ORIGINAL RESEARCH

IJSPT BIOMECHANICS AND PATHOMECHANICS

OF THE PATELLOFEMORAL JOINT
Janice K. Loudon, PT, PhD, SCS, ATC, CSCS1

ABSTRACT
The patellofemoral joint is a joint that can be an area of concern for athletes of various sports and ages. The
joint is somewhat complex with multiple contact points and numerous tissues that attach to the patella.
Joint forces are variable and depend on the degree of knee flexion and whether the foot is in contact with
the ground. The sports medicine specialist must have a good working knowledge of the anatomy and bio-
mechanics of the patellofemoral joint in order to treat it effectively.
Key Words: Anatomy, biomechanics, patella

CORRESPONDING AUTHOR
Janice K. Loudon, PT, PhD, SCS, ATC, CSCS
Rockhurst University
Department of Physical Therapy Education
1100 Rockhurst Road
Kansas City, MO 64110
Office: 816-501-4848
1
Rockhurst University, Kansas City, MO, USA E-mail: Janice.loudon@rockhurst.edu

The International Journal of Sports Physical Therapy | Volume 11, Number 6 | December 2016 | Page 820
INTRODUCTION
Patellofemoral joint pain (PFP) is one of the most
common conditions presented to the sports physical
therapist.1 Disorders of this articulation are found
in a variety of active individuals including runners,2
tennis players,3 and military personnel.4 Females
tend to report more patellofemoral pain due to
numerous speculations for this reason.5–8

One of the most common contributory factors caus-

ing PFP is biomechanical dysfunction.5 The patella
and trochlea articulation is variable and for some Figure 1. Anterior view of the patella (14.4a in Loudon – Clin-
individuals the patella does not fit well.9 Also, the ical Mechanics and Kinesiology) © Human Kinetics
patellofemoral joint requires an intricate balance
of the soft tissue structures that surround the joint. and the inferior patella is the apex (Figure 1). The
Unequal pull from one set of structures can cause peak dimensions of the average patella are 4 - 4.5
increased force distribution between the patella and centimeters in length, 5 -5.5 centimeters in width
femur leading to pain.10–12 To treat PFP effectively, it and 2 - 2.5 centimeters thick.14,15
is imperative that the clinician understand the anat-
The patella is composed of a thin cortical shell with
omy and biomechanics of this joint.13 The purpose
a trabecular core. The anterior surface of the patella
of this clinical commentary is to provide the reader is convex in both anterior-posterior, and medial-lat-
with a thorough understanding of anatomy and bio- eral planes. The posterior surface of the patella is
mechanics of the patellofemoral joint. divided into a variety of facets (Figure 2). A major
vertical ridge divides this surface into a medial and
FUNCTIONAL ANATOMY lateral half. The two halves can be further divided
Osseous Structure/cartilage into seven facets, three horizontal pairs: proximal,
The patellofemoral joint is a diarthrodial plane joint middle, and distally and an odd facet that is located
that consists of the posterior surface of the patella on the far medial, posterior aspect of patella. The
and the trochlear surface of the distal anterior patellar facets are convex in shape in order to accom-
femur. The patella is the largest sesamoid bone in modate the concave femoral surface with the lateral
the body. Geometrically, the patella is shaped like side wider to help maintain patellar position. The
an upside-down triangle that sits distal to the muscle majority of the articulating surface of the patella is
bulk of the quadriceps that forms the patellar ten- covered with a thick layer of articular cartilage, up
don. The superior surface is referred to as the base to seven millimeters.16 This thick cartilage is thought

Figure 2. Posterior view of the patella (14.4c in Loudon – Clinical Mechanics and Kinesiology) © Human Kinetics

The International Journal of Sports Physical Therapy | Volume 11, Number 6 | December 2016 | Page 821
to dissipate large joint reaction forces that are cre- would indicate trochlear dysplasia (less depth of the
ated during forceful contractions of the quadriceps trochlea) and a tendency for patellar subluxation.
muscle.
Soft tissue
The distal femur forms into an inverted U-shaped
Due to the shallow and incongruent fit between the
intercondylar groove (or trochlear sulcus) with con-
patella and the trochlea, the stability of the patello-
cave lateral and medical facets covered by a thin
femoral joint is dependent on the static and dynamic
layer of articular cartilage (Figure 3). As with the
soft tissue structures.15 Static stability is offered by
patella, the lateral facet of the femur is larger and
the patellar tendon, joint capsule, and ligamentous
extends more proximally to provide a bony buttress
structures. The medial structures become important
to improve patellar stability. A sulcus angle can
in minimizing lateral translation and the primary
be identified with radiograph (skyline view) that
structure to lateral restraint is the medial patello-
measures the angle between the lateral and medial
femoral ligament (MPFL) This ligament runs from
femoral condyle (Figure 4). Normally, this angle
the adductor tubercle to the medial border of patella.
averages around 138 ± 6 degrees.16 A greater angle
Desio et al. describe the MPFL as providing 60% total
restraint at 20 degrees of knee flexion.15,17 A second-
ary restraint includes the medial mensicopatellar
ligament which originates from the anterior aspect
of the menisci and inserts into the inferior 1/3 of
patella and the medial retinaculum with superficial
fibers that interdigitate with the medial collateral
ligament and the medial patellar tendon.17

On the lateral side of the patellofemoral joint, the

following structures aide in stability: lateral patello-
femoral ligament, joint capsule, iliotibial band (ITB),
and lateral retinaculum. The lateral retinaculum
consists of a thinner superficial layer that extends
from the ITB to the patella and quadriceps expan-
sion and a thicker deep layer that interdigitates with
Figure 3. The distal femur and articulating surface with the the vastus lateralis, patellofemoral ligament, and
patella (14.2 in Loudon – Clinical Mechanics and Kinesiology) patellotibial ligament.18 The joint must rely on the
© Human Kinetics medial and lateral retinaculum and joint capsule
at angles less than 20-30 degrees of flexion because
there is minimal to no bony stability.

Dynamically, the contractile structure of the quad-

riceps, pes anserine muscle group, and biceps femo-
ris muscle help to maintain patellar alignment. The
importance of the vastus medialis oblique (VMO)
has been discussed extensively in the literature.18–20
The VMO attaches to the mid-portion of patella,
the MPFL and adductor magnus tendon. Its more
oblique alignment (as compared to the vastus medi-
alis longus) provides mechanical advantage to pro-
mote medial stabilizing force to the patella.21,22 The
rectus femoris inserts on the anterior portion of
Figure 4. Sulcus Angle – (25.5 in Reiman – Orthopedic Clini- superior aspect of patella22. The vastus intermedius
cal Exam) © Human Kinetics inserts posteriorly at the base of patella. The vastus

The International Journal of Sports Physical Therapy | Volume 11, Number 6 | December 2016 | Page 822
lateralis provides lateral dynamic reinforcement in
conjunction with the ITB and the superficial oblique
retinaculum.23 Tightness in the ITB can cause the
patella to glide and/or tilt laterally. Inferiorly, the
patella is secured via the patellar tendon and its
attachment to the tibial tubercle.

KINESIOLOGY/BIOMECHANICS
Function
The function of the patella is multifaceted. Its pri-
mary purpose is to serve as a mechanical pulley
for the quadriceps as the patella changes the direc-
tion of the extension force throughout knee range
of motion. Its contribution increases with progres-
sive extension. According to Huberti and Hayes the
patella is critical in the last 30 degrees of knee exten-
sion.24 At full knee extension the patella provides
31% of total knee extension torque, while between
90 and 120 degrees of flexion it provides only 13%.
Additionally, the patella acts as a bony shield for the
anterior trochlea and due to its interposed position
between the quadriceps tendon and femur it pre-
vents excessive friction between the quadriceps ten-
don and the femoral condyles.25,26 Figure 5. Quadriceps Angle (Q-angle) (Figure 14.9 in Loudon
– Clinical Mechanics and Kinesiology) © Human Kinetics

Static Alignment
The static alignment of patella is related to the depth a line connecting the center of patella with tibial
of the femoral sulcus, height of the lateral femoral tuberosity (Figure 5). Normal Q-angle for males is
condyle wall, and the shape of patella. Typically, 10-13 degrees and 15-17 degrees for females. An
gross alignment is assessed with the patient in a increased Q-angle is thought to create excessive
supine position. McConnell27 has established assess- lateral forces on the patella through a bowstring
ment criteria; however the inter-reliability of this effect.10,16 Recently, studies have shown no associa-
method has been questioned28. For the clinician, tion between the static Q-angle and patellofemoral
observational analysis of obvious abnormalities kinematics or pain.29,30 Therefore the best way to
remains clinically useful but is subjective and can- assess Q-angle is during dynamic active function
not be easily quantified. using video analysis.31

When observing in the frontal plane with the knee In the sagittal plane with the knee in slight flexion,
in full extension the patella typically sits midway the apex of the patella rest just at or slightly proxi-
between the two condyles, although some sources mal to the joint line. A more sophisticated method to
suggest a slight lateral deviation.12 In this position, measure sagittal plane patellar position is the Insall-
the patella is superior to the trochlea and minimal Salvati ratio.32 This measurement is the ratio of the
contact exists between the patella and femur, thus, patellar tendon length compared to the patellar
in this position the patella is most mobile. Clinically, height with the knee bent to around 30 degrees. A
the Q-angle is commonly used to identify alignment ratio of around 1.0 is considered normal. A ratio less
of the quadriceps muscle pull. The Q-angle is the than 0.80 is indicative of an inferior patella or “patel-
angle between the line of pull of the quadriceps lar baja” that may be due to a shortened patellar ten-
(anterior superior iliac spine to mid-patella) and don. A ratio greater than 1.2 is termed “patella alta”

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Figure 6. Patellar reference positions (Figure 14.15 in Loudon – Clinical Mechanics and Kinesiology) © Human Kinetics

(Figure 6). In this more superior position it takes when the inferior pole is directed medially (Figure
longer for the patella to reach the bony constraint of 9). This rotational position may indicate underlying
the femoral trochlea, thus the patella is at a greater torsion of the tibia such as lateral tibial torsion.
risk for subluxation.
DYNAMIC MOVEMENT/KINEMATICS
Additionally, the patella should be lined up so that More important than assessing static alignment is
the superior and inferior borders are equidistant for the clinician to understand the dynamic move-
from the femur. If any surface of the patella deviates ment of the patella, commonly referred to as patellar
either anterior or posterior this is termed “tilt”. In tracking. Movement of the patella during tibiofemo-
the sagittal plane, these motions are described by the ral motion is dependent upon the active contraction
location of the inferior pole of the patella in either of the quadriceps, the extensibility of the connec-
a depressed (inferior tilt) or elevated (superior tilt) tive tissue about the patella, and the geometry of
position (Figure 7). An inferiorly tilted patella can the patella and trochlear groove. As a gliding joint,
be problematic as it may pinch or irritate the patel- the patella has movement in multiple planes. These
lar fat pad that lay underneath the patellar tendon. motions include superior/inferior glide, medial and
In the transverse plane, the patella should lie hori- lateral glide, medial and lateral tilt, and medial and
zontally such that the medial and lateral borders lateral rotation. Superior glide is also termed patellar
are equidistant from the femur. A lateral tilt, when extension and this motion occurs during tibiofemo-
the medial border is higher than the lateral border, ral extension when the quadriceps contract creating
can lead to lateral patellofemoral compression syn- a superior pull on the patella. An inferior glide is
drome (Figure 8).4 patellar flexion and occurs in conjunction with tib-
iofemoral flexion. Lateral and medial glide occur
Rotation of the patella occurs around an anterior – as translations in the frontal plane that correspond
posterior axis and is described by the direction of the with tibiofemoral motion. During lateral glide the
inferior pole of the patella. A lateral rotation occurs lateral edge of the patella moves closer to the lateral
when the inferior pole is directed toward the lat- side of the knee (Figure 10), and during medial glide
eral side of the knee, while a medial rotation occurs the medial side moves toward the medial edge of the

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Figure 7. Inferior tilted patella (Figure 14.14 in Loudon – Clinical Mechanics and Kinesiology) © Human Kinetics

Figure 8. Lateral tilted patella (Figure 14.14 in Loudon – Clin-

ical Mechanics and Kinesiology) © Human Kinetics

knee. Tilt occurs about a longitudinal axis. Tilts are

described by which direction the reference facet is
moving. In a medial tilt, the medial posterior facet
Figure 9. Lateral and medial rotation of the patella (Figure
moves closer to the medial femoral condyle, while a
14.14 in Loudon – Clinical Mechanics and Kinesiology) ©
lateral tilt is movement of the lateral posterior patel- Human Kinetics
lar facet moving closer toward the lateral femoral
condyle.

Open chain
During open chain knee motion, the patella follows
the path of the tibia due to the distal insertion of
the patellar tendon to the tibial tubercle. The patella
Figure 10. Lateral glide of patella during knee motion (Figure
glides inferiorly with knee flexion and superiorly
14.14 in Loudon – Clinical Mechanics and Kinesiology) ©
with knee extension (Figure 11). With a quadriceps Human Kinetics
set the patella should migrate approximately 10 mm
superiorly.32 The contact point moves proximally along the patella
and inferior-posterior along the femoral condyles
As the knee flexes, the articulating surface of the (Figure 12). The overall pattern of patellar contact
patella changes throughout the range of knee motion. area increases with increasing knee flexion, which

The International Journal of Sports Physical Therapy | Volume 11, Number 6 | December 2016 | Page 825
 Figure 12. Patellar contact points during knee motion. (Fig-
ure 14.16 in Loudon – Clinical Mechanics and Kinesiology) ©
Human Kinetics

60 degrees of knee flexion, the superior half of the

patella contacts part of the femoral groove slightly
inferior to the contact area at 30 degrees. The contact
Figure 11. Open chain patellar motion with knee extension
area gradually increases as the joint becomes more
(superior glide) and knee flexion (inferior glide) (Figure 14.13 in
Loudon – Clinical Mechanics and Kinesiology) © Human congruent. The contact area continues to increase
Kinetics as the knee flexes to 90 degrees and is estimated
to be 6.0cm2. At this point, the superior portion of
patella is contacting an area of the femoral groove
serves to distribute joint forces over a greater surface just above the notch.
area. In those with normally aligned patellofemoral
After 90 degrees and until 120 degreed of knee flex-
joints, this distribution of force allows the knee to
ion the superior aspect of the patella contacts the
resist the deleterious effects that could occur from
area of the femoral groove immediately surrounding
routine exposure to high compressive forces.
the intercondylar notch. In deep flexion the patella
Several references report that in full knee extension, actually bridges the span of the intercondylar notch
the patella lies just proximal to the trochlea of the and there is only contact on the far medial and lateral
femur, resting on the suprapatellar fat pad and supra- edges of the patella.34 At full flexion, the odd facet is
patellar synovium.15,16,25,26 Contrary results by Powers the only articulating contact between the patella and
et al. indicate that there is contact of the patella and the lateral surface of medial femoral condyle.
the trochlea at full knee extension.33 Nevertheless,
Besides the superior and inferior motion of the
the trochlear groove is shallow at this point resulting
patella, it also tracks lateral-medial-lateral during
in compromised stability of the patella and there is a
tibiofemoral extension to flexion.16 In the normal
greater potential for instability at this position.
knee little excessive medial or lateral motion occurs
As the knee begins to flex, the inferior aspect of the during flexion as the patella remains relatively cen-
patella contacts the uppermost portion of the femo- tered on the trochlea. It is important to note that
ral condyles. This contact begins between the lateral in full knee extension the patella sits slightly lateral
femoral condyle and the lateral facet of the patella, because of the external rotation of the tibia. The esti-
but by 30 degrees the contact is evenly distributed mated amount of medial and lateral displacement
on both sides of the condyles and the total contact is about 3 mm in each direction. As the knee flexes,
area has been estimated to be approximately 2.0cm2. the patella glides medially and centers itself within
The contact area initially is small and gradually the trochlear groove. During knee extension from 45
increases as the joint become more congruent. At degrees to 0 the patella tilts medially 5–7 degrees

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 PATELLOFEMORAL JOINT REACTION
FORCE (PFJRF)
Patellofemoral joint reaction force (PFJRF) is the
resultant compression force acting on the joint and
is dependent on knee joint angle and muscle tension
(Figure 13).26 The actual stress placed on the patel-
lofemoral joint is the PFJRF divided by the patel-
lofemoral joint contact area and referred to as joint
stress measured as force per unit area. The greater
the contact area between the patellar surface and
femur the less stress is placed on the articular tis-
sue.16 A high PFJRF combined with a small contact
area results in high patellofemoral joint stress and
may be harmful to the joint cartilage. This stress can
be amplified with poor patellar positioning which
will be discussed in the next section.

As the contact point changes between the patella

and trochlea throughout the range of motion;
accordingly, the joint forces change too due to a
Figure 13. Patellofemoral joint reaction force (Figure 14.17 in
change in the lever system. In non-weightbear-
Loudon – Clinical Mechanics and Kinesiology) © Human Kinetics
ing, the contact area between patella and trochlea
increases as the knee flexes from 0-90 degrees and
from a laterally tilted position related to the geom- therefore less patellofemoral stress occurs as knee
etry of the femoral trochlear groove.35 At around 30 flexion increases. It has been commonly accepted
degrees of flexion the patella glides back towards the to minimize patellofemoral joint stress open chain
lateral side where it maintains this lateralization for exercises should occur from 90 to 30 of knee flexion.
the remaining knee flexion. The motion has been
described as a C-curve pattern.26 When the foot is fixed, the PFJRF increases from 90
to 45 degrees, then decreases as the knee approaches
In normals, the patella may be tilted laterally (lat- full extension.16 PFJRF and patellofemoral joint
eral side down) when the knee is in extension and stress can be tremendous during even the simplest
in earlv flexion, but this tilt is slight and considered of activities of daily living, not to mention with
“reducible” (the lateral border can easily be lifted sports and recreational activities.38 Studies have
off the lateral femoral condvle to make the patella demonstrated forces of 1.3 times body weight (BW)
horizontal). during level ambulation, 3.3 times BW during stair
ambulation, 5.6 times BW during running, and up
Closed Chain to 7.8 times BW during a deep knee bend or squat.39
In closed kinetic chain movements the patella is
relatively tethered within the quadriceps tendon so
CLINICAL APPLICATION
as the femur rotates in the transverse plane, it is the
Excessive patellofemoral joint stress appears to be
femoral surface that glides behind the patella.12 With
the cause of PFP.3,10 The joint stress can be caused
excessive femoral internal rotation, the lateral facet
by abnormal anatomy or alignment, abnormal patel-
of the patella approximates to the lateral anterior
lar tracking, lower kinetic chain factors, and general
femoral condyle.35 Increased hip adduction/internal
overuse.8 The goal of the evaluation is to identify the
rotation has been proposed to be a risk factor associ-
likely cause of symptoms.
ated with PFP.36 The frontal plane projection angle
has been clinically useful in determining faulty Wiberg has suggested that the shape of the patella as
kinematics with individuals with PFP (Figure 13).37 an influencing factor in the development of patellar

The International Journal of Sports Physical Therapy | Volume 11, Number 6 | December 2016 | Page 827
pain.40 Wiberg devised a classification system based have reported the development of PFPS in subjects
on the articular facet shape of the patella40. However, who exhibited lack of pronation during gait.46,47
the various shapes are hard to identify radiographi- Other distal factors that may influence the kinemat-
cally and may not be as helpful as Wiberg proposed. ics at the knee are limited dorsiflexion and excessive
Different forms of dysplastic patellae are associated midfoot mobility.
with subluxation and dislocation. Examples of dys-
plastic patellae include alpine hunter’s cap, pebble, CONCLUSIONS
patella magna, and patella parva. Some individuals Excellent comprehension of the structures and forces
have trochlear dysplasia in which the facets are not that influence patellofemoral function is paramount
properly formed. Those who have a smaller lateral to understanding the wide variety of clinical prob-
trochlea than normal tend to be more prone to lat- lems found at the patellofemoral joint. This informa-
eral dislocations or subluxations of the patellofemo- tion may be applied when examining and assessing
ral joint. Beyond anatomy, patellar malalignment athletes, as well as when prescribing rehabilitation
(lateralization) causes excessive compressive stress interventions so that exercises are performed in
to the lateral patella facets inducing PFP. ranges of motion that place minimal strain on dam-
aged or vulnerable structures.
Abnormal tracking will also create undue stress
on the patellofemoral joint. The balance between
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