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EXCESSIVE Q ANGLE A large quadriceps angle (Q angle) also plays a part in knee problems related to malalignment, and assessment should include at least an estimation of the Q angle. The size of the Q angle is also affected by the width of the pelvis. The wider the pelvis, the greater the chance of having a large Q angle. The Q angle is measured by drawing an imaginary line between the tibial tuberosity and the midpoint of the patella, which continues in a superior direction. Another line is drawn between the anterior superior iliac spine and the midpoint of the patella. The angle between these two lines is called the Q angle and is a measure of how much the femur angles in a medial direction from its proximal end to its distal end (Image 2). An excessive Q angle is considered to be more than 20 degrees in women and 15 degrees in men. Clinical evaluation of the Q angle remains somewhat controversial because it is difficult to accurately measure. 1 However, the concept of the Q angle is still pertinent and helps us understand biomechanics of the extensor mechanism at the knee. An increased Q angle causes an increase in lateral patellar displacement and is a common cause of anterior knee pain in MMS, as we will see. INCREASED FEMORAL ANTEVERSION Femoral anteversion is one of the more challenging facets of MMS to identify. Anteversion of the femur refers to the amount of twisting or torsion that is present in the femur, with the lower portion of the femur appearing more medially rotated than the upper portion. It is best observed by comparing the angle of the femoral neck relative to the condyles of the femur (in relation to the coronal plane) (Image 3). Femoral anteversion causes problems with correct tracking of the patella. When the lower portion of the femur is medially rotated in relation to the upper portion, the patella will not move straight up and down between the femoral condyles. As the patella tracks improperly between the condyles, it may lead to a host of knee issues, such as patellofemoral pain syndrome or chondromalacia patella. Chondromalacia is a softening of the cartilage on the underside of the patella that occurs as the patella is dragged across the top of the femoral condyles during flexion and extension movements. Anteversion occurs with greater frequency in infancy and lessens as people age. Infants may have a normal anteversion of about 30 degrees, while adults are about 15 degrees. F r e e S O A P n o t e s w i t h M a s s a g e B o o k f o r A B M P m e m b e r s : a b m p . u s / M a s s a g e b o o k 97 2 3 4 The Q angle. Image is from 3D4Medical's Essential Anatomy 5 application. Squinting patella. The patella on each side angles medially due to torsion in the distal femur. Image created from 3D4Medical's Essential Anatomy 5 application. The patella don't aim forward, but instead turn medially due to torsion (twisting) in the femur. Femoral anteversion: (a) anatomical landmarks (b) looking along the axis of the femur from the inferior view to see condyles rotated medially due to torsion in the bone. Image created from 3D4Medical's Essential Anatomy 5 application. (b) Medially rotated condyles due to torsion in the bone. (a) femoral condyles femoral neck Q angle