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0968-0160/03/$ - see front matter 2003 Elsevier Science B.V. All rights reserved.
doi:10.1016/S0968-0160(03)00006-1
Review
Anatomy and biomechanics of the medial patellofemoral ligament
A.A. Amis *, P. Firer , J. Mountney , W. Senavongse , N.P. Thomas
a,b, c d a d
Mechanical Engineering Department, Biomechanics Section, Exhibition Road, London SW7 2BX, UK
a
Musculoskeletal Surgery Department, Imperial College, London SW7 2BX, UK
b
Linksfield Park Clinic, Johannesburg 2192, South Africa
c
Department of Orthopaedic Surgery, North Hants Hospital, Basingstoke, Hants RG24 9NA, UK
d
Received 14 October 2002; accepted 9 December 2002
Abstract
The medial patellofemoral ligament (MPFL) is a band of retinacular tissue connecting the femoral medial epicondyle to the
medial edge of the patella. The MPFL is approximately 55 mm long, and its width has been reported to range from 3 to 30 mm.
The MPFL is overlaid by the distal part of vastus medialis obliquus to a variable extent, and fibres of MPFL merge into the deep
aspect of the muscle. Despite the MPFL being very thin, it had a mean tensile strength of 208 N, and has been reported to be
the primary passive restraint to patellar lateral displacement. Lateral patellar displacement tests in vitro showed that the patella
subluxed most easily at 208 knee flexion. The contribution of the MPFL to resisting patellar lateral subluxation was greatest in
the extended knee. This finding was linked to the retinaculae being tightest in full knee extension, and slackening with flexion.
2003 Elsevier Science B.V. All rights reserved.
Keywords: Medial patellofemoral ligament; Patella; Stability; Strength; Anatomy
1. Introduction
Although patellofemoral joint instability or maltrack-
ing symptoms are extremely common, there is still an
incomplete understanding of the various interactions
between the different mechanical factors that control the
movement and stability of the patella. There is a com-
plex interplay between the active muscle tensions, the
passive tensions in the retinacular structures, and the
reactive forces on the articular surfaces.
The quadriceps muscle structure may be split into
different components that act either directly along the
femoral axis, or diverge to either side. In particular,
both the vasti lateralis and medialis have small distally
placed oblique components that act with a larger trans-
verse force vector, and so are important as medial-lateral
patellar stabilisers
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. There is evidence that the vastus
medialis obliquus (VMO) weakens more than the other
parts of the extensor musculature in the face of patel-
lofemoral pain
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.
*Corresponding author. Tel.: q44-020-7594-7062; fax: q44-020-
7584-7239.
E-mail address: a.amis@ic.ac.uk (A.A. Amis).
The patellofemoral joint articular geometry is an
important factor in cases of patellar dislocation. The
resultant force of the quadriceps acts along the axis of
the femur and is resisted by the patellar tendon tension.
These two forces are not collinear, but diverge by
approximately fifteen degrees
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, the Q angle. This
causes the patella to have a lateral resultant force
component acting on it that is resisted by the prominent
lateral facet of the femoral trochlea
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. Instability may
result if the lateral slope of the trochlea is deficient, and
the Lyons school have devised trochleoplasty proce-
dures in order to deepen the trochlear groove and so
give the patella greater stability
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.
In addition to the muscle forces and articular factors,
the passive soft tissue restraints are important for patellar
tracking and stability. It may be argued that the essential
lesion, without which the patella cannot move to an
abnormal lateral position, is damage to the medial
patellofemoral ligament (MPFL). This article will pres-
ent some anatomical and biomechanical data on the
MPFL, that may be useful when considering both the
function of the patellofemoral joint, and procedures to
restabilise it.
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Fig. 1. The MPFL of a right knee, connecting the medial epicondyle
to the medial edge of the patella. Note that the superficial fascial layer
and the overlaying distal part of the vastus medialis obliquus have
been removed to show the MPFL.
Fig. 2. The relationship of the MPFL to other structures. VML: vastus
medialis longus, AM: adductor magnus, VMO: vastus medialis obli-
quus, PMC: posteromedial capsule;MPFL: medial patellofemoral lig-
ament; SMCL: superficial band of medial collateral ligament.
2. Anatomy
The MPFL is a thin fascial band approximately 53
(range 4564) mm long
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, that links from the region
of the medial epicondyle of the femur to the proximal
part of the medial border of the patella (Fig. 1). The
appearance and bulk of the MPFL varies from knee to
knee, and it may be vanishingly thin in some cases, so
that it is hard to see how it could act as an important
stabilising structure. Indeed, some authors have reported
that they could not identify this structure in all knees
examined. At one extreme, Reider et al
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documented
the presence of an MPFL in only 35% of knees (7 of
20). Conlan et al.,
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could not detect or palpate the
MPFL in 4 of 33 knees, while several other studies
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identified the MPFL by palpation of the
more distinct proximal edge, from the deep aspect, in
all of the 93 knees in these studies. We do not have
sufficient information about the MPFL and how it relates
to other morphological features to know if there may be
a correlation between its appearance, strength, or even
presence, and other features of the knee, such as shape
of the trochlear groove or muscle orientations.
The femoral attachment is relatively compact. Both
Tuxoe
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and Conlan et al.
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reported that this is at
the adductor tubercle, with the MPFL, the superficial
medial collateral ligament (MCL) and adductor magnus
tendon all converging towards the same place (Fig. 2).
There has recently, however, been some debate about
the exact site of attachment. This is because some of
the deeper fibres, which may only be demonstrated by
elevating the MPFL away from the femur, attach anterior
to the proximal attachment of the long parallel fibres of
the superficial MCL at the epicondyle (Arendt, ESSKA
conference, 2000). Other superficial fibres of the MPFL
have been shown to wrap over the epicondyle, passing
just distal to the adductor tubercle, and then attach
immediately posterior to the epicondyle
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. Feller et
al.
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reported the femoral attachment to be just anterior
to the epicondyle. Desio et al.
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reported that the
femoral attachment was spread by decussating fibres
that attached to both the adductor tubercle and to the
superficial fibres of the MCL, with more direct attach-
ment to the epicondyle. This agrees with our own
observations. The spreading fibres mean that the MPFL
may widen towards both attachments. In addition, it
often seems to have two functional bands of fibres, that
run along the proximal and distal edges (Fig. 3). The
femoral attachment of the MPFL is typically 1015 mm
wide, from proximal to distal, although Tuxoe et al.
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, who found it difficult to identify a free distal edge
in 23% of their cases, reported a mean width of the
MPFL of 19 mm (range 1030 mm), at 10 mm lateral
to the femoral attachment. Conlan et al.
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found a
mean width of 13 mm, range 825 mm, and Reider et
al.
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reported the MPFL to be 3 to 10 mm wide
laterally, and 5 to 12 mm medially. The range of
descriptions shows that the MPFL femoral attachment
is not a clearly delineated feature, and that the conver-
gence of a number of structures and tissue layers towards
the medial epicondyle makes it difficult to separate the
MPFL. The superficial fibres of the MPFL wrap over
the femoral attachment of the long anterior fibres of the
superficial MCL, which itself wraps over the epicondyle
(Fig. 2). Thus, the epicondyle appears to be a practical
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Fig. 3. The MPFL may have thicker fibre bands running along the
proximal and distal edges, and attach to the whole length of the patel-
la. White pins show attachments of the thicker bands, black pins show
the paths of the thicker bands, and the grey pin is at the VMO
attachment.
landmark to use for placing an MPFL reconstruction in
the absence of evidence to the contrary.
The patellar attachment of the MPFL is usually wider
than the femoral attachment, and is to the most promi-
nent medial edge of the patella (Fig. 1). It extends
distally from the proximal-medial corner of the patella
over approximately a half of the length of the medial
aspect of the patella, perhaps 20 mm, but may attach to
the entire medial aspect (Fig. 3). Thus, the fibres of the
MPFL fan out from the femur to the patella
The tissues overlying the anteromedial aspect of the
knee are arranged into several distinct layers. Warren
and Marshall
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and Feller et al.
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placed the MPFL
into the second of three layers, below the deep fascia
and superficial to the joint capsule, along with the
superficial band of the medial collateral ligament.
Towards the femoral attachment, the MPFL passes
beyond the limit of the joint capsule and then lies over
the periosteum of the femoral condyle. In cases where
the distal edge of the MPFL was difficult to find, Tuxoe
et al.
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found that it had merged with the overlying
fascial layer, and Feller et al.
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reported that this was
a constant feature. This finding explains why it is easiest
to identify the MPFL by palpation of the more prominent
proximal border.
The patellar end of the MPFL passes deep to the
distal part of the vastus medialis obliquus (VMO),
which overlays the MPFL at the patellar attachment,
and which also attaches to the proximal part of the
medial border of the patella (Fig. 2). The anatomy of
the VMO is variable in this area, with the muscle fibres
extending over the MPFL in some knees but not others.
In other knees, the medial aspect of the patella may be
embraced by a distal fascialytendinous continuation
from the muscle belly
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. Reider et al.
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found that
the VMO became tendinous up to 25 mm proximal to
the patella, although this transition was usually 5 mm
from it.
The distal edge of the VMO creates a distinct trian-
gular space proximal to the transverse MPFL and ante-
rior to the adductor magnus tendon (Fig. 2), and
palpation into this space allows the proximal edge of
the MPFL to be identified if the MPFL is difficult to
see. Conlan et al.
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reported that the distance proxi-
mally from the MPFL femoral attachment to the VMO
attachment was 33 mm on average, ranging from 560
mm. Similar measurements have been reported by Bose
et al.
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: 35 mm mean distance, ranging from 1575
mm. There is some merging of the fibres of the MPFL
into the deep aspect of the VMO, and this can mean
that it is both difficult to separate them and also difficult
to locate a lesion of the MPFL, if it is near to the
patella. Their close association also means that these
two structures are often damaged together, and it has
been reported that the VMO is often torn progressively
in a proximal direction from the femoral attachment to
the adductor magnus tendon
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. It was suggested that
MPFL repair should, therefore, also include reattachment
of the VMO distally to the adductor magnus tendon, so
as to maintain its correct transverse orientation, that is
important for patellar stability.
3. Strength of the MPFL
We have recently examined the strength of the MPFL,
and are not aware of published data. A series of ten
cadaveric specimens were tensile tested to failure in an
Instron materials testing machine. The patella was sep-
arated from the other bones, leaving only its link via
the MPFL. The femur was held stationary while the
patella was pulled away in a physiological anterolateral
direction. The mean failure load was 208 N (Mountney
et al., unpublished). This was higher than had been
expected, particularly noting that these cadaveric knees
had a mean age of approximately 70 years. There are
no data available on how the strength of retinacular
structures varies with age, but it is known
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that the
anterior cruciate ligament is approximately 2.5 times
stronger in the third decade of life than in the seventh.
4. Function of the MPFL
Several studies in vitro have found that the MPFL is
the primary passive restraint that resists lateral transla-
tion of the patella. Although they did not measure the
contribution of the MPFL to resisting a lateral force,
two studies have measured the laxity resulting from
MPFL transection. Nomura et al.
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measured the
increase in laxity resulting from cutting the MPFL, at a
range of angles of knee flexion. In cadaver knees with
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Fig. 4. Graph of patellar lateral displacing force at 10 mm displace-
ment, for the intact knee with 175 N quadriceps tension, and after
transection of the MPFL. The drop between the two curves shows
that the contribution of the MPFL was greatest in the extended knee.
*significant difference.
Fig. 5. The retinaculae hold the patella tight against the femur when
the knee is extended, but allow the patella to fall away in the flexed
knee, indicating slackening. View is looking distally, after removal of
the quadriceps muscles, with knee flexed 15 degrees and 90 degrees.
the quadriceps tensed to 10 N and a lateral displacing
force of 10 N applied to the patella, they found that, in
the intact knee, the patella was displaced approximately
6 mm laterally, while cutting the MPFL allowed the
displacement to increase to 13 mm. A similar result was
found by Hautamaa et al.
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, who tensed the quadriceps
to 9 N, then applied a lateral displacing force of 22 N
to the patella, with the knee at 30% flexion. A mean
patellar lateral displacement of 9 mm increased to 14
mm after cutting the MPFL. Both studies found that
patellar lateral laxity was restored to normal by repair
of the MPFL.
Conlan et al.
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tested 25 knees in full extension,
using a materials testing machine to apply controlled
lateral forcedisplacement cycles to the patella. There
was no tension applied to the quadriceps, so these were
purely tests of the medial restraints. By a sequence of
repeated tests after cutting individual structures, they
could calculate the forces in them that had resisted the
lateral displacement. They found that the MPFL resisted
53% of the force needed to cause a 12.7-mm-patellar
lateral displacement. The patellomeniscal ligament and
related retinacular fibres in the deep capsular layer of
the knee contributed a further 22% of the resistance,
while the patellotibial band was functionally
unimportant.
In a similar study, Desio et al.
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displaced the
patella laterally at 20% knee flexion, with a ball joint
to allow the patellar to tilt. By sequential cutting of
structures, they found that the MPFL had resisted 60%
of the force.
The studies described above
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tested their knees
at or near to full extension, because the patella is known
from clinical experience to dislocate most commonly in
that posture. The data of Nomura et al.
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suggested
that the maximum patellar lateral laxity, which may
have been at 45% knee flexion, was not a distinct
maximum. The authors
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have also tested knees at a range of flexion angles. The
quadriceps was loaded to 175 N, with each muscle head
tensed in its physiological direction. The patella was
displaced in a material testing machine, using a ball
joint fixed within the patella. This was repeated from 0
to 90% knee flexion with the knee intact and after
MPFL transection. In the intact knee, the patella could
be subluxed laterally most easily at 20% flexion (Fig.
4). The contribution of the MPFL to resisting patellar
lateral displacement was determined as the difference
between the force measured at 10 mm lateral displace-
ment before and after the MPFL was transected. This
was greatest with the knee fully extended, and fell
rapidly up to 20% flexion (Fig. 4).
The authors are not aware of published data on the
length change pattern of the MPFL as the knee flexes.
Our subjective observations of the overall length change
pattern of the natural MPFL suggest that the retinacular
structures are tight in the extended knee, as the muscles
pull the patella proximally, and slacken as it flexes. This
is shown clearly if the tissues are formalin fixed, and
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the knee extended and flexed (Fig. 5). When the knee
is extended the patella presses against the anterior aspect
of the distal femur and the retinaculae appears to be
tight. As the knee flexes, the distal aspect of the femur
apparently rolls back on the tibia, due to its cam shape,
leaving a gap behind the patella. This gap represents the
retinacular slackness that would occur if the patella were
pulled back onto the femur. In contrast, Nomura et al.
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found that the MPFL was slightly relaxed at 15 to
30% knee flexion, and tight at other angles. They
reported that the length change pattern was affected
greatly if the femoral fixation point moved only 5 mm
from the normal femoral attachment. Thus, the natural
structure is clearly not isometric. In addition, we do not
know the functional significance, if any, of the two-
banded structure noted above. Our observations show
that the length change pattern of a reconstruction of the
MPFL depends critically on the site of femoral attach-
ment, with a proximal point leading to increasing dis-
tance to the patellar attachment as the knee flexes, and
vice versa for a distal attachment. This led to an
experimental MPFL reconstruction that reproduced the
two-bundled structure that had a reciprocal tightening-
slackening pattern as the knee flexed and extended
(Firer and Amis, unpublished).
5. Discussion
The MPFL is a very thin band of tissue linking the
region of the femoral adductor tubercle and epicondyle
to the proximal part of the medial edge of the patella
that has been found in nearly all knees reported in the
literature. It seems clear that a lateral dislocation of the
patella must cause the MPFL to rupture, because collag-
enous structures typically fail in the region of 2030%
elongation, which represents approximately 1218 mm
patellar lateral subluxation. The tensile testing of the
MPFL has shown that it is surprisingly strong for such
an insubstantial appearance. It should be expected that
it will be difficult for a simple suture repair to reproduce
a similar strength, considering the thin tissue, and so
reconstruction may be appropriate. If the MPFL is
reconstructed, the evidence shows that the length change
pattern is sensitive to the site of femoral attachment. At
present, there is insufficient knowledge of the behaviour
of the MPFL to provide a scientific basis for a specific
attachment point to be recommended. Pending the pub-
lication of such work, we feel that the femoral medial
epicondyle is an adequate landmark, where the MPFL
wraps over the proximal attachment of the long anterior
fibres of the MCL.
The close attachment of the MPFL to the deep aspect
of the vastus medialis obliquus has been noted, and this
leads to the muscle being damaged along with the
MPFL in acute patellar lateral dislocations
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. The
muscle is stripped progressively in a distal to proximal
direction from the origin on the adductor magnus tendon.
Although some surgeons have used a vastus medialis
obliquus advancement, or reefing, procedure to tighten
the muscle during surgery intended to stabilise a laterally
maltracking patella, this will still leave the muscle acting
in a more proximal direction than normal, because the
abnormality of the femoral attachment has not been
addressed. It is more appropriate biomechanically to
reattach the muscle to the adductor magnus tendon
distally, because that will restore the normal medial-
lateral component of the resultant muscle tension, which
is important for patellar stability.
Acknowledgments
Dr Senavongse and the Instron materials testing
machine were funded by the Arthritis Research Cam-
paign. We also thank the Arthrex Company for their
support for this work.
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