Sports Medicine: Just the Facts

patellar tendonitis or jumper’s knee. The tenderness is

more pronounced with the patellar tendon relaxed

with the knee in the extended position. Usually this

area is less tender with the knee in the flexed position.

• Lateral displacement may cause apprehension in pts
  with patellar instability. When assessing for instabil-
  ity, measure patellar mobility (patellar glide). This is
  based on the maximum amount of passive displace-
  ment of the patella (using quadrant system with the
  patella divided into four vertical quadrants) both
  medially and laterally with the knee at 30°flexion.
  This test evaluates the integrity and tightness of the
  medial and lateral restraints. The passive patellar tilt
  test determines the tension of the lateral restraints.
  With the knee fully extended, the patella is manually
  elevated. A passive tilt of less than 0°(neutral or
  below the horizontal plane), may imply lateral reti-
  nacular tightness and a diagnosis of excessive lateral
  pressure syndrome(ELPS).

RADIOGRAPHS

• The standard patellar radiograph is the merchant view
  or sunrise view. It is generally performed with the
  patient supine with the knee flexed 45°to evaluate for
  articular cartilage loss, tilt, and subluxation. The
  Laurin view (20°sunrise view) may be more sensitive
  for delineating subluxation or tilt. A computed tomog-
  raphy(CT) scan from 10–60°of knee flexion may be
  useful to evaluate for tilt, subluxation.

CHONDROMALACIA PATELLA

• Predisposing extrinsic anatomic factors leading to
  patellofemoral pathology include femoral antever-
  sion, external tibial torsion, foot pronation, and
  extreme genu varum/valgum. Nonoperative manage-
  ment is the mainstay of treatment of most
  patellofemoral disorders. Chrondromalacia refers to
  some type of disruption in the articular cartilage of the
  the patella that is either painful or nonpainful.
  Proposed etiologies of chondromalacia include
  trauma, malalignment, biomechanical, and metabolic.
  Most patients with symptomatic chondromalacia
  present with an insidious onset and complain of a dull
  ache around the anterior knee, pain with loaded flex-
  ion activities, particularly descending stairs or a pro-
  longed seated position (theatre sign). Nonoperative
  management of chondromalacia patella includes rest,
  flexibility exercises especially of the hamstrings,
  quadriceps strengthening, and anti-inflammatory
  medication. Return to play is dictated by symptoms.

SYNOVIAL PLICA

•A synovial plica is a redundant fold in the synovial

lining of the knee. This is a normal finding but may

become symptomatic when it becomes inflamed or

fibrotic. A symptomatic plica is most commonly

located on the medial side with a localized tender

thickening along the medial border of the patella or

condyle on palpation (knee at 45°of flexion). An

audible snap with flexion may sometimes be elicited

with a plica. Nonoperative management of a synovial

plica includes relative rest, flexibility exercises espe-

cially of the hamstrings, quadriceps strengthening,

and anti-inflammatory medication. If the synovial

plica is significantly scarred or fibrotic and cannot be

rehabilitated, arthroscopic excision is indicated.

EXCESSIVE LATERAL PRESSURE

SYNDROME

• Excessive lateral pressure syndrome(ELPS), or lat-
  eral facet syndrome, represents a loss of equilibrium
  of the patella in the trochlea associated with tilt. This
  results in increased pressure on the lateral patellar
  facet. This is secondary to a tight lateral retinaculum.
  The patient with ELPS usually has a spontaneous or
  posttraumatic onset with patellofemoral arthralgia
  (dull aching in the center of the knee) and occasion-
  ally swelling and giving way may be present.
  Radiographs or CT of patients with ELPS will usually
  show lateral patellar tilt on the axial views.

PATELLAR MALALIGNMENT

AND INSTABILITY

•Patellar malalignment and instability are two separate

issues:

1. Malalignment indicates maltracking of the patella
   based on physical examination and imaging stud-
   ies such as X-rays or CT.


2. Instability is a functional symptom with the patella
   transiently displacing (usually lateral) either par-
   tially (subluxation) or completely (dislocation).
   Initial treatment for instability is nonoperative.
   Surgical correction is indicated when there is fail-
   ure of nonoperative management or evidence of
   progressive articular cartilage damage as a result of
   the instability. Patellar realignment for recurrent
   instability is categorized as either proximal
   realignment (tightening, repairing, or reconstruct-
   ing the medial soft tissue patellar restraints) or
   distal realignment (transposing the tibial tubercle

358 SECTION 4 • MUSCULOSKELETAL PROBLEMS IN THE ATHLETE