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. Figure 2 – Patela Alta Ref. Figure 3 – Anteversion of the femoral neck Ref. 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 Revista de Medicina Desportiva informa november 2018 · 27