chapter 12: Nonoperative Treatment
The physical examination has yielded some concept of the extent and location of articular lesions. The goal of rehabilitation is to reduce contact on these lesions when possible, mobilize sensitive and stiff retinacular structures around the degenerating patella, reduce effusion when possible, and control structural factors that may have led to this problem in the first place (eg, infrapatellar contracture, tilt, subluxation).
Throughout the rehabilitation of patients with patellar chondrosis‑arthrosis, it is important to avoid excessive contact stress on a lesion. Consequently, exercises should be individualized to avoid loading the lesion. When the articular lesion is distal on the patella, quadriceps exercise will be best done with the knee more flexed. If the lesion is proximal on the patella (as in a dashboard‑type injury), exercise will be better accomplished closer to full knee extension (see Chapter 2 on Biomechanics). Taping and bracing as well as nonsteroidal anti‑inflammatory medication may facilitate the exercise program and improve muscle reactivity by providing proprioceptive feedback.
Most important in the patient with an articular lesion is to mobilize the retinaculum and extensor mechanism. Prone stretching of the quadriceps is the cornerstone of this mobilization process.
Surgery, blunt trauma, or chronic stress of any sort around the anterior knee can lead to retinacular damage, small neuromata in the peripatellar retinaculum, or painful scar tissue in the structure around the patellofemoral joint. Retinacular pain, related to soft-tissue trauma or stress, will respond only to strengthening, stretching, or surgery that is specifically designed to treat the affected area. Only a careful correlation of clinical examination with the patient's history will uncover the specific source of pain.
Once identified, a retinacular source of pain may be treated by stretching, mobilization, modalities, injection, nonsteroidal anti‑inflammatory medication, or skillful neglect (the more acute strains may get better with time alone). Reassurance is particularly helpful in these patients, who may feel that the joint itself is deteriorating and that previous activities (sports, work, and so on) may no longer be possible. When therapy directed to the affected area of retinaculum fails, surgical exploration, selective release, and/or excision may be curative in carefully selected patients.
Inside Chapter 12: