chapter 12: Nonoperative Treatment
There are a variety of braces that can lend a feeling of support to the patellofemoral joint. Aircast (Summit, New Jersey) produces a comfortable patellofemoral support. Orthotech (Tracy, California) produces the author's (JPF) new (1996) Tru‑Pull patella support. Some patients find relief with a simple patellar strap. Elastic or neoprene knee braces with a patellar cut‑out are useful in many patients. Almost any elastic support around the front of the knee can provide relief or an enhanced ability to exercise in selected patients. The type of brace may be chosen empirically, and some patients may try two or three braces before finding one that works well and is comfortable. The concept of proprioceptive feedback around the front of the knee, together with comfort and affordability, makes bracing desirable in patients who do not respond to exercise alone. Patellofemoral braces are particularly useful in athletes and for exercise during cold weather. Voight and Wieder (19) have emphasized that patients with patellofemoral mechanism dysfunction may have a neurophysiologic motor control imbalance, as demonstrated by a faster vastus lateralis response time in patellofemoral dysfunction patients. As with taping, bracing may help to modify some of the feedback mechanisms in this neurophysiologic balance.
Cherf and Paulos (20) pointed out that orthotics and braces around the patellofemoral joint are helpful, particularly those applying a medially directed force on the patella. Nonetheless, they emphasize that well‑designed clinical studies on the use of patellar braces are lacking.
Although progression to an aerobic exercise program is desirable for most anterior knee pain patients, some patients will require reduction of activities or withdrawal from sports participation. This tends to be more important in patients with post‑traumatic pain or patellofemoral degeneration after anterior cruciate ligament reconstruction (21). If the problem is one of overuse, excessive metabolic activity in the patella or surrounding structures, acute damage, or chronic pain that has not responded to rehabilitative exercise, reduction of activity, splinting for short periods of time, ice application, and relative rest must be seriously considered. When rest of the patellofemoral joint is necessary, it is advisable to think in terms of 6 to 8 weeks minimum, using cryotherapy and anti‑inflammatory treatment simultaneously. It is usually possible to maintain some muscle tone and flexibility during this period of relative rest while cutting back on the more extreme levels of physical activity, which may be aggravating the knee. This is particularly true if there has been effusion. In this case, anti‑inflammatory treatment, rest, ice, and reduction of aggravating stresses will be important to bring the joint into balance.
When effusion and pain have been eliminated for 7 to 14 days, gradually increasing activity may be re‑introduced, using cryotherapy after activity. The goal is to move each patient into normal activities of daily living, and then to introduce a tailored aerobic conditioning program that is structured to avoid aggravating the pain problem while gaining aerobic capacity as tolerated, emphasizing home programs.
Inside Chapter 12: