Patellofemoral patients

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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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