The effects of a dynamic patellar realignment brace on disease determinants for patellofemoral instability in the upright weight-bearing condition
© Becher et al. 2015
Received: 11 May 2015
Accepted: 22 July 2015
Published: 19 August 2015
Patellar stabilizing braces are used to alleviate pain and prevent subluxation/dislocation by having biomechanical effects in terms of improved patellar tracking. The purpose of this study is to analyze the effects of the dynamic patellar realignment brace, Patella Pro (Otto Bock GmbH, Duderstadt, Germany), on disease determinants in subjects with patellofemoral instability using upright weight-bearing magnetic resonance imaging (MRI).
Twenty subjects (8 males and 12 females) with lateral patellofemoral instability were studied in an open-configuration magnetic resonance imaging scanner in an upright weight-bearing position at full extension (0° flexion) and 15° and 30° flexion with and without the realignment brace. Disease determinants were defined by common patellofemoral indices that included the Insall–Salvati Index, Caton–Deschamps Index, and the Patellotrochlear Index to determine patella height and patella tilt angle, bisect offset, and tuberositas tibiae–trochlear groove (TT–TG) distance to determine patellar rotation and translation with respect to the femur and the alignment of the extensor mechanism.
Analyses of variance revealed a significant effect of the brace with reduction of the three patellar height ratios, patella tilt angle, and bisect offset as well as TT–TG distance. Post hoc pairwise comparisons of the corresponding conditions with and without the realignment brace revealed significantly reduced patella height ratios, patella tilt angles, and bisect offsets at full extension and 15° and 30° flexion. No significant differences between the TT–TG distances at full extension but significant reductions at 15° and 30° flexion were observed when using the realignment brace compared to no brace.
This study suggests that the dynamic patellar realignment brace is capable of improving disease determinants in the upright weight-bearing condition in the range of 0° to 30° flexion in patients with patellofemoral instability.
KeywordsKnee Patellar instability MRI Patellofemoral indices Weight bearing Realignment brace
The etiology of lateral patellar instability is multifactorial with various contributing factors such as trochlear dysplasia, patella alta, malrotation as well as medial soft tissue disruption and insufficiency [1, 2]. Various parameters to define and quantify these factors have been described . Radiological assessments with radiography, computed tomography (CT), and magnetic resonance imaging (MRI) are of high importance for further evaluation of these parameters to assist clinical decision-making and differential diagnosis [2–5].
MRI has evolved as the most essential method offering numerous options such as the examination during weight-bearing conditions and at different flexion angles [6–8]. This appears important since at extension and early flexion, patellar motion is largely influenced by quadriceps activation [6, 8–10] and most patients are prone to lateral subluxation and/or dislocations within the first 30° of flexion when the patella is not constrained by the trochlea .
Various conservative and operative options are available for the treatment of patellar instability. In conservative management, physical therapy represents an important factor since muscular dysfunction might be positively influenced [12–14]. Supportive devices such as patellar stabilizing braces and patellar taping are used to alleviate pain by restoring better joint kinematics and prevent subluxation/dislocation by having biomechanical effects in terms of improved patellar tracking [15–18] and improved proprioception [14, 19]. A new dynamic patellar realignment brace (Patella Pro, Otto Bock GmbH, Duderstadt, Germany) with a dynamic tracking system to apply a medially directed force on the patella was recently introduced and is currently being subjected to a clinical trial . A biomedical study using human cadaver specimens showed that the brace has the potential to medialize the patella during 0°–45° flexion . However, the biomechanical effects of the brace in vivo remain to be proven.
In this study, it was hypothesized that the dynamic patellar realignment brace Patella Pro has positive effects on typical disease determinants in subjects with lateral patellar instability defined by common patellofemoral indices used in MR imaging at 0°, 15°, and 30° flexion in the upright weight-bearing condition.
Materials and methods
Study design and study group
In this explorative case–control study, the participants had to fulfill the following inclusion criteria: age >16 years, a minimum of two lateral patellar dislocations, and demonstration of appropriate fit of the realignment brace with the patients’ anatomy. Exclusion criteria were inability to keep the target knee positions for the estimated examination time as evaluated by pre-testing, significant frontal plane femorotibial malalignment >7° as measured on long leg standing radiography in the clinical routine, pregnancy, body mass index >35 kg/m2, and implanted devices that could interact with the magnetic field of the MRI scanner. Accordingly, 20 subjects (8 males and 12 females) with lateral patellofemoral instability scheduled for realignment surgery were included. The average age was 25.3 ± 7.0 (17–39) years; the average BMI was 23.6 ± 3.7 (18–34) kg/m2. The gender distribution of the study sample (8 males and 12 females) was chosen disproportionally based on epidemiological data that females are more frequently affected by chronic patellofemoral instability . Institutional review board approval (ID blinded) was obtained from the ethics committee of Hannover Medical School prior to the study.
Patellar realignment brace (Patella Pro)
The following sequences were obtained: (1) 3-dimensional (3D) weighted gradient-echo sagittal images with an 8 × 29 × 9.6 cm field of view (FOV); slice thickness 1.5 mm; matrix 64 × 160 pixel with a pixel resolution of 1.25 × 1.25; echo time (TE) 5.6 ms, repetition time (TR) 11.2 ms, flip angle 40°; scan time ~50 s. (2) T1-weighted axial images with an 26 × 26 × 6.5 cm FOV; slice thickness 2.5 mm; matrix 416 × 416 pixel with a pixel resolution of 0.625 × 0.625; TE 15 ms, TR 140 ms, flip angle 90°; scan time ~135 s.
Measurement of disease determinants
Further important factors as determinants of patellofemoral alignment are dependent on the geometry of the trochlear groove and rotation of the femur relative to the tibia. The patella tilt angle (PTA) [6, 27] and the bisect offset (BO) [6, 28] are used to quantify patellar rotation and mediolateral displacement of the patella relative to the femur. The TT–TG distance  determines the alignment of the extensor mechanism measured as the distance between the trochlear groove and the tibial tuberosity. These parameters were determined on the axial MR images. The PTA is defined as the angle between the patella and the posterior femoral condyles (Fig. 3d). Larger values indicate increased external rotation of the patella relative to the femur. The BO is reported as the percentage of the patella positioned lateral to the midline of the femur (Fig. 3e). Larger values indicate a more lateralized position of the patella relative to the femur. The alignment of the extensor mechanism was determined with the TT–TG, measured as the distance between the midpoint of the patellar tendon insertion at the tibial tuberosity and the first craniocaudal transverse slice that depicts complete cartilaginous trochlea coverage (Fig. 3f). Larger values indicate increased malalignment with increased lateral force displacement of the patella.
Measurements of the patellofemoral indices were made using OsiriX DICOM viewer software (Version 5.5.2; OsiriX Foundation, Geneva, Switzerland). All measurements were performed by one experienced investigator. The methodology was validated previously with good to excellent inter-rater reliability for all parameters .
Analyses were conducted using SPSS (version 21.0; SPSS Inc., Chicago, IL, USA). All outcome parameters were tested for normal distribution. Due to the approximately normal distribution, means and standard deviations (SDs) were calculated for continuous variables (i.e., all outcome parameters). The effect of the brace and differences between the three angles were tested in a two-way analysis of variance (ANOVA) with two repeated measures (angle as one within-subjects factor and brace as the second within-subjects factor). If Mauchly’s sphericity test was significant, the Greenhouse–Geisser correction was used. Post hoc tests were calculated (paired t tests) after alpha adjustment according to Bonferroni.
The most important findings of the study are that the dynamic patellar realignment brace, Patella Pro, appears to be able of improving typical disease determinants used in MR imaging for lateral patellar instability at flexion angles between 0° and 30° in the upright weight-bearing condition. The strength of this study is that it found objective MRI data demonstrating the effect of the brace in patients with clinically significant patellar instability in the weight-bearing condition. The examined knee positions of full extension and 15° and 30° flexion reflect the clinically most important range of motion when the patella is not constrained by the trochlea. Since patellar motion is particularly influenced by quadriceps activation at extension and early flexion , it appears important that the evaluation of patellofemoral indices that have an influence on the treatment decisions is done during conditions with muscle activation such as weight bearing. Upright weight-bearing MRI has been shown to be a feasible method at different flexion angles [14, 23, 29] with good to excellent inter-rater agreement for the measurements of the parameters used in this study [23, 30, 31].
Among the conservative treatment options for patellofemoral pain and instability, taping and bracing of the patella to modify the patella position in order to improve patellar tracking have evolved as popular treatment modalities [14, 18, 32]. Furthermore, neuromotor and proprioceptive function can be improved [19, 33]. A meta-analysis published in 2002 revealed that the use of a patellar brace in patients with patellofemoral pain syndrome has positive effects on pain, function, and patellofemoral congruence angle compared with an untreated control group . However, in another meta-analysis of 2008 to evaluate the evidence for patellar taping and bracing in the management of chronic knee pain, only limited evidence was reported to demonstrate the efficacy of patellar bracing . In subjects with lateral patellar instability, the effects of stabilizing braces that exert a medially directed force that may counteract lateral patellar maltracking might be more pronounced. However, evidence to demonstrate the efficacy of patellar bracing for patellofemoral instability is limited.
The Patella Pro dynamic realignment brace used in this study was evaluated for biomechanical efficacy in an experimental setup using six fresh frozen human cadaver specimens tested in a knee simulator. Although not reaching statistically significance, average medialization of the patella of 1.04–1.66 mm in the tests with the brace compared to no brace was observed in 0°–45° flexion . In the present study, it was demonstrated in vivo that the realignment brace significantly medialized the patella (reduction of BO) relative to the femur by 12.3–15.6 % and reduced the PTA by 3.2°–5.0° between 0° and 30° flexion. This is in line with the findings of a study evaluating the effects of a patellar realignment brace that consisted of a viscoelastic silicone insert with an integrated control guide designed to counteract patellar subluxation or dislocation during joint motion. In 19 patients with subluxation of the patella during active movement, loaded kinematic MR imaging, the authors reported that in 76 % of the included subjects, a qualitative correction of or improvement in patellar subluxation (i.e., centralization of the patella or a decrease in the displacement of the patella) occurred after application of the brace . However, in a study evaluating 21 patients with clinical signs of patellar subluxation (n = 16) or dislocation (n = 5) using the same brace, no significant effect on the BO and PTA before or after wearing the patellar brace was found during active extension in the kinematic MR imaging . Draper et al. evaluated the effects of a patellar-stabilizing brace in women with patellofemoral pain syndrome compared to a sleeve and a condition with no brace as in our study by real-time MRI in weight-bearing conditions in an open-bore MRI scanner . The patellar-stabilizing brace significantly reduced the BO of pain subjects between 0° and 60° of knee flexion by an average of 4 % compared to the condition with no brace. The largest reduction of 6 % occurred at full extension. In the same study, the PTA of the pain subjects significantly decreased by 3° on average when using the brace at knee flexion angles between 0° and 20°. As for the BO, the largest reduction of the PTA (4°) occurred at full extension. Accordingly, in both parameters, the reduction was significantly better than with a sleeve . In a comparable study, Powers et al. analyzed the BO and PTA comparing two different patellar braces and the no-brace condition using MRI in supine position with muscle activation forced by resistance put on the extensor mechanism using a custom-built loading apparatus that resembled a leg press machine . As in the study of Draper et al., only females with patellofemoral pain syndrome were evaluated. On average, the amount of decrease in the BO was 3.6 and 2.4 % of patellar width for the two patellar braces, respectively. The greatest decrease of 4.8 % occurred at 20°. The average PTA was insignificantly reduced by 0.7° and 1.4°, respectively . In summary, the brace effect on the reduction of the BO and PTA were greater in the present study than observed by the aforementioned studies [15, 35]. Possible reasons may be that different braces were used and the patients included in the studies of Draper et al. and Powers et al. did not present patellofemoral instability. In subjects with patellofemoral pain syndrome and no history of patellar dislocation, the BO and PTA are usually expected to be less pronounced than in patients with significant lateral patellofemoral instability, which is highlighted by the greater absolute values of these indices found in the present study.
With respect to the patellar height ratios, a significant reduction was observed at all evaluated angles by using the realignment brace in the present study. Since increased patellar height is acknowledged as a contributing factor to patellar instability [8, 36], the brace effect may be important to prevent subluxation and dislocation. Other aforementioned studies that evaluated brace effects with MRI did not consider the changes of patellar height. However, in a study of McWalter et al. evaluating 19 subjects with lateral patellofemoral osteoarthritis, a patellar realignment brace caused a significant distal translation of 1.09 mm in the loaded condition with static knee positions in a supine position with 15 % body weight pushed against a foot plate compared to 0.67 mm in the unloaded condition throughout 0°–50° flexion during MR imaging . A possible explanation for the distalizing brace effect could be that weight-bearing results in a significant increase in patellar height ratios in subjects with patellofemoral instability . This effect is less pronounced while wearing the brace as indicated by McWalter et al. who studied the brace effect with and without loading . The tracking system of the Patella Pro, which is mounted on a hinged sleeve and covers the patella from the inferior over the medial to the superior aspect, obviously not only applies a dynamic, medially directed force but also additionally an inferiorly directed one in cases of patella alta when the patella is not in its designated space.
Accordingly, the TT–TG has not been considered in other studies evaluating brace effects. In the present study, the TT–TG was significantly reduced by the realignment brace at 15° and 30° flexion but not at full extension. The TT–TG is influenced by various factors, especially femoral and tibial rotation and trochlea dysplasia and, when increased, regarded as one of the important factors in patella instability [7, 31, 37, 38]. Since the patellar realignment brace does not directly influence any of these factors, the brace effect on the TT–TG appears surprising at first sight. However, with the reverse “screw-home” mechanism during early flexion of the knee, which leads to a medialization of the tibial tubercle and femoral external rotation [39, 40], the TT–TG decreases during flexion [23, 41, 42]. It was shown in an experimental study with knee cadaver specimens that activation of the vastus medialis leads to increased tibial internal rotation and thus a reduction of the TT–TG distance compared to no muscle activity . Gilleard et al. described an earlier onset of the vastus medialis obliquus (VMO) activity when the patella was taped compared with the untaped condition during step-up and step-down tasks . Thus, an explanation for the effect of the realignment brace could be a possibly improved VMO activity. Furthermore, since the patella is medialized by the brace with consecutive reduction of the Q-angle, tibial internal rotation or femoral external rotation might be more pronounced during flexion with a resulting decrease in TT–TG distance. However, as for the reduction of patellar height, more research is necessary to confirm these findings.
This study has the following limitations: (1) weight-bearing kinematics were evaluated in static upright standing conditions, which do not fully reflect the dynamic flexion kinematics of the lower limb. (2) Blinding of the investigator to the two conditions of brace or no-brace was not possible, since a certain degree of artifacts occurred in the area of the metal spring of the tracking system, which was outside of the area of interest for the assessment of the parameters. (3) Adding a further study condition with a simple sleeve without specific biomechanical patellar tracking function as a control for the dynamic patellar realignment brace could have reduced bias of wearing a brace and improved the assessment of the hypothesized biomechanical benefits of the patellar realignment brace. (4) The heterogeneity of the patterns that lead to lateral patellar instability in the included patients can be estimated by the standard deviations observed. Further evaluation may warrant clarification in which specific pathological patterns an effect of the brace may or may not be expected, respectively.
From this study, it can be concluded that the dynamic patellar realignment brace, Patella Pro, may be able to improve disease determinants in patients with lateral patellofemoral instability in the upright weight-bearing condition at 0°–30° flexion. If clinical symptoms can be meaningfully reduced and subluxation or dislocation can be prevented warrants further investigation.
The authors thank the staff of the “Privatpraxis für Upright-Kernspintomographie, Hannover” for their help and support during the study.
Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
- Amis AA, Firer P, Mountney J, Senavongse W, Thomas NP. Anatomy and biomechanics of the medial patellofemoral ligament. Knee. 2003;10:215–20.View ArticlePubMedGoogle Scholar
- Dejour H, Walch G, Nove-Josserand L, Guier C. Factors of patellar instability: an anatomic radiographic study. Knee Surg Sports Traumatol Arthrosc. 1994;2:19–26.View ArticlePubMedGoogle Scholar
- Smith TO, Davies L, Toms AP, Hing CB, Donell ST. The reliability and validity of radiological assessment for patellar instability. A systematic review and meta-analysis. Skeletal Radiol. 2011;40:399–414.View ArticlePubMedGoogle Scholar
- Pandit S, Frampton C, Stoddart J, Lynskey T. Magnetic resonance imaging assessment of tibial tuberosity-trochlear groove distance: normal values for males and females. Int Orthop. 2011;35:1799–803.PubMed CentralView ArticlePubMedGoogle Scholar
- Schoettle PB, Zanetti M, Seifert B, Pfirrmann CW, Fucentese SF, Romero J. The tibial tuberosity-trochlear groove distance; a comparative study between CT and MRI scanning. Knee. 2006;13:26–31.View ArticlePubMedGoogle Scholar
- Draper CE, Besier TF, Fredericson M, Santos JM, Beaupre GS, Delp SL, et al. Differences in patellofemoral kinematics between weight-bearing and non-weight-bearing conditions in patients with patellofemoral pain. J Orthop Res. 2011;29:312–7.View ArticlePubMedGoogle Scholar
- Hill PF, Vedi V, Williams A, Iwaki H, Pinskerova V, Freeman MA. Tibiofemoral movement 2: the loaded and unloaded living knee studied by MRI. J Bone Joint Surg Br. 2000;82:1196–8.View ArticlePubMedGoogle Scholar
- Pal S, Besier TF, Beaupre GS, Fredericson M, Delp SL, Gold GE. Patellar maltracking is prevalent among patellofemoral pain subjects with patella alta: an upright, weightbearing MRI study. J Orthop Res. 2013;31:448–57.PubMed CentralView ArticlePubMedGoogle Scholar
- Pal S, Draper CE, Fredericson M, Gold GE, Delp SL, Beaupre GS, et al. Patellar maltracking correlates with vastus medialis activation delay in patellofemoral pain patients. Am J Sports Med. 2011;39:590–8.View ArticlePubMedGoogle Scholar
- Powers CM, Ward SR, Fredericson M, Guillet M, Shellock FG. Patellofemoral kinematics during weight-bearing and non-weight-bearing knee extension in persons with lateral subluxation of the patella: a preliminary study. J Orthop Sports Phys Ther. 2003;33:677–85.View ArticlePubMedGoogle Scholar
- Colvin AC, West RV. Patellar instability. J Bone Joint Surg Am. 2008;90:2751–62.View ArticlePubMedGoogle Scholar
- Harvie D, O’Leary T, Kumar S. A systematic review of randomized controlled trials on exercise parameters in the treatment of patellofemoral pain: what works? J Multidiscip Healthc. 2011;4:383–92.PubMed CentralPubMedGoogle Scholar
- Heintjes E, Berger MY, Bierma-Zeinstra SM, Bernsen RM, Verhaar JA, Koes BW. Exercise therapy for patellofemoral pain syndrome. Cochrane Database Syst Rev. 2003;4:CD003472.PubMedGoogle Scholar
- Werner S. Anterior knee pain: an update of physical therapy. Knee Surg Sports Traumatol Arthrosc. 2014;22:2286–94.View ArticlePubMedGoogle Scholar
- Draper CE, Besier TF, Santos JM, Jennings F, Fredericson M, Gold GE, et al. Using real-time MRI to quantify altered joint kinematics in subjects with patellofemoral pain and to evaluate the effects of a patellar brace or sleeve on joint motion. J Orthop Res. 2009;27:571–7.PubMed CentralView ArticlePubMedGoogle Scholar
- McWalter EJ, Hunter DJ, Harvey WF, McCree P, Hirko KA, Felson DT, et al. The effect of a patellar brace on three-dimensional patellar kinematics in patients with lateral patellofemoral osteoarthritis. Osteoarthritis Cartilage. 2011;19:801–8.PubMed CentralView ArticlePubMedGoogle Scholar
- Shellock FG, Mink JH, Deutsch AL, Fox J, Molnar T, Kvitne R, et al. Effect of a patellar realignment brace on patellofemoral relationships: evaluation with kinematic MR imaging. J Magn Reson Imaging. 1994;4:590–4.View ArticlePubMedGoogle Scholar
- Warden SJ, Hinman RS, Watson Jr MA, Avin KG, Bialocerkowski AE, Crossley KM. Patellar taping and bracing for the treatment of chronic knee pain: a systematic review and meta-analysis. Arthritis Rheum. 2008;59:73–83.View ArticlePubMedGoogle Scholar
- Callaghan MJ, McKie S, Richardson P, Oldham JA. Effects of patellar taping on brain activity during knee joint proprioception tests using functional magnetic resonance imaging. Phys Ther. 2012;92:821–30.PubMed CentralView ArticlePubMedGoogle Scholar
- Petersen W, Ellermann A, Rembitzki IV, Scheffler S, Herbort M, Sprenker FS, et al. The Patella Pro study—effect of a knee brace on patellofemoral pain syndrome: design of a randomized clinical trial (DRKS-ID:DRKS00003291). BMC Musculoskelet Disord. 2014;15:200.PubMed CentralView ArticlePubMedGoogle Scholar
- Brüggemann GP, Heinrich K, Ellermann A, Potthast W. Patella kinematics are controlled by a novel knee brace: an in-vitro evaluation on the PatellaTrack orthosis. ISPO World Congress, Proceedings. 2010. p. 421–2.Google Scholar
- Fithian DC, Paxton EW, Stone ML, Silva P, Davis DK, Elias DA, et al. Epidemiology and natural history of acute patellar dislocation. Am J Sports Med. 2004;32:1114–21.View ArticlePubMedGoogle Scholar
- Becher C, Fleischer B, Schumacher T, Ettinger M, Ostermeier S, Smith T. The effects of upright weightbearing condition and knee flexion angle on patellofemoral indices at MRI examination in subjects with patellofemoral instability. under Review. 2015.Google Scholar
- Biedert RM, Albrecht S. The patellotrochlear index: a new index for assessing patellar height. Knee Surg Sports Traumatol Arthrosc. 2006;14:707–12.View ArticlePubMedGoogle Scholar
- Caton J, Deschamps G, Chambat P, Lerat JL, Dejour H. Patella infera. Apropos of 128 cases. Rev Chir Orthop Reparatrice Appar Mot. 1982;68:317–25.PubMedGoogle Scholar
- Insall J, Salvati E. Patella position in the normal knee joint. Radiology. 1971;101:101–4.View ArticlePubMedGoogle Scholar
- Fulkerson JP, Schutzer SF, Ramsby GR, Bernstein RA. Computerized tomography of the patellofemoral joint before and after lateral release or realignment. Arthroscopy. 1987;3:19–24.View ArticlePubMedGoogle Scholar
- Brossmann J, Muhle C, Schroder C, Melchert UH, Bull CC, Spielmann RP, et al. Patellar tracking patterns during active and passive knee extension: evaluation with motion-triggered cine MR imaging. Radiology. 1993;187:205–12.View ArticlePubMedGoogle Scholar
- Fulkerson JP, Shea KP. Disorders of patellofemoral alignment. J Bone Joint Surg Am. 1990;72:1424–9.PubMedGoogle Scholar
- Charles MD, Haloman S, Chen L, Ward SR, Fithian D, Afra R. Magnetic resonance imaging-based topographical differences between control and recurrent patellofemoral instability patients. Am J Sports Med. 2013;41:374–84.View ArticlePubMedGoogle Scholar
- Dornacher D, Reichel H, Lippacher S. Measurement of tibial tuberosity-trochlear groove distance: evaluation of inter- and intraobserver correlation dependent on the severity of trochlear dysplasia. Knee Surg Sports Traumatol Arthrosc. 2014;22:2382–7.View ArticlePubMedGoogle Scholar
- D’hondt NE, Struijs PA, Kerkhoffs GM, Verheul C, Lysens R, Aufdemkampe G, et al. Orthotic devices for treating patellofemoral pain syndrome. Cochrane Database Syst Rev. 2002;2:CD002267.PubMedGoogle Scholar
- Thijs Y, Vingerhoets G, Pattyn E, Rombaut L, Witvrouw E. Does bracing influence brain activity during knee movement: an fMRI study. Knee Surg Sports Traumatol Arthrosc. 2010;18:1145–9.View ArticlePubMedGoogle Scholar
- Muhle C, Brinkmann G, Skaf A, Heller M, Resnick D. Effect of a patellar realignment brace on patients with patellar subluxation and dislocation. Evaluation with kinematic magnetic resonance imaging. Am J Sports Med. 1999;27:350–3.PubMedGoogle Scholar
- Powers CM, Ward SR, Chan LD, Chen YJ, Terk MR. The effect of bracing on patella alignment and patellofemoral joint contact area. Med Sci Sports Exerc. 2004;36:1226–32.View ArticlePubMedGoogle Scholar
- Ward SR, Terk MR, Powers CM. Patella alta: association with patellofemoral alignment and changes in contact area during weight-bearing. J Bone Joint Surg Am. 2007;89:1749–55.View ArticlePubMedGoogle Scholar
- Johal P, Williams A, Wragg P, Hunt D, Gedroyc W. Tibio-femoral movement in the living knee. A study of weight bearing and non-weight bearing knee kinematics using ‘interventional’ MRI. J Biochem. 2005;38:269–76.Google Scholar
- Tennant S, Williams A, Vedi V, Kinmont C, Gedroyc W, Hunt DM. Patello-femoral tracking in the weight-bearing knee: a study of asymptomatic volunteers utilising dynamic magnetic resonance imaging: a preliminary report. Knee Surg Sports Traumatol Arthrosc. 2001;9:155–62.View ArticlePubMedGoogle Scholar
- Fuss FK. Principles and mechanisms of automatic rotation during terminal extension in the human knee joint. J Anat. 1992;180(Pt 2):297–304.PubMed CentralPubMedGoogle Scholar
- Piazza SJ, Cavanagh PR. Measurement of the screw-home motion of the knee is sensitive to errors in axis alignment. J Biomech. 2000;33:1029–34.View ArticlePubMedGoogle Scholar
- Dietrich TJ, Betz M, Pfirrmann CW, Koch PP, Fucentese SF. End-stage extension of the knee and its influence on tibial tuberosity-trochlear groove distance (TTTG) in asymptomatic volunteers. Knee Surg Sports Traumatol Arthrosc. 2014;22:214–8.View ArticlePubMedGoogle Scholar
- Izadpanah K, Weitzel E, Vicari M, Hennig J, Weigel M, Sudkamp NP, et al. Influence of knee flexion angle and weight bearing on the Tibial Tuberosity-Trochlear Groove (TTTG) distance for evaluation of patellofemoral alignment. Knee Surg Sports Traumatol Arthrosc. 2014;22:2655–61.View ArticlePubMedGoogle Scholar
- Wunschel M, Leichtle U, Obloh C, Wulker N, Muller O. The effect of different quadriceps loading patterns on tibiofemoral joint kinematics and patellofemoral contact pressure during simulated partial weight-bearing knee flexion. Knee Surg Sports Traumatol Arthrosc. 2011;19:1099–106.View ArticlePubMedGoogle Scholar
- Gilleard W, McConnell J, Parsons D. The effect of patellar taping on the onset of vastus medialis obliquus and vastus lateralis muscle activity in persons with patellofemoral pain. Phys Ther. 1998;78:25–32.PubMedGoogle Scholar