

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Procedures

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  • Arthroscopy
    • Arthroscopy helps to confirm the diagnosis patellofemoral syndrome (PFS) by allowing direct visualization of the cartilage surface. Arthroscopic evaluation also provides assessment of joint structures that may cause symptoms that mimic PFS when they are impaired.
    • Arthroscopy also has the ability to facilitate surgical alteration of patellar tracking (eg, lateral release). Visualization of the patella may allow for some revision of the cartilage surface. However, most authors agree that surgical treatment is rarely indicated.
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Histologic Findings

Histologic findings are dependent on the extent to which the cartilage surfaces have been compromised. Shearing stresses may result in changes in subchondral bone and dysplasia of the cartilage surface. More severe cartilage changes have been identified in persons with patellofemoral syndrome that has been refractory to conservative measures.

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Contributor Information and Disclosures
Author

Patrick J Potter, MD, FRCSC Associate Professor, Department of Physical Medicine and Rehabilitation, University of Western Ontario School of Medicine; Consulting Staff, Department of Physical Medicine and Rehabilitation, St Joseph's Health Care Centre

Patrick J Potter, MD, FRCSC is a member of the following medical societies: Academy of Spinal Cord Injury Professionals, College of Physicians and Surgeons of Ontario, Canadian Association of Physical Medicine and Rehabilitation, Canadian Medical Association, Ontario Medical Association, Royal College of Physicians and Surgeons of Canada

Disclosure: Nothing to disclose.

Coauthor(s)

Keith Aj Sequeira, MD, FRCPC Associate Professor, Director of Education, Department of Physical Medicine and Rehabilitation, Parkwood Hospistal, University of Western Ontario

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Patrick M Foye, MD Director of Coccyx Pain Center, Professor and Interim Chair of Physical Medicine and Rehabilitation, Rutgers New Jersey Medical School; Co-Director of Musculoskeletal Fellowship, Co-Director of Back Pain Clinic, University Hospital

Patrick M Foye, MD is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation, International Spine Intervention Society, American Association of Neuromuscular and Electrodiagnostic Medicine, Association of Academic Physiatrists

Disclosure: Nothing to disclose.

Chief Editor

Consuelo T Lorenzo, MD Medical Director, Senior Products, Central North Region, Humana, Inc

Consuelo T Lorenzo, MD is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation

Disclosure: Nothing to disclose.

Additional Contributors

Robert E Windsor, MD, FAAPMR, FAAEM, FAAPM President and Director, Georgia Pain Physicians, PC; Clinical Associate Professor, Department of Physical Medicine and Rehabilitation, Emory University School of Medicine

Robert E Windsor, MD, FAAPMR, FAAEM, FAAPM is a member of the following medical societies: American Academy of Pain Medicine, American Academy of Physical Medicine and Rehabilitation, American College of Sports Medicine, American Medical Association, International Association for the Study of Pain, Texas Medical Association

Disclosure: Nothing to disclose.

References
  1. Petersen W, Ellermann A, Gosele-Koppenburg A, et al. Patellofemoral pain syndrome. Knee Surg Sports Traumatol Arthrosc. 2014 Oct. 22 (10):2264-74. [Medline]. [Full Text].

  2. Piva SR, Fitzgerald GK, Irrgang JJ, et al. Associates of physical function and pain in patients with patellofemoral pain syndrome. Arch Phys Med Rehabil. 2009 Feb. 90(2):285-95. [Medline].

  3. Price JL. Patellofemoral syndrome: how to perform a basic knee evaluation. JAAPA. 2008 Dec. 21(12):39-43. [Medline].

  4. Finnoff JT, Hall MM, Kyle K, Krause DA, Lai J, Smith J. Hip strength and knee pain in high school runners: a prospective study. PM R. 2011 Sep. 3(9):792-801. [Medline].

  5. Kettunen JA, Visuri T, Harilainen A, et al. Primary cartilage lesions and outcome among subjects with patellofemoral pain syndrome. Knee Surg Sports Traumatol Arthrosc. 2005 Mar. 13(2):131-4. [Medline].

  6. Näslund JE, Odenbring S, Näslund UB, Lundeberg T. Diffusely increased bone scintigraphic uptake in patellofemoral pain syndrome. Br J Sports Med. 2005 Mar. 39(3):162-5. [Medline]. [Full Text].

  7. Schutzer SF, Ramsby GR, Fulkerson JP. Computed tomographic classification of patellofemoral pain patients. Orthop Clin North Am. 1986 Apr. 17(2):235-48. [Medline].

  8. Bolgla LA, Malone TR, Umberger BR, et al. Reliability of electromyographic methods used for assessing hip and knee neuromuscular activity in females diagnosed with patellofemoral pain syndrome. J Electromyogr Kinesiol. 2009 Jan 2. [Medline].

  9. Ferrari D, Kuriki HU, Silva CR, et al. Diagnostic accuracy of the electromyography parameters associated with anterior knee pain in the diagnosis of patellofemoral pain syndrome. Arch Phys Med Rehabil. 2014 Apr 15. [Medline].

  10. Syme G, Rowe P, Martin D, et al. Disability in patients with chronic patellofemoral pain syndrome: a randomised controlled trial of VMO selective training versus general quadriceps strengthening. Man Ther. 2009 Jun. 14(3):252-63. [Medline].

  11. Kooiker L, Van De Port IG, Weir A, et al. Effects of physical therapist-guided quadriceps-strengthening exercises for the treatment of patellofemoral pain syndrome: a systematic review. J Orthop Sports Phys Ther. 2014 Jun. 44(6):391-B1. [Medline].

  12. Chiu JK, Wong YM, Yung PS, Ng GY. The effects of quadriceps strengthening on pain, function, and patellofemoral joint contact area in persons with patellofemoral pain. Am J Phys Med Rehabil. 2012 Feb. 91(2):98-106. [Medline].

  13. Alba-Martin P, Gallego-Izquierdo T, Plaza-Manzano G, Romero-Franco N, Nunez-Nagy S, Pecos-Martin D. Effectiveness of therapeutic physical exercise in the treatment of patellofemoral pain syndrome: a systematic review. J Phys Ther Sci. 2015 Jul. 27 (7):2387-90. [Medline]. [Full Text].

  14. Peters JS, Tyson NL. Proximal exercises are effective in treating patellofemoral pain syndrome: a systematic review. Int J Sports Phys Ther. 2013 Oct. 8(5):689-700. [Medline]. [Full Text].

  15. van der Heijden RA, Lankhorst NE, van Linschoten R, et al. Exercise for treating patellofemoral pain syndrome. Cochrane Database Syst Rev. 2015 Jan 20. 1:CD010387. [Medline].

  16. Collins N, Crossley K, Beller E, Darnell R, McPoil T, Vicenzino B. Foot orthoses and physiotherapy in the treatment of patellofemoral pain syndrome: randomised clinical trial. BMJ. 2008 Oct 24. 337:a1735. [Medline]. [Full Text].

  17. Barton CJ, Menz HB, Crossley KM. Clinical Predictors of Foot Orthoses Efficacy in Individuals with Patellofemoral Pain. Med Sci Sports Exerc. 2011 Feb 8. [Medline].

  18. Teitge RA. Patellofemoral syndrome a paradigm for current surgical strategies. Orthop Clin North Am. 2008 Jul. 39(3):287-311, v. [Medline].

  19. Lankhorst NE, van Middelkoop M, van Trier YD, et al. Can We Predict Which Subjects With Patellofemoral Pain Syndrome Are More Likely to Benefit From Exercise Therapy: A Secondary Explorative Analysis of a Randomized Controlled Trial. J Orthop Sports Phys Ther. 2015 Jan 27. 1-24. [Medline].

  20. Devan MR, Pescatello LS, Faghri P, Anderson J. A Prospective Study of Overuse Knee Injuries Among Female Athletes With Muscle Imbalances and Structural Abnormalities. J Athl Train. 2004 Sep. 39(3):263-267. [Medline]. [Full Text].

  21. Johnston LB, Gross MT. Effects of foot orthoses on quality of life for individuals with patellofemoral pain syndrome. J Orthop Sports Phys Ther. 2004 Aug. 34(8):440-8. [Medline].

  22. Karlsson J, Thomee R, Sward L. Eleven year follow-up of patello-femoral pain syndrome. Clin J Sport Med. 1996 Jan. 6(1):22-6. [Medline].

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