Strengthening VMO / Preventing dislocating knees

[mikedadude]

Hi, let me give you guys some background info.

In 2005, dislocated left knee - it buckled under pressure. Resulted in a fracture, had an athroscopy in 2006 to remove fractured bone (it broke off) and remove scar tissue. (The doctors left it dislocated for three hours before putting it back in place)

In 2007, dislocated my right knee playing football. No fractures, no issues with knee. Sidelined from sports for 4ish months

October 2008, dislocated my right knee again when i slipped on the dancefloor (nice ey?). This dislocation didn't feel as bad.


So, when I last dislocated it, it wasn't as bad. I was prescribed to be in a splint and crutches for 4 weeks, I was walkin within 2 weeks. Only issue I have with my knee is that my knee may click after going up a set amount of stairs but this isn't happenin as often anymore.


My question; my knees are always likely to dislocate because the bone (think its femur.. not sure) is flat at the top so the patella can easily side. So I was told by doctors and so forth to strengthen my VMO to prevent it from happening as easy. I was wondering if you could let me know of any exercises I can do which will really help me with this. I know of some from the times Ive done physio but was wonderin if theres perhaps some I can do at home?

I plan to have surgery on my right knee to further help prevent dislocation.

Thanks in advance! (Main sports I do are skiing and football)

edit: oh and I'm 20.. not sure if thats useful info or not.

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[KiwiDPT]

Hi
Sorry to hear about all your issues. Isolated VMO training has been shown to not be possible according to recent research. I will try and find the articles. I have them in the pile upstairs somewhere. Sometimes I wish physicians would leave the rehabilitation to those who actually studied it for several years, and not a few hours (Sorry off my soap box now). General quadriceps strengthening is usually performed. For example quadsetting, straight leg raises etc. There are a myriad of them.
Part of the problem with multiple dislocations is the loss of or laxity of medial restraints that help hold the patella centered. The quadriceps muscles have a general lateral pull and without medial restraints it is hard to stop lateral dislocation.
One of the key things I do with pts is teach them how to control the knee during activities. A knee that collapses inwards under load can increase the chances of lateral dislocation. I am sure to have pts learn motor control, look at the hip for weak hip muscles causing the femur to internally rotate, and also at the ankle for excessive pronation, which all can contribute to medial collapse.

Hope that helps
KiwiDPT

[mikedadude]

Hi Kiwi, thanks for the quick reply.

So if I understand correctly, this notion of strengthening the VMO to prevent lateral dislocations is incorrect? And that I should try to find a physiotherapist rather than even attempt to build up the muscles on my own?

[KiwiDPT]

Hi
The VMO can be strengthened it can not be strengthened in isolation as once thought. I would go to a physio and have them check you out to make sure that the other things I mentioned, (weak hips allowing femoral internal rotation, excessive ankle pronation, or poor motor control causing incorrect biomechanics) are not occurring. If any these other things are present solely strengthening the quads is like swimming up hill. With as many dislocations as you have had I would suspect that there would be significant medial restraint laxity, and addressing all possible contributors will be required for an possible benefit. The next step would probably be a knee brace with a firm lateral "J" support to externally control the patella. Not sure on the success of those braces but worth a shot if the fixing the other factors fails.

Let me know if I can help with anything else
Kiwi DPT

[blueholy]

I am a chronic dislocator so I have some help for you in terms of what works for me. I have dislocated my patella on my right knee 4 times and my left twice. I started in 1998 when I was 18 and my last was May of 2003. After my last dislocation I said enough with that. I was extremely active and just couldn't say no to a pick up basketball game or any other sport for that matter but realized the way things were that it was too risky to do it again. Well around 2005 I got tired of being on the sidelines so I bought braces. One for the left and one for the right. What the previous DPT said on here was a J brace and I think that is what I have. You velcro it around your leg and there is an additional part of the brace that you then pull from the outside up and over the patella that velcros to the rest of the brace. Underneath that part that you pull up and over is a horseshoe looking pad that when pulled over the patella serves to give external support. So the good thing is that I have not dislocated since. Now I know my limits. I stay on the outside during basketball games and shoot from the perimeter. I play defense to a degree but I know to let a guy past me if I get beat laterally. I basically stay restricted to sand volleyball and softball (well, and golf). But no dislocations which is greatness.

Problem is: after you dislocate as much I have, other problems show up later. I had a partial tear in my meniscus that wasn't even noticable in activity. When the knee becomes structually unstable, other things get jacked up. Well I was wearing my brace and rounded third in the spring of 2007 when I blew out my medial and lateral meniscus. Since had surgery to trim those out, had microfracture surgery on the backside of the patella to promote resurfacing because they had to smooth the cartilage there (every time you dislocate it jacks up the cartilage as the knee cap rides up and over the groove and then back in), and did a lateral release to help the dislocation because the doc said what the heck, we are in there already.

Can't really run on pavement anymore, but I can still play softball (shortstop) and sand volleyball. The eliptical is my friend.

My advice is to take it easy. I know you are young and if you are like me just love to be active. There are bigger pictures to consider. Every time you dislocate you increase the problems you will have later in life. I am now 28 and I will tell you that later in life is already upon me Get the braces. I know some doctors will say they don't work. I can't give you guarantees, only what I have experienced in terms of no dislocations after thousands of hours of sports with them on. My braces look like the ones on this site (I can't show you this because I don't have enough posts so email me if you want a picture of what I use)

I won't ever say to not play sports but be selective. Once you dislocate you are exponentially more ept to do it again and again. The braces worked for me so there is that too. My doc also said to take glucosamine. He mentioned that all of the other stuff is junk in terms of it is not shown to actually get to the cartilage in the knee. Glucosamine does and he is a big proponent of it. He was Dallas' doctor of the year in 2004 or 5 or something and a stand up guy so I believe him. Good luck!

[Fiona Mellor]

Realise this is an old thread but whilst I'm here thought I'd share my personal expereince of recurrent bilaterall patella dislocations. Sometimes they only subluxed in that the patella would 'click' laterally, then as I inevitably fell over it would pop back into place. Other times as I fell over my patella would stay in the dislocated position. Mostly I could re-locate it by quickly straightening my leg and putting my hand on the outside of the patella and pushing it back. Was always painful to do this, but much better than leaving it and a trip to A&E. Always tried to get it moving ASAP too rather than allowing it to be braced and using crutches which made it stiffer overall.

Initially treated with physiotherapy to strengthen my quads. However I found the stronger my quads the more serious the dislocations! It was as if the stronger quad muscle prevented me from re-locating the patella when it did give way, so I stopped these. Then I tried foot orthoses and learnt about the biomechanics of the leg - never letting my knee collpase inwards and not letting it move further than my toes. Helped to a small extent but they still occasionally dislocated if I did a twisting turn or a lunge (as you do often in sports). Braces didn't help, infact when they dislocatred whilst wearing a brace it was excruciating! The patella would pop under the brace and the brace would stop if popping pack into place again!

Finally ended up with bi-lateral tibial tubercle transfers and these have done the job pretty well, though there have been a few subluxations/incomplete dislocation since. However I have since found I do not use my 'posterior chain' when walking/running etc and have started to strengthen my hamstrings and glutes, since then I have hardly had any problems! From a completely novice laypersons viewpoint it seems that PT for knees seems to concentrate on quads with little attention paid to hamstrings and glutes, but in my case it was the weak hamstrings and glutes that contributed to the problem overall. My skyline patella x-rays were normal, my Q angle was normal and I can't help wondering that if my posterior chain issues had been identified earlier I may have avoided surgery. That said the surgery and the excercises I now do (lots fo horse-riding) have given me the confidence to run full pelt down a hill again!! ;-) The surgery was tough but I made sure I went to the pool every day for 90 minutes once the cast was removed, and within a week I had full RoM.

I'd be interested to hear the thoughts of PT's with experience of treating recurrent dislocation.