Patellofemoral Anatomy

and Biomechanics
Seth L. Sherman,

MD*,

Andreas C. Plackis,

BS,

Clayton W. Nuelle,

MD

KEYWORDS
 Patella anatomy  Trochlea anatomy  Patella pathology  Trochlea pathology
 Patellofemoral anatomy  Patellofemoral biomechanics
KEY POINTS
 Patellofemoral disorders encompass a large spectrum of disease including patellofemoral
pain, instability, focal chondral disease, and arthritis.
 Most patellofemoral disorders are the result of aberrant anatomy (ie, soft tissue injury,
bony malalignment) that predisposes the patient to biomechanical abnormalities (ie, patella maltracking).
 There are multiple bony and soft tissue stabilizers to the patella. Soft tissue stabilizers (ie,
medial patellofemoral ligament [MPFL]) are critical from 0 to 20 of knee flexion, while the
trochlear groove provides stability at greater than 20 .
 Abnormalities of dynamic muscle strength (ie, vastus medialis obliquus [VMO]), static soft
tissue restraint (ie, MPFL, lateral retinaculum), patella height and tilt, trochlear
morphology, and tibial tubercle position have profound effects on patellofemoral kinematics and may lead to clinical dysfunction.

INTRODUCTION

A thorough understanding of the basic anatomy and biomechanics of the patellofemoral joint is critical for any clinician who wishes to treat the broad spectrum of disorders that can occur.
EPIDEMIOLOGY

In orthopedic and musculoskeletal clinics, evaluation of patellofemoral pain encompasses up to 10% of all visits and has been reported as high as 30% in the 13- to
19 year-old age group.1,2 Patellofemoral disorders comprise nearly 25% of all knee injuries.35 They are more common in women than in men.6 The incidence of primary

Disclosures: No external funds were used in the completion of this text, and none of the
authors received payments or services from a third party for any aspect of this work.
Department of Orthopaedic Surgery, University of Missouri, 1100 Virginia Avenue, DC953.00,
Columbia, MO 65212, USA
* Corresponding author.
E-mail address: dr.seth.sherman@gmail.com
Clin Sports Med 33 (2014) 389401
http://dx.doi.org/10.1016/j.csm.2014.03.008
sportsmed.theclinics.com
0278-5919/14/$ see front matter 2014 Elsevier Inc. All rights reserved.

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patellar dislocation is 5.8 cases per 100,000 population, and up to 29 cases

per 100,000 population in patients aged 10 to 17 years.7 Chondral lesions have
been reported in upwards of 60% of patients who underwent routine knee arthroscopies.8 Patellofemoral pathology has a significant impact on time lost from sport or
work.9
SPECTRUM OF DISEASE

Patellofemoral disorders encompass a large spectrum of disease, including patellofemoral pain, instability, focal chondral disease, and arthritis. Dysfunction can be the
direct result of trauma (ie, patella dislocation) or insidious in nature (ie, patellofemoral
pain, arthritis). Most patellofemoral disorders are the result of aberrant anatomy (ie,
bony malalignment) that predisposes the patient to biomechanical abnormalities (ie,
patella maltracking). Successful treatment requires an understanding of the anatomy/biomechanics of the joint, in order to recognize and correct common patterns
that lead to patellofemoral dysfunction. Anatomic and biomechanic abnormalities
may be addressed nonoperatively (ie, dynamic strengthening/stability, bracing) or
operatively (ie, tubercle osteotomy, MPFL repair/reconstruction, patellofemoral cartilage restoration or resurfacing, or trochleoplasty). A comprehensive treatment plan
must address both the biology and the biomechanics for optimal results.
ANATOMY
Osseous Anatomy of the Patella

The patella is the largest sesamoid bone in the body. It resides within the trochlear
groove of the distal femur and links the extensor mechanism through connections
to the quadriceps tendon at its superior pole and the patellar tendon at its inferior pole.
The patella is convex on its anterior surface, but is divided by a longitudinal median
ridge on the articular side. The patella has 7 total facets, but is primarily divided into the
2 large medial and lateral facets.
The lateral facet is typically longer and more sloped to match the lateral femoral
condyle, while the medial facet is smaller, with a shorter but consequently steeper
slope.10 The Wiberg classification delineates 4 different types based on the location
of the median ridge (Fig. 1).11 The primary blood supply to the patella occurs from a
complex arterial plexus that forms an anastomotic ring surrounding the patella.12,13
Patellar articular cartilage is the thickest found in the body, measuring up to 7 mm.14
Patella cartilage has much greater congruency in the axial plane compared with the
sagittal plane, contributing to the gliding capability of the joint itself. Contour of the
cartilage does not always follow that of its underlying subchondral bone.15
The articular surface is only present on the superior two-thirds of the patella, as the
distal pole serves as the patellar tendon insertion and is extra-articular (Fig. 2).
Osseous Anatomy of the Trochlea

The trochlea is formed by the anterior aspect of the distal femur. It has a centralized
trochlear groove (TG) with associated medial and lateral facets.

Fig. 1. Illustration demonstrating the Wiberg classification of patella anatomy.

Patellofemoral Anatomy and Biomechanics

Fig. 2. Illustration demonstrating the posterior aspect of the patella, which consists of cartilage over the proximal two-thirds and an extra-articular portion along the distal one-third
of the patella.

The lateral facet is larger and extends more proximally than the medial facet. The
depth of a normal TG is 5.2 mm, with the lateral femoral condyle being 3.4 mm higher
than the medial femoral condyle in the axial plane.10
The TG deepens as it extends distally and deviates lateral before it terminates at the
femoral notch. The facets transition into the medial and lateral femoral condyles.16
The depth of the TG can be measured by the sulcus angle (Fig. 3).
Trochlear dysplasia is characterized by a loss of the normal concave anatomy and
depth of the TG, creating a flat trochlea with highly asymmetrical facets. This
frequently predisposes to patellar dislocation during knee flexion secondary to the
loss of restraint of the patella within the groove.
Dejour and colleagues17 quantified trochlear dysplasia radiographically and defined
the trochlear bump, deemed pathologic when greater than 3 mm, and the trochlear
depth, deemed pathologic at 4 mm or less (Figs. 4 and 5). The lateral condyle forms

Fig. 3. The sulcus angle (red lines) is the angle formed in the axial plane from the highest
point on the lateral facet, to the trochlear groove, to the highest point on the medial facet.
An angle of 138 represents normal anatomy, with an angle of 150 or greater representing
an abnormally shallow groove. The congruence angle (green lines) is formed from a line
drawn through the apex of the trochlear groove with a line through the lowest point on
the articular ridge of the patella. A value of -6 represents normal anatomy, while a value
greater than 16 represents an abnormal patellofemoral articulation. Patellar tilt (blue lines)
is the angle formed by a line drawn parallel to the posterior femoral condyles and a line
drawn through the transverse axis of the patella.

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Fig. 4. Illustration depicting the Dejour classification of trochlear dysplasia with the corresponding lateral radiograph of each type.

Patellofemoral Anatomy and Biomechanics

Fig. 5. Illustration depicting the crossover sign (white arrow), as seen on a lateral radiograph in the setting of trochlear dysplasia.

the lateral wall of the patellofemoral articulation and is the primary restraint to lateral
patellar translation once the patella is deeply engaged in the groove.18 Hypoplasia
of either the medial or lateral femoral condyle can also contribute to abnormal trochlear anatomy and subsequent patellofemoral articulation abnormality.
ANATOMY OF PATELLOFEMORAL SOFT TISSUE STRUCTURES
Quadriceps Mechanism

The quadriceps mechanism is an important contributor to dynamic patellofemoral joint

stability. It is formed by the convergence of 4 muscles: the rectus femoris, vastus
medialis, vastus lateralis, and vastus intermedius.
The tendon results as a confluence of these individual muscle tendons 5 cm to 8 cm
superior to the patella and subsequently inserts on the proximal pole of the patella.
The femoral nerves supply the muscles of the quadriceps mechanism.
Patella Tendon

Arising from the inferior pole of the patella, the patellar tendon has an average length of
4.6 cm (3.5 cm5.5 cm), and width between 24 mm and 33 mm.19 Its insertion is found
on the tibial tubercle, slightly lateralized in relation to the long axis of the tibia. Separating
the posterior part of the patellar tendon from the synovial membrane of the joint is the
infrapatellar fat pad, whereas a bursa separates the tendon from the tibia more distally.
Medial Soft Tissues

Medial soft tissues include the vastus medialis obliquus (VMO), medial patellofemoral
ligament (MPFL), the medial patellotibial ligament, and the medial retinaculum (Fig. 6).
The VMO is one of the most important muscles contributing to patellar mechanics, as
it is the primary dynamic restraint to lateral tracking of the patella.14 In a cadaveric
study, VMO weakness was found to increase lateral patellar translation when simulated from 0 to 15 of flexion.20
VMO hypoplasia or dysplasia is a major cause of dynamic patella instability. VMO
strengthening is a mainstay of rehabilitation for many patellofemoral disorders.
The MPFL is the primary passive restraint to lateral patellofemoral translation. The
MPFL contributes up to 60% of the restraint to lateral patellar displacement at 0 to
30 of flexion and is vital to the maintenance of patellar stability.2123 MPFL laxity
may be the result of congenital abnormalities, or due to traumatic lateral subluxation
or dislocation events of the patella.

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Fig. 6. Illustration of the soft tissue restraints to the patella on the medial aspect of the
knee, including the medial patellofemoral ligament.

The MPFL originates at a point just proximal and posterior to the medial epicondyle
and distal to the adductor tubercle. It inserts on the proximal and medial surface of the
patella.21 The mean length of the MPFL is 53 mm to 55 mm, whereas its width may
range from 3 mm to 30 mm and widen at its attachments.19,21
Lateral Soft Tissues

The lateral soft tissue restraint to the patella is comprised of multiple layers but is
frequently divided into a superficial and deep layer. The superficial layer is composed
of the oblique lateral retinaculum, while the deep layer is composed of oblique and transverse fibers, specifically the patellotibial band and the epicondylopatellar bands (Fig. 7).24
The lateral retinaculum is an important secondary stabilizer of lateral translation of
the patella. In the setting of patella instability due to loss of medial soft tissue restraints, isolated surgical lateral release may worsen lateral patella instability, and/or
cause iatrogenic medial patella instability.
Lateral retinacular tightness is a common cause of patellofemoral pain. This may
result in lateral patella tilt, abnormally high forces between the lateral facet of the
patella and the lateral trochlea, and degenerative changes over time.
Clinically, patellar tilt can be evaluated with the patient supine, the knee in full extension, and the quadriceps muscle relaxed. In a normal knee, there is no tenderness to
palpation along the lateral patella facet, and the lateral edge of the patella can be
gently lifted away from the lateral femoral condyle.
Patellar tilt may be measured radiographically by use of radiograph, computed tomography (CT), or magnetic resonance imaging (MRI). It can be on measured on an
axial image by the angle formed by the posterior femoral condyles and the transverse
patellar axis (see Fig. 3).25 Normal patellar tilt is 2 , whereas abnormal patellar tilt is
defined as greater than 5 .14

Patellofemoral Anatomy and Biomechanics

Fig. 7. Illustration depicting the soft tissue restraints to the patella on the lateral aspect of
the knee.

Surgical lateral release may be indicated in the setting of isolated lateral patellofemoral pain and/or chondrosis from fixed patella tilt and lateral retinacular tightness
that is refractory to conservative treatment.
BIOMECHANICS

Patellofemoral motion requires a complex interplay of the previously described bony

and soft tissue structures. Anatomic abnormalities of the bones cause malalignment
and may predispose patella maltracking. Abnormalities of the dynamic and static
soft tissue structures have significant effects on patellofemoral biomechanics.
As a sesamoid bone, the patella enhances the mechanical advantage of the
extensor mechanism.
Functioning as a lever, the patella acts to magnify either force or displacement,
depending on the activity, and helps to increase the moment arm of the quadriceps.
This decreases the amount of quadriceps force necessary to extend the knee.14
Normal Patella Tracking

Different components of the patellofemoral joint play crucial stabilizing roles

throughout the normal motion arc. From 0 to 30 of knee flexion, the primary restraints
to lateral patellofemoral translation are the soft tissues mentioned previously, particularly the MPFL.26
In full knee extension, there are minimal posterior directed forces on the patella. The
patella rests in a slightly lateralized position.
Due to the patellas unique articular surface orientation, a medial patellar shift is produced when the knee begins to flex. This centers the patella as it engages the trochlea
groove.14

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At 20 to 30 of knee flexion, the patella is engaged in the trochlea, providing
increased stability.27
As flexion increases from 0 to 60 , contact area of the patella increases, and moves
from distal to proximal. Trochlea contact area advances distally.18
There is also an increasing posterior directed force exerted from the patellar and
quadriceps tendons, which increases the overall joint reactive force (Fig. 8). Once
the knee flexes past 90 , the quadriceps tendon contacts the trochlea and absorbs
some of the joint reaction force. This either causes the force to level off or decreases
as the quadriceps tendon becomes responsible for some of the total joint reaction
force and contact area.14,28,29
Between 90 and 135 of knee flexion, the patella rotates, and the ridge that divides
the medial and odd facets engages the femoral condyle.24
MEASUREMENTS OF OSSEOUS RESTRAINT

The coronal, sagittal, and axial plane alignment of the patella can be measured clinically and radiographically. Aberrant anatomy predisposes to biomechanical
abnormalities.
Coronal and Axial Planes

Clinically, the quadriceps or Q-angle plays a significant role in evaluation of patellofemoral tracking and patellofemoral forces. Measurement of the Q angle is demonstrated in Fig. 9. A Q angle greater than 20 is considered abnormal and may lead

Fig. 8. Illustration depicting the patellofemoral joint reaction force (PFJRF). The PFJRF becomes higher as the knee flexion angle increases. In complete extension, M1 and M2 are
in opposite directions, but in the same plane; the resultant PFJRF is almost zero. As flexion
increases, M1 and M2 converge, and the vector PFJRF increases. (From DeJour D, Saggin PRF.
Disorders of the patellofemoral joint. In: Scott WN. Insall & Scott surgery of the knee. Philadelphia: Elsevier/Churchill Livingstone, 2012; with permission.)

Patellofemoral Anatomy and Biomechanics

Fig. 9. Illustration depicting the measurement of the Q angle. The Q angle is measured by
the intersection of a line drawn from the anterior superior iliac spine through the center of
the patella and a line from the tibial tubercle through the center of the patella.

to both increased lateral displacement force and increased patellar contact

pressures.30
The mean Q angle typically measures 14 in men and 17 in women, with the gender
difference being the result of a wider pelvis in women, leading to an increase in knee
valgus alignment.31
The tibial tuberositytrochlear groove (TT-TG) distance is a more accurate method
of quantifying axial anatomy of the patellofemoral articulation (Fig. 10). The mean
TT-TG in normal patients ranges from 10 mm to 13 mm, with a value greater than
15 mm associated with increased risk of patellar instability.32 The congruence angle
is a static radiographic measure of patella position in the axial plane (see Fig. 3).
Sagittal Plane

Abnormal patellar height has been shown to contribute to patellar instability and subsequent recurrent patellar dislocation.30,33 In addition, abnormalities in patellar height
relative to the joint line may affect overall patellofemoral function and result in pain
syndromes.34,35
A high-riding patella, or patella alta, results in more knee flexion prior to the patella
engaging the trochlea, which may result in chondromalacia or an increased risk of
dislocation episodes.30,33 A low-riding patella, or patella baja, results in increased joint
reactive forces on the patella, which may lead to motion limitation and early patellofemoral arthritis (Fig. 11).35
Numerous methods have been described to evaluate patellar height, including: the
Insall-Salvati index,36 The Blackburne-Peel index,34 and the Caton-Deschamps index.37

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Fig. 10. (A) Illustration demonstrating how to calculate the tibial tuberositytrochlear
groove distance. (B) CT scan demonstrating how to calculate the TT-TG distance. The
TT-TG is calculated by the superimposition of 2 axial CT or MRI slices: one through the
apex of the trochlear groove and one through the center of the proximal tibial tuberosity.
The distance between these 2 perpendicular lines is measured, as referenced from the posterior condylar line of the distal femur. (From Sherman SL, Erickson BJ, Cvetanovich GL, et al.
Tibial tuberosity osteotomy: indications, techniques, and outcomes. Am J Sports Med. 2013
Nov 6. [Epub ahead of print]; with permission.)

The Caton-Deschamps index is a widely used method, as its value does not vary
with knee flexion. Unlike Insall-Salvati, this measurement changes with tibial tubercle
osteotomy (ie, distalization). This allows the surgeon to use the measurement to accurately template and implement the desired amount of correction of patella height during surgery. It is measured by dividing 2 lengths: (1) the distance between the distal
most aspect of the articular surface of the patella and the superior anterior angle of
the tibia, and (2) the length of the articular surface of the patella (Fig. 12).

Fig. 11. Illustration of a lateral view of the knee depicting: patella alta, normal patella
height, and patella baja.

Patellofemoral Anatomy and Biomechanics

Fig. 12. Lateral radiograph exhibiting the Caton-Deschamps index (B/A): the ratio of the distance of the inferior aspect of the articular surface of the patella and the anterosuperior
angle of the tibias outline (B) and the length of the articular surface of the patella (A).
(From Sherman SL, Erickson BJ, Cvetanovich GL, et al. Tibial tuberosity osteotomy: indications, techniques, and outcomes. Am J Sports Med. 2013 Nov 6. [Epub ahead of print];
with permission.)

Abnormal Patella Tracking

Central tracking within a normal TG and the absence of any patellar tilt are required
for normal patellofemoral motion.38
Various previously described anatomic abnormalities can lead to altered patellofemoral forces and abnormal patella tracking. Clinically, these anatomic and biomechanical abnormalities may manifest as patellofemoral pain, instability,
chondrosis, or a combination.
Critically important factors to consider include
Hypoplasia or weakness of the VMO
Injury or absence of static medial soft tissue restraints (MPFL)
Trochlear dysplasia
Abnormally high Q angle and increased TT-TG (or TT-posterior cruciate ligament
[PCL])
Patella tilt with tight lateral retinaculum
Patella alta or baja
SUMMARY

Patellofemoral disorders are common. There is a broad spectrum of disease, ranging

from patellofemoral pain and instability to focal cartilage disease and arthritis. Regardless of the specific condition, abnormal anatomy and biomechanics are often the root
cause of patellofemoral dysfunction. A thorough understanding of normal patellofemoral anatomy and biomechanics is critical for the treating physician. Recognizing

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and addressing abnormal anatomy will optimize patellofemoral biomechanics and

may ultimately translate into clinical success.
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