moderators, program chairs, and Anna and AOSSM for inviting me for this talk. These are my disclosures. So the patellofemoral joint is arguably one of the most difficult joints to examine in the human body. Often not straightforward. And even though we try to put things into little black boxes of pain and instability, what we do know that often there's a lot of overlap, and you really shouldn't consider one without the other in terms of your evaluation. Patients have variable presentation. It can be nuanced at pain and instability, or it can be complex pain and complex instability with multiple surgeries. So it's important to get the physical examination right so we know what the treatment to provide so that we don't end up with recurrent injury, recurrent surgeries, and get to this other end of the spectrum. This is never a short examination. You really want to leave no stone unturned. And much is gleaned from this even before you lay hands on the patient. And you want to consider the entire extremity and don't forget about syndromes and body types. There's a lot of predisposing factors for both pain and instability, and we'll go over some of these things, but it's a laundry list of things that you have to consider for successful treatment of these patients. You have to see the entire extremity. Patients have to be in shorts. You have to see the entire quad. You should be able to evaluate their feet and ankles. And we do this in multiple positions, standing, walking, supine, sitting, and even prone in some instances. The standing evaluation is of extreme importance. We can see in this patient on the right. She has significant rotatory malalignment with her patella pointing anteriorly. Her feet are externally rotated. And when you tell her to point her feet straight ahead, her patella pointed towards a straight line. That is abnormal. And remember that kids with miserable malalignment turn into adults and teenagers with miserable malalignment. You can get a good sense of quad tone and other issues just from the standing evaluation. The foot examination is huge as we know that this affects the biomechanics of the patella femoral joint. We can see in the top picture significant hind foot valgus and pes planus. For both my pain and instability patients, I do do a half squat test for different reasons. You can assess quadriceps strength, especially for the patient who thinks that they've been adequately rehabilitated but can't perform a squat. And in this patient, we see that at the engagement of the patella into the trochlea, they get pain related to some chondrosis in the knee. But you can also see some poor mechanics at both the hip and the knee. So this can give you a lot of information. A lot has been looked at recently about looking at the J-sign and patellar tracking. I do this with standing above the patient and I can assess for ALTA. So if you're standing above and the patella is staring up at you, you know that they may be ALTA. You can assess tilt in this position. And also you have the patient actively extend. And this is more than just a J-sign here. This is sort of the jumping J-sign or what some would consider an L-sign. And then, you know, certainly some of these things are very subtle. This patient is actually located in extension. And as they go into flexion, the patella dislocates. So this is one of our obligate or habitual dislocators. So very important part of the examination. In a sitting position, I do what I call the poor man's Q-angle. So we put our fingers on the epicondyles. You drop a line down the patellar tendon. And then a line perpendicular to your trans-epicondylar axis. And if this is more than 10 degrees, this is abnormal. So this is kind of a quick and dirty way to look at the patellofemoral malalignment while sitting. Palpation is critical. We palpate the facets, the retinaculum, plica. The fat pad is huge. And we've known that many people have shown that there is, Scott Dye and others have shown that there's a lot of pain fibers within the fat pad. And that could be an important pain generator. So we really want to assess that. Palpate the tendons. And then you want to assess for any joint line pain in the anterior aspect. It's post and focus and have both shown that patellofemoral issues can present as joint line pain. Once we get them supine, one of the hallmarks and one of the workhorses is the apprehension examination. You want to push laterally and see the patient's response. But also really get a good sense of what the translation of the patella. Medial apprehension and instability has been recently shown to be not just iatrogenics. And so this is something that we are assessing for now more commonly. But we also want to assess for pain and crepitation within the patellofemoral joint. Supine, we try to tilt the patella. It's important to reduce the patella into the trochlea when you do this. And you want to assess whether the patella is just horizontal, if you can't get it straight to horizontal, or if you can actually tilt it all the way up. And then again, assess for medial and lateral glide, which should be one to two quadrants. We also assess the position of the tibial tubercle in relation to the patella. We see in this patient with their patella in the trochlea that they have a significant angle between the patella and the tibial tuberosity. I don't often perform a Q angle. So this is something I personally will eyeball. But certainly, if you do that, you want to do it with some degree of flexion. The prone examination can be important to assess femoral anaversion. You see in the picture on the top, the examiner has their fingers on the greater trochanter of the femur. And as they externally rotate the leg, they're really going to get a sense of just how much femoral anaversion this patient has. And we can assess thigh foot angle to assess for tibial torsion. And this is extremely important. Other special examinations, we want to check for hamstring tightness. The BITEN score is something that many of us will do, especially in our patella-femoral instability patients, but certainly is applicable in our pain patients also. I may not do all these exams, and typically, I will have the patient come into the room and I'll say, can you put your thumb in your forearm, like the top picture? And if they can do that, in my book, I think they're loose and we can forego some of these other things. But certainly, elbow extension, knee hyperextension, and being able to place the palms on the ground are also important indicators here. So in conclusion, a comprehensive exam needs to be accurate in terms of getting a great diagnosis. You really want a multifaceted approach to this, and really look at this in standing, sitting, supine, and prone, because this is all key. And remember that overlap often exists between the pain and the instability examination. Thank you.

patellofemoral joint

pain

instability

physical examination

diagnosis