chapter 12: Nonoperative Treatment
Many patients, following the initial diagnosis, will respond to a home treatment program. Tailoring the home program to the specific diagnosis, as noted earlier in this chapter, is most important. Nonsteroidal anti‑inflammatory medication will usually help with pain control, incorporating exercise and stretching with the patient's day‑to‑day activities. When quadriceps or hamstring strengthening is advisable, a program that allows strengthening through a pain‑free range of motion, without stressing articular lesions, must be created. The seat of an exercise bicycle, or even a regular bicycle, can be adjusted for the desired knee range of motion. The seat will generally be lowered when there is an articular lesion on the distal articular surface, such that exercise is accomplished in a more flexed‑knee position. Similarly, for a lesion on the more proximal patella (such as dashboard injury), the seat may be set very high, such that there is more exercise toward full extension of the knee. Ankle weights, theraband, or surgical tubing may be used in a similar fashion.
A simple elastic knee sleeve with patella cut‑out or a patellar tendon strap may be used for pain control in the patient with patellofemoral pain. Beware, however, of using a patellar tendon strap in the patient with a distal patella articular lesion, however, because there is risk of increasing load on the distal patella articular lesion with one of these straps.
Stretching at home is advisable in most patients with anterior knee pain. The prone quadriceps stretch (lying on the stomach, grasping the ankle and pulling the knee into flexion gradually over a period of 20 to 30 seconds) will reduce adhesions, stiffness, and muscle tightness. There is substantial benefit with minimal cost and effort doing stretching at home. The patient can also stretch the hamstrings by doing simple toe-touching exercises with the legs straight.
Simple orthotics may be extremely helpful in the home management of patients with pronation. We recommend simple off‑the‑shelf orthotics initially, at considerable cost savings, when orthotics seem to be necessary to balance the kinetic chain. When effective, these may be replaced selectively with custom orthotics for more long‑term use at a later time. Also, some patients prefer a soft off‑the‑shelf type of orthotic, or cork-and‑leather orthotic, to the more rigid plastic custom orthotic.
Aerobic exercise should be a goal in most patients with anterior knee pain. Once there is pain control using anti‑inflammatory medication, strengthening, stretching, and bracing, a program of gradual aerobic conditioning will help to enhance self‑esteem and confidence while further mobilizing retinacular structures around the patella. Water exercise, such as bobbing or swimming laps, may be available to some patients, whereas the more vigorous exercise bicycle using high repetition and lower resistance training may be best for other patients. Still others may progress into a running program when articular disease is absent or less pronounced. The specific form of exercise will vary, depending upon the severity of articular disease, the amount of pain, the patient's preference, and the success of other home therapy management techniques.
Inside Chapter 12: