Patella dislocation

[Hayden123]

I need some advice on patella dislocation. I have a 32 yr old female with hx of knee injury in 1992. She did not recall any ligament problem at that time. She did recall her knee swelling in a short time after injury. She said she was dancing and twisted it. She has had trouble with it since this injury. She recently has had increase pain in R knee. She states that it is difficult to bear full weight. She says her knee feels as though it slips. She had recent Xray with no fx, but no current MRI. I performed lateral glide of patella with positive apprehension. she said when walking she feels as though pain is on lateral knee, but with examination she has severe medial tenderness and immediate apprehension with patella movement. Patient has 3-/5 quad strength and lag with SLR. Patient does state popping currently with walking and ascending >descending stairs.I would like more advice on other tests I might need to perform and exercises. I performed Lachmen's and anterior drawer test (no obvious laxity)for ACL but hard to assess secondary to patient leg girth and pain. My first initial thought on treatment is to perform assisted SLR, Quad set, LAQ, tapping for proper patella alignment and heel slide. I also would like to perform ER SLR for VMO but she is not to this stage yet. Any lower level VMO exercises would be beneficial. Estim, IFC with ice. Any advice would be appreciated.
Thanks

[clinicalpt]

how are you? I think you can do palpation whether there is a tightness on IT band. Also you need to do Ober's test for the same reason. In my opinion, you'd better teach VMO exercise in sitting position or other functional position and progress to standing or lunge postion later.

Was her patellar dislocation happened toward lateral side, right? Is she having pain on lateral side of the patella, not medial side??? are other ligaments are ok? have you done varus test?

you might need to check ACL lig again if there is no progress...
i thought one of my patients had patella dislocation. when i checked ACL lig test after injury, i couldnt detect his ACL tear. I recalled he had strong hamstrings. the hamstring could be the reason i miss the ACL tear. he had no IT band tightness. i thought it was strange... yes, it was wrong...

hope this helps.

Yours sincerely,

[alophysio]

Hi,

Also wondering if hip rotators are strong enough and the pelvis able to support weight properly.

Cartilage damage to the patella surface can give the problems described as can meniscal damage.

I would personally assess glut med, SIJ, hip joint and L/S. Obviously there must be some sort of pathology at the knee but if nothing has really helped then see if other structures are stressing the knee joint. I am a "tracks" man when it comes to Patellofemoral disorders (the patella is the train - do you pull the train (patella taping, VMO etc) or change the tracks (control femoral and tibial torsions to help keep the patella on track). Having said that, the approach i take depends on the person obviously!

Good luck!

[neurospast]

In order to establish the cause of dislocation you have to look further, as alophysio already pointed out, than the knee. This for the simple reason that a dislocation can be forced upon the patella by a impropriate movement pattern at the hip, Pelvis and the foot.
You should start with observing if there is any visible differences between the left and the right e.g. Valgus/ varus ankle, inward rotation at the hip.
Secondly are you sure it is the patella and not e.g. the fat pad between the Tibia and the Ligamentum tibiopatellare or a slight tear of the latter (this would change the direction of pull on the patella). You state that pain is felt in a rather obscure manner: felt on the lateral side of the knee while provocation is on the medial side. What sort of pain is felt? This description can help you to alocate what structure might be responsible. Any obvious referred pain?
What puzzles me is your 3/5 muscle strength, I assume of hip flexion and knee extension (SLR). Also your popping sound could come from e.g. Ilio Tibial Band (always on movement last part from flexion to extension)
A good examination of a knee problem can be found in the book; Clincal reasoning for manual therapists, I think it is chapter 14. Anyhow a book worthwhile getting.
Good luck.

[jayyappanbpt]

hello,
i am post graduate student, i need some research topics in orthopaedics,.please help me...

[Yarok]

hi

have you assessed trigger points of vastus medialis, lateral/medial ligment,hamstrings,iliotibial band, sacrotuberal lig., around patella, and SIJ, L3/4

all the best
Yaro

[jwilso]

could this be a case of chondral defect of the lateral femoral condlye. maybe when she originally dislocated it she could have damaged the underlying cartilage or she could have osteochondritis dessicans. if it was my knee and still having problems this long after original injury i would be pushing for an arthroscopy or MRI. good luck

[alophysio]

Agreed - MRI would be nice to ensure the cartilage on all surface were ok. Did you check the other areas?

[linbin]

hi frinds
i am wondering whether it can be a internal derrangement of knee,secondary to knee injury.menisci might have injured .associated ligament injury to acl,mcl should be ruled out.the weakness might be due to arthrogenic pain inhibition of quadriceps