Revista de Medicina Desportiva (English) November 2018 | Page 29

bicondylar femoral line. The limited
angle for the anteversion is 13°. The
tibial rotational alignment is calcu-
lated with the angle formed by a
tangential line to both condyles and
the ankle axis. The value of the tibial
torsion is on average between 30 and
35°.
Clinical presentation and physical
examination
Physical examination is an essential
component for the evaluation of the
femoropatelar joint. The apprehen-
sion test is part of the physical exam
and usually is performed bilaterally
for comparative analysis. This sign
is positive when the patient refers
a discomfort when the patella is
laterally dislocated with the knee
at slight flexion. 2,7 The laxity of
the medial retinaculum must also
be documented with the physical
exam and with stress X-rays. 7 The
increase of the medio-lateral mobil-
ity is quantified during the different
grades of knee flexion. 2
Local pain at palpation of the
medial retinaculum and of the
medial and lateral facets of the
patella bone with the medio-lateral
and cranio-caudal movement, with
Figure 1 – Dejour’s classification of the patellar dysplasia
Ref. http://www.mskrad.med.br/notas_medidas/classificacao-de-dejour-da-displasia-troclear/
Figure 2 – Patela Alta
Ref. http://www.drmarcelotostes.com/joelho/outras-lesoes-do-joelho/luxacao-da-patela
Figure 3 – Anteversion of the femoral neck
Ref. http://limatreinamento.blogspot.com/2018/05/alem-do-arredondamento-da-lombar-no.html
or without pression, may indicate
chondral injury.
In the cases of medial femoropate-
lar ligament insufficiency and, in
particular, when there is significant
trochlear dysplasia, the patella can
move laterally when the knee is
actively positioned on full extension:
when this movement occurs, there
is a positive J signal. The position and
the patellar tilt are evaluated in the
seated patient with the knees at 90°
of flexion. 7
Therapeutic considerations
The patellar stabilization objective
is to prevent future dislocations
and the subsequent development of
patelofemoral arthrosis. 7 The correct
treatment of the primary or recur-
rent dislocation, especially when
there is patelofemoral dysplasia, is
still a dilemma. 6 It is consensual at
the literature that the first episode
in children with femoropatelar dis-
location, without intraarticular free
bodies seen on MRI, the treatment of
choice is non-surgical and focused
on quadriceps strengthening and
improvement of core stability. 11 On
primary episodes, the conservative
treatment has historically consid-
ered the elected treatment with
similar results to the surgical treat-
ment 1,6,12 . However, the better knowl-
edge of the biomechanics and of
the anatomy, and the improvement
of the surgical technics, it is shown
on a recent meta-analysis lower
re-dislocation rates after surgical
treatment. 13
There is no evidence of the supe-
riority of one rehabilitation program
over other and the patients usu-
ally undergo a program for 3 to 4
months supervised by a rehabilita-
tion doctor. The first objective aims
to treat edema and pain, followed
the restauration of the joint mobility,
muscle strengthening and, at last,
specific exercises to the related sport
for return to sports and preven-
tion of future instability episodes.
The program starts with isomet-
ric exercises of the quadriceps to
specifically strengthen the muscle
vastus medialis with progression to
the complex dynamic stabilization
of the lower limb. After this phase,
the patient must be kept motivated
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