PTA 215 subluaxtion, dislocations, and Patellofemoral Dysfunction/Anterior Knee Pain

A. X-ray B. Angiography (knee dislocation) C. Apprehension test (53)

Diagnosis of subluxation and dislocations

A. Usually closed reduction as soon as possible B. Neurovascular assessment is done before and after reduction. C. If closed reduction is ineffective, open reduction is necessary. D. Usually followed by joint immobilization (better outcome E. Surgical procedures for glenohumeral joint instabilities (designed to improve stability and prevent recurrent instability while maintaining near normal rotation of the glenohumeral joint; arthroscopic or open approaches):

managaement of subluxationa and dislocation

1. Exercise therapy has a strong pain-reducing effect and decreases activity limitations; however, the question of which exercise modality is most effective is uncertain.7 2. Reinforce VMO contraction during open- and closed-chain extension exercises (tactile clues over the muscle belly, e-stim, or biofeedback) 3. Both weight-bearing and non-weight-bearing quadriceps exercises can significantly improve outcomes in patients with PFPS.8 4. QS with SLRs (some advocate lateral rotation of the hip, but EMG studies do not support this) 5. Splinting the patella with a brace or taping may unload the joint and relieve the irritating stress. 6. Increase flexibility of the lateral fascia and insertion of the IT band 7. Mini-squats emphasize VMO contraction (there are higher compressive loads when the knee is flexed > 60°) 8. Step-downs for eccentric strengthening of VMO 9. Strengthening of hip abductors14,15 10. Core stabilization16 11. Activity modification17 12. Possibly a foot orthosis

management of Patellofemoral instability (emphasize lateral flexibility and medial stability)

1. Quadriceps strengthening 2. Hamstring strengthening 3. Arch supports if excessive pronation is a possible contributor 4. NSAIDs

management of chondromalacia

1. Glenohumeral (shoulder) dislocation (95% are anterior) 2. Elbow dislocation (usually posterior) 3. Radial head subluxation ("nurse-maid's elbow") 4. PIP dislocation (usually dorsal rather than volar) 5. Hip dislocation (usually posterior) 6. Tibiofemoral (knee) dislocation 7. Lateral patellar dislocation

most commonly affected joints of subluxation and dislocations

Subluxations

partial separations (i.e., an unstable joint; the bone goes in and out).

1. Weakness, inhibition, or poor recruitment or timing of firing of the VMO 2. Overstretched medial retinaculum 3. Restricted lateral retinaculum, IT band, or fascial structures around the patella 4. Decreased medial gliding or medial tipping of the patella 5. Pronated foot 6. Pain in the retropatellar region 7. Tight gastrocnemius soleus, hamstrings, or rectus femoris muscles 8. Irritated patellar tendon or subpatellar fat pads 9. Patellar crepitus, swelling, or locking

symptoms in general of Patellofemoral Dysfunction/Anterior Knee Pain

often begins in middle school and then reaches peak prevalence during the high school years.

symptoms of Anterior knee pain in female athletes

1. Pain in the knee after running, especially on hills 2. Pain and stiffness after sitting for any length of time (positive movie sign) 3. Pain reproduced by compression of the patella against the femur

symptoms of chondromalacia

A. Pain B. Swelling C. Muscle guarding D. Deformity E. Inability to move

symptoms of dislocations and subluxations

A. Thorough review of the injured athlete's training program B. History of symptom onset and aggravating factors C. Complete lower extremity examination D. Chondromalacia diagnosed with arthroscopy or arthrogram E. Ober Test (253) F. Patellar Apprehension Test (272) G. Patellar Grind Test (Clarke's Test) (287)

diagnosis of Patellofemoral Dysfunction/Anterior Knee Pain

Patellofemoral Dysfunction/Anterior Knee Pain

Anterior knee pain is common among athletes.

1. Patellofemoral instability (subluxation or dislocation of single or recurrent episodes) 2. Patellofemoral pain with malalignment or biomechanical dysfunction 3. Patellofemoral pain without malalignment

Classification of Patellofemoral Dysfunction/Anterior Knee Pain

confusion, largely related to the use of broadly inclusive terminology such as chondromalacia patellae and patellofemoral pain syndrome.

Historically, the differential diagnosis of patellofemoral pathologies has been plagued with

broadly inclusive terminology such as chondromalacia patellae and patellofemoral pain syndrome.

Historically, the differential diagnosis of patellofemoral pathologies has been plagued with confusion, largely related to the use of

a. Medial glide patellar mobilizations b. Friction massage around the lateral aspect of the patella c. Medial tipping of the patella d. Self-stretching of the insertion of the IT band

Increase flexibility of the lateral fascia and insertion of the IT band

1. Patellofemoral instability (subluxation or dislocation of single or recurrent episodes) 2. Patellofemoral pain with malalignment or biomechanical dysfunction 3. Patellofemoral pain without malalignment

Patellofemoral Dysfunction/Anterior Knee Pain classification

1. Soft tissue lesions 2. Tight medial and lateral retinacula or patellar pressure syndrome (increased contact pressure of the patella in the trochlear groove) 3. Osteochondritis dissecans of the patella or femoral trochlea 4. Traumatic patellar chondromalacia (softening and fissuring of the cartilaginous surface of the patella; common among younger running athletes) 5. Patellofemoral osteoarthritis 6. Apophysitis is the inflammation of an apophysis (a projection from a bone). a. Osgood-Schlatter's disease (traction apophysitis of the tibial tuberosity) b. Sinding-Larsen-Johansson syndrome (traction apophysitis on the inferior pole of the paella 7. Symptomatic bipartite ("having two parts") patella 8. Trauma (e.g., tendon rupture, fracture, contusion, and articular cartilage damage) 9. Referred pain from lumbar spine or hip

Patellofemoral pain without malalignment

a. Plica syndrome (enfolding of the normal synovial lining of the knee) b. Fat pad syndrome (irritation of the infrapatellar fat pad from trauma or overuse) c. Tendinitis of the patellar or quadriceps tendons (often occurs from overuse as the result of repetitive jumping) d. Iliotibial (IT) band friction syndrome (irritation as it passes over the lateral femoral condyle; can cause anterior knee pain because it is attached to the patella and lateral retinaculum) e. Prepatellar bursitis ("housemaid's knee"; occurs from prolonged kneeling or recurrent minor trauma to the anterior knee)

Patellofemoral pain without malalignment: soft tissue lesions

1. Release of the lateral retinaculum 2. Chrondoplasty or abrasion arthroplasty of the patella 3. Proximal or distal realignment of the extensor mechanism 4. Patellectomy 5. "Reefing" (build up lateral part of femur or patella) 6. A high tibial osteotomy (HTO) aims to realign the bones to restore even weight bearing between the medial and lateral compartments of the knee. 7. Medial patellofemoral ligament (MPFL) repair or reconstruction to restore normal patellar tracking (used with a dislocating patella).

Surgery when conservative management fails of Patellofemoral Dysfunction/Anterior Knee Pain

1. Capsulorrhaphy is a tightening of the capsule to reduce capsular redundancy and overall capsule volume by incising, overlapping, and then suturing, tacking, or stapling the lax or overstretched portion of the capsule. 2. Electrotheramally assisted capsulorrhaphy is an arthroscopic procedure that uses thermal energy (radio frequency thermal-delivery or nonablative laser) to shrink and tighten loose capsuloligamentous structures (despite ease of application, it has higher complication rates).9 3. Bankart reconstruction is an open or arthroscopic repair of a Bankart lesion, which commonly occurs during traumatic anterior dislocation.10 4. Soft tissue transfer is an open transfer and realignment of the subscapularis tendon to stabilize the anterior capsule (often done with total shoulder replacement). 5. Repair of a SLAP lesion occurs when the lesion is debrided arthroscopically, and the tom portion of the superior labrum and biceps anchor are reattached with tacks or suture anchors. 6. Posterior capsulorrhaphy is an open or arthroscopic stabilization procedure to tighten the posterior capsule.

Surgical procedures for glenohumeral joint instabilities

a. Greater than 5° difference in TAM between left and right shoulders b. Greater than 10° difference in internal rotation between left and right shoulders (GIRD= Glenohumeral Internal Rotation Deficit)

There is increased risk of shoulkder dislocation for throwers with the following characteristics:

1. Axillary nerve injury x~" 2. Bankart lesion/fracture (a detachment of the capsulolabral complex from the anterior rim of the glenoid) 3. Hill-Sachs lesion (indentation fracture of the humeral head) 4. SLAP lesion (Superior Labrum Anterior to Posterior) occurs when a labrum tear at the attachment of the biceps tendon. 5. Rotator cuff tears 6. Unidirectional or multidirectional recurrent subluxations or dislocations when there is significant ligamentous and capsule laxity. 7. Postoperatively, some patients may have permanent restrictions placed on functional activities that involve high-risk movements (e.g., contact sports and overhead activities)3 and that could potentially cause recurrence of the instability. 8. A significant proportion will require eventual surgery and up to a third of these patients will go on to develop long-term shoulder arthritis. Even patients who have experienced a single episode of dislocation may go on to develop long-term sequelae

Warnings, Concerns, Potential Complications: shoulder dislocation

1. Arterial injury (especially with anterior dislocations) with subsequent avascular necrosis of the femoral head. 2. Sciatic nerve injury

Warnings, Concerns, Potential Complications: Hip dislocation

obvious deformities (e.g., boutonniere deformity)

Warnings, Concerns, Potential Complications: PIP dislocation

Recurrent dislocation is usually an indication for surgery to redirect the forces through the patella.

Warnings, Concerns, Potential Complications: Patellofemoral Dysfunction/Anterior Knee Pain

1. Fractures 2. Injuries to the ulnar or median nerves, and possibly injury to the brachial plexus

Warnings, Concerns, Potential Complications: elbow dislocation

1. Gross instability of the knee 2. Injury to the popliteal artery

Warnings, Concerns, Potential Complications: knee dislocation

A. Arterial and nerve injuries are a risk especially when a dislocation is not rapidly reduced.

Warnings, Concerns, Potential Complications: subluxation and dislocation

Hip dislocation

caused by a severe posteriorly directed force to the knee with the knee and hip flexed (e.g., against a car dashboard).

Elbow dislocation

caused by fall on an extended, abducted upper extremity.

PIP dislocation

caused by hyperextension

Patella dislocation

caused by quadriceps contraction plus flexion and lateral tibial rotation; many patients have an underlying chronic patellofemoral abnormality.

Radial head dislocation

caused by traction on the forearm as when a reluctant toddler is pulled forward.

1. Problems that cause an increased Q angle (e.g., femoral anteversion, hip adduction, external tibial torsion, genu valgus, foot hyperpronation) 2. Tight lateral retinaculum 3. Weak quadriceps (possibly weak VMO) 4. Patella alta (abnormally high patella) or patella baja (abnormally low position of patella) 5. Dysplastic trochlea

causes Patellofemoral pain with malalignment or biomechanical dysfunction

1. Direct trauma 2. Forceful quadriceps contraction while the foot is planted and the femur is externally rotating while the knee is flexed. 3. Abnormal Q angle (represents the pull of the quadriceps) 4. Dysplastic trochlea (shallow groove or flat lateral femoral condyle) 5. Patella alta (abnormally high patella) 6. Tight lateral retinaculum (extension of the vastus lateralis; part of the joint capsule) 7. Inadequate medial stabilizers such as the VMO (only dynamic stabilizer of the knee; origin is on adductor magnus)

causes of Patellofemoral instability (faulty patellar tracking to subluxed patella; usually in a lateral direction)

1. In older people, it usually is caused by a fall on an outstretched arm. 2. In young people, the cause is typically sports-related with the shoulder in abduction and lateral rotation.

causes of anterior shoulder dislocation

1. Anterior dislocation is caused by hyperextension. 2. Posterior dislocation is caused by a posteriorly directed force to the proximal tibia with the knee slightly flexed.

causes of knee dislocation

Dislocations

complete separations of the bone ends that normally articulate to form a joint.

A. Modify biomechanical stresses (e.g., foot orthosis for foot pronation). B. Until the knee is symptom free, the patient should avoid positions and activities that provoke the symptoms.

education of Patellofemoral Dysfunction/Anterior Knee Pain

1. May require sedation, analgesia, or general anesthesia 2. Should be undertaken only by someone trained in the maneuver because of the vulnerability of nerve tissue and blood vessels. 3. Immobilization of the shoulder in lateral rotation can prevent recurrent dislocation.

how reduction closing happens in dislocation and subluxation

1. Duration is usually shorter for elderly persons because they are more likely to develop shoulder stiffness). 2. The position of dislocation (e.g., shoulder abduction and lateral rotation) must be avoided during exercises and ADLs (ROM limitations will be determined by the physician). 3. Shoulder rehab will emphasize strengthening of the rotator cuff and the scapular stabilizers.

immobilization of subluxation and dislocation