Chapter 12: Nonoperative Treatment

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Figure 12.1. Looking at the patient will reveal alignment problems, muscle atrophy, skin changes, and gait alteration. Observe the patient standing and walking, with and without sneakers.

Figure 12.2. A, Look critically to see if the patella is tilted or just displaced on the trochlea. This is also an ideal time to palpate muscle and retinacular structure around the patella. B, Look at the patella from above and below. This is particularly helpful in identifying tilt.

Figure 12.3. Palpate carefully above and below the patella to detect tenderness of the patellar tendon or quadriceps tendon.

Figure 12.4. Evaluate the patient for tightness of the hamstrings (A), quadriceps (B), or iliotibial band (C). The prone position is particularly useful for stretching the quadriceps (B).

Figure 12.4. Continued.

Figure 12.4. Continued.

Figure 12.5. A and B, The therapist should stabilize the knee and then carefully mobilize the lateral reti­nacular structure with continuous firm pressure. This may be accomplished best with the patient lateral and the affected side up. By relaxing the extensor mechanism in this manner, the therapist may stretch the lateral retinaculum more effectively in varying degrees of knee flexion.

Figure 12.6. The patient should learn to contract the vastus medialis and exercise it regularly.

Figure 12.7. Ultrasound, iontophoresis, and other modalities may be used to facilitate stretching and also for pain relief.

Figure 12.8. An aerobic conditioning program is important for every patient. Pain‑free exercise is possible for almost all patients, but the thera­pist may have to improvise and supervise an ex­ercise program initially to assure that the patient did not aggravate his/her condition.

Figure 12.9. Awareness and control of vastus medialis obliquus contraction will help the patient gain confi­dence and control of extensor mechanism function.

Figure 12.10. Mobilization of the kinetic chain above and below the knee is usually helpful. Stretching the gastrocnemius‑soleus, balancing the foot, and working on balance‑proprioception should be part of most patellofemoral rehabilitation programs.

Figure 12.11. Taping the patella as described by Jennie McConnell involves the application of tape to control (A) tilt, (B) subluxation, and (C) rotation of the patella. New devices and braces to control the patella are also available using modified taping and brace combination techniques.

Figure 12.11. Continued.

Figure 12.12. One must be particularly aware of the skin when applying tape.

Figure 12.13. Regaining vastus medialis strength is important in most all patellofemoral rehabilitation.

Figure 12.14. The trampoline is a convenient device for gaining both eccentric and concen­tric motor strength in both lower extremities.

Figure 12.15. Leg‑press exercise is most desirable in early range of motion from 0‑ to 30‑degree knee flexion. Reprinted with permission from Steinkamp LA. Dillingham MF, Markel MD, Hill JA, Kaufman KR. Biomechanical considerations in patellofemoral joint rehabilitation. Am J Sports Med 1993;21(3):438‑446.

Figure 12.16. Knee extension exercise against resistance is more desirable in the 60‑ to 90‑degree range of motion. Reprinted with permission from Steinkamp LA, Dillingham MF, Markel MD, Hill JA, Kaufman KR. Biomechanical considerations in patellofemoral joint rehabilitation. Am J Sports Med 1993;21(3):438‑446.

Figure 12.17. Biofeedback techniques help the patient to understand when the vastus medialis contracts and how to control it.

        

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