chapter 12: Nonoperative Treatment

PLANNING TREATMENT

Having examined the patient closely after obtaining a detailed history, the clinician can develop a treatment plan. In particular, the therapist should observe the patient (Fig. 12.1); evaluate patellar position, tilt and alignment (Fig. 12.2, A and B); determine if there is retinacular, patellar tendon, or quadriceps tendon tenderness (Fig. 12.3); identify tightness of the quadriceps, hamstrings or iliotibial band (Fig. 12.4, A to C); and gain some insight into the patient's motivation. The goal will be to match a treatment plan with the specific findings. One must define the (1) patellar malposition, (2) degree and location of chondrosis‑arthrosis, (3) retinacular‑soft tissue causes of pain, (4) referred pain, and (5) compensation‑related problems.

Malposition

Short of surgery, it is unlikely that patellar tracking can be changed much. Tight structures can be stretched. Tape and braces can apply some mild support. One can strengthen muscles to give dynamic support. Structural alignment is maintained by dense retinacular structures that are not likely to elongate significantly with stretching. Whereas it is possible to reduce stiffness and increase mobility, stretching, bracing, and taping probably will not make a malaligned patella track normally in most patients.

Consider the quadriceps‑patellar tendon mechanism. One can mobilize the muscle with strengthening, but one will not elongate the patellar tendon itself. On the other hand, if the patellar tendon is tethered by bands of scar, as in an infrapatellar contracture syndrome (IPCS) (11), the patient and therapist may be able to stretch out some of the abnormal scar tissue and allow the tendon to come back to length if the scar has not become fixed. This concept is important, because there is a difference between releasing abnormal tissues that have formed in the short term (adhesions related to immobility) and changing the structural alignment of the extensor mechanism that is genetically or developmentally determined. One must consider also, however, that it may be possible to compensate for abnormal alignment by developing strength in muscles that will selectively counteract tight, deforming forces around the anterior knee. Doucette and Goble (5) have suggested that proper rehabilitation will improve iliotibial band flexibility and radiographic alignment but not the Q angle, patellofemoral index, or hamstring flexibility.

A tilting patella will not come to sit normally in the femoral trochlea by nonoperative treatment alone. After identifying structural tilt, however, the therapist will be able to mobilize those structures that have dynamic components (iliotibial band and quadriceps muscle) while reducing stiffness and discomfort in a tight retinaculum (Fig. 12.5, A and B), mostly on the lateral side of the patella. Quadriceps strengthening with emphasis on the vastus medialis obliquus (VMO) will add to the subjective feeling of support and will improve functional capability in many patients (Fig. 12.6). Prone stretching of the quadriceps (see Fig. 12.4, B) becomes particularly important in the patient with a tilting patella in order to further mobilize stiff retinacular or muscular structures around the anterior knee. Local modalities may provide symptomatic relief during the rehabilitation process (Fig. 12.7). Ultimately, the patient should work into an aerobic conditioning program (Fig. 12.8) for improved confidence and self‑esteem as well as to maintain supple connective tissue around the front of the knee.

A patient with recurrent subluxation and feelings of instability, however, will need emphasis predominantly on support of the patella, including emphasis on the VMO (Fig. 12.9). These patients may have little or no connective‑tissue stiffness, but generally have an abnormal extensor mechanism vector that is not likely to become normal with nonoperative treatment alone. Orthotics may give enough support to alter this vector somewhat and should be included when there is need to balance the kinetic chain, particularly in the patient with excessive pronation. Bracing and taping may be helpful in giving proprioceptive feedback and improved dynamic support for the extensor mechanism thereby.

In the patient with patella baja (however severe or mild), the emphasis will be on prone stretching of the extensor mechanism and strengthening of the hamstrings and quadriceps (see Fig. 12.3). Such patients need a lot of assurance and may need surgical intervention if there is a true IPCS. Following release of an IPCS surgically, such patients may be undergoing continuous passive motion and a regular regimen of stretching‑extensor mechanism mobilization. Aquatic therapy can be particularly helpful in these patients as they regain motion and confidence.

Physical therapy will not correct a patella alta, as the patella cannot be brought distally by nonoperative means. Often, however, there is malalignment or soft‑tissue strain associated with patella alta that will respond to physical therapy.

The patient with recurrent patellar dislocation needs particularly close attention, as he/she is at high risk for articular damage to the patella and may need to have surgical correction of the extensor mechanism vector. In the rehabilitation program, VMO support for the patella is extremely important, along with mobilization of tight, deforming lateral structures. Following acute dislocation, there may be a significant hemarthrosis. Removal of this by aspiration is usually helpful to reduce tension of the medial soft tissues that need to heal in as shortened a position as possible. Fortunately, following a single patellar dislocation, many patients will have adequate healing, and rehabilitation may enable these patients to return to normal activities without surgery. The patient who experiences recurrent dislocations, however, should seek surgical intervention. Each dislocation carries a significant risk of damaging the joint further.

        

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