chapter 15 KNES 315 b
causes of patellofemoral pain
PATELLAR INSTABILITY CAUSED BY: abnormally shaped medial patellar facet shallow patellofemoral (trochlear) groove variable length and width of the patellar tendon patella alta (high-riding patella) weak VMO or VMO dysplasia HYPERMOBILITY OF THE PATELLA CAUSED BY: muscle atrophy after an injury tightness of the lateral reticulum, iliotibial band, and hamstrings ANATOMICAL MALALIGNMENT CAUSED BY: shallow patellofemoral groove excessive femoral anteversion or external tibial rotation genu valgum or genu recurvatum increased Q angle excessive foot pronation 278
iliotibial band friction syndrome factors
_________________- include: genu varus excessive pronation in feet leg-length discrepancy prominent greater trochanter of femur preexisting iliotibial band tightness muscle weakness in knee extensors, knee flexors, and hip abductors training errors, such as excessive distance in a single run, increasing mileage too quickly, inadequate warm-up,, and running on the same side of a crowned road ITB 281
chondromalacia patellae
____________________ is a true degeneration in the articular cartilage of the patella, which results when compressive forces exceed the normal physical range or when alterations in patellar excusion produce abnormal shear forces that damage the articular surface; because articular cartilage does not contain nerve endings, condromalacia should not be considered the true source of anterior knee pain; chondromalacia is a surgical finding that represents areas of hyaline cartilage trauma or aberrant loading, but is not the cause of pain; the medial and lateral patellar facets are most commonly involved CP 278
Osgood-Schlatter's disease signs and symptoms
assessment of the condition is usually straightforward; the individual points to the tibial tubercle as the source of pain, and the tubercle appears enlarged and prominent; it is reported that the pain generally occurs during activity and is relieved with rest; point tenderness can be elicited directly over the tubercle, but ROM is not usually affected; pain is present at the extremes of knee extension and forced flexion; severity is rated in three grades depending on the duration of pain: GRADE 1- pain after activity that resolves within 24 hours GRADE 2- pain during and after activity that does not hinder performance and resolves within 24 hours GRADE 3- continuous pain that limits sport performance and daily activities OSD 280
patellar tendinitis (Jumper's Knee) management
immediate treatment standard acute care and NSAIDS; the individual should be referred to a qualified healthcare practitioner for a definitive diagnosis and ongoing treatment options jk 280
meniscal conditions
longitudinal tears result from a twisting motion when the foot is fixed and the knee flexed; this action produces compression and torsion on the posterior peripheral attachment; the tear can be partial, affecting only the peripheral segment of the meniscus, or a complete tearing of the inner substance of the meniscus; a bucket-handle tear occurs when an entire longitudinal segment is displaced medially toward the center of the tibia; this tear can lead to locking of the knee at about 10 degrees of flexion; however, this occurs in only about 40% of complete meniscal tears 276
knee dislocations signs and symptoms
subsequent to a cutting, twisting, or pivoting maneuver, the individual may describe feeling a severe injury to the knee and hearing a loud pop; deformity of the knee may be present if the knee dislocated and remained unreduced; unfortunately, knee dislocations often reduce spontaneously, making identification difficult; swelling occurs within the first few hours, but the swelling may not be large due to an associated capsular injury and extravasation of the hemarthrosis 276
coach assessment of knee conditions
subsequent to the history and observation components of an assessment, the coach should have established a strong suspicion of the structures that may be damaged; if the coach elects to perform the testing component of the assessment, it should begin with active ROM; active movements can be performed with the individual in a seated or prone position; knee extension and knee flexion should be assessed as well as movement of the hip (i.e. flexion, extension, abduction and adduction); if those motions are pain-free, the coach could continue with resisted ROM and, if there are no positive findings, perform functional testing; otherwise, the assessment should be considered complete 286
stress fractures
the femoral supracondylar region, medial tibial plateau, and tibial tubercle are common regions for stress fractures; these fractures occur when: the load on the bone is increased (e.g. jumping or high-impact activity) the number of stresses on the bone increase (e.g. changes in training intensity, duration, frequency, or running surface, or unevenly worn shoes) the surface area of the bone that receives the load is decreased (i.e. during the normal process of bone repair, certain portions of the bone remain immature and less able to tolerate stress for a period of time) sf 283
patellofemoral stress syndrome management
treatment involves standard acute care and NSAIDS; the individual should be referred to a qualified healthcare practitioner for a definitive diagnosis and ongoing treatment options PSS 278
extensor tendon rupture management
treatment involves standard acute care, fitting the individual for crutches, and immediate referral to a physician ETR 281
coach assessment of knee conditions
while the coach should restrict their assessment to on-site injuries, *it may be appropriate to initiate the history component of an assessment if an individual reports to an activity with complaints of pain or discomfort*; in doing so, the coach can confirm the presence of an acute or chronic/overuse injury and proceed accordingly; when it becomes apparent that an injury is overuse in nature, the coach should refrain from any continued assessment and, instead, refer the individual to an appropriate healthcare practitioner 286
on-site assessment of an acute knee injury
HISTORY -CHIEF COMPLAINT what's wrong? -MECHANISM OF INJURY what happened? what were you doing? was there a direct blow? was your foot fixed on impact? were you decelerating, cutting, or pivoting? did you fall? are you able to demonstrate how it happened? -PAIN location where is the pain? can you point to a location where it hurts the most? type-can you describe the pain (e.g. sharp, shooting, dull, achy, diffuse)? intensity-what is the level of pain on a scale from 1 to 10? -SOUNDS/FEELINGS did you hear anything when the injury happened (e.g. pop, snap, crack)? did you feel any unusual sensations (e.g. tearing, knee giving way, locking, cracking) when the injury happened? -PREVIOUS HISTORY have you ever injured your knee before? If so, what happened? What was the injury? were you treated for it? -OTHER IMPORTANT/HELPFUL INFORMATION how old are you (remember that many problems are age-related)? Which leg is dominant? have you made any changes in performance (i.e. technique, intensity, playing surface)? have you changed your weight training workouts (e.g. increased weight or number of repetitions; added new exercises)? are you able to perform normal motions/ ADLs? -Is there anything else you would like to tell me about your condition? OBSERVATION -GENERAL PRESENTATION guarding moving easily; hesitant to move -Injury site appearance-deformity, swelling, discoloration, position of patella PALPATION the coach should only preform palpation if there is a clear understanding of what is being palpated and why? A productive assessment appropriate to the standard of care of a coach does not necessitate palpation. TESTING -ACTIVE RANGE OF MOTION (AROM)- bilateral comparison Knee flexion Knee extension Hip motions-flexion, extension, abduction, adduction -PASSIVE RANGE OF MOTION should not be performed by the coach -RESISTIVE RANGE OF MOTION the coach should only perform resistive range of motion for the muscles that govern the knee if: instruction and approval for doing so has been obtained in advance from an appropriate healthcare practitioner AROM is normal and pain free as a way to assess strength -ACTIVITY/SPORT SPECIFIC FUNCTIONAL TESTING Performance of active movements typical of the movements executed by the individual during sport or activity participation (including weight training) should assess strength, agility, flexibility, joint stability, endurance, coordination, balance, and activity-specific skill performance 285
Osgood-Schlatter's disease
______________ is a traction-type injury to the tibial apophysis where the patelalr tendon attaches onto the tibial tubercle; ____________ typically develops in girls between the ages of 8 and 13 years, and in boys between the ages of 10 and 15 years at the beginning of their growth spurt; it is estimated that the condition occurs in 21% of adolescent athletes as compared with 4.5% of age matched nonathletes; the condition is more common in boys, but the ratio may be equalizing with girl's increased participation in sports OSD 280
coach assessment of knee conditions observation
________________ the assessment beings as the coach approaches the individual or as the individual walks towards the coach; the focus should be on individual's overall presentation, attitude, and general posture; if the person is walking, it is important to determine any abnormal actions (e.g. presence of a limp; walking on the toes); the history component of the exam should focus on the major complain, mechanism of injury, and presence of any unusual sensations (e.g. pain, sounds, feelings); in particular, location of the pain (e.g. deep in the knee, medial side of the knee, directly over the tibial tubercle), sounds (e.g. pop, click,) and feelings (e.g. knee giving way, locking, shocking, radiating pain) can provide valuable information in determining the potential injury 285
extensor tendon rupture
__________________ can occur at the superior or inferior pole of the patella, tibial tubercle, or within the patellar tendon itself; ruptures result from powerful eccentric muscle contractions, or in conjunction with severe ligamentous disruption at the knee; the rupture may be partial or total ETR 281
avulsion fractures
___________________ are caused by direct trauma, excessive tensile forces from an explosive muscular contraction, repetitive overuse, or a tensile force that pulls a ligament from its bony attachment; for example, getting kicked on the lateral aspect of the knee may avulse a portion of the lateral epicondyle, or the tibial tubercle may be avulsed when the extensor mechanism pulls a fragment away AF 282
patellar instability and dislocations
___________________ occurs when the patella has normal or abnormal alignment in the trochlear groove, but is displaced by internal or external forces; displacement can range from microinstability to subuluxation (partial displacement) or gross dislocation; *factors that may lead to congenital extensor mechanism malalignment includ eVMO dysplasia, vastus lateral hypertrophy, high and lateral patellar posture, increased Q-angle, and bony deformity* PID 279
knee dislocations
____________________ and less-severe multiple-ligament injuries make up about 20% of all grade III knee ligament injuries; to dislocate the knee, at least three ligaments must be torn; most often, this involves the ACL, PCL, and one collateral ligament; although dislocation can occur in any direction, the most common is in an anterior or posterior direction; as with any dislocation, additional damage can occur to other joint structures, including the ligaments, capsular structures, menisci, articular surfaces, tendons, and neurovascular structures; associated injuries include vascular damage in 20 to 40% and nerve damage in 20 to 30% of all knee dislocations; *posterior knee dislocations are associated with the highest incidence of damage to the popliteal artery* 276
knee conditions that necessitate immediate referral to physician (box 15.4 page 284)
_____________________ include: obvious deformity suggesting a dislocation or fracture significant loss of motion or locking of the knee excessive joint swelling gross joint instability reported sounds, such as popping, snapping, or clicking, or giving way of the knee possible epiphyseal injuries abnormal sensations in the leg or foot any unexplained or chronic pain that disrupts an individual's play or performance 284
patellofemoral stress syndrome
______________________, also called *lateral patellar compression syndrome*, is pain in the patellofemoral joint without documented instability; the condition often occurs when either the VMO is weak or the lateral retinaculum that holds the patella firmly to the femoral condyle is excessively tight; in either case, the end result is lateral excursion of the patella; the condition is found more commonly in women because of their higher Q- angle 278
chondral and osteochondral fractures
a ________________is a fracture involving the articular cartilage at a joint; an _________________involves the articular cartilage and underlying bone; these fractures are the result of compression from a direct blow to the knee causing shearing or forceful rotation; a substantial amount of articular surface on the involved bone can be damaged COF 283
iliotibial band friction syndrome
a condition common in runners, cyclists, weight lifters, and volleyball players is IT band friction syndrome; the band originates on the lateral iliac crest and continues the line of pull from the tensor fasciae latae and glenus maximus muscle; the deep fibers are associated with the lateral intermuscular septum; the distal fibers become thicker at their attachment on Gerdy's tubercle adjacent to the tibial tuberosity behind the lateral femoral epicondyle with knee flexion, and then snaps forward over the epicondyle during extension; weight-bearing increases compression and friction forces over the greater trochanter and lateral femoral condyle; individuals with a malalignment problem are predisposed to this condition ITB 281
extensor tendon rupture signs and symptoms
a partial rupture produces pain and muscle weakness in knee extension; if a total rupture occurs distal to the patella, assessment reveals a high-riding patella, a palpable defect over the tendon, and an inability to perform knee extension or perform a straight leg-raise; if the quadriceps tendon is ruptured from the superior pole of the patella and the extensor retinaculum is still intact, knee extension is still possible, although it is weak and painful ETR 281
Sinding-Larsen-Johansson's Disease
a similar condition to OSD is _______________________; pain, swelling, and tenderness result from excessive strain on the inferior patellar pole at the origin of the patellar tendon; the condition is usually seen in children 8 to 13 years old SLJ 280
patellar instability and dislocations signs and symptoms
a traumatic displacement has acute effusion associated with a hemarthrosis occurring within the first 2 hours; a dislocation without acute effusion should signal chronic laxity; the tissues are so lax that the patella moves in and out of the groove without traumatizing surrounding tissues; occasionally, a fracture of the patella or lateral femoral condyle occurs, resulting in a loose, bony fragment in the joint PID 279
patellar instability and dislocations signs and symptoms
acute patellar subluxations and dislocations appear the same, and generally occur during deceleration with a cutting maneuver; distinguishing one from the other depends on patient history; in a dislocation, the individual reports that the patella moved and had to be pushed back into place; with a subluxation, the individual reports that the patella slipped out, then went back into place spontaneously; the majority of the medial muscular and retinaculum attachments are torn from the medial aspect of the patella, leading to an audible pop and violent collapse of the knee; the individual reports intense pain as well as localized tenderness along the medial border of the patella; there may also be localized tenderness along the peripheral edge of the lateral femoral condyle where impaction from the patella occurs with flexion of the knee; if the patella remains dislocated (i.e. does not spontaneously reduce), there will be a loss of limb function as the individual will not be able to straighten the knee PID 279 (CONTINUED ON NEXT SLIDE)
epiphyseal and apophyseal fractures
adolescents in contact sports are particularly susceptible to ______________ in the knee region; a shearing force across the cartilaginous growth plate may lead to a disruption of growth and a shortened limb 282
meniscal conditions management
an individual reporting signs and symptoms that suggest a meniscal tear should be referred to a physician for definitive diagnosis and ongoing treatment; the coach should not permit the individual to continue activity, as doing so could potentially exacerbate the condition; standard acute treatment including cold and compression can be used to manage pain and swelling 277
chondromalacia patellae management
asymptomatic chondromalacia does not require treatment; if symptomatic, treatment involves standard acute care and NSAID as well as referral to a aquaulified healthcare practitioner for a definitive diagnosis and ongoing treatment options 279
patellar and related conditions
deficiencies in stabilization of the extensor mechanism can be caused by several abnormalities of the patellofemoral region, which can lead to anterior knee pain; each condition can be counterbalanced in a healthy knee by the triagular shape of the patella, depth of the patellofemoral groove, and limiting action of the static ligamtous structures; failure of medial structures to restrain the patella in a balanced position or the presence of bony anomalies can result in lateral tilting or lateral excursion of the patella, which can lead to patellofemoral arthalgia, or severe joint pain; in addition, a Q-angle less than 13 degrees or greater than 18 degrees is considered abnormal and can be a predisposing factor to patellar injuries or degeneration 278
patellar fractures signs and symptoms
diffuse extra-articular swelling on and about the knee is present; a portion of the patella is retracted proximally; there is a visible and palpable defect between the fragments, which are mobile; a straight-leg raise is impossible to perform 284
distal femoral epiphyseal fractures
fractures to the distal femoral epiphyses are 10 times more common than proximal tibial fractures, and are more serious because of possible damage to the growth plate; they may occur at any age, but are often seen in boys aged 10 to 14 years; these fractures occur when a varus or valgus stress is applied on a fixed, weight-bearing foot, as when someone falls on the outer aspect of the knee while the foot is planted DF 283
chondromalacia patellae signs and symptoms
generalized anterior knee pain and crepitus are present in activities such as walking up and down stairs or doing deep knee bends; localized pain and tenderness can be palpated on the medial and lateral patellar borders; pain and creptius increase with active and resisted knee extension CP 278
meniscal conditions
horizontal cleavage tears result from degenration, and often affect the posterior medial portion of the meniscus; with age, shearing forces from rotational motions tear the inner substance of the meniscus; if detached, momentary locking, associated pain, and instability may occur; a parrot-beak tear is two tears that commonly occur in the middle segment of the lateral menisci, leading to the characteristic shape of a parrot's beak; it is seen more frequently in individuals with a history of previous trauma or some cystic pathology that makes the meniscus more fixed at its periphery 277
coach assessment of knee conditions observation
in continuing the ________________-, a bilateral comparison should be performed as a means for recognizing any deformity, swelling, discoloration, or alignment abnormalities (E.g. patella position); again, if the individual is able to walk, an assessment of gait (e.g. favoring one limb, inability to perform a fluid motion, toe walking) could aid in identifying the structures involved and the seriousness of the condition 286
iliotibial band friction syndrome signs and symptoms
initially, pain is present over the lateral aspect of the knee after running a certain mileage, typically late in the run, but does not restrict distance or speed; as the condition progresses, the pain begins to occur earlier and earlier, and it does restrict distance and speed; pain may occur while running uphill and and downhill, and while climbing stairs; it is particularly intense on weight bearing from foot strike through midstance; it is during this part of the gait cycle that the IT band is most compressed between the lateral femoral epicondyle and greater trochanter of the femur; with continued activity, the initial lateral ache progresses into a more painful, sharp, and localized discomfort over the lateral femoral condyle just above the lateral joint line, and occasionally radiates distally to the tibial attachment or proximally up the thigh; flexion and extension of the knee may produce a creaking sound; eventually pain restricts all running and becomes continuous during activities of daily living ITB 282
meniscal conditions signs and symptoms
meniscal injuries are difficult to assess because they are not inneervated by nociceptors, and only 10 to 30% of the outer border receives direct blood supply; localized pain and joint line tenderness near the collateral ligament are probably the most common findings; the individual may experience a clicking sensation accompanied with pain that can lead to the knee buckling or giving way; in addition, the individual has difficulty doing a deep squat or a duck walk; a chronic degenerative meniscal tear often results from multiple episodes of minimal trauma leading to almost no pain, disability, or swelling, although atrophy of the quadriceps may be present; painful clocking sensations, as well as recurrent locking, are typical symptoms 277
meniscal conditions
menisci, which become stiffer and less resilient with age, are injured in a similar manner as ligamentous structures; in addition to compression and tensile forces, shearing forces caused when the femur rotates on a fixed tibia can trap portions of both menisci, leading to some tearing; tears are classified according to age, location, or axis of orientation; medial meniscus damage is more common than lateral meniscus damage due to less mobility of the structure 276
patellar tendinitis (Jumper's Knee) signs and symptoms
most individuals will complain of chronic anterior knee pain of insidious onset, which might be described as a sharp or aching pain; initially, pain after activity is concentrated on the inferior pole of the patella or the distal attachment of the patellar tendon on the tibial tubercle; as the condition progresses, pain is present at the beginning of activity, subsides during warm-up, then reappears after activity; increased pain is often reported while ascending and descending stairs or after prolonged sitting; eventually, pain is present both during and after activity, and can become too severe for the individual to participate jk 279-280
iliotibial band friction syndrome management
the immediate treatment should be focused on alleviating inflammation with standard acute care and NSAIDS; this individual should be referred to a physician for definitive diagnosis and ongoing treatment; the coach should not permit the individual to continue activity, as doing so could potentially exacerbate the condition ITB 282
stress fractures signs and symptoms
the individual complains of localized pain before and after activity that is relieved with rest and nonweight bearing; in a stress fracture, of the medial tibial plateau, pain runs along the anteromedial aspect of the proximal tibia just below the joint line; localized tenderness and edema are present, but initial radiographs of the stress fracture may be negative; as the condition progresses, pain becomes more persistent; follow-up radiographs 3 weeks postinjury may show periosteal new bone development; early bone scans are highly recommended 283
distal femoral epiphyseal fractures signs and symptoms
the individual complains of pain around the knee and is unable to bear weight on the injured leg DF 283
avulsion fractures signs and symptoms
the individual has localized pain and tenderness over the bony site; in some instances, a fragment may be palpated; if a musculotendinous unit is involved, muscle function is limited; when the anterior cruciate ligament is involved, the bony fragment may lodge in the joint, causing the knee to lock AF 282
tibial tubercle fractures signs and symptoms
the individual has pain, ecchmyosis, swelling, and tenderness directly over the tubercle; difficulty going up and down stairs is also reported; when the fracture extends form the tubercle to the tibial epiphysis (Type II), or through the secondary epiphysis and into the joint (type III), quadriceps insufficiency makes knee extension painful and weak; in larger fractures involving extensive retinacular damage, the patella rides high, and knee extension is impossible ttf 283
patellofemoral stress syndrome signs and symptoms
the individual may report a dull, aching pain in the anterior knee made worse by squatting, sitting in a tight space with the knee flexed, and descending stairs or slopes; point tenderness can be located over the lateral facet of the patella, with intense pain and crepitus elicited when the patella is manually compressed into the patellofemoral groove PSS 278
chondral and osteochondral fractures signs and symptoms
the individual usually feels a painful snap and reports considerable pain and swelling within the first few hours after injury; displaced fractures can cause locking of the joint and produce crepitation during ROM COF 283
coach assessment of knee conditions
the lower extremity works as a unit to provide motion; the knee plays a major role in supporting the body during dynamic and static activities; biomechanical problems at the foot and hip can directly affect strain on the knee; as such, assessment of the knee complex must encompass an overview of the entire lower extremity; it is important for the coach to recognize that while injuries to this region are rarely life-threatening, there are some conditions that will require activation of the emergency plan as they require immediate referral to a physician 284
patellar and related conditions
the main dynamic stabilizer is the quadriceps mechanism; more accurately called the extensor mechanism, it is made up of the vastus lateralis, vastus intermedius, VM, and rectus femoris; the VM has two heads, the superior longus head (vastus medialis longus VML), and the VMO; although the VMO is incapable of producing knee extension, it provides a dynamic restraint to forces that would laterally displace the patella; atrophy of this muscle is nearly always evident in patellofemoral dysfunction; the structures that resist medial displacement of the patella (i.e. lateral retinaculum and IT band) are thicker and stronger than the soft tissue structures that resist laterally displacing forces (i.e. medial retinaculum and lateral aspect of femoral sulcus) 277
Sinding-Larsen-Johansson's Disease management
the management is the same as OSD 280 this individual should be referred to a physician for definitive diagnosis and ongoing treatment; the coach should not permit the individual to continue activity, as doing so could potentially exacerbate the condition SLJ280
Sinding-Larsen-Johansson's Disease signs and symptoms
the onset of pain over the inferior patellar pole is gradual and seen in children involved in running and jumping sports; the condition is often missed unless the clinician palpates the inferior patellar pole with the individual's knee extended and the patellar tendon relaxed; repeating the exam with the knee flexed at 90 degrees should reveal diminished tenderness as the patellar tendon becomes taut SLJ 280
patellar tendinitis (Jumper's Knee)
the patellar tendon frequently becomes inflammed and tender from repetitive or eccentric knee extension activities; these occur in running and sports such as volleyball and basketball and basketball in which jumping is a critical action, hence the name jumper's knee; extrinsic factors that can lead to the condition include frequency of training, years of play, playing surface, type of training, stretching and warm-up practices, and type of shoe worn; some intrinsic factors that may have a role in contributing to the condition include lower extremity malalignment, leg-length discrepancies, muscle imbalance, muscle length, and muscle strength jk 279
patellar and related conditions
the patellofemoral joint is the region most commonly associated with anterior knee pain; patellar tracking disorders and instability within the joint, along with obesity, direct trauma, and repetitive motions, all contribute to a variety of injuries; patellofemoral pain may be classified into mechanical causes (E.g. patellar subuluxation or dislocation), inflammatory causes (e.g. prepatellar bursitis or patellar tendinitis), and other causes (e.g. reflex sympathetic dystrophy or tumors) 277
tibial tubercle fractures
the tibial tubercle, a common site for apophyseal fractures in boys, may occur as a result of OSD; the typical patient is a muscular, well-developed individual who has almost reached skeletal maturity, and almost always is involved in a jumping sport, most commonly basketball; these fractures usually result from forced flexion of the knee against a straining quadriceps contraction or a violent quadriceps contraction against a fixed foot ttf 282
Osgood-Schlatter's disease management
this individual should be referred to a physician for definitive diagnosis and ongoing treatment; the coach should not permit the individual to continue activity, as doing so could potentially exacerbate the condition OSD 280
knee dislocations management
this injury is considered a medical emergency; the emergency plan should be activated, including summoning EMS; the coach should not move the individual; while waiting for EMS to arrive, the coach should assess vital signs and treat for shock as necessary 276
patellar fractures
traumatic _______________- can be transverse, stellate or communiate, or longitudinal; these fractures occur as a result of a fall onto the knee, a direct blow to the knee, or an eccentric contraction of the quadriceps that overloads the intrinsic tensile strength of the bone, as occurs in jumping activities pf 284
fractures and associated conditions
traumatic fractures about the knee area are rare in sports competition, except for high-velocity sports, such as motocycling and auto racing; these fractures are usually associated with multiple traumas; other more common fractures and associated bony conditions can occur with regular participation in sport and physical activity; the management for each of the fracture conditions is the same; specifically, the individual should be referred immediately to a physician; cold should be applied to the area, and if possible, the individual should be fitted for crutches and instructed to use a non-weight-bearing gait en route to the physician 282
patellar instability and dislocations management
treatment includes ice, elevation, immobilization, and immediate referral to a physician; the coach should not attempt to reduce a dislocated patella PID 279
