Clinical Radiology (2004) 59, 543557

REVIEW

Imaging of patellofemoral disorders

D.A. Eliasa,*, L.M. Whiteb
Departments of aRadiology, Kings College Hospital, London, UK; and bDiagnostic Imaging, University of
Toronto, Mount Sinai Hospital and the University Health Network, Toronto, Ontario, Canada
Received 12 June 2003; received in revised form 5 January 2004; accepted 13 January 2004

KEYWORDS
Patellofemoral; Knee;
Computed tomography
(CT); Magnetic resonance
(MR); Conventional
radiographs

Anterior knee pain is a common symptom, which may have a large variety of causes
including patellofemoral pathologies. Patellofemoral maltracking refers to dynamic
abnormality of patellofemoral alignment and has been measured using plain film,
computed tomography (CT) and magnetic resonance imaging (MRI) using static and
kinematic techniques. Patellar dislocation is usually transient, but specific conventional
radiographic and MRI features may provide evidence of prior acute or chronic dislocation.
In addition, chondromalacia patellae, osteochondritis dissecans, patellofemoral osteoarthritis, excessive lateral pressure syndrome, and bipartite patella have all been
implicated in causing patellofemoral pain. The imaging and clinical features of these
processes are reviewed, highlighting the specific diagnostic features of each condition.
q 2004 The Royal College of Radiologists. Published by Elsevier Ltd. All rights reserved.

Introduction
Patellofemoral disorders commonly cause anterior
knee pain and giving way. Anatomical features
associated with these disorders, and features of
joint degeneration or prior trauma can be identified
clinically and radiologically. However, the link
between anatomical or pathological findings and
symptoms is variable, and many surgical procedures
used for patellofemoral disorders have variable
results, especially at long-term follow-up.1 This
may be in part because patellofemoral relationships
are usually measured in the supine resting knee, but
failure occurs in the loaded, functioning joint.
Methods for imaging the joint in both resting and
functional states will be reviewed.

Anatomical and biomechanical

considerations
The posterior surface of the patella articulates with
the trochlear groove along the anterior surface of
*Guarantor and correspondent: D.A. Elias, Department of
Radiology, Kings College Hospital, Demark Hill, London SE5 9RS,
UK. Tel.: 11-44-20-7346-4599; fax: 11-44-20-7346-3157.
E-mail address: david.elias@kingsch.nhs.uk

the femoral condyles to form the patellofemoral

joint. The posterior patella has a narrower medial
and a wider lateral facet. A variable, usually small,
odd facet lies along the medial border of the
patella.
By displacing the fulcrum of motion of the extensor
mechanism anterior to the femur, the patellofemoral
articulation produces a mechanical advantage
increasing the force of the quadriceps muscles in
extending the knee. Because of this, considerable
force is transmitted across the patellofemoral joint,
which may vary from half body weight during walking,
up to 25 times body weight on lifting a weight with the
knees flexed at 908.2
In the fully extended knee the patella lies superior
to the trochlear cartilage. As the knee flexes to 308,
the patella begins to engage with the trochlea.
Between 30 and 908 of flexion, first the inferior and
then the superior patella cartilage articulates with
the trochlear cartilage. Beyond 1208, contact is
reduced between the patella and trochlea such that
only the small odd facet remains in contact with the
femur. The depth of the trochlear groove is important
in maintaining the patella stabilized over the anterior
knee, but contact between the articular surfaces is
limited during normal motion, and additional passive
and active mechanisms help maintain articular
stability.

0009-9260/$ - see front matter q 2004 The Royal College of Radiologists. Published by Elsevier Ltd. All rights reserved.
doi:10.1016/j.crad.2004.01.004

544

D.A. Elias, L.M. White

Passive stabilizers

Active stabilizers

The patellar ligament and the medial and lateral

patellar retinacula form the passive stabilizers of
the patella. The retinacula have deep and superficial layers.3,4 The superficial layers of the retinacula attach to the patella and patellar ligament and
extend to the fascia of sartorius medially and to the
fascia of the iliotibial band laterally. The deep
layers contain thickenings that form ligaments,
which provide significant stabilizing support to the
patella.
On the medial side, the medial patellofemoral
ligament (MPFL) a fascial thickening of the deep
layer of the medial retinaculum has been shown to
be the major passive restraint preventing lateral
patellar dislocation (Fig. 1).5 This ligament originates between the adductor tubercle and the
medial epicondyle of the femur and extends
forwards just deep to the inferior fibres of vastus
medialis to insert onto the superior two thirds of
the medial patellar margin.4 7 Inferior to the MPFL,
the patellomeniscal and patellotibial ligaments
play a more minor role in medial restraint of the
patella.
On the lateral side, the deep layer consists of the
transverse ligament, which extends from the
iliotibial tract to the lateral patellar margin.
Above this ligament lies the epicondylopatellar
band and below it the patellotibial band.

The four quadriceps muscles form the active

stabilizers of the patella. The inferior portions of
the vastus medialis and lateralis muscles form small
muscle groups with a distinct oblique orientation of
their fibres, the vastus medialis obliquus and the
vastus lateralis obliquus muscles (Fig. 1). These
provide active restraining forces on the patella in
the medial and lateral directions, respectively. The
vastus medialis obliquus attaches to the distal
adductor magnus tendon and inter-muscular
septum, and inserts onto the medial retinaculum
and superomedial patellar border.5

Pathological processes
Anterior knee pain is a common clinical symptom
with many potential causes, some of which relate to
the patellofemoral articulation (Table 1). The
terms used to describe patellofemoral disorders
discussed below have been used rather loosely. In
particular chondromalacia patellae has sometimes
been used as a catch-all phrase to describe
patellofemoral pain with or without documented
chondral abnormality. The term patellofemoral
pain syndrome may be used in preference to
include multiple conditions described in Table 1,
each of which is associated with patellofemoral
pain.8

Patellofemoral malalignment and

maltracking
Patellofemoral alignment refers to the static
relationship between the patella and the trochlea
at a given degree of knee flexion. Tracking refers to

Table 1 Causes of anterior knee pain

Figure 1 Schematic diagram of the medial knee. The

medial patellofemoral ligament (MPFL) arises between
the adductor tubercle (the insertion of the adductor
magnus tendon), and the medial epicondyle (the site of
origin of the medial collateral ligament). The ligament
then runs forward just deep to the distal vastus medialis
obliquus muscle to attach to the superior two thirds of the
medial patella margin. Reprinted with permission from
Radiology.48

Patellar malalignment
Chondromalacia patellae
Patellofemoral osteoarthritis
Excessive lateral patella pressure
Patella osteochondritis dissecans
Osteochondral injury
Pre-patella bursitis
Infra-patella bursitis
Hoffas syndrome
Synovial plica
Patella/quadriceps tendonosis/tears
Osgood-Schlatter disease
Sinding-Larsen-Johansson disease
Meniscal tears
Reflex sympathetic dystrophy

Imaging of patellofemoral disorders

dynamic patellofemoral alignment during knee

motion. Thus, malalignment and maltracking refer
to conditions in which there is an imbalance of
forces on the patella that produce abnormalities of
alignment and tracking, respectively.9 This imbalance may result from a combination of variables in
bony geometry, function of active and passive softtissue restraints and functional demands. The result
of patellofemoral malalignment and maltracking is
unfavourable stresses and shearing forces that
exceed the physiological threshold of tissues and
may result in cartilage damage, degenerative
changes, strain of ligamentous structures, mechanical failure or patellar dislocation. Symptoms
therefore include pain, apprehension and giving
way.
Clear definition of patellofemoral malalignment
and maltracking is hindered by the fact that clinical
and radiological measures described are often
abnormal in asymptomatic knees, and within
described normal ranges in symptomatic knees.
Also measures of alignment will vary depending on
the degree of knee flexion, and may be very
different in the supine resting knee (in which
position most clinicoradiological measurement is
performed) compared with the loaded walking knee
(in which symptoms occur).
Imaging studies of patellofemoral tracking
should focus on the first 30 458 of flexion, as
beyond 458 most patellae engage fully with the
trochlear groove. In early flexion anatomical
factors including an elevated patella (patella
alta), trochlear dysplasia and abnormalities of the
soft-tissue restraints of the patella have the most
pronounced effect in producing abnormal tracking.
The Q angle is formed between a line joining the
anterior superior iliac spine and the centre of the
patella, and a line joining the centre of the patella
and the tibial tuberosity (Fig. 2). This angle is
measured clinically, and is thought to indirectly
reflect the degree of valgus translational force
exerted upon the patella with contraction of the
extensor mechanism of the knee. It may therefore
help explain the tendency to lateral instability of
the patella, and some studies have suggested that
the Q angle may be increased in patients with
patellofemoral pain.10 Other authors have, however, contradicted this finding,11 possibly because
in the fully extended knee, a malaligned patella
may be laterally translated, artificially reducing the
Q angle measurement. The measurement may
therefore be more successfully performed at 308
of knee flexion with the patella engaged in the
trochlea thus preventing this lateral displacement.12

545

Figure 2 The Q angle is formed between a line joining

the anterior superior iliac spine (ASIS) and the centre of
the patella, and a line joining the centre of the patella
and the tibial tuberosity.

Radiographs
The standard radiographic series for assessment of
patellofemoral relationships includes an anteroposterior, a lateral and an axial view. Several techniques have been described for the axial view of the
patellofemoral joint (Fig. 3). The most widely
accepted techniques are performed with the
patient supine. The feet are placed either on13 or
off14 the end of the examination table and the
radiograph is taken with 20 458of knee flexion. In
order to attempt a more physiological assessment
of patellofemoral alignment, a technique for
performing a standing axial view has been advocated.2
Wiberg15 described three patellar types based on
morphology on the axial view (Fig. 4). However, the
value of such classifications in predicting patella
instability is unproven. Additionally, as patellar
configuration appears to change from level to level
on cross-sectional patellar imaging, the validity of
morphological assessment on axial radiographs
appears questionable. Trochlear depth may be
measured using the sulcus angle (Fig. 5a). This
measurement has been shown to be relatively
insensitive to the angulation between the beam
and the femur with a normal range of 126 1508.14,16
Measurements of lateral patellar displacement
include the congruence angle,14 and lateral displacement.13 Lateral tilt may be measured using

546

Figure 3 Techniques for performing the axial radiograph of the patella. The prone technique (a) requires
knee flexion . 908, and therefore eliminates subluxation
in most patients with tracking abnormality. Supine
techniques are more valuable for assessment of patella
alignment and include those of Laurin et al.13 (b) with the
knee flexed at 208, and Merchant et al.14 (c) with the knee
flexed at 458. The Merchant technique may be performed
with the beam direction reversed (d), which eliminates
the need for a special cassette holder. To perform a
weight-bearing axial view (e) a specially designed knee
support is required, but this may provide a more
physiologic assessment, of patellofemoral alignment.2

the lateral patellofemoral angle (Fig. 5).17 Abnormalities to these measurements may represent
malalignment, but in mild degrees of knee flexion,
abnormal measurements of patellar tilt and subluxation may be seen in asymptomatic patients with
normal patellofemoral biomechanics. Recent work
suggests that apparent discrepancies between
radiographic measures of the patellofemoral articulation and clinical symptoms may be resolved when
measurements are performed on weight-bearing,
axial views.18
The lateral view of the knee allows assessment of
the vertical position of the patella. A high-riding
patella (patella alta) is associated with lateral
patellar dislocation and subluxation, chondromalacia patellae, patellar ligament rupture and
Sinding-Larsen-Johansson disease. A low-riding
patella (patella baja) is seen in quadriceps tendon
rupture, neuromuscular disorders, achondroplasia,
and after surgical advancement of the tibial
tuberosity. For the Insall-Salvati method of patellar

Figure 4 Anatomic variations in patellar shape.15 Type

1 patellae have concave medial and lateral facets
approximately equal in size. Type 2 also have concave
facets, but the medial facet is smaller than the lateral.
Type 3 have a small convex medial facet.

D.A. Elias, L.M. White

position measurement, the patellar ligament length

is divided by the maximal diagonal length of the
patella on the lateral radiograph (Fig. 6a).19 The
normal ratio is approximately 1, and a ratio of , 0.8
is considered to show patella baja, whilst a ratio of
. 1.2 is indicative of patella alta. A modification of
this index, which is less sensitive to variation in
patella morphology, is calculated as the distance
between the inferior articular surface of the patella
and the patellar ligament insertion divided by the
length of the patella articular surface (Fig. 6b).20
For the modified index, patella alta is defined as a
ratio of . 2.
On a true lateral radiograph with the posterior
borders of the femoral condyles overlapping, an
assessment may be made of patella tilt and
trochlear groove depth (Fig. 7).21,22 Measurement
of patellar tilt on lateral radiographs with the knee
in full extension, has been shown to have a greater
sensitivity for patellofemoral pain and prior dislocation than measures of patellar tilt on the axial
view.22 This is because patellar tilt may become
less pronounced at the greater degrees of flexion
required for performing an axial radiograph.23
Measurement of trochlear groove depth on lateral
radiographs of the knee additionally allows for
assessment of the critical proximal portion of the
groove at which site dysplasia reduces patellofemoral engagement during early flexion. In contrast, only the more distal trochlear groove is
typically seen on axial radiographs.
Where there is no patellar tilt (designated grade
I) the median ridge of the patella lies posterior to
the lateral patellar facet. Therefore, on a true
lateral radiograph of the knee the median ridge and
lateral facet form two separate borders that appear
slightly concave.22 With mild patellar tilt (grade II)
the median ridge and lateral facet lie in the same
coronal plane, so that on the true lateral radiograph
only one border is seen. With further tilt (grade III),
the lateral facet projects posterior to the median
ridge and appears convex. The depth of the
trochlear groove may be measured on the lateral
radiograph of the knee, 1 cm distal to its upper
limit. A depth of , 5 mm is considered dysplastic.
Cross-sectional imaging
A number of studies have shown that computed
tomography (CT) and magnetic resonance imaging
(MRI) of the patellofemoral joint can effectively
demonstrate abnormalities of patellar tracking in
patients with patellofemoral symptoms.24 31 These
studies have demonstrated that in many patients
with patellofemoral symptoms and patella subluxation at less than 308 of flexion, the patella
centralizes in the trochlear groove as flexion

Imaging of patellofemoral disorders

547

Figure 5 Measurements of patellofemoral relationships on the axial radiograph. (a) A line is drawn from the lowest
point of the intercondylar sulcus, B, to the highest points of the lateral and medial femoral condyles, A and C. The angle
between lines AB and BC is the sulcus angle (normal range 126 1508). To measure the congruence angle (curved arrow),
the sulcus angle is bisected to produce a reference line, and the angle is measured between this reference and a line
joining the apex of the sulcus, B, and the lowest point of the patellar articular surface, D. In the normal knee, point D
should lie no more than 168 lateral to the bisected sulcus angle.14 (b) Lateral patellar displacement is measured by
drawing a line joining the summits of the medial and lateral femoral condyles and dropping a perpendicular to this at the
level of the summit of the medial condyle. The distance of the medial margin of the patella from this perpendicular is
measured (arrowheads). In the normal knee the medial patellar margin should lie no more than 1 mm lateral to the
perpendicular.13 (c) The lateral patellofemoral angle (curved arrow) is the angle between a line joining the apices of the
femoral condyles and a line joining the limits of the lateral patellar facet. The angle is taken to be normal when it opens
laterally, and abnormal when it opens medially.13

increases beyond this point (Fig. 8). Conversely,

asymptomatic knees often show some degree of
physiological patellar tilt or subluxation at full
extension. Imaging over the range of 5 308 of
flexion is therefore of greatest value in discriminating normal from abnormal tracking and alignment.
For CT or MRI examination patients may lie
supine or prone. A passive supine examination may
be performed with the knee at 0, 10, 20 and 308 of
flexion. For a patient with an equal leg and thigh
length of 450 mm, this requires raising the back of
the knee by 0, 40, 80 and 115 mm from the table.32
Alternatively, various devices are described to
allow passive placement of the joint in fixed
degrees of early flexion. At each position axial
images are performed through the patellofemoral
joint. Prone examination requires a cut out in the
table top below the knee to prevent artificial
patella displacement by the table.
In order to assess patellofemoral relationships
more physiologically, rapid techniques able to
capture images during active knee motion are
described. With CT this was initially performed
using electron beam imaging,33 but more recently a
technique using a helical CT machine to perform a
continuous 10 s exposure with no table movement
has been described.25,26 The images are acquired at
mid-trochlea level, and during the exposure the
knee is actively flexed and extended with the thigh
strapped down at the end of the examination table.
A weighted boot may be used to increase quadriceps loading. With MRI, fast imaging sequences,
such as spoiled gradient recalled acquisition in the
steady state (GRASS) have been used,28 with
sequences triggered manually or using motion
sensitive detectors. In supine MR studies, active
motion appears to accentuate the measured differences in patellar tracking between painful and

asymptomatic knees.31 This may be reproduced in

prone studies by using a device for quadriceps
loading,29 and is presumably because quadriceps
dysfunction may contribute to maltracking, a factor
not assessed in passive studies.
For evaluation of subluxation and tilt on crosssectional patellofemoral studies some authors
advocate a purely qualitative assessment and
evaluation of a series of axial images at a single
level combined as a cine loop allows tracking
abnormalities to be readily identified.27,34 Others
have adapted various plain radiographic measurements,23 25,30,31,33,35 including the sulcus angle,
lateral patellofemoral angle, congruence angle and
lateral patella displacement. The trochlea tubercle distance is an additional measurement performed on cross-sectional images, whichsimilarly
to the Q angleis a measurement of the lateral pull
on the patella. For this measurement axial images
through the apex of the intercondylar notch and the
tibial tubercle are overlapped, and the horizontal
distance between the apex of the notch and the
tubercle is measured. A tubercle lying more than
2 cm lateral to the apex of the notch has been
shown to be specific, but is poorly sensitive for
maltracking.34
Post-operative imaging
Surgery for correction of patellar maltracking
includes procedures for bony and soft-tissue
realignment. Several forms of osteotomy transfer
the tibial tuberosity to a more medial position so as
to reduce the Q angle and reduce the lateral
translational stress on the patella. The Hauser
procedure36 was an early example, which has now
fallen out of favour. This osteotomy transfers the
tibial tuberosity not only medially, but also
posteriorly, causing a significant increase in

548

D.A. Elias, L.M. White

Figure 7 Patellofemoral measurements on the lateral

radiograph.21,22 (a) Axial diagrams depicting grades I, II
and III patellofemoral alignment. (b) Diagrams representing the corresponding appearance of the patellar on a
true lateral radiograph of the knee for grades I, II and III
alignment. In grade I alignment (normal) the median ridge
of the patella (open arrow) lies posterior to the lateral
facet (curved arrow). On a lateral radiograph the median
ridge and lateral facet form two separate borders which
appear slightly concave. With mild patellar tilt (grade II)
the median ridge and lateral facet line up on the lateral
views so that only one border is seen. With further tilt
(grade III), the lateral facet projects posterior to the
median ridge and appears convex. (c) Normal lateral
radiograph of the knee. The depth of the trochlear groove
may be measured 1 cm distal to its upper limit (arrows).
Less than 5 mm is considered dysplastic. Patella alignment is grade I. Note that these measurements may only
be made on a true lateral radiograph in which the
posterior borders of the femoral condyles virtually
overlap.
Figure 6 Measurements of patellar height on a lateral
radiograph of the knee of a 14-year-old male with
recurrent patellar dislocation. (a) For the Insall-Salvati
method the patellar ligament length is divided by the
maximal diagonal length of the patella on the lateral
radiograph.19 The ratio here is 1.5 (. 1.2 indicates patella
alta). (b) A modified index, which is less sensitive to

variation in patella morphology, is calculated as the

distance between the inferior articular surface of the
patella and the patellar ligament insertion divided by
the length of the patella articular surface.20 The ratio is
measured at 2.2 (. 2 indicates patella alta).

Imaging of patellofemoral disorders

549

Figure 8 Supine CT examination of both knees at 0, 10,

30 and 458 of knee flexion in a 14-year-old male patient
with right-sided anterior knee pain and a history of
recurrent left patella dislocations. The right knee shows
no subluxation, but there is lateral patella tilt at 10 and
308 which normalizes by 458 of flexion. The left knee
shows osteochondral irregularity to the medial patella
with a small separated adjacent bony fragment (arrowhead) as well as an osteochondral fragment at the lateral
femoral condyle (arrow), all consistent with prior patellar
dislocation. There is a joint effusion. There is patellar tilt
and lateral subluxation at 10 and 308 which revert to mild
medial subluxation at 458. Both knees show shallow
femoral trochlear grooves.

pressure within the medial patellofemoral joint,

and resultant complications of patellofemoral
osteoarthritis37 (Fig. 9). Therefore realignment
osteotomies that transfer the tibial tuberosity
medially but not posteriorly are preferred (such as
in the Roux-Elmslie-Trillat procedure).38 Where
patella alta is felt to be significant in causing late
engagement of the patella with the trochlea
during knee flexion, tibial tuberosity advancement
has been advocated. In patients with excessive
femoral anteversion or external tibial torsion,
rotational osteotomies can be performed to
reduce lateral translational stress on the patella.
In patients with significant lateral patellar tilt a
lateral retinacular release is sometimes performed. This can be identified as a vertical
disruption in the lateral retinacular fibres on
MRI. Repair or reconstruction of the medial
ligaments may be performed where there has
been prior traumatic disruption. Multiple realignment procedures may be combined in a single
operation. For example the Roux-Elmslie-Trillat
procedure includes lateral release, medial capsular tightening and medial and distal displacement
of the tibial tuberosity.

Lateral patella dislocation

Figure 9 Medial patellofemoral osteoarthritis 15 years

after tibial tuberosity transfer for patellar instability. (a)
Sagittal fat-saturated T2-weighted image demonstrates
surgical changes at the tibial tuberosity, as well as
marrow oedema of the inferior patella. (b) Axial fatsaturated T2-weighted image demonstrates medial tilt,
as well as cartilage loss and marrow oedema at the medial
patella and trochlea. Medialization of the tibial tuberosity has increased stresses in the medial patellofemoral
compartment leading to osteoarthritis.

Lateral patellar dislocation is a common cause of

acute traumatic haemarthrosis in young active

patients, usually occurring during sporting activities.39 However, patellar dislocation is usually

550

transient, with patients frequently unaware that it

has occurred. Additionally, full examination of the
acutely swollen painful knee may be difficult. For
these reasons patellar dislocation has been found to
be initially clinically unsuspected in as many as 45
73% of cases,40,41 and MRI findings are sometimes
the first indication of the diagnosis.
As the patella dislocates laterally, there may be
injury to the medial soft-tissue restraints of the
patella. During spontaneous relocation, the medial
patella impacts upon the anterior aspect of the
lateral femoral condyle resulting in osteochondral
fractures and potential impaction deformity of the
inferomedial patella, analogous to the Hill-Sachs
lesion of the humeral head, which follows anterior
dislocation of the glenohumeral joint.
On conventional radiographs the patella is rarely
seen to be dislocated (Fig. 10). There may,
however, be patella tilt and or subluxation. A
haemarthrosis may be present. Osteochondral
fractures of the medial patella or anterior lateral
femoral condyle may be seen,42 44 and there may
be a separated intra-articular fragment. However,
the plain radiographic findings of patellofemoral
dislocation are often subtle.
A constellation of findings have been described at
MRI, characteristic for previous lateral patellar
dislocation, and which may be helpful diagnostically. 40,41,45,46 These include joint effusions,
injuries to the medial retinaculum, and contusion
or osteochondral injury of the anterolateral portion
of the lateral femoral condyle and of the medial
patella. Signal changes are also described within
the superior portion of Hoffas fat pad.47 Bone
contusions occur at characteristic locations, at the
anterior portion of the lateral femoral condyle
(anterior and superior to the typical site of
contusion occurring with anterior cruciate ligament
injury), and at the medial patellar margin inferiorly. In one study, a concave impaction deformity
of the inferomedial patella, identified on MRI on at
least two consecutive slices, had a sensitivity of 44%
and a specificity of 100% for previous lateral patella
dislocation (Fig. 11).48
Injuries to the medial retinaculum are identified
after lateral patella dislocation at its midsubstance
and patella attachment, and this appears as
surrounding oedema, or fibre irregularity or discontinuity. Emphasis on the biomechanical importance of the MPFL is noted in some recent surgical
studies, some with MRI correlation, which have
identified injury to the ligament in as many as 94
100% of acute patella dislocators at open operation.6,49 51 Arthroscopically, such injury may be
relatively occult as the MPFL is an extra-capsular
structure. Almost all of the MPFL injuries in these

D.A. Elias, L.M. White

Figure 10 Knee radiographs after lateral patellar dislocation. (a) Anteroposterior radiograph of the knee
showing a laterally dislocated patella. The patella usually
spontaneously reduces and this appearance is rare. (b)
Axial radiograph of the patella in a different patient. The
patella is reduced, but note the osteochondral fragment
adjacent to the medial patella and the small concave
defect at the medial patellar margin. These occur due to
impaction of the medial patella upon the anterior aspect
of the lateral femoral condyle at the time of dislocation.

studies occurred at or close to its femoral attachment, and it is this portion of the ligament that is
best identified on axial MR images (Figs. 12 and
13).52 Identification of these injuries may be
important as several authors have advocated
MPFL repair to prevent recurrent patellofemoral
instability and dislocation.49,53 55
Evidence of injury to the vastus medialis obliquus
muscle, after lateral patellar dislocation has been
noted on MRI as oedema about its distal fibres and

Imaging of patellofemoral disorders

551

Figure 11 Axial gradient echo MRI image of the knee 3

weeks after acute transient lateral patellar dislocation
demonstrates a concave impaction deformity (small
white arrows) of the medial patella. There is a contusion
(asterisk) at the lateral femoral condyle. Note the
complete tear (open white arrow) at the patellar
insertion of the medial patellar retinaculum. Reprinted
with permission from Radiology.48

possibly stripping of its distal attachment to the

adductor tubercle (Fig. 14).48 50

Excessive lateral pressure syndrome

Excessive lateral pressure syndrome refers to a
condition in which lateral patellar tilt is dominant
with little or no subluxation.56 This condition occurs
in adolescents and adults often presenting with
patellofemoral pain. Imaging studies may reveal
cartilage loss, sclerosis and cystic change of the
lateral patella and trochlea (Fig. 15). Dynamic
studies may show lateral patella tilt, which tends to
increase with increasing flexion, but with little
subluxation.27

Chondromalacia patellae
The term chondromalacia patellae is properly
applied to a syndrome of anterior knee pain,
typically in young patients, with initial pathological
changes of cartilage softening, swelling and
oedema.15,57 Proposed causes include trauma,
chronic stress, patellofemoral instability and anatomic variations in bony morphology. Chondromalacia patellae may be reversible, or may progress to
develop patellofemoral osteoarthritis.58

Figure 12 Appearance of the normal MPFL on MRI. (a)

Axial gradient echo MR image of the knee immediately
inferior to the adductor tubercle demonstrates a normal
femoral origin of the MPFL (open arrow). The distal vastus
medialis obliquus muscle (arrowhead) lies anteriorly. (b)
Axial gradient echo MR image just inferior to (a)
demonstrates the proximal origin of the medial collateral
ligament (open arrowhead). Note that the medial patellar
retinaculum (open arrow) shows a bilaminar appearance
(see text) Reprinted with permission from Radiology.48

Cartilage lesions typically occur along the medial

patella at the ridge between the medial and the odd
facets, but may occur anywhere along the patellar
articular surface. A variety of classifications for
cartilage disease have been proposed. In one
system, grade 1 represents cartilage softening and

552

Figure 13 Axial fat-saturated T2-weighted image of the

knee 4 days after acute transient lateral patellar
dislocation. There is complete disruption of the medial
patellofemoral ligament from its femoral attachment
(thin white arrow). Note the concave impaction deformity of the inferomedial patella (black arrow) with marrow
contusion. There is a joint effusion and prominent
oedema along the lateral patellar retinaculum. Note the
site of origin of the medial collateral ligament (open
white arrow).

Figure 14 Coronal spin-echo T2-weighted MR image of

the knee 3 weeks after acute transient lateral patellar
dislocation demonstrates high T2 signal (white arrows)
surrounding the distal vastus medialis obliquus muscle
(VMO), consistent with oedema.

D.A. Elias, L.M. White

Figure 15 Axial fat-saturated T2-weighted MR image of

the knee in a patient with findings of excessive lateral
pressure syndrome. There is marked lateral patellar tilt
but little subluxation and there is full-thickness cartilage
loss and marrow oedema confined to the lateral patella
facet. Note the normal cartilage thickness at the medial
patella (white arrows).

swelling, grade 2 represents cartilage fragmentation or fissuring of up to 1.3 cm in diameter, grade 3

represents fragmentation or fissuring of . 1.3 cm in
diameter, and grade 4 represents cartilage loss
down to subchondral bone.59
Conventional radiographs are insensitive for the
assessment of cartilage lesions, but will show joint
space loss when cartilage loss is extensive, as well
as associated changes of sclerosis and cystic change
in the underlying subchondral bone. Arthrography
combined with axial imaging of the patella may
show imbibition of contrast into areas of chondromalacia, but again sensitivity is low. CT arthrography after the intra-articular injection of air or
iodinated contrast may successfully demonstrate
focal areas of cartilage irregularity or loss. Scintigraphy may show abnormality in chondromalacia,
but usually only when changes in the subchondral
bone are present.
MRI holds promise in having the unique ability to
potentially identify cartilage defects, as well as
internal derangement of the cartilage layer before
gross morphological cartilage loss. Images are best
performed in the axial plane. Numerous MRI
techniques have been investigated for imaging of
patella cartilage. Normal cartilage may have
variable signal characteristics dependent upon the
sequences used, and a bi- or tri-laminar appearance
has variably been reported.60,61 The appearance of
normal cartilage may be affected by truncation,
chemical shift and magic angle artefacts, as well as

Imaging of patellofemoral disorders

its anatomical and chemical structure. Unsurprisingly therefore, the reported accuracy of MRI for
cartilage lesions varies widely in the literature,
with sensitivities reported of 31%62 up to 100%.63
The accuracy of MRI for early chondromalacia
without cartilage loss is unproven.
For successful cartilage imaging, an MRI
sequence must demonstrate good contrast at the
interfaces between cartilage and subchondral bone
and between cartilage and joint fluid. Fast spinecho intermediate-weighted or T2-weighted
images with fat saturation fulfil these criteria,
with black subchondral bone, intermediate signal
cartilage and high signal joint fluid, and have been
shown to be accurate in the assessment of cartilage
lesions (Fig. 16).64 These sequences additionally
demonstrate oedema and subchondral cystic
change in the underlying subchondral bone. A
variety of two and three-dimensional gradientrecalled echo techniques have also been successfully used. Three-dimensional fat-suppressed
spoiled gradient-recalled echo (SPGR) sequences
have been shown to be accurate, but require
relatively lengthy examination times.61 MR arthrography, using intra-articular administration of
saline or dilute gadolinium has also been advocated. Many other techniques have been extensively studied but a discussion of these is beyond
the scope of this article. Magnetization transfer,
diffusion-weighted imaging, ultra-short TE
sequences and spectroscopic imaging may prove

Figure 16 Axial fat-saturated T2-weighted MR image of

the knee in a patient with cartilage loss at the medial
patellar facet consistent with chondromalacia patellae.
Note the cartilage flap (black arrow) and the joint
effusion.

553

to be valuable techniques for imaging articular

cartilage in the future.

Patellofemoral osteoarthritis
Involvement of the patellofemoral compartment in
osteoarthritis of the knee is common. Typically the
lateral patellofemoral joint is involved in conjunction
with either the lateral or medial femorotibial joint.
Medial patellofemoral disease may occur in association with medial femorotibial osteoarthritis, but
isolated involvement of the medial patellofemoral
joint is distinctly unusual. Where osteoarthritis
appears to predominate in the patellofemoral compartment with sparing of the femorotibial joint, and
particularly where subchondral cysts are a dominant
feature, the possibility of calcium pyrophosphate
deposition disease should be considered.
The radiographic features of patellofemoral
osteoarthritis include joint space loss, subchondral
sclerosis and cysts and osteophytes at the posterior
margins of the patella. On MRI, cartilage loss and
subchondral sclerosis, oedema and cystic changes
are identified at the patellar and trochlea surfaces.

Osteochondritis dissecans
Osteochondritis dissecans of the patella is much
less common than osteochondritis of the femoral
condyles. It is usually unilateral and typically occurs
in males between 15 and 20 years old. The condition
is thought to be traumatic in origin, and there is
often a history of onset of pain during knee flexion
whilst lifting a weight.65,66
Osteochondritis dissecans of the patella almost
never affects the superior pole and is most
commonly seen along the medial patellar facet.
On conventional radiographs there is an osseous
defect and a separated bony fragment or fragments
may be seen. MRI may be helpful in determining the
stability of the osteochondral fragment.67 Signs of
instability on T2-weighted images include the
presence of a high signal intensity line between
the fragment and the host bone, articular fracture
indicated by fluid signal traversing the subchondral
bone plate, a focal osteochondral defect filled with
joint fluid, and a 5 mm or larger fluid-filled cyst
deep to the lesion.68
Differentiation of osteochondritis dissecans from
chondromalacia patellae may be difficult in some
cases, but in general, the latter condition is
confined to the overlying cartilage, whilst osteochondritis involves a fragment of subchondral bone
(Fig. 17).

554

D.A. Elias, L.M. White

Dorsal defect of the patella

A dorsal defect of the patella is a well-defined focal
defect in the subchondral bone that is confined to
the superolateral aspect of the patella. On arthrography and MRI the overlying articular cartilage
appears intact and indeed thickens to fill the defect
(Fig. 18). This lesion is usually asymptomatic and
appears to represent a variant of ossification,
possibly within the spectrum of the bipartite
patella. All of these features serve to differentiate
this lesion from osteochondritis dissecans.69,70

Bipartite patella
Bipartite patella occurs in approximately 2% of
individuals and is much more common in males
(Fig. 19). It is usually a bilateral finding. With rare
exceptions this anomaly occurs at the superolateral
aspect of the patella. The lesion is usually asymptomatic, but can be associated with localized anterior
knee pain.71 Histologically there may be evidence
of chondro-osseous tensile failure at the junction
with the host bone similar to that seen in OsgoodSchlatter disease and Sinding-Larsen-Johansson. It
has been suggested therefore that the lesion may
relate to stress at the site of insertion of vastus

Figure 18 Dorsal defect of the patella. (a) Sagittal T1weighted MR image shows a defect in the subchondral
bone of the superior patella. (b) Axial fat-saturated T2weighted MR image confirms the superolateral defect of
the subchondral bone. Note that the overlying cartilage is
thickened over the defect to produce a near normal
articular surface.

Figure 17 Axial fat-saturated T2-weighted MR image of

the knee in a patient with osteochondritis dissecans of
the lateral patellar facet. There is focal full-thickness
cartilage loss, as well as loss of a fragment of subchondral
bone, as evidenced by loss of the black stripe representing the subchondral bone plate within the lesion. Deep to
the lesion there is marrow oedema.

lateralis,69 challenging the previously held belief

that the lesion simply represented a normal variant
of ossification of no clinical significance.
The presence of increased activity on Tc99m bone
scintigraphy has been correlated with painful
bipartite patellae and may represent evidence of
abnormal stress.72

Imaging of patellofemoral disorders

555

complex nature of patellofemoral biomechanical

function and dysfunction. Imaging techniques have
contributed to the further understanding of these
processes, but the goal of imaging under true
conditions of everyday physiological function and
biomechanical loading has yet to be realized. In the
meantime, optimal patient management is best
informed when imaging protocols are appropriately
tailored to highlight patellofemoral pathology and
interpreted in the context of a current understanding of the various pathological processes
occurring in the patellofemoral articulation.

References

Figure 19 Bipartite patella. (a) Coronal T1-weighted

MR image demonstrates an accessory ossification centre
at the superolateral patella. (b) Axial fat-saturated T2weighted image demonstrates that the overlying cartilage appears intact.

Conclusion
Anterior knee pain is a common symptom with a
large variety of possible causes including pathologies related to the patellofemoral joint. Many of
these pathologies have been rather loosely defined
and remain incompletely understood because of the

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