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