Patella dislocations make up for about 2-3% of all knee injuries. Research has shown that it happens most commonly amongst teenagers between the age of 15-21 years old , with re-dislocations happening in 44% of teenagers within 6 months of sustaining a first time patella dislocation.
Knee caps can either be dislocated out of it’s groove or subluxed out of it’s groove. The main difference between the two depends on whether the patella has derailed completely off it’s tracks (dislocation) or whether it has partially derailed off it’s tracks (subluxation). Generally , a subluxation is less traumatic with the patella going back in it’s track quickly and spontaneously after moving outwards. A dislocation will require a medical relocation to help move the patella back in it’s tracks. The longer the patella stays out of it’s tracks , the more serious complications will be.
In both instances , a patella dislocation is serious and leads to knee symptoms such as patellar instability , pain and patella-femoral arthritis. Furthermore functional limitations such as a decreased level of sporting activity , pain with walking and stair climbing as well as driving will be affected and difficult.
Anatomy of the patella and the structures around it
The patella is given its stability through multi-factorial structures which work together to allow the smooth gliding of the patella. The patella is a small bone which moves a lot during the movement of your knee. It sits in a boney groove known as the intercondylar groove. Think of the intercondylar groove as being a track with the patella being a sled that moves and slides on the track when bending or straightening the leg.
The strength and movement of the patella is provided by passive and active structures surrounding the knee joint which helps keep the patella in it’s groove. There are passive structures which consists of your tensor fascia late , a patella-femoral ligament as well as a patella ligament. The medial patello-femoral ligament (MPFL) is the primary stabiliser (Up to 67%) of the patella.
The active structures which provides further strength and stability to the patella are your quadricep muscles and patellar ligament. These structures are responsible for actively keeping the patella in place when bending and straightening the knee.
Three main structures are looked at when determining the strength and smooth gliding of your patella , namely:
– Ligament integrity: This refers to how strong your main stabiliser of the patella (MPFL) is when moving your knee. Any structural weakness to this ligament will result in easier outwards dislocation of the patella.
– Quadricep muscles: Your Vastus Medialis Obliques (VMO) connects to the inside of your knee and sits just above the patella. When contracting this group of muscles , the VMO is the one largely responsible for the ensuring the patella “stays in it’s lane”. Together with the Vastus Lateralis , they act as a strong hold on the patella , ensuring that smooth bending and straightening of the knee can occur.
– Intercondylar Groove: Your trochlea or intercondylar groove is the actual “track” that the patella sits in. This is the structure that the patella glides on.
With respect to these multi-factoral structures , any damage , weakness or trauma within these structures will result in a clinical instability of the patella and knee. A clinical instability can defined as the inability of a structure to cope with normal load or stresses. In the knee , this is usually perceived with symptoms ranging from “ My knee is popping out” or giving way when walking or climbing stairs.
What is the function of the patella?
Thinking of the knee as being a hinge that connects our upper leg (the thigh) to our lower leg (the shin). This type of connection allows us to bend and straighten out the joint , similar to a door hinge that enables a door to open and close. The patella , which slides and glides over this hinge is classified as dislocated when it moves off it’s tracks , most commonly outwards.
The main movement of the knee is bending and straightening. Normal range for bending is 140 degree’s and straightening is 0 degree’s. The patella moves and glides on it’s track in relation to the knee bending and straightening. As the knee bends the patella glides downwards and as the knee extends it glides upwards. The main function of the patella is to provide ease of movement during knee movement as well as distributing the force coming through the knee.
When you have an instability (To one of the 3 multi-factorial structures) , the patella is known to maltrack. This refer’s to the patella not being able to glide smoothly on it’s track resulting it in going off track.
When the knee is fully straightened out in full knee extension at 0 degree’s, the quadricep muscle’s are relaxed and the patella is resting at it’s station known as the suprapatellar fat pad. The patella then glides downwards as you flex the knee.
During the first 20-30 degrees of bending your knee , the patella moves downwards, locking in the the track known as the intercondylar groove. This comes in handy to know as this is where majority of where outwards patella dislocations occur. The patella then prepares the sit tight and glide.
During the next 60-90 degree’s of you bending your knee the patella sits comfortably in the track. This is where there is maximum contact between the patella and the track (Intercondylar groove).
At the last 135 -140 degree’s of knee flexion , the patella makes contact with your thigh bone (Femur). Once here, the patella sits and rests below the track (Intercondylar groove) at it’s end destination after completing it’s gliding journey from it’s first station.
I have a patella dislocation!.. How did it happen?
Research has shown that outwards dislocations account for 82% of all patella dislocations. A dislocation can occur when you are playing sport (traumatic) or even when you try to get up from sitting on your knees (atraumatic). In a traumatic event , there has to be force that pushes the knee cap out of position. In a atraumatic event , such as playing golf – the motion can be too much for the knee structures to handle and can also result in a knee cap dislocation.
Lets have a look at how the different multi-factorial structures play a part in WHY you dislocated it in the first place.
As the patella moves from it’s first station , gliding to the end station – there are three primary factors that determine the likelihood of your patella going off it’s tracks.
– Ligament strength: This refer’s to your medial patella-femoral ligament (MPFL). If this ligament has been injured before by being sprained or torn and has not received any targeted rehabilitation it will make your patella more likely to slip outwards when bending the knee or when performing tasks such as side stepping. This also refers to how much stretch your ligament has as a ligament that is hyper mobile (extra flexable) will put you more at risk of a patella dislocation.
– Muscular Strength: This refers to the strength difference between your Vastus Medialis Oblique (VMO) quadricep muscle and your Vastus Lateralis (VL) quadricep muscle. When we bend the knee the VMO is there to pull and stabilise the patella towards the inside , thus avoiding it from slipping outwards. However, when this muscle is not strong enough , the strength and pull of the VL muscle , which sits on the outer part of the thigh , is so strong that it ends up pulling the patella outwards – resulting in it going off it’s track. Previous quadricep muscle tears , a decrease or imbalance in the quadricep activation will result in the overcompensation of your VL quadricep muscle and will result in either a patella dislocation or subluxation.
– Bony alignment: This specific factor relates to the size and depth of the intercondylar groove. If this surface is rough , not smooth , deeper or shallower than usual – it will result in a patella mal-track and frequent dislocation. Dislocations do not have to be traumatic in this sense as this is a mechanical issue that could lead to further intervention if not assessed correctly.
Causes of a patella dislocation
Underlying factors that could lead to a high risk of patella dislocations include:
- Ligament flexibility – If the ligaments in your knee are bit more flexible than normal it can lead to dislocations that are not necessarily traumatic. This is known as atraumatic dislocations which means your patella will subluxate while doing a normal tasks such as getting up from sitting on your knees.
- High impact collisions or accidents – This traumatic event can cause the structures of your knee to move out of place due to the force being stronger than that they are able to handle.
- Uneven surfaces on your lateral femoral condyle – If the surfaces of your knee bones are rough or uneven , it creates a uneven surface for the knee cap to glide on which will result in a patella dislocation.
- High riding patella – Patella Alta is when your knee cap sits a bit higher on your thigh bone than usual. This extra movement results your knee being unstable and causes dislocations much easier than normal.
- Knock Knee’s – When your knee’s face more inwards than usual , it places more stress on the structures keeping the knee stable. This then results in your knee cap not gliding correctly and can lead to knee instability.
- Patellar hypermobility – A knee cap that moves too much makes it easier for it to dislocate as the excess movement makes it easier to slip out when gliding up or down the knee.
This is the core message I want you to understand, think about after you’ve read this article
Stating something is in a bad state is Information.
Explaining the influence of a bad state is Knowledge.
How severe is my patella dislocation?
An acute patella dislocation will always be painful to move or put weight on it. If it happened immediately , you will not be able to use the limb normally until the patella has been shifted back into its groove. When your knee cap pops out of it’s track , there will also be associated symptoms linked to your dislocation. These symptoms will vary depending on the severity of your dislocation.
In a atraumatic dislocation, no traumatic event is needed for your knee cap to subluxate or dislocate. The patella will slide off it’s tracks just by you performing a simple activity like getting in or out of your car. When this happens , the patella generally slips back into it’s groove spontaneously and a medical relocation of the patella is generally not needed. A subluxation will lead to your knee ligaments and muscles to be bruised , swollen and painful. The symptoms will range from mild to moderate and should not be severe.
Below are a few details on how bad it will be after having an atraumatic dislocation:
- Frequency: Pain will come and go depending on how you move your knee.
- Intensity: The intensity of the pain will make walking uncomfortable and you’ll have a feeling of your knee being untrustworthy , especially when climbing stairs.
- Duration: The pain lasting will depend on the type of activities that you do. The pain will not be constant and will last for at least 5-10minutes after climbing stairs.
- Size: The size of discomfort will be around the patella and in front of the knee cap.
- Colour: A slight redness around the knee cap is normal. In moderate injury , the knee cap and knee joint will have a slight blue bruising to it.
- Range of motion: Your knee will struggle to bend and straighten. You should not try and force it further if you feel as if it’s locking as this will aggravate your symptoms.
- Stiffness: Your knee will be moderately stiff when trying to move it with limitations due to pain and swelling.
- Swelling: There will swelling around knee cap , lasting anywhere between 4 days – 1 week.
In a traumatic dislocation, research has shown that the longer a knee cap stays off it’s tracks – the longer and more severe post-injury complications and symptoms will be. If you are playing rugby , and someone tackles your knee or you land incorrectly – this is known as a traumatic dislocation. Putting the knee cap back in it’s tracks can be done on field by the appropriate medical professional. In extreme cases , a relocation will be done in an emergency room under local anaesthesia.
Your knee will be very swollen and painful from the trauma so you shouldn’t try to walk if it’s too painful. Lets have look at some of the differences between the above-mentioned moderate presentation compared to a more serious presentation of your knee:
- Frequency: Pain is constant and does not go away. The pain is unchanging whether you walking around the house or trying to clim stairs.
- Intensity: The intensity of the pain does not go away. Your knee feels wobbly every time you try to stand on it.
- Duration: The pain lasting will be longer and constant. Usually getting worse throughout the day, the longer you walk or load your knee , the more strain the injured knee is taking.
- Size: The size of discomfort will be around the patella , knee joint and surrounding quadricep muscles.
- Colour: The knee will be purple and blue. Blood collection at the injured site can happen which will result in a redness under the skin. Bleeding into the joint spaces one of the most severe form of post patella dislocation complications
- Range of motion: Your knee will not be able to bend and straighten at all.
- Stiffness: Your knee will be extremely stiff , especially when trying to get out of the bed in the mornings.
- Swelling: There will swelling around knee , lasting anywhere between 7 days – 3 weeks.
- Loading: Crutches would be recommenced as a tool to prevent the patella from suffering further damage as walking on it will aggravate the symptoms and potentially harm the knee further.
Diagnosis
Physiotherapy diagnosis
Our knowledgable expert Physiotherapist’s are well versed , confident and experienced in their approach to diagnose your patella dislocation. We are well aware that research shows that most first time patella dislocations can be treated without surgery.
Beginning with a thorough subjective history of you , this gives us a great understanding of any events or trauma that may have happened previously as well as making us aware of the structures in your knee which lead to you dislocating your patella. By understanding and listening to your case , we can then approach your case with the confidence and “know-how” of how to get you (and your patella) back on track.
By zoning in and functionally assessing your knee , we then do a physical examination which we assess the movement , strength and stability of your patella and knee joint. This is important as we can identify any other lower limb injuries that may put you at risk of re-injuring your knee-cap.
Things we look out for will be alignment of your lower limb , range of the knee as well as how your patella glides on it’s tracks while you moving your knee. A patella that moves too much is important to identify as this can result in patella that goes off it’s tracks. Special testing includes a patella apprehension test or a patella tracking assessment which allows us to test if the patella glides smoothly or not.
Patella ligament testing will also guide us in identifying the root cause of your patella-femoral instability as a ligament like your Medial-patella-femoral ligament is responsible for keeping the knee-cap in place when moving your knee. If there is damage to this ligament , a knee cap dislocation will be much easier.
Muscular testing is focused on the Quadricep muscles. As your VMO muscle is responsible for keeping the patella on it’s tracks , its important to identify if the outside quadricep muscle is not over-powering the VMO , which sits on the inside of your leg. This is one of the most common ways a patella is pulled off it’s tracks , as the force of the outside quadricep muscle is too strong – resulting in your patella sublaxing outwards.
By clinically assessing your patella, knee joint and muscles we are able to then confidently build up a rehabilitation program and treatment approach that best suits your case.
X-rays
X-rays will show the integrity and alignment of the bones in your knee and enable us to rule out any associated fractures following a patella dislocation. Fractures include but are not limited to osteochondral, avulsion and stress fractures.
The type of views that are recommended are:
- AP extended knee , weight bearing view
- Mercer-Mechant view. This will show us any oestochondral fractures following a first time dislocation.
- A 45° flexion weight-bearing view
- 30° flexion lateral view
Your physiotherapist can refer you to get x-rays taken if necessary.
Diagnostic ultrasound
When we do a ultrasound , we look at the damage to the Medial patella-femoral ligament. We also have a look at the quadricep muscle (VMO) to show the presence of a muscle or ligament tear.
If you need an ultrasound, your physio will refer you.
MRI
An MRI scan can image all of the structures in your knee joint , including soft tissue, nerves and bones. However, MRI imaging is very expensive and is only recommended for younger patients with a primary dislocation, to rule out fractures or severe tears.
An MRI allows us to evaluate the boney surfaces of the patello-femoral joint and to look at the location and extent of any soft tissue damage to the medial patellar ligament.
If your physiotherapist suspects anything more than just a muscle spasm, you will be referred to the right specialist.
Why is the pain not going away?
It is not uncommon for a patella to “pop back” by itself after sustaining a subluxation. This is known as a transient dislocation. Although anatomically corrected , the patella-femoral complex , surrounding ligaments and entire knee joint capsule will continue to be painful , swollen and could still have limited range. It is imperative that even with a transient patella dislocation – one should NOT ignore the symptoms. We have years of expertise in these types of conditions , so rather get it assessed before it worsens.
What happens when my patella dislocates?
When a patella dislocates , it’s not just as simple as a “sled going off the tracks.” There are multiple surrounding structures such as the joint capsule , ligaments , muscles , tendons and nerves that needs to be assessed , cleared and allowed time to heal before returning to your full capacity. Research has shown that up to 58% of patients struggle with strenuous activities 6 months after sustaining their first knee cap dislocation. Furthermore 50% of patella dislocations have complications following a first-time dislocation including re-dislocation, subluxation and patello-femoral pain with instability.
How long does it need to heal?
Healing is a process and any injury needs time to recover and become strong again. As the knee complex is responsible for weight bearing and walking , the structures that are affected when a patella dislocates needs sufficient time to rest , recover and heal. It will not help continuing to walk , squat , run or climb stairs with the injured knee as the structures that are bruised , swollen and tender will not be allowed the necessary time to sufficiently heal. The medial patella femoral ligament (MPFL) is one of the primary ligaments that provides stability to the patella. The MPFL needs to regain its tensile strength through optimal loading via rehabilitation. Without this , there will be complications arising that could potentially lead to chronic patella-femoral instability. The same concept can be applied to the other surrounding structures such as the quadricep muscles. The muscles need to be loaded and put through a strengthening process as to be able to avoid the patella from mal-tracking in the future. Ligaments can get worse by being loaded when sprained , this will develop into a tear if not approached with caution.
I’m resting but the pain is still there?
The more you walk or run through the pain, the longer it will take to heal. If the pain returns every time you go from sitting to standing , walking , climbing stairs or even getting in and out of your car , you have missed the most vital aspect of the healing process. We are skilled to deal with the loading and phases of healing , do not hesitate getting in contact with us so you can rather be safe than sorry.
Problems we see when patients come to us with …
There are a number of complications that may arise if you do not get the correct management and treatment following your knee cap dislocation. We are able to prevent these complications from happening or getting worse , however – we can only do it you see us before it’s too late.
Below are some general complications and how we are able to manage and prevent it from getting worse:
Waiting too long
- The longer you wait, the bigger your chances of causing permanent damage to your dislocated knee. Research has shown that the longer a patella spends off it’s tracks , the longer the rehabilitation process will be. Treatment and rehabilitation can start within the first 24 hours of you dislocating it. We aid the healing process by performing techniques and exercises that allows the pain and swelling to decrease. The longer you continue to avoid treating it , the more compensation will occur to opposite structures of the body. This brings up challenges in the treatment process that can be avoided if rehabilitation starts immediately.
Longer than usual immobilisation
- Wearing a knee brace or guard is important in the first phase of healing. Usually worn between 2 days to one week , a brace allows the knee to heal while also protecting it while recovering from the damage of the dislocation. By not allowing the patella to slide , we have seen individuals who “get used” to wearing a knee support guard as they’ve gotten dependant on it. This is not good as you are only making it worse and making the knee joint lazy. We aim to rehabilitate the muscles and ligaments of the knee following a dislocation in order to make it stronger again , so there will not be a need to be dependant on a knee brace.
Not completing different forms of treatment or trying out different treatment strategies
- A common trend amongst patients is once they’re feeling a bit better , they stop doing rehabilitation or treatment. Complications that comes from this are continuous feeling of knee instability 4 months after the injury , pain with climbing stairs or performing exercises such as squats or running. We are able to give you a strict exercise protocol that has to be completed to enable the structure to adapt , overcome , and come back stronger. Stopping half way is only setting yourself up for re-injury later down the line.
Medication
- Taking medication has a place in your road to recovery. During the first week , medication is a tool of management to allow for the management of pain. However , we advise that medication is not going too fix your knee. Taking it longer that a week is not advised as this will complicate your stomach , make you sleepy and more importantly , mask your pain levels. Medication will not provide stability , increase strength or get you to be more functional.
Incorrect diagnoses
- Research has shown that osteochondral fractures have been reported to be missed in 30% to 40% of initial radiographs. Getting a clear and correct diagnoses is important as this is aid us in the planning of your rehabilitation journey. If left untreated , it may cause bleeding into your knee joint capsule and potentially the muscle. We prevent this by ensuring that all the structures are examined thoroughly , thus making sure that we exclude any potential fractures that have been missed.
Physiotherapy treatment
As expert Physiotherapist’s we trust ourselves to deliver the best clinically balanced program and protocol for your knee instability. Through our calm and thorough approach we can provide the necessary guidance , education and answers related to your patella-femoral pain and instability filling your patella dislocation.
Most first time patella dislocations are treated without surgery , making physiotherapy a vital component on your road to recovery. The different type of techniques that we use not only focusses on your knee , but also surrounding structures such as:
- Muscles
- Patella ligaments and their stability
- Nerve control and de-sensitization of the nerve pathways
- Knee joint range of motion
- Joints above and below the affected area such as your hip and lower back
Physiotherapy interventions and treatment aims will be based around:
Improving daily function
- Assessing functional capacity and your limitations. Things like driving your car can be troublesome so we are able to modifying your functional capacity for work , home or even in the gym!
Prevent further dislocation
- Taping: Lateral reinforcement to reduce the movement of the patella (to prevent dislocation)
- Bracing
Improve range of motion
- Manual therapy to the knee joint to get it moving pain free through it’s full range.
- Patella mobilisations to allow to correct sliding of the patella on it’s tracks
Combination therapy
- Strengthening exercises: Quadriceps , hamstrings, adductors, hip and lower abdomen
Stretching
- Improve flexibility of hamstring and quadricep muscles
Proprioception and Balance
- Improve stability of the knee
- Improve balance and proprioception of the knee
By using these techniques – we are able to get the results you need while still respecting the healing approach that a patella dislocation needs. We are experts at finding this balance and tailoring it to your specific goals and outcomes.
Phases of rehabilitation
1st Phase: (Week 0 – 2)
Protect
- The main focus in the initial acute phase is to rest and protect the patella. Due to the dislocation and the patella “going off track” , it is essential that the joint is protected from further damage and inflammation. This is achieved through resting and unloading from strenuous activity. Walking , driving and standing are activities that place tremendous load on the patella-femoral joint. It is vital that these activities are limited as to allow optimal healing of the joint.
- Crutches are the mainstay for unloading. You will walk with crutches as no weight bearing provides the environment to allow decreasing of swelling and pain in the affected patella femoral joint.
Inflammation and medication
- Anti-inflammatory’s may be administered during the first phase although we advise that this should be taken with caution or not at all. Treatment of swelling and pain via ice is proven to be as efficient in the initial phase. Anti-inflammatories will not fix the underlying issue , as it delays healing. Pain medication can be taken , provided it does not have any adverse effects.
Strapping
- Compression strapping in this phase provides the management of pain and swelling. There are a variety of different strapping techniques we use to achieve optimal healing within phase 1.
Education
- One of the main objective measures in this phase , is educating you with all the do’s and dont’s regarding your patella dislocation. Once we have informed you of the process ahead , what to expect and what objectives need to be met before progressing to the next phase , the path ahead becomes a lot easier to digest.
2nd Phase: (Week 2 – 3)
Once we have objectively met the criteria of phase 1 whereby we’ve decreased pain and swelling , protected the joint as well as resting – we are now able to progress to phase 2.
The main objectives set out in phase 2 are as follows:
- Increasing load on the patella femoral joint
- Establishing and maintaining range of motion in the knee joint
- Establishing good isometric contraction and co-contraction of the surrounding muscles
- Increasing functional capacity
Load
- Increasing the load through the knee joint is essential in this phase. By going from no weight bearing in the initial phase to partial weight bearing allows us to optimally get the knee accustomed to taking load again. Weight bearing will be as pain allows and depending on the severity of the patella dislocation , should not be more than 50%-60% weight. This allows loading sufficient enough to stimulate the patella femoral joint , associated muscles and nerves as well.
Range
- Range exercises will be commenced in this phase , as phase 1 objectives will allow for more pain-free movement without causing too much inflammation in the patella femoral joint. Due to the dislocation , the quality of movement is important as our aim is to promote flexion and extension while avoiding patella mal-tracking.
Strength
- Isometric exercises will be commenced in this phase. Research has shown great benefits in reducing perception of pain as well as stimulating muscle fibres via an isometric contraction. With an increase in blood supply to the muscle , we can proceed with laying the foundation of strength training in order to accommodate the more intensive muscular exercise in the later phases. We aid this objective by using modalities such as laser therapy , dry needling and slow isometric stretches.
3rd Phase: (Week 3 -5)
Progression into this phase is dependent on phase 2. Once you’re able to partial weight bear , flex and straighten your knee with minimal discomfort and able to hold a pain-free muscle contraction for at least 3×6 reps (15seconds) we can progress accordingly.
Focus in phase 3 revolves around:
- Increasing load to full weight bearing
- Achieving full range of motion with no to minimal discomfort
- Increasing functional capacity in daily activities such as driving and walking without crutches
- Continuing and progressing
Treatment focus in this phase includes the continuing of soft tissue and patella mobilisations as to allow further smooth gliding of the patella. Laser therapy to aid fibre healing of the affected ligaments (MPFL) as well as the management of loading.
Too much too soon can cause a flare up in this stage as you will start feeling better but still within certain limitations in your function.
4th Phase: (Week 5 – 7)
By now you should have achieved:
- Full range of motion of your knee joint with no discomfort.
- Full weight bearing with no limping or compensating
- Sufficient strength and stability of the patella femoral joint
- Smooth gliding of the patella
It is by this phase that the more intensive rehabilitation can commence to allow further loading of the patella-femoral joint. It is through this loading that adaptation of the tissue will enable it to become more stable , stronger and provide a platform to return to high loading activities such as running or jumping.
Stability and strength
- Focussing on the stability of the joint will allow us to integrate different forms of stress through the patella femoral joint. These exercises will include rotational forces , single leg balancing as well as introducing higher strengthening exercises such as a squat or a step down.
- By introducing these movements , we are able to isolate and optimally load the patella femoral instability.
Cardiovascular
You should be able to commence cycling activity at a perceived exertion rate of around 60% in this phase , provided there are no complications or unticked boxes from the previous phases.
Light treadmill walking can also be introduced , if the individual is able to cope with it.
5th Phase: (Week 7 – 9)
By this phase , you are comfortable and should be able to:
- Drive effectively
- Walk , stair climb with no pain or discomfort
- Return to activity in the gym , sport – within limitations
In this phase we are now able to progress neuromuscular control and introduce explosive movements and patterns into your rehabilitation program while still maintaining all the previous phases hard work you’ve put in!
Types of movements we will introduce:
- Drop landings from a step
- Box jumping
- Dynamic strengthening exercises
- Single leg balancing and proprioceptive control
6th Phase: (Week 9 – 12)
This phase prepares you to fully integrate back into training and function. By now you should be able to:
- Walk , Stair climb with no pain or avoidance
- Comfortable with cycling and treadmill walking
- Integrated well into gym or sport training
The main focus on this stage is pushing the structures to mimic the effects of your specific goals and aims. Rehabilitation is in it’s final phase and revolves around functionally improving performance and safe reintegration of high functioning activity.
Some key movements that should be achieved in this phase:
- Single leg split squat
- Single leg lunge
- Jump squats
- Balance reactions (stepping out sideways, forwards & backwards)
- Jump & Land from a step
- Agility drills
By the end of this phase you will be medically cleared based on the objectives that are met. This will enable you to confidently get back to activities and tasks you love without having the fear or doubt that your patella is not stable. By putting the patella femoral joint through a series of graded exercises and loading we are able to identify any shortfall before it’s too late.
We are experts at rehabilitation and have the knowledge , resources and capacity to get you back in the most timely and appropriate manner possible.
Healing time
Physiotherapy rehabilitation is of vital importance following an initial patella dislocation. Whether you underwent surgery or have just sustained a knee-cap subluxation , rehabilitation is essential for the longevity of your knee. Research has shown that there is more than a 40% risk of re-dislocation , with even 50% higher rates following a second patella dislocation. Furthermore, participation in sport was reduced in the first 6 months following injury , with over 50% of patients having complications following a first-time dislocation including re-dislocation, subluxation or patellafemoral pain.
The aims of physiotherapy are to restore knee range of motion and to strengthen the quadriceps muscles with the aim of restoring soft tissue balance and patellar stability. The return to pre-injury sport and participation is dependant on your individual recovery rather than time from injury.
Conservative approach
- Following a acute patella dislocation , with no surgical intervention, a healing period of 6-8 weeks is common to allow the structures to heal and start loading again. This is not attributed to the function specific tasks an individual is required to do , as this may require additional rehabilitation up until 12 weeks.
Surgical approach
- Following your surgery a healing time of a 12-16 week period can be anticipated. This is due to the tissue needing extra time to heal , as well as the wounds that’s associated with the surgery to form and close. Exercises and loading will generally start in hospital and will gradually increase over the course of your recovery journey.
Following clinical outcomes and measures , we space your appointments over the course of an 8 week period. Sessions are weekly , although depending on the severity , we may even opt to see you twice a week , especially in the acute phase. This allows us unparalleled time with your patella dislocation and gives us enough time to fully rehabilitate the patella. Each individual is different and so are their healing times. Allow us to cater for your specific healing time while still loading your patella in the most optimal way possible.
Other forms of treatment
Medication
- Your doctor will prescribe anti-inflammatory medication. This will either be in the form of a cortisone or voltaren injection.
- Alternatively , a topical cream or a anti-inflammatory rub can also be used although the evidence for this is largely undecided.
- Both of these medications will give temporary relief to the pain and inflammation that you are experiencing. However, it will not be the solution to your problem. Once the effect of the medication wears off and you try to get back into your normal routine, the pain will simply return and the knee joint starts paining again.
Drainage and braces
- A brace or knee guard is important for the management in the acute phase only. This will provide compression to the affected knee and will decrease swelling as well as giving you a sense of stability when you are walking.
- Drainage is achieved by elevating your leg at least 30cm above the rest of your body. This will help the drain the swelling in the knee joint capsule.
Stretching
- Foam rolling and stretching your quadriceps and hamstring muscle might give you some momentary relief. However, stretching your muscles will not change the muscle strength , or provide stability to your dislocated patella therefore it can only be used for symptom relief.
- A biokineticist will be able to help you in the final stages of rehabilitation. As Physiotherapists , we can identify if that’s a necessary referral or not.
Is surgery an option?
Surgery for a patella instability becomes a last resort option when all other conservative management has failed. As with any surgeries , there are a number of factors that has to be taken into account. Although stabilisation via surgery reduces the rate if re-disclocations in the young adult population , it is also associated with a higher risk of patella-femoral joint osteoarthritis.
Indications for surgery are as follows:
- Recurrent/chronic dislocation
- Patellofemoral symptoms
- Associated osteochondral fracture or major chondral injury
- Substantial disruption of the medial patellofemoral ligament (MPFL) as well as to the vastus medialis obliquus muscle
- Laterally (Outwards) subluxated patella
- Failed conservative management
There are different types of surgeries , thus depending on the severity of the patella dislocation as well the secondary complications that could potentially arise from a first time dislocation.
Below are the general outlines of the surgeries regarding a patella-femoral dislocation:
- Lateral release:
Release of the tight lateral retinaculum to allow more medial tracking of the patella.
Indication: Mild patellar instability
- Medial patellofemoral ligament reconstruction / proximal realignment:
Balancing of the patellar , enabling it to track properly. Often done with a lateral release.
Indication: Severe patellar instability
- Distal realignment / anteromedialisation:
Transferring of the tibial tubercle (where the patellar tendon attaches to the shin). The bony attachment of the tendon is moved more medially to allow the patella to track normally. Used with a lateral release with a medial patellofemoral ligament reconstruction.
Indication: Severe patellar instability
As these surgical interventions correct the “hardware” of the joint , it does not rehabilitate the joint. The clinical care , exercise prescription and balancing of the functional tasks in order to get you back to your fullest capacity , still depends on rehabilitation. We are experts at this and know precisely how to navigate the rehabilitation following a patella femoral dislocation or surgery.
What else could it be?
- Osteochondral fractures – Fracture relating to the cartilage at the end of a joint is torn.
- Avulsion fractures – A type of bone fracture where fragments of bone are torn away from where they insert or start. Usually seen with corresponding ligament or tendon involvement as well.
- Patellar fracture – A fracture of the knee cap
- Patellar tendon tear – A tear in the tendon that connects the knee cap to the tibia (Shin).
Also known as
- Knee cap dislocation
- Patella subluxation
- Patella-femoral instability
- Mal-tracking patella
- Patella sublimation
