Pathogenesis of Anterior Knee Pain in the Active Young: Is There a Relation Between the Presence of Patellofemoral Malalignment and Pain?

What Have We Learned from Realignment Surgery?
  • Vicente Sanchis-Alfonso
  • Fermín Ordoño
  • Alfredo Subías-López
  • Carmen Monserrat


For many years, patellofemoral malalignment (PFM), an abnormality of patellar tracking that involves lateral displacement or lateral tilt of the patella (or both) in extension that is reduced in flexion, was widely accepted as an explanation for the genesis of anterior knee pain and patellar instability, the most common knee complaints in clinical practice in young patients.


Vastus Lateralis Anterior Knee Pain Lysholm Score Patellar Instability Lateral Patellar 



The authors gratefully acknowledge the invaluable assistance of Professor Jesús Basulto from the University of Sevilla, Spain, with the statistical analysis, and Paco Ferriz for his technical assistance in CT studies.


  1.  1.
    Abraham E, Washington E, Huang TL. Insall proximal realignment for disorders of the patella. Clin Orthop Relat Res. 1989;248:61-65.PubMedGoogle Scholar
  2.  2.
    Aglietti P, Buzzi R, De Biase P, et al. Surgical treatment of recurrent dislocation of the patella. Clin Orthop Relat Res. 1994;308:8-17.PubMedGoogle Scholar
  3.  3.
    Ahmed AM, Duncan NA. Correlation of patellar tracking pattern with trochlear and retropatellar surface topographies. J Biomech Eng. 2000;122:652-660.PubMedCrossRefGoogle Scholar
  4.  4.
    Arnbjornsson A, Egund N, Rydling O. The natural history of recurrent dislocation of the patella. Long-term results of conservative and operative treatment. J Bone Joint Surg. 1992;74-B:140-142.Google Scholar
  5.  5.
    Barber-Westin SD, Noyes FR, McCloskey JW. Rigorous statistical reliability, validity and responsiveness testing of the Cincinnati knee rating system in 350 subjects with uninjured, injured, or anterior cruciate ligament-reconstructed knees. Am J Sports Med. 1999;27:402-416.PubMedGoogle Scholar
  6.  6.
    Buchthal F. An Introduction to Electromyography. Glydendal: Scandinavian University Books; 1957.Google Scholar
  7.  7.
    Cerny K. Vastus medialis oblique/vastus lateralis muscle activity ratios for selected exercises in persons with and without patellofemoral pain syndrome. Phys Ther. 1995;75:672-683.PubMedGoogle Scholar
  8.  8.
    Crosby EB, Insall J. Recurrent dislocation of the patella. Relation of treatment to osteoarthritis. J Bone Joint Surg. 1976;58-A:9-13.Google Scholar
  9.  9.
    Dye SF, Staubli HU, Biedert RM, et al. The mosaic of pathophysiology causing patellofemoral pain: therapeutic implications. Operat Tech Sports Med. 1999;7:46-54.CrossRefGoogle Scholar
  10. 10.
    Farahmand F, Tahmasbi MN, Amis AA. Lateral force-­displacement behaviour of the human patella and its variation with knee flexion – a biomechanical study in vitro. J Biomech. 1998;31:1147-1152.PubMedCrossRefGoogle Scholar
  11. 11.
    Ficat P, Ficat C, Bailleux A. Syndrome d’hyperpression externe de la rotule (S.H.P.E). Rev Chir Orthop. 1975;61:39.PubMedGoogle Scholar
  12. 12.
    Fithian DC, Nomura E, Arendt E. Anatomy of patellar dislocation. Operat Tech Sports Med. 2001;9:102-111.CrossRefGoogle Scholar
  13. 13.
    Fithian DC, Paxton EW, Cohen AB. Indications in the treatment of patellar instability. J Knee Surg. 2004;17:47-56.PubMedGoogle Scholar
  14. 14.
    Fulkerson JP. The etiology of patellofemoral pain in young active patients: a prospective study. Clin Orthop Relat Res. 1983;179:129-133.PubMedGoogle Scholar
  15. 15.
    Fulkerson JP, Tennant R, Jaivin JS. Histologic evidence of retinacular nerve injury associated with patellofemoral malalignment. Clin Orthop Relat Res. 1985;197:196-205.PubMedGoogle Scholar
  16. 16.
    Grelsamer RP, McConnell J. The Patella. A Team Approach. Gaithersburg: An Aspen Publication; 1998.Google Scholar
  17. 17.
    Heegaard J, Leyvraz PF, Van Kampen A. Influence of soft structures on patellar three-dimensional tracking. Clin Orthop Relat Res. 1994;299:235-243.PubMedGoogle Scholar
  18. 18.
    Hughston JC. Subluxation of the patella. J Bone Joint Surg. 1968;50-A:1003-1026.Google Scholar
  19. 19.
    Insall JN. “Chondromalacia Patellae”: patellar malalignment syndrome. Orthop Clin North Am. 1979;10:117-127.PubMedGoogle Scholar
  20. 20.
    Insall J, Bullough PG, Burnstein AH. Proximal “tube” realignment of the patella for chondromalacia patellae. Clin Orthop Relat Res. 1979;144:63-69.PubMedGoogle Scholar
  21. 21.
    Lysholm J, Gillquist J. Evaluation of knee ligament surgery results with special emphasis on use of a scoring scale. Am J Sports Med. 1982;10:150-154.PubMedCrossRefGoogle Scholar
  22. 22.
    Merchant AC. Radiography of the patellofemoral joint. Operat Tech Sports Med. 1999;7:59-64.CrossRefGoogle Scholar
  23. 23.
    Merchant AC, Mercer RL. Lateral release of the patella: a preliminary report. Clin Orthop Relat Res. 1974;103:40.PubMedCrossRefGoogle Scholar
  24. 24.
    Merchant AC, Mercer RL, Jacobsen RH. Roentgenographic analysis of patellofemoral congruence. J Bone Joint Surg. 1974;56-A:1391-1396.Google Scholar
  25. 25.
    Sanchis-Alfonso V, Gastaldi-Orquín E, Martinez-SanJuan V. Usefulness of computed tomography in evaluating the patellofemoral joint before and after Insall’s realignment. Correlation with short-term clinical results. Am J Knee Surg. 1994;7:65-72.Google Scholar
  26. 26.
    Sanchis-Alfonso V, Roselló-Sastre E. Immunohistochemical analysis for neural markers of the lateral retinaculum in patients with isolated symptomatic patellofemoral malalignment. A neuroanatomic basis for anterior knee pain in the active young patient. Am J Sports Med. 2000;28:725-731.PubMedGoogle Scholar
  27. 27.
    Sanchis-Alfonso V, Roselló-Sastre E. Anterior knee pain in the young patient – what causes the pain? “Neural model”. Acta Orthop Scand. 2003;74:697-703.PubMedCrossRefGoogle Scholar
  28. 28.
    Sanchis-Alfonso V, Roselló-Sastre E, Martinez-SanJuan V. Pathogenesis of anterior knee pain syndrome and functional patellofemoral instability in the active young. A review. Am J Knee Surg. 1999;12:29-40.PubMedGoogle Scholar
  29. 29.
    Sanchis-Alfonso V, Roselló-Sastre E, Monteagudo-Castro C, et al. Quantitative analysis of nerve changes in the lateral retinaculum in patients with isolated symptomatic patellofemoral malalignment. A preliminary study. Am J Sports Med. 1998;26:703-709.PubMedGoogle Scholar
  30. 30.
    Sanchis-Alfonso V, Roselló-Sastre E, Revert F. Neural growth factor expression in the lateral retinaculum in painful patellofemoral malalignment. Acta Orthop Scand. 2001; 72:146-149.PubMedCrossRefGoogle Scholar
  31. 31.
    Sanchis-Alfonso V, Roselló-Sastre E, Revert F, et al. Histologic retinacular changes associated with ischemia in painful patellofemoral malalignment. Orthopedics. 2005;28: 593-599.PubMedGoogle Scholar
  32. 32.
    Schutzer SF, Ramsby GR, Fulkerson JP. The evaluation of patellofemoral pain using computerized tomography. A ­preliminary study. Clin Orthop Relat Res. 1986;204:286-293.PubMedGoogle Scholar
  33. 33.
    Scott J, Huskisson EC. Graphic representation of pain. Pain. 1976;2:175-184.PubMedCrossRefGoogle Scholar
  34. 34.
    Tegner Y, Lysholm J. Rating systems in the evaluation of knee ligament injuries. Clin Orthop Relat Res. 1985;198:43-49.PubMedGoogle Scholar
  35. 35.
    Wojtys EM, Beaman DN, Glover RA, et al. Innervation of the human knee joint by substance-P fibers. Arthroscopy. 1990;6:254-263.PubMedCrossRefGoogle Scholar
  36. 36.
    Zeichen J, Lobenhoffer P, Gerich T, et al. Medium-term results of the operative treatment of recurrent patellar dislocation by Insall proximal realignment. Knee Surg Sports Traumatol Arthrosc. 1999;7:173-176.PubMedCrossRefGoogle Scholar

Copyright information

© Springer-Verlag London Limited 2011

Authors and Affiliations

  • Vicente Sanchis-Alfonso
    • 1
  • Fermín Ordoño
  • Alfredo Subías-López
  • Carmen Monserrat
  1. 1.International Patellofemoral Study Group, International ACL Study Group, Hospital 9 de Octubre, Hospital Arnau de Vilanova, School of MedicineCatholic University of ValenciaValenciaSpain

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