INDEX Anatomy of patella 1-3 Biomechanics of patella 4 Types of recurrent dislocation of patella 5 Anatomy & mechanism of injury 6- 7 Predisposing factors 8 Clinical features 9-12 Rehabilitation protocol no 1 (non operative treatment of Recurrent (not acute) 13-14 Patellar instability) Rehabilitation protocol no 2 (conservative rehabilitation (acute)) 15-17 Rehabilitation protocol no 3 (Distal and/or Proximal Realignment Procedures) 18-20 Rehabilitation protocol no 4 (Distal and/or Proximal Patellar Tendon 1
Transcript
INDEX
Anatomy of patella 1-3Biomechanics of patella 4Types of recurrent dislocation of patella 5Anatomy & mechanism of injury 6-7Predisposing factors 8Clinical features 9-12Rehabilitation protocol no 1
(non operative treatment of Recurrent (not acute)13-14
Patellar instability)
Rehabilitation protocol no 2(conservative rehabilitation (acute)) 15-17
Rehabilitation protocol no 3 (Distal and/or Proximal Realignment Procedures)
18-20
Rehabilitation protocol no 4(Distal and/or Proximal Patellar Tendon 21-24 Realignment)
Rehabilitation protocol no 5 (Lateral Retinacular Release) 25-30
Rehabilitation protocol no 6(Medial patelofemoral ligament 31-32Reconstruction)
Rehabilitation protocol no 7
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(Trochleoplasty) 33-34
ANATOMY OF PATELA
The patella is a flat, triangular bone, situated on the front of the knee-joint. It is usually regarded as a sesamoid bone, developed in the tendon of the Quadriceps femoris, and resembles these bones in being developed in a tendon; in its center of ossification presenting a knotty or tuberculated outline;in being composed mainly of dense cancellous tissue. It serves to protect the front of the joint, and increases the leverage of the Quadriceps femoris by making it act at a greater angle. It has an anterior and a posterior surface three borders, and an apex.
SURFACES :1. anterior surface is convex, perforated by small pertures for the passage of
nutrient vessels, and marked by numerous rough, longitudinal striæ. This surface is covered, in the recent state, by an expansion from the tendon of the Quadriceps femoris, which is continuous below with the superficial fibers of the ligamentum patellæ. It is separated from the integument by a bursa.
2. posterior surface presents above a smooth, oval, articular area, divided into two facets by a vertical ridge; the ridge corresponds to the groove on the patellar surface of the femur, and the facets to the medial and lateral parts of the same surface; the lateral facet is the broader and deeper. Below the articular surface is a rough, convex, non-articular area, the lower half of
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which gives attachment to the ligamentum patellæ; the upper half is separated from the head of the tibia by adipose tissue.
BORDERS :1. base or superior border is thick, and sloped from behind, downward, and forward: it gives attachment to that portion of the Quadriceps femoris which is derived from the Rectus femoris and Vastus intermedius.2. medial and lateral borders are thinner and converge below: they give attachment to those portions of the Quadriceps femoris which are derived from the Vasti lateralis and medialis. APEX :The apex is pointed, and gives attachment to the ligamentum patellæ. STRUCTURE :The patella consists of a nearly uniform dense cancellous tissue, covered by a thin compact lamina. The cancelli immediately beneath the anterior surface are arranged parallel with it. In the rest of the bone they radiate from the articular surface toward the other parts of the bone. OSSIFICATION :The patella is ossified from a single center, which usually makes its appearance in the second or third year, but may be delayed until the sixth year. More rarely, the bone is developed by two centers, placed side by side. Ossification is completed about the age of puberty. ARTICULATION :The patella articulates with the femur.
Undersurface articulates with the intercondylar region of the femur and has a thick articular cartilage layer to disperse large compression forces of this patellofemoral joint
ARTICULATING SURFACE : cartilaginous posterior surface is divided by a rounded vertical ridge into a
larger lateral portion for articulation w/ lateral condyle of femur smaller medial portion for articulation w/ medial condyle of femur
w/ increasing knee flexion, contact pressure moves proximally on patella up to superior pole and onto quadriceps tendon;
articular surface of patella, varying in thickness from approximately 2 to 5.5 mm, is divided into 7 fascets medial and lateral facets are divided into = 1/3 sections; superiorly and inferiorly, with the 7th facet being the most medial portion called the odd facet;
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Wiberg: 3 shapes based on position of vertical ridge; - type I: there are roughly = medial and lateral facets - type II most common: medial facet is only 1/2 size of lat. facet; - type III medial facet is so far medial that the central ridge is barely noticable
BLOOD SUPPLY:
blood supply to patella originates from as many as 12 nutrient arteries at the inferior pole, which run upward on the anterior surface of the bone in a series of furrows
supply also described as arising from mid patellar vessels penetrating the middle 1/3 of anterior surface & inferior pole vessels that anastomose at inferior pole of patella
geniculate system feeds these primary vessels; - anterior tibial recurrent vessels - inferior medial genicular - inferior lateral genicular
Patellar (kneecap) dislocations occur with significant regularity, especially in younger athletes. Most of the dislocations occur laterally (outside). When these occur, they are associated with significant pain and swelling. Following a patellar dislocation, the first step must be to relocate the patella into the trochlear groove. This often happens spontaneously as the individual extends the knee either while still on the field of play or in an emergency room or training room as the knee is extended for examination. Occasionally relocation of the patella occurs spontaneously before examination and its occurrence must be inferred by finding related problems.
Associated problems normally occur with patellar dislocations, the most obvious of which is tearing of the ligaments that stabilize the kneecap itself. As is the case with all other joints, ligamentous disruption or tearing occurs to allow the joint to dislocate. In the case of patellar dislocation, the ligaments on the inside of the knee are the most commonly injured as the kneecap slides laterally. While tearing of these ligaments is unfortunate, they do have the
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potential to heal. Of much more concern, are the small fragments of cartilage and bone that often are knocked off of the kneecap or the lateral femoral condyle during the relocation of the kneecap. These fragments become loose bodies and usually require removal during an arthroscopic procedure. Patellar dislocations can cause significant quadriceps muscle injuries, which can be made worse due to the effusion within the knee or to early onset of exercises and premature return to play.
A condition referred to as patellar subluxation also exists. The problem exists on a continuum between patellofemoral malalignment and patellar dislocation. It can be sequelae of a traumatic dislocation or in situations where patellar hyperlaxity exists. A subluxation is a partial dislocation in which the patella attempts to dislocate but does not do so completely. Situations such as these are very disconcerting and often give the patients a sense of giving way or buckling. At a minimum, these situations should be treated with aggressive therapeutic intervention as the constant subluxation events not only will interfere with competition, but will also potentially cause repeated wear and discomfort within the patellofemoral joint.
PATELLAR DISLOCATION ANATOMY :
(trochlear groove) and soft tissue structures. There are multiple soft tissue layers that surround
the patellofemoral joint. Medially, the superficial layer is consists of the fascia over the sartorius
muscle, the second layer contains the medial patellofemoral ligament (MPFL) and the
retinaculum, and the third layer contains the medial collateral ligament and joint capsule. The
MPFL provides 50-80% of total restraining force medially. Fascial interconnections between
fibers of the iliotibial band, lateral hamstrings, lateral collateral ligament, and lateral quadriceps
comprise the lateral retinaculum.
MECHANISM OF INJURY :
Patellar dislocations occur in 2 ways:
Direct blow to the kneecap knocking the patella out of place Awkward twisting motions of the knee (Dath et al., 2006).
Sports commonly associated with patellar dislocation include soccer, gymnastics and ice hockey. The patella wobbles out of the patellofemoral groove, usually to the lateral side of the knee (away from the middle of the
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body) (Dath et al., 2006). This occurs when the quadriceps tendons and other ligament stabilizers attached to the borders of the patella contract forcefully as the knee is rotating, pulling the patella out of place (Dath et al., 2006).
MEDIAL DISLOCATION OF PATELLA
LATERAL DISCOTION OF PATELLA
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PREDISPOSING FACTORS
1) DemographicsAge:• Average age of occurrences for patellar dislocation is 16–20 yrs old (Atkin et al., 2000)• Primarily due to increased participation in sports and recreation
Gender:• Female are more susceptible to patellar dislocation
Athletic Population (Atkin et al., 2000):• Particularly in sports with twisting, rotational motion of the knee• Direct trauma to the knee
2) Positive Family History• Related up to 24% of patellar dislocation incidences (Dath et al., 2006)
3) Anatomical Factors
Excessive Q-angle Angle greater than 25 degrees between the patellar tendon and quadriceps muscle (Buchner et al., 2005)
Misalignment of the patella on the knee joint• Due to malformed patella/knee joint, patella situated abnormally higher on the knee than normal (Buchner et al., 2005)
Patella alta
Insufficient Vastus Medialis Obliquus Muscle (VMO) (Dath et al., 2006)• Normal function is to keep patella in stable position• If function is decreased, will result in instability of the patella
ligament laxcity in Down’s syndrome and Ehlers-Danlos syndrome femoral anteversion genu valgum loose medial retinaculum tight lateral retinaculum vastus medialis dysplasis excessive subtalar pronation trochlear dysplasia - abnormally low side walls in the trochlear groove -
the groove in which the patella rides during bending and straightening of the knee
patellar dysplasia - abnormal patella shape - this may be a small patella, or a flat one, or one in which there is inequality of the facets(the flat under-surfaces)
patella alta - a high riding patella, which makes contact with the groove at a high level where the groove is flat, and is therefore more prone to being forced out of the groove
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general hypermobility
CLINICAL FEATURES :
A.SYMPTOMS :
Rapid, acute swelling.
Extreme pain initially until relocation occurs.
Continued pain along medial (inside) ligaments.
Sense of instability and apprehension that problem will recur.
B.SIGNS :
Gross effusion Tenderness over the medial border of patella Positive lateral apprehension test Hyper mobile patella Contracture of lateral retinaculum with minimal medial displacement of
the lateral edge of the patella from lateral femoral condyle Increased Q angle
RADIOLOGICAL :
Radiographically, valuable information can be obtained. The patellar height can be assessed by either the Insall-Salvati index or the Blackburne-Peel index:
1. The Insall-Salvati index compares the length of the patella (in its longest diameter on a lateral x-ray) to the length of the patellar tendon. These measurements should be almost the same - patella usually very slightly shorter - and the ratio should be 0.9 -1.1 in males and 0.94 -1.18 in females (adults).Although probably the most widely used index, apparently there is inter-observer error in defining the point of attachment of the tendon to the tibia. Moreover, the length of the patella is not consistently related to the length of the articular surface, which is the more relevant variable.
2. The Blackburne-Peel index relates the length of the articular surface of the patella to the distance from the patella to the tibial plateau. The normal range for men is 0.85 -1.09, and for women is 0.70 -1.09. This gives a better idea of the relationship between the patella and the femoral trochlea.
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Dysplastic condyles and a shallow trochlear groove may be evident on a true lateral x-ray of the knee. The Q-angle (the angle between the quadriceps vector - approximated by a line joining the ASIS to the centre of the patella - and the line of pull of the patellar tendon from the centre of the patella to the tibial tubercle) can be measured on a long-leg film. Some authors accept that while the Q-angle is a useful dynamic concept, an unstable patella will tend to lie more laterally than normal in full extension thereby decreasing the angle.
Arthroscopy is not routinely performed, but (through a medial or suprapatellar approach) allows visualisation of the engagement in the trochlea of the patella. A normal patella should centre in the trochlear groove at between 30o and 60o of flexion.
X RAY 1
XRAY 2
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X RAY 3
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X RAY 4
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REHABILITATION PROTOCOL NO 1
General guidelines for non operative treatment of Recurrent (not acute) patellar instability(LATERAL).
Goals
Decrease symptoms and instability. Increase quadriceps strength and endurance (VMO>lateral structures). Use of passive restraints (palumbo-type bracing or mcconnell taping ) to
augment stability during transition. Enhance patellar stability by dynamic stabilization or passive
mechanisms.Exercises
Modify or avoid activities that aggrevate or induce symptoms (running, squatting, stair climbing, jumping, high-impact activities)
Rest, ice, limb elevation. Use of cane or crutches if needed. NSAID’s fo anti inflammatory effect, no steroid injections. Modalities to modify pain, reduce effusion and edema. Electrical stimulation. VMO biofeedback for VMO strengthening. External palumbo-type bracing or mcconnell taping based on patients
preference and skin tolerance to taping. Orthotics posted in subtalar neutral to control foot pronation ,decrease Q
angle , or correct leg length discrepancy . General conditioning and cross training
Aqua exercises, deep pool running Swimming Avoid bicycling in the early phase
Pain free quadriceps strengthening exercises with VMO efficiency enhancement.
No exercises isolate the VMO but several produce high EMG activity of the VMO
Leg press Lateral step ups Isometric quadriceps setting Hip adduction exercises
Gradual restoration of flexibility (stretching) for noted deficits Iliotibial band Quadriceps Hamstrings Gastrocnemius soleus
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Avoid mobilization of the medial retinaculum. Re-establish knee proprioception skills .
Nonoperative Versus Operative Management:
Conservative treatment includes bracing andtaping to restore proper patellar alignment and physical therapy to regain strength and range of motion. Conservative treatment is most often attempted first, especially with a first-time dislocation. Operative treatment is recommended in the presence of anatomical abnormalities orosteochondral fractures. It is more effective in preventing recurrence of dislocations and is oftenonly considered after conservative treatment has been unsuccessful.
Surgical Procedure:
Many different procedures are performed to correct patellar instability.
A.Proximal realignment procedures include lateral release, medial reefing, advancement of the vastus medialis oblique (VMO), Galleazzi’s procedure.
1. Lateral release involves an incision of the lateral retinaculum. 2. Medial reefing involves tightening the medial structures and is often done in conjunction with a lateral release. 3. VMO realignment involves reattaching the VMO insertion more distally and laterally on the patella. 4. The Galeazzi procedure is seldom performed however involves
attaching the semitendinosus tendon to the medial side of the patella.
B. Distal realignment consists of transferring the patellar tendon and tibial tubercle medially. transferring the medial 1/3 of the patellar tendon to the tibial
collateral ligament. Evidence has shown that lateral release is more effective when combinedwith another procedure (i.e. proximal or distal realignment) and for many investigators would only be used it there was a residual patellar tilt after repair/reconstruction of the medial retinacular structures.
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REHABILITATION PROTOCOL NO 2
CONSERVATIVE REHABILITATION (Acute)
Note: The following rehabilitation progression after a first-time acute lateral patellar dislocation is a summary of the guidelines provided by D’Amato and Bach, published in Clinical Orthopaedic Rehabilitation by S. Brent Brotzman and Kevin E. Wilk.
Phase I
Goals: Decrease pain and swelling
Limit range of motion and weight-bearing to protect healing tissues
Return muscle function
Avoid overaggressive therapy that may lead the patient into a patellofemoral pain
syndrome
Intervention:
• Bracing: set at 0 degrees initially with ambulation, lateral buttress pad in brace
• Ice
• McConnell taping; light compressive bandage
• Instruction in partial weight-bearing with crutches
• Electrical stimulation for activation of the VMO
Ben Cornell PT, Joe Godges PT Loma Linda U DPT Program KPSoCal Ortho PT Residency3
• Supine straight leg raise (SLR) with minimal to no pain
• Ankle pumps if edema is present
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• Isometric hamstrings
Phase II
Criteria: no significant joint effusion, no quadriceps extension lag, minimal to no pain with
activities of daily living
Goals: Full ROM – pain-free
Improve quadriceps strength
Low-level functional activities
Initiate conditioning
Avoid patellofemoral symptoms or instability
Intervention:
• Continue patellar bracing or taping
• Weight-bearing as tolerated; discard crutches when extension lag is no longer present
• Continue electrical stimulation and modalities as needed
• Continue supine SLR and add adduction and abduction SLRs
• Toe raises with equal weight bearing
• Closed kinetic chain exercises
• Low-level endurance and pool exercises
Phase III
Criteria: full active ROM, good to normal quadriceps strength, full weight-bearing with normal gait pattern
Goals:
Improve function
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Gradual return to high-level activities
Intervention:
• Bracing: wean from bracing and taping as quadriceps function improves
• Four-way hip exercises
• Pool therapy – walking with progression to running
• Sport and skill-specific training
• Proprioceptive training
• Patient education
Criteria for Return to Full Activity (8-12 weeks)
Ben Cornell PT, Joe Godges PT Loma Linda U DPT Program KPSoCal Ortho PT Residency4
• Equal ROM between lower extremities
• No pain or edema
• 85% strength compared with uninvolved limb
• Satisfactory 1-minute single leg hop test, two-legged hop test
Maintain quadriceps strength and flexibility of the hamstrings
Patellar bracing and taping to restore proper alignment
POSTOPERATIVE REHABILITATION
Distal and/or Proximal Realignment Procedures
Note: The following rehabilitation progression is a summary of the guidelines after a distal and/or proximal realignment procedure provided by D’Amato and Bach, published in Clinical Orthopaedic Rehabilitation by S. Brent Brotzman and Kevin E. Wilk. The same rehabilitation protocol is used for both distal and proximal realignment procedures, with a few exceptions noted below. For a combined distal and proximal realignment, the protocol for distalrealignment is used.
Phase I for Immediate Postoperative – Weeks 1-6
Goals:
Control inflammation
Protect fixation
Activation of quadriceps and VMO
Full knee extension and minimize adverse effects of immobilization
• Brace: 0-4 wks – locked in full extension 24 hours 7 days a week except for therapeutic exercises and continuous passive motion use, 4-6 wks – unlocked for sleeping, locked for ambulation
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• Weight-bearing: Proximal realignment – as tolerated with two crutches, Distal realignment – 50% with two crutches
• Quadriceps sets and isometric adduction with electrical stimulation for VMO (* no electrical stimulation for 6 wks with proximal realignment procedure)
Criteria for progression: Good quadriceps set, ~90 degrees of flexion, no signs of active inflammation
Goals: Increase flexion
Avoid overstressing fixation
Control of quadriceps and VMO for proper patellar tracking
Intervention:
• Brace: discontinue use for sleeping, unlock for ambulation as per physician's orders
• Weight bearing: As tolerated with crutches
• Progress to weight-bearing gastrocnemius/soleus stretching, full flexion with heel slides
• Aquatic therapy
• Balance exercises
• Stationary bike – low-resistance, high seat
• Wall slides 0-45 degrees of flexion progress to mini squats
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Phase III Week 8-4 months
Criteria for progression: No quadriceps extensor lag with SLR, nonantalgic gait, no evidence of lateral patellar tracking or instability
Intervention:
• Discontinue crutches when: no extensor lag with SLR, full extension, nonantalgic gait pattern
• Step-ups - 2 inches progress to 8 inches
• Stationary bike – moderate resistance
• Endurance – swimming, Stairmaster
• Gait training
• 4-way hip exercise
• Leg press 0-45 degrees of flexion
• Toe raises, hamstring curls
• Continue balance activities
• Hamstrings, gastrocnemius/soleus, add quadriceps and iliotibial band stretches
Phase IV 4-6 months
Criteria for progression: Good to normal quadriceps strength, no soft tissue complaints, no evidence of patellar instability, clearance from physician to progress closed-chain exercises and resume full or partial activity.
· Same rehab protocol is followed for proximal and distal procedures except weight-bearing and other limitations as noted
· After combined proximal and distal realignment, the protocol for distal realignment is used
Phase I (1 – 5 days post-op)
oWound care: Observe for signs of infectionoModalities: prn for pain and inflammation (ice, IFC)oBrace
Locked in full extension for all activities except therapeutic exercises and CPM use
Locked in full extension for sleepingo Gait
WBAT with two crutches for proximal realignment procedure 50% weight bearing with two crutches for distal realignment
o ROM 0 – 30 degrees of flexion Ankle AROM
o Strengthening: nonePhase II (5 days – 4 weeks post-op)
o Wound care: Monitor site for signs of infection and initiate scar management techniques when incision
closedo Modalities: Modalities PRN for pain and inflammation (ice, IFC)o Brace
0-4 weeks locked in full extension for all activities except therapeutic exercises and CPM use
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Locked in full extension for sleepingo Gait
WBAT with two crutches for proximal realignment procedure 50% weight bearing with two crutches for distal realignment
o ROM 0 – 2 weeks: 0 – 30 degrees of flexion 2 – 4 weeks: 0 – 60 degrees of flexion Goal of full knee extension by week 6
o Strengthening Quad sets for isometric adduction with biofeedback and E-stim for VMO
(no E-stim for 6 weeks for proximal realignment). Goal of regaining active quad and VMO
control by end of 6 weeks. Heel slides from 0 – 60 degrees of flexion for proximal realignment, 0 –
90 degrees of flexion for distal realignment CPM for 2 hr, bid from 0 – 60 degrees of flexion for proximal
realignment, 0 – 90 degrees of flexion for distal realignment NWB gastroc, soleus, and hamstring stretches SLR in four planes with brace locked in full extension lying down or
standing Resisted ankle ROM with Theraband Patellar mobilization (begin as tolerated) Begin aquatic therapy at 3 – 4 weeks, emphasis on gait
Phase III (4 – 10 weeks post-op)
o Wound care: Observe for signs of infection, continue scar mobso Modalities: continue prn for pain and inflammation (ice, IFC)
4 weeks to 6 weeks:
o Brace: Unlocked for sleeping, locked in full extension for ambulationo Gait
WBAT with two crutches for proximal realignment procedure 50% weight bearing with two crutches for distal realignment
o ROM: 0 – 90 degrees of flexiono Strengthening: continue same as phase II
6 weeks to 8 weeks:
o Brace: Discontinue use for sleeping, unlock for ambulation as allowed by physician
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o Gait: As tolerated with two crutcheso ROM: Increase flexion gradually to normal range for patiento Strengthening:
May begin NMES for proximal realignment Continue exercises progressing to full flexion with heel slides Progress to weight-bearing gastroc, soleus stretching D/C CPM if achieved 90 degrees knee flexion Continue aquatic therapy Closed chain balance exercises Stationary bike, low resistance, high-seat Wall slides progressing to mini-squats, 0-45 degrees of flexion
8 weeks to 10 weeks
o Brace: D/Co Gait: May D/C crutches if no extension lag is present, patient is able to achieve
full extension, and gaito pattern is normalized with one crutch.o Strengthening:
Should be able to demonstrate SLR without extension lag May begin closed chain strengthening including step-ups (begin at 2 inch
step) Moderate resistance for stationary bike Four way resisted hip strengthening Leg press for 0-45 degrees of flexion Swimming and/or stairmaster for endurance Toe raises, hamstring curls and proprioceptive exercises Treadmill walking Flexibility exercises continued
Phase IV (10+ weeks post-op)
o Criteria Clearance from physician to begin more concentrated closed-kinetic
chain exercises and resume full or partial activity level At least 0 – 115 degrees AROM with no swelling and complete voluntary
contraction of quad No evidence of patellar instability No soft tissue complaints
o Strengthening Progression of closed-kinetic chain activities including partial squats (60
degrees), leg press, forward and lateral lunges, lateral step-ups, leg extensions 60 – 0 degrees,
bicycle and /or
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stepper. Functional progression, sport specific activities
o Functional testing: Performance to < 25% deficit compared to non-surgical side by D/C
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REHABILITATION PROTOCOL NO 5
Surgical Procedures:
Arthroscopic lateral release is primarily indicated for patients with persistent anterior knee pain despite of supervised physical therapy with a tight lateral retinaculum clinically and radiographically documented by lateral patellar tilt, a tender lateral retinaculum, a medial glide of two or less quadrants, a normal Q-angle, and minimal or nonexistent patellofemoral chondrosis.
The superomedial portal is established 3-6 cm proximal to the superior pole of the patella in line with the medial edge. Excessive superior extension should be avoided so as not to damage the vastus lateralis muscle. The entire retinaculum is released, paralleling the lateral edge of the patella. At the superior aspect of the patella, the release should stay posterior. The patella should be able to tilt 70 to 90 degrees.
Goal: Allow the patella to seek a central position and prevent lateralization of the patella.
Complications: Hemarthrosis, infection, medial patellar subluxation if excessive lateral release.
An isolated lateral release has poor prognosis in patients with patella alta, an abnormal q-angle or a hypoplastic trochlea.
Some studies reported better results when this release was combined with another procedure on the medial retinaculum. Many investigators suggest performing a lateral release if there is a residual patellar tilt after repair/reconstruction or reefing (tightening the medial structures) of the medial retinacular structures.
Other proximal realignment procedures include reefing (mentioned above, open or via arthroscopy) and the advancement of the vastus medialis oblique (VMO), which involves reattaching the VMO insertion more distally and laterally on the patella.
Goal: Restore patellofemoral alignment in recurrent subluxation or dislocation and to centralize
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the patella after a lateral retinacular release.
Complication: Reflex sympathetic dystrophy (possible entrapment of the saphenous nerve).
The lateral retinacular release and the other proximal realignment procedures do not address bone malalignment. Studies have reported a 86% return to previous level of activity within 3-4 months for individuals having a proximal realignment procedure.
Distal realignment consists of transferring the patellar tendon and tibial tubercle medially. Soft tissue distal realignment involves transferring the medial 1/3 of the patellar tendon to the tibial collateral ligament. Osteotomy involves reorienting the tibial tubercle medially or anteromedially to reduce the Q-angle.
Goal: correct patellar tracking on the skeletally mature patient with recurrent
subluxation/dislocation, or an increased Q-angle, and unload damaged articular surfaces.
Indications for surgical procedures are: failure of nonoperative care, osteochondral injury, patella instability, disruption of MPFL-VMO, high level athletic demands and risk factors.
Surgical Outcomes: 79% obtain good to excellent functional outcome after lateral release with a combined VMO advancement and tibial tubercle transfer (Palmer 2004).
Preoperative Rehabilitation:
• Control pain and inflammation: protection, rest, ice, compression, elevation (if acute)
• Maintain or improve strength and flexibility of the quadriceps and the hamstrings
• Improve general lower extremity alignment
• Patellar bracing and taping to prevent more damage
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POSTOPERATIVE REHABILITATION
Lateral Retinacular Release
The following is a general guideline for the rehabilitation after lateral retinacular release.
Advancement of the patient to the next phase should be considered on an individual basis taking also into consideration the surgeon’s directives.
The overall goal of rehabilitation is to reestablish appropriate extensor mechanism function and reduce patellofemoral contact forces.
Phase I: Immediate Postoperative – Weeks 1-2
Goals: Control postoperative pain and swelling Protect tissues in the process of healing limiting range of motion Improve muscle function of the lower extremity, specially quadriceps and
VMO Improve range of motion: 0º- 115º knee flexion and full knee extension Full weight bearing if extension ROM is controlled by muscle Independent ambulation
Intervention:
o Pain, inflammation and hemarthrosis management: Cryotherapy, compression bandage,
elevation and ankle pumpso ROM: Early range of motion is needed to ensure that the lateral structures are
maintained in an opened or released position. Knee flexion: 0-1 week: 0º- 90º flexion, 75º by day 3, 110º-115º by week
2. Knee extension: full.
o Brace: 0-2/4 wks – locked in full extension, removed for rehabilitation Some do not recommend the use of immobilizers
o Weight bearing: immediate post-operative ambulation with crutches, weight bearing as
tolerated (WBAT). Full by 2 weekso Therapeutic Exercise:
Quadriceps sets at full extension progressing to multi angle isometrics
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Electrical stimulation for VMO Hip external rotators strengthening Heel slides and wall slides Non-weight bearing gastrocnemius/soleus, hamstring, ITB, hip flexors
stretching 4-way SLR with brace locked in full extension. Begin abduction at approximately 3 weeks to minimize lateral pulling of this muscle group on the patella. Patellar mobilization (when tolerable) Aquatic therapy at 2 wks (when wound is healed) with emphasis on gait
training Stationary bike for ROM when sufficient knee flexion is achieved
Phase II – Weeks 3-5
Criteria for progression: Well-controlled swelling and pain Good quadriceps strength and control ROM: 90º of active knee flexion and full active knee extension Full weight bearing
Goals: Increase lower extremity strength and flexibility: 70% muscle
reconditioning Control of quadriceps and VMO for proper patellar tracking Exercise swelling controlled Improve gait pattern, balance and proprioception. Establish home exercise program Independent activities of daily living
Intervention:
o Brace: if brace is used, discontinue use for sleeping, brace at 0º-60º when ambulating
o Weight bearing: WBAT without crutches if: Full active knee extension, active 90º- 100º knee flexion, non-antalgic
gait pattern, and no extension lag with SLR. Patient can progress from two to one crutches, and then ambulate without
them.o ROM: Knee flexion: Week 2: 100º-115º
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Week 3: 115-125º Knee extension: 60º-0º
o Therapeutic Exercise: 45º flexion with heel slides Complete lower extremity flexibility: Quadriceps, ITB and hip flexors
stretching and progress to weight-bearing gastrocnemius/soleus stretching Calf raises 4 way hip exercises Wall slides progression (0-45º) to mini squats Closed chain kinetic terminal knee extension with resistive tubing or
weight machine, and open chain reconditioning. Balance and proprioceptive activities Stationary bike Treadmill walking with emphasis on normalization of gait pattern Aquatic therapy Aerobic reconditioning
Phase III Week 6 weeks return to activity
Criteria for progression:
Good to Normal quadriceps strength Non-antalgic gait No evidence of lateral patellar tracking or instability Pain is controlled and associated with activity only Clearance from physician to progress closed-chain exercises and resume full or partial activity Necessary joint range of motion, muscle strength, and endurance to safely return to athletic participation Knee extension: 70% of contralateral side.
Goals: Restore any residual loss of ROM Improve functional strength and proprioception Return to appropriate activity level Maintenance program development
Intervention:
o Brace: for activity onlyo Therapeutic Exercise:
Endurance – swimming, stairmaster
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Complete lower extremity flexibility Continue balance activities and gait training Progression of closed-kinetic chain exercises and proprioception
exercises Step-ups - 2 inches progress to 8 inches: forward and lateral Stationary bike – moderate resistance Leg press 0-45 degrees of flexion 0-70º wall squats Knee extension 90-0º Toe raises, hamstring curls Jogging/running in pool with resistance Walk/jog progression, Jogging in pool with progression to land Forward and backward running, cutting, figure 8’s Slide Board Plyometrics Emphasis on sport/work -specific activity development Return to sports when the knee is pain free, near full ROM has been
obtained, and they have achieved at least 80% strength as compared with the opposite leg. Most
patients are able to go back to sports by four to six months (Arendt, Fithian and Cohen 2002).
31
REHABILITATION PROTOCOL NO 6
MEDIAL PATELOFEMORAL LIGAMENT
RECONSTRUCTION
A MPFL reconstruction was performed using a semitendinosis free graft. A longitudinal incision was made over the patella. The patella was accessed, and a bony tunnel was made in its upper medial border. The graft was passed through this, tunnelled through the second layer of the medial retinaculum and “whip-stitched” together. A second incision was made over the medial femoral condyle. A pit was formed at the medial femoral condyle, at the origin of the MPFL, and the graft was held in this femoral pit using a screw. The knee was then assessed arthroscopically to ensure that the patella was lying correctly within the femoral trochlear and that there was no instability on flexion and extension of the knee. The incisions were closed and the knee was dressed in gauze, wool and crepe bandage. Figure 1 illustrates the 2 incisions required for graft fixation from the patella, to the medial femoral condyle.
Figure 1: The MPFL Reconstruction Incisions.
The post-operative instructions permitted knee range of movement exercises after 2 hours post-operatively, to mobilise full weight-bearing and out-patient physiotherapy.
A modified Dejour trochleoplasty, described by Donell et al,1 was performed. Using this technique, a mid-line incision was made and a medial para-patellar approach everting the patella laterally. This exposed the distal femur. A trench of subchondral bone was removed from underneath the dysplastic trochlea creating a thick osteochondral flap with a diamond shape. A new groove was fashioned by dividing this into two triangular flaps and pushing them downwards. These were then anchored down using countersunk screws into the distal femur. Any exposed cancellous bone was then covered with bone wax. Figure 1 illustrates the trochlea before and after this procedure.
Figure 1: The femoral trochlea pre- and post-operatively.
To address the patient's abnormal patella tracking, the tibial tubercle was transposed medially twelve millimetres and fixed with a cortical screw (Elmslie procedure). A lateral release with double-breasted medial reefing was also performed to address the proximal realignment.
The post-operative notes permitted the immediate application of a continuous passive motion (CPM) machine, full weight-bearing, and, once quadriceps control had been regained, the Raymed splint could be replaced with a Donjoy brace (Donjoy, Vista, California, USA) fixed at zero to ninety degrees until the tibial tubercle had fused.
