chapter 12: Nonoperative Treatment
Stretching the Kinetic Chain
Excessive tightness above or below the patellofemoral joint can create elevated stress around the patella by limiting the normal progression of impact absorption through the kinetic chain. An unyielding gastrocnemius muscle, for instance, may give an abrupt pronation moment at the foot during the "foot flat" component of gait.
The gastrocnemius will stretch most effectively with the knee extended, because the gastrocnemius crosses the knee joint. Stretching the heel cords at home on a step after warm‑up exercises is important.
Stretching the hamstrings following warm‑up will help reduce elevated patellofemoral contact stress during knee extension. Toe‑touch exercises or standing hamstring stretches usually suffice if these are conducted on a regular basis. Doucette and Goble (5) noted that hamstring flexibility was not always increased during a minimum 6‑week rehabilitation program. We have observed, however, that rigorous hamstring stretches following warm‑up exercises frequently will increase hamstring flexibility in the motivated patient.
Quadriceps flexibility should be examined with the patient prone, and stretching the quadriceps is also accomplished best in this position. The patient may need to use a towel or sheet around the ankle to stretch the quadriceps in the prone position initially, until the knee can be flexed to bring the ankle to the hand of the patient for manual stretching. It is surprising how often patients come to our office for evaluation of anterior knee pain having never been examined or stretched in the prone position! Prone quadriceps stretching is useful (see Fig. 12.3), particularly because it enables the patient to see his/her progress and reduces stiffness around the anterior knee. This is, in our opinion, the most important component of extensor mechanism rehabilitation. Prone stretching also helps to mobilize any minor infrapatellar contracture, postoperative scar from arthroscopy, stiffness of the patellar tendon, hematoma, and some plicae.
Prone stretching also helps to mobilize the lateral retinaculum. Patients should learn manual stretching of the lateral retinaculum (see Fig. 12.5), with emphasis both on reducing patellar tilt and improving medial mobility of the patella. Deep friction massage may help in this area, and modalities such as ultrasound may help in mobilizing the lateral retinaculum. Patellar taping also facilitates mobilization of the lateral patellofemoral support structures.
Mobilization of the iliotibial band adds to compliance of the lateral retinaculum. In any patient with lateral tightness, the therapist should incorporate iliotibial band stretches with the pelvis neutralized, patient lateral, hip extended, and preferably with the ankle held by the patient (knee flexed) while bringing the hip into adduction. Again, modalities may be helpful, at least in initiating these exercises.
If hip internal rotators are tight, preventing adequate external rotation at the hip, stretches should start at the hip level. Tight hip internal rotators or tight anterior hip capsule may diminish normal hip external rotation, which can be important in maintaining patellofemoral congruence.
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