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patella. A second line is drawn from the centre
of the patella to the tibial tubercle. The resultant
angle is the quadriceps (Q-) angle. Normal is
valgus 10º to 15º degrees in men and 15º to 20º
for women.
Quadriceps definition
The technique is not described but reduced
definition of the quadriceps may indicate
atrophy.
VMO capability
The patient sits on the edge of the examination
couch. The leg is actively extended and held at
45º flexion. A concavity on the medial aspect of
the distal thigh indicates vastus medialis
obliquus (VMO) atrophy.
Patellar glide test
The patient lies supine with the knee relaxed at
30º flexion. The patella is pushed medially and
laterally. It is divided into four quadrants and
displacement equal to three or more quadrants
indicates reduced patellar restraint.
Patellar apprehension test
With the patient supine and the knee relaxed at
30º flexion, the patella is pushed laterally. If the
patient exhibits anxiety and/or an involuntary
quadriceps contraction then this is a positive
apprehension test.
Modified apprehension test
With the patient supine and the knee relaxed at
30º flexion and in neutral rotation, the patella is
pushed in a distal and lateral direction at 45º
(towards the fibular head). This is said to isolate
the MPFL by relaxing the medial patellotibial
ligament. It is also said to reduce the effect of
the lateral trochlear flare by the distal
displacement.
Bassett’s sign
This is demonstrated when there is tenderness
on palpation of the adductor tubercle and
medial epicondyle. It indicates damage at the
origin of the MPFL.
Palpation medial retinaculum
Palpation of the medial retinaculum and medial
patellar border reveals a defect or tenderness at
the site of injury i.e. along the middle portion
of the MPFL to its insertion into the patella.
Gravity subluxation test
With the patient lying in lateral decubitus and
the affected leg uppermost, the patient relaxes
as the examiner abducts the leg. In patients
with medial subluxation the patella displaces
medially. If when the patient isometrically
contracts the quadriceps and the patella remains
medially displaced this indicates complete
disruption of the lateral retinaculum. If it
relocates, the lateral retinaculum is intact at the
level of the vastus lateralis muscle.
Patellar positioning
The patient initially lies supine and is re-tested
sitting. The knee is relaxed in full extension
and the tilt, height, and mediolateral displace
ment of the patella observed whilst the knee
actively flexes to full flexion. Abnormal
positions of the patella are noted, including
patella alta and infera and excessive lateral tilt.
Patellar tilt test
With the patient supine and the knee relaxed at
20º flexion, the patella is held between thumb
and index finger and the medial side is pushed
down to elevate the lateral edge. Normal results
in an elevation of neutral to 20º, less than this is
associated with lateral retinacular tightness.
Quadriceps pull test
With the patient supine and the knee relaxed in
full extension the centre point of the patella is
marked and a line drawn to the tibial tubercle.
The patient performs an isometric quadriceps
contraction and its horizontal displacement
from the reference line is measured. Greater
than 15mm is abnormal and suggests imbalance
of the muscle forces.
Tibial tubercle to Trochlear Groove
(TTTG) Assessment
The patient lies semi-recumbent and the
midpoint between the pubic symphysis and the