LIVRE JDG 2012

S. Donell

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Abnormal was therefore more useful than the

actual number of degrees. In fact quantitative

information can be gained from images, where

this is needed. Experienced clinicians showed

moderate consistency in their examination

findings despite the poor agreement between

them.

This means that examination tests cannot be

relied upon to give consistent and accurate

numerical data, and therefore cannot be used as

decision tools for surgical management of the

patient. Standardisation of the physical

examination, both the test chosen, and how it is

performed and recorded, is needed for research

studies and clinical management.

Personal examination

tests

My personal protocol when examining a patient

with a history of patellar instability does not

include the Q-angle as it does not add anything

[4]. The only measure that is likely to be

reliable, although we have not achieved

consensus on this is the mediolateral glide [5].

My personal examination protocol is:

Assess the Beighton score for hypermobility

before asking the patient to lie on the

couch.

Assess the rotational profile of the lower

limb with the patient supine and the knees

extended. The feet are raised noting the

relative leg lengths, and knee alignment (e.g.

recurvatum or valgus), then internally and

externally rotate the ankles to check femoral

version. Tibial torsion is noted by pointing

the patellae vertically and noting the foot

alignment with the ankle plantegrade.

Perform a stroke test to find a slight knee

effusion.

Ask the patient to push their knees

backwards and palpate the VMOs to check

their presence and power.

Palpate the medial border of the patella, the

medial retinaculum and adductor tubercle

and test for apprehension in extension. My

personal grading system for apprehension is

0 = none, + = apprehension after lateral

patellar displacement, ++ = apprehension at

the start of lateral displacement and +++ =

apprehension on moving the hand towards

the knee. Then assess the mediolateral glide

in extension, noting if there is any crepitus.

Note the active range of knee flexion. With

the knee in full flexion palpate the anterior

surface of the distal femur and note if there

is a normal groove or dysplasia.

Check the integrity of the ACL.

Sit the patient over the side of the bed and

note patella tracking with active extension

from 90º flexion. The range of abnormalities

is much greater than just the J-sign. A slight

J is normal, especially in the presence of

recurvatum. In some the maltracking may

be almost L-shaped, or with a visible clunk

at 20º to 30º flexion. There may be bayonet

tracking, dislocation in flexion, or permanent

lateral dislocation. The more severe the

more likely the patient has a significant

trochlear dysplasia.

Check core and gluteal muscle control. The

former is demonstrated by the patient lying

supine and flexing both knees to 90º. They

are then asked to lift their pelvis so that their

chest pelvis and knees are in a straight line.

They then fold their arms across their chest.

They are then asked to straighten each knee

keeping their pelvis lifted (normal side

first). With weak lumbar muscles the patient

is unable to sustain the elevation of the

pelvis. Gluteal muscle control is

demonstrated by being balanced on each

leg, and then performing a unilateral squat.

With a weak gluteus maximus muscle the

femur internally rotates on squatting, often

precipitating the symptoms.

Conclusion

Examination of the patellofemoral joint in

patellar instability is undertaken to confirm the

diagnosis. The evidence base shows that there

is no reliable test that can be used to decide on

surgical management. The more severe the

grade of apprehension, the more likely an