Re-evaluating the functional implications of the Q-angle and its relationship to in-vivo patellofemoral kinematics

- The Q-angle does not represent the true “line-of-application the quadriceps force” and has low to moderate reliability.
- The Q-angle has weak to moderate correlations with medial patellar shift and tilt.
- None of the Q-angles measured were different between cohorts.
- PF interventions are likely best guided by measuring in vivo patellar kinematics acquired with active quadriceps.
- We recommend that the clinical Q-angle not be used as a surrogate for the patellar kinematics.

BackgroundThe Q-angle is widely used clinically to evaluate individuals with anterior knee pain. Recent studies have questioned the utility of this measure and have suggested that a large Q-angle may not be associated with lateral patellofemoral translation, as often assumed. The objective of this study was to determine: 1) how accurately the Q-angle represents the line-of-action of the quadriceps and 2) if adding active quadriceps contraction or a bent knee position to the measurement of the Q-angle improves its reliability, accuracy, and association with patellofemoral kinematics.MethodsThe study included individuals diagnosed with chronic idiopathic patellofemoral pain and control subjects (n = 43 and n = 30 knees). Three measures of the clinical Q-angle (straight- and bent-knee with relaxed quadriceps and straight-knee with maximum isometric quadriceps contraction) were obtained with a goniometer and compared to a fourth MR-based measure of Q-angle. Patellofemoral kinematics were derived from dynamic cine-phase contrast images, acquired while subjects extended/flexed their knee from approximately 0° and 45°.FindingsThe Q-angle did not represent the line-of-action of the quadriceps. The average difference between each clinical and the MR-based Q-angle ranged from 5° to 8°. These differences varied greatly across subjects (range: − 28.5° to 3.9o). Adding an active quadriceps contraction or a bent knee position, did not improve the reliability of the Q-angle. An increased Q-angle correlated to medial patellar displacement and tilt (r = 0.38-0.54, P < 0.001) in the cohort with anterior knee pain.InterpretationClinicians are cautioned against using the Q-angle to infer patellofemoral kinematics.