Grade 2 quads, PF problems!!

[cadenz2]

A patient underwent an arthroscopy for patella debridement. Quads are now grade 2 as there was significant pain/swelling post op that was difficult to control. He is unable to extend the knee against gravity due to pain/weakness. Walking is also painful/difficult. The patient has a signficant Q angle however the orthopod is not suggesting any further realignment surgeries.

I have been getting him to do closed chain activities to reduce the patella pain, but he is still unable to extend the knee against gravity. He has been rehabbing everyday for a couple of months. Any suggestions???

I NEED HELP!!! Thanks

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[physiobob]

The first question is does he had full extension passively, without pain?

Secondly do you feel that this is weakness or pain causing the lack of extension. If it is pain then maybe address pain control measures, e.g. iceing first and during the work or meds.

Can he get on an exercise bike and ride with the seat quite high, or is there access to hyrdo at this time? The time frame is most unusual so I would suggest either there is a complication or it is psychosomatic in some way. Has the swelling now resolved or are there still signs of oedema or an effusion. The more info you can give on the assessment the better guided the smawer will be.

I have used gentle, open chain muscle stim with active assisted extension and ice successfully for knee ops to get early end of range extension, especially in ACL where the patient might be a bit timid. Sounds a bit barbaric but this often got the brain to understand that extension is in fact OK. I hope you see what I am saying here (i.e. not to blow of the patella tendon after a graft has been taken from it, just get still to the quads).

Anyway closed chain is always the best option so you can try mm. stimulation with a host of closed chain activities with the good leg assisting.

Looking fwd to hearing more on your assessment.

[bmc]

Dear cadenz2,

about open vs closed chain exercises in patellofemoral rehab. I think the "traditional wisdom" is that closed chain exercises are the way to go for a variety of reasons. These include more simultaneous activation of the quadriceps muscles (therefore better patellar tracking), supposedly lower patellofemoral joint stress, and because closed chain exercises are generally much more functional than open chain.

However closed chain exercises of the knee such as squats, step ups and lunges are much more complex movements, involving multiple joints and there is a great deal of potential for other muscle groups to compensate for weakness or inactivity in the quadriceps. I'd say this is the case with your patient given given he has been "rehabbing" for a couple of months but is still only grade 2 in his quads.

I wouldn't think that open chain exercises would be contraindicated in your patient. Cohen et al (Am J Sports Med. 2001 Jul-Aug;29(4):480-7) found little difference between patellofemoral joint stress in open and closed chain quadriceps exercises, and I think especially when you consider the amplitude of contraction we're talking about here and the fact it is now months since the surgery, I think there is little risk of damaging his patellofemoral joint cartilage.

My suggestion would be to perform exercises in side lying with a low-friction board underneath his leg. Otherwise you could always eliminate gravity by getting him in a pool...

Also I think EMG biofeedback and even EMG triggered muscle stimulation could be very useful with this guy.

As his strength improves you can progress to more functional, closed chain exercises. EMG biofeedback can still be very usefull in that phase in order to work on VMO co-ordination, especially given his mal-alignment problems.

If he is getting a lot of pain with open chain exercises I would assess the position of the patella, try taping, lateral retinaculum stretches etc and see if you can reduce it.

By the way how is the swelling now? Even a mild amount of effusion can reduce quadriceps EMG activity, and this could also be a factor.

Hope this helps.
bmc

[bmc]

PS what was his quadriceps strength like before the operation?

[cadenz2]

Thanks for your replies and ideas.

To add to the picture, the patient has a fissure down to bone on the medial patella facet (which was diagnosed upon arthroscopy).

Current symptoms include: stiffness (full ROM), signficant patella pain, effusion (particulary after exercise).

An infection was excluded via a blood test.

He has full extension passively. It is not painful, but there is a click at around 90 degrees flexion. Weakness but more so pain is limiting active extension. Preop, quads were gr~4 and was definitely a weakness compared to the other side.

The program I have him doing includes bike riding ~5-10 mins(which he has just started as fat pad pain made it very painful until the last few weeks), elliptical ~ 5mins, pool work, SLR, step ups, sidelying quads, , leg press 0-40 degrees, hip exs.... but doing all closed chain exercise.

He is very diligent with the program, but pain has been limiting the amt of exercise he can do. I guess this can explain the lack of progression.

What's an average time frame for progressing from grade 2 (lot of wastage) to grade 3???

I'm stretching lat ret., taping, and have used muscle stim. (but he can't access that out of the clinic).

Good idea about icing before, pain meds ... I think I might try that avenue.. Just worries me a little that it could be damaging his knee..

Thanks

[physiobob]

Perhaps also a review and followup xray might be useful to check the status of the patella as a whole.It is very surprising that he does not have at least grad 4 post op when he has grade 4 preop. I would suggest this is inhibition due to pain and or psych. factors (conscious or unconscious) and not true weakness. How old is the individual. Are they working at the moment. Are they happy about returning to work asap?

[MrPhysio+]

Hi
Happy New Year to all.
All good advice so far. I agree that muscle inhibition post arthroscopy can be pain / swelling induced. The longer the patient goes without good active control, the more the brain forgets what it is supposed to do. Some patients take longer post arthroscopy to regain control, regardless of their pre surgical strength. A couple of points:
If your taping has not addressed patella tracking to ensure that the vastus medialis is assisted, do so. Muscle stims to the VMO, even if attached to trigger point needles (acupuncture type needles), can help re establish control. Passive assisted knee extension whilst looking at the knee during stims has proved useful to some of my patients. You can also ask the patient to perform three quick knee extensions with the contralateral leg, then try the affected leg. Focus the patients attention on what they can feel. Ultimately, it will be time, despite the frustration of patient and therapist.
If all the above fails, try using an oedema pump, if available, before and after treatment (using a long leg sleeve with the limb elevated.) During the decompression phase, have the patient dorsi/plantarflex the ankle to use the calf as an assist.
Another technique involves passive flexion / extension of the knee with the patient supine, and the therapist holding the lower leg in a figure four leg lock position, and whilst applying traction bending the knee back and forth. Take the knee to the point of discomfort in each direction, and also apply a mild medial or lateral torgue to the joint through range (you need to change grip for the torque effect, doing one side of the knee, and repeating the other side). Difficult to describe. If the patient is not on anti inflammatory medication and can tolerate it, check with the Doctor for supply.
Good luck.
MrPhysio+

[jordan physiotherapist]

I will give you idea
I want to now your opinion ,that is important to me
Use hydrotherapy and active assisted movement
To increase patient strengthening and reduce the pain
I now that too late but I a new member
Thank to all