chapter 3: History and Physical Examination
Putting It All Together
Once history and physical examination defines patellofemoral malalignment and/or patellofemoral soft‑tissue pain as the diagnosis, examination findings direct treatment. So, even if the history is diagnostic, careful examination is important. Put together the "whole picture" of extremity alignment, soft‑tissue mobility, and dynamic control when making treatment decisions. Remember to include evaluation of the entire extremity. When flexibility is asymmetric in patients with anterior knee pain, stretching should be focused on all tight muscle groups. Consider not only quadriceps atrophy and weakness but also the timing of VMO contraction. Avoid the painful ranges of motion identified by articular compression during initial strengthening. Treat painful foci of tendinitis or retinacular inflammation with anti‑inflammatory modalities, massage, and ice. Address static factors contributing to malalignment such as excessive hindfoot pronation and leg length discrepancy by orthotic and heel lift prescriptions. Patients with soft‑tissue tightness and resultant malalignment may benefit from patellar taping and stabilizing braces. The importance of an accurate examination and precise diagnosis to successful treatment should be clear.
If surgery becomes necessary, examination findings also impact on surgical selection. For example, hypermobile patients are less likely to benefit from lateral release. Significant signs of pain on articular compression and crepitus suggest advanced articular injury and the need for pressure relieving anteriorization, patellectomy or arthroplasty instead of isolated realignment. Observing the degree of flexion that provokes the most pain on articular compression probably helps predict the site of patellofemoral arthrosis. Because some cadaver models of tubercle anteriorization have shown better unloading of distal lesions (73, 74), more articular pain near extension may prove to be prognostic for superior results after anteriorization.
In summary, history and physical examination form the cornerstones of accurate diagnosis and treatment in patients with patellofemoral disorders. There is no substitute for a thorough history and physical examination. Radiographic studies usually corroborate the clinical impression and must not be relied upon in the absence of confirmatory clinical data. Combining knowledge of the mechanics and natural history of patellofemoral problems with information from the history and physical examination, logical treatment can begin.
Inside Chapter 3: