Assessment determines the primary factor.
Patients are then classified with:
1. Ligamentous instability (ligament incompetency/laxity)
2. Tension (inability to tolerate high loads, especially eccentric loads)
3. Friction (inability to tolerate repeated flexion/extension activities)
4. Compression (inability to tolerate compression loads, weight-bearing activities)
Figure 63-3 Patellofemoral patients.
Table 63-1 Ligamentous Instability Rehabilitation Pearls*
• Avoid terminal extension (patella must not laterally bias excessively)
• Exercise in the groove (lower range of motion, patella within the sulcus). Fingers, tape, brace, get the patella medial for exercise, exercise must be pain free
• Remember gluteals, adductors, and abductors
• Strengthen the quadriceps: open and closed sequences ♦Common problems: patellar dislocation/subluxation, lateral instability.
Table 63-4 Compression Rehabilitation Pearls*
• Pain-free exercise: partial range of motion, multiple-angle isometrics
• Avoid full range of motion loaded activities that cause pain, viscolastic inserts
• Strengthen the quadriceps: open and closed chain but pain free, do not abuse the damaged surface
• High-speed isokinetics can be used (low torque and short time of loading)
♦Common problems: articular defects, arthritis, abnormal muscular absorption.
Table 63-5 Articular Cartilage Rehabilitation Pearls: Nonoperative*
• Strengthen the quadriceps: open and closed chain but pain free, do not abuse the damaged surface, open lower in range of motion, closed closer to extension range of motion
• Control shear forces (use submaximal exercises, high-speed exercise, partial range-of-motion exercises, again pain free)
• Decrease maximal loads: pool programs/aquatic approach
• Walking: soft, multidensity absorbent inserts, limit fatigue, 12-minute rule
• Limit range of motion of some exercise devices (cross-country simulator and stepmachine)
*Common problem: articular abnormality.
Table 63-2 Tension Rehabilitation Pearls*
Avoid high-speed isokinetics
Emphasis on eccentric maximal exercise
Use plyometrics but late in rehabilitation sequence (advance weight prior to speed)
10-12 week rule (it takes several weeks for eccentric program to work)
♦Common problems: jumper's knee, tendonitis/tendonosis, muscle strains.
Table 63-3 Friction Rehabilitation Pearls*
Avoid repetitive flexion/extension loaded patterns
Avoid high-speed isokinetics
Multiple-angle isometrics and partial range-of-motion exercise sequences
Modify footwear if pronation related but remember other leg (often pronating to shorten the long leg, put heel lift under other leg)
♦Common problems: plica, iliotibial band, bursal irritation.
motor program/pattern selected, open/closed, shear/compression, and external modifiers (e.g., braces, tape, medications, orthotics). Each protocol is designed to optimally use these factors through an evaluation-based selection/application.
The application of this process has been described previously with a more specific listing of diagnostic classifications.6 The categorization into four rehabilitation patterns is somewhat arbitrary and designed to illustrate the special concepts for patellofemoral patients. However, Table 63-4 (compression rehabilitation concepts) is quite reflective of the approach to patients with arthritis or articular injury. Table 63-5 presents approaches to these patients in a nonoperative situation.
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