mpfl reconstruction presentation...review of biomechanics of the knee identify and palpate mpfl ......
TRANSCRIPT
1
Advancements in Patellofemoral Pain Syndrome & MPFL Reconstruction &
Rehab
Stefanie Bourassa, MSPT, DPT, CSCS, FMSC
Sports Medicine Clinical Program DirectorRehabilitation Director of Bone & Joint Institute of Musculoskeletal
Health at Hartford Hospital
1
Provider Disclaimer
• Allied Health Education and the presenter of this webinar do not have any financial or other
associations with the manufacturers of any
products or suppliers of commercial services that
may be discussed or displayed in this
presentation. • There was no commercial support for this
presentation.
• The views expressed in this presentation are the
views and opinions of the presenter.
• Participants must use discretion when using the information contained in this presentation.
Objectives
Review of Anatomy of the knee
Review of biomechanics of the knee
Identify and Palpate MPFL
Understand the biomechanics of MPFL failure
Understand MPFL pathogenesis and reconstruction procedure
Identify and implement a rehabilitation protocol
Identify and evaluate based on the cross diagonal principle
Return the athlete to their sport through specific testing
3
2
The Knee Joint
• Knee Joint
(tibiofemoral joint)
Largest Joint in body
Complex
Primarily hinge joint
(Ginglymus joint)
Patellofemoral Joint
Arthrodial classification
Gliding of patella on femoral condyles
4
Bones Enlarged Femoral Condyles articulate with respective med. & lat.
Tibial condyles on the plateau
Tibia bears most of the weight
5
Bones Fibula: lateral
Attachment for knee joint structures
Does not articulate on femur or patella
Not considered officially part of the knee joint**
6
3
Bones Patella
Sesmoid
Imbedded in quadriceps and patella tendon
Pulley system for mechanical advantage in knee extension
7
Meniscus
Medial meniscus
Larger more open C
Lateral meniscus
Thicker on outside
border
Can slip
Closed C
Both connected by
arcuate fibers
Radicular blood supply
8
Meniscus
Functions
Protection of articular cartilage
Joint Stability
Relieve joint incongruity
Increase joint mobility
Load Transmission
In Extension
Lateral: 70%
Medial: 50%
Compressive Load
50% of compression load at 0°
85% at 90° of flexion
9
4
Ligaments/Capsule
10
Ligaments: Major
Tibial Collateral Ligament (MCL): Originates on Medial aspect of upper medial femoral condyle and inserts on medial tibialsurface
Fibular Collateral Ligament (LCL): Originates on Lateral femoral condyle close to popliteus origin; inserts on fibular head
Anterior Cruciate Ligament (ACL): Originates PM corner of Femur; inserts via collagen fibers via transitional zone to tibia Resists anterior translation of tibia and rotational forces
Posterior Cruciate Ligament (PCL): Originates AL corner of Femur; inserts posterior tibia Resists posterior translation of tibia and tibial external rotation
11
Ligaments: Major
Tibial Collateral Ligament (MCL): Superficial: two separate
tibial attachments
Deep: mensicofemoral: longer proximal to distal
Deep: Meniscotibial: shorter and thicker attached to edge of articular cartilage of medial tibial plateau
12
5
Ligaments: Minor (maybe not so
much)
Medial Patellofemoral Ligament (MPFL)
Posterior Oblique Ligament (POL)
Oblique Popliteal Ligament (OPL)
Popliteofibular ligament (PFL)
Arcuate Ligament (AL)
Fabellofibular ligament (FfL)
Anterolateral Ligament (ALL)
13
Ligaments
14
Ligaments: Minor
Medial Patellofemoral Ligament (MPFL) O: Medial epicondyle (adductor tubercle
and adductor tendon) as well as MCL
I: Runs transversely deep to the VMO and inserts on superomedial aspect of the patella
F: resists lateral migration of the patella 50-80% of restraining force of lateral patella
dislocation
Most effective between 0°and 30°of flexion
15
6
Ligaments: Minor
Posterior Oblique Ligament (POL) O:adductor tubercle
I:tibia and posterior aspect of the capsule
Inferior arm attaches to the semimembranosus tendon
Superior arm with the posterior capsule and proximal part of oblique popliteal ligament
Femur and anterior to gastrocnemius tubercle
F:provides static resistance to valgus loads as knee moves into full extension
Dynamic stabilizer via attachment of semimembranosus to valgus force as knee moves into flexion
16
Ligaments: Minor
Oblique Popliteal Ligament (OPL) O: arises from semimembranosus
tendon and POL
I: lateral head of the gastrocnemius and the arcuate ligament
F: assists with lateral capsular stability
17
Ligaments: Minor
Arcuate Ligament (AL)
O: lateral femoral condyle: two heads for the triangular shape
I: traverses over the popliteal tendon and inserts into the fibular head
F: posterolateral stabilizer of the knee
18
7
Ligaments: Minor
Fabellofibular ligament (FfL)
Part of the acruate complex; may be
absent or present depending on size
of ligament itself and arcuate
ligament
O: lateral head of the gastrocnemius
I: fibular styloid process
F: reinforces posterolateral aspect of the capsule
19
Ligaments: Minor
Anterolateral Ligament
(ALL) O: lateral femoral
epicondyle; congruous with the LCL
I: Gerdy’s tubercle, fibular head and lateral meniscus
F: anterolateral rotational stability
20
Ligaments
21
8
Posterolateral Corner Ligaments
22
Anterior Musculature
23
Anterior Knee Musculature Three Vasti Muscles originate at proximal femur; insert on
patellar superior pole To Tibial Tuberosity via the patella tendon (ligament)
Tensor Fascia Latae inserts on Gerdy’s Tubercle via IliotibialBand
Sartorius, gracilis, semitendinosus insert Ant. Med. tibialsurface
Iliacus
Iliopsoas24
9
Medial Knee musculature Sartorius: Inserts: medial condyle: hip flexion, weak
abductor, external rotator and mild knee flexor
Adductor Longus: Inserts: Medial Femur; Adducts femur
Adductor Magnus: Two portions: adductor and hamstring portion: Inserts: medial femur: adductor portion: adducts, Hamstring portion medially rotates
Gracilis: Inserts: Proximal medial tibia; Adducts the hip; secondary flexion and medial rotation
25
PosteriorMusculature
26
Posterior Knee Musculature Semimembranosus: inserts PM on medial tibial condyle
Semitendonosis: inserts on medial tibial condyle
Biceps Femoris: inserts primarily on Fibular Head
Popliteus: Originates on lateral aspect of lateral femoral condyle
Triceps Surae: gastronemius, soleus and plantaris Plantaris: arises from the oblique popliteal ligament and inserts along the
lateral head of the gastrocnemius
Gastrocnemius: Medial Head: medial femoral condyle Lateral Head: lateral femoral condyle
Soleus: proximal soleal line of posterior tibia and proximal 1/3 of fibula
27
10
Posterior Hip Musculature Gluteus Maximus: Posterior Femur: Hip extension
Gluteus Medius: Inserts: lesser trochanter: Abducts and Internally Rotates
Gluteus Minimus: Inserts: Lesser trochanter: Abducts and Internally rotates
Pectineus: Pubis to pectinal line: hip flexor and internal rotator
Piriformis: Inserts: greater trochanter; External rotator
Inferior gemelli: Inserts: medial surface of greater trochanter: External rotator
28
Palpation
Bony Landmarks: Femoral Epicondyles
(Med./Lat.)
Fibular Head
Patella poles (Sup./Inf./Med./Lat.)
Tibial Tuberosity
Gerdy’s Tubercle
Adductor Tubercle
Musculature Quadriceps (all 4)
Hamstrings and Adductors
Quadriceps Tendon
Patella tendon (some call it a ligament now)
Gastrocnemius
Popliteus
Plantaris
29
Palpation
30
• Ligaments:• MPFL• MCL• LCL• POL
• Joint Line• Medial • Lateral
11
Current Knee Injuries: Layer Approach Layer 1: Osteochondral
Patella, Femoral condyles, tibia, tibial plateau, Osteochondral lesions
Layer 2: Inert Capsule, ACL, MCL, PCL, LCL, MPFL, POL, ALL, Meniscus
Layer 3: Contractile Musculature crossing the knee, musculature crossing the hip
Layer 4: Neuromechanical or Neurokinetic Movement deficits, Tib-fib mechanics, Tib-Femur mechanics,
neurovascular structures, regional mechanoreceptors, kinetic chain
31
Treatment Pearls:
Delineate which layer the knee injury is in
Remember tissue healing time
Implement treatment guidelines
Proximal stability before distal mobility
Phases of rehabilitation
32
Patellofemoral Pain Syndrome
33
12
Patellofemoral Pain Syndrome
General anterior knee pain
Diagnosis code M22.2X1 (R) M22.2X2 (L)
Affects 15-33% of population; 21-45% adolescent population
Females > Males
Lower Extremity Malalignment Pronation
Genu valgum
Excessive Ext. Tib. Torsion
> 15°Q angle
Excessive hip IR
Patella Alta
Altered kinematics
Over training/under training 34
PFPS: Etiology
Compressive and shearing forces to undersurface of patella
Excessive lateral pressure to patella
Lateral maltracking or displacement of the patella Tight lateral retinacular attachments MPFL sprain Tight/inflexible sartorius, rectus femoris, biceps femoris, vastus lateralis
or ITB Weak medial tracking forces (VMO) vs stronger lateral (vastus lateralis
and ITB) Weak hip abductors and external rotators
Recurrent lateral subluxation MPFL
35
PFPS: Pathogenesis
Softening, thinning and fibrillation of the retropatellararticular cartilage
MPFL length tension failure
36
13
PFPS: Clinical Presentation and Evaluation
Subjective Intake is Key H/O subluxation or dislocation
Mechanism of Injury
Where is the pain located
Movie goers sign
Ascend/descend stairs
37
PFPS: Pearls of Evaluation ROM
Knee Flexion and extension
Hip flexion, extension, abduction, adduction, ER, IR
Ankle dorsiflexion in standing
MMT Keys:
Hip
Core
Palpation
Special Tests Patellar Tilt Test and Lateral Pull test
POOR interrater and FAIR intrarater reliability
Ober’s Thomas (preferred for even ITB)
J Sign Test
38
PFPS: Pearls of Evaluation
Special Tests Cont. Q angle
Craig’s test Ely’s Test McMurray’s for patella tracking Tibial torsion
SLR and Popliteal angle
Gait Barefoot
Shoes
Orthotics
Functional Tests OH Squat
Single Limb Squat
Step downs 39
14
PFPS: Pearls of Treatment Manual:
DFM/STM distal ITB, MPFL
Foam Rolling: ART; don’t just roll
Dynamic Stretching
Decrease inflammation
Proximal Stability before distal mobility
Posterior chain strengthening
Prevention of Dynamic valgus
Improve functional movement
40
Review Strengthening and Taping
Videos 1 - 8
41
42
15
43
44
MPFL Reconstruction
Patella Dislocation Classification*:
Type Features
Syndromic Genetic Predisposition
Obligatory Dislocates with every episode of knee flexion, self-reduces with extension
Fixed Lateral Remains laterally dislocated, irreducible
Traumatic Initial dislocation due to traumatic event, repeated traumatic dislocations, less energy required
with subsequent episodes
45
* Guasden et al. Medial Patellofemoral Reconstruction in Children and Adolescents JBJS Reviews 2015; 3
(10): 2
16
Literature Review: Natural History Following Primary Patella Dislocation as Reported in Literature*
Study No. Recurrent
Instability %
Included
Adults?
Risk Factors Identified
Cofield and
Bryan, 1977
48 44 Yes No risk factors identified; 13 patients later underwent
surgical intervention
Hawkins et. al,
1986
27 71 No Patellofemoral malalignment; abnormal patella
configuration
Fithian et al,
2004
110 17 Yes Younger age at initial dislocation; history of
developmental hip dysplasia
Palmu et al,
2008
28 44 Yes Positive family history of recurrent patellofemoral
instability
Sillanpää et al,
2008
21 48 Yes No associated risk factors identified
Lewallen et al,
2013
198 38 No Trochlear dysplasia; immature physes
46
*Guasden et al. Medial Patellofemoral Reconstruction in Children and Adolescents JBJS Reviews 2015; 3 (10): 3
Risk Factors for Patella Dislocation Patella alta
Trochlear Dysplasia
Increased Q angle
Increased Tibial tubercle-trochlear groove (TT-TG) distance Index > 0.23 is pathological
Genu valgum
Excessive femoral anteversion
Ligamentous laxity
Excessive Tibial torsion
47
MPFL Pathology
Typically avulses from the medial femoral epicondyle
Inconsistent healing capacity which increases risk of reinjurywith recurrent instability
48
17
Indications for MPFL Reconstruction Surgery
Recurrent lateral instability and laxity of the MPFL resulting in incompetent medial restrain
Excessive lateral patella translation
49
Contraindications for
MPFL Reconstruction
Surgery
• Patellofemoral arthritis
• Patellofemoral pain
unrelated to instability
• Patellofemoral
malalignment ***
• Requires a tibial turbercle transfer
or osteotomy
• Most Surgeries require both a TTO
and an MPFL reconstruction
• MPFL reconstruction NOT usually
done without a TTO
• Unless within the appropriate Q
angle confirmed on X-ray film
measurements
Surgical Procedure
MPFL Reconstruction with grafting WITH: Tibial tubercle osteotomy/transfer
Lateral retinacular release
MPFL Reconstruction Alone
50
Graft Options for MPFL Reconstruction
Semitendonosis tendon graft
Quadriceps tendon graft
Gracilis tendon graft ** Usually combined with semitendonosis tendon
Tibialis anterior tendon graft
Artificial graft
51
18
MPFL Reconstruction Surgical Techniques
3.5 mm titanium anchor
Transosseous 1-mm braided polyester suture
Interference screw fixation
Medial bone bridge
Transpatellar tunnels
52
Procedure:
Reference: https://www.youtube.com/watch?v=rmPhjuZ7MFQ
53
Procedure: Video of TTO with AMZ and MPFL reconstruction
Reference: https://www.youtube.com/watch?v=dyuiuZvJlTU
54
19
Post-operative rehabilitation of MPFL Reconstruction - **WITHOUT TTO**
Phase I: (weeks 0-2) Full WBAT with crutches
Hinged brace
Locked 0-20° when ambulating
Passive ROM 0-60°
Phase II: (weeks 2-6) Hinged brace 0-90°when ambulating until quad control regained
Full Passive ROM progression
Formal Physical Therapy Initiated
Phase III: (2-3 months) Return to running
Phase IV: (4-6 months) Return to sport
55
Post-operative rehabilitation of MPFL Reconstruction - **WITHOUT TTO**
Phase I: (weeks 0-2) Full WBAT with crutches
Hinged brace
Locked 0-20° when ambulating
Passive ROM 0-60°
Phase II: (weeks 2-6) Hinged brace 0-90°when ambulating until quad control regained
Full Passive ROM progression
Formal Physical Therapy Initiated
56
Rehabilitation GUIDELINES:
Consult with MD regarding depth of procedure and grafting type
Remember your tissue healing time
Phases of Rehab: Phase I: Pain control and Swelling
Phase II: Increase ROM
Phase III: Increase Strength/Neuromuscular Control/Proprioception
Phase IV: Improve Functional Movement and Strength
Phase V: Return to Play
57
20
58
Phase I-IV Guidelines
Phase I: GuidelinesRehabilitation Program: Phase I
Phase of
RehabilitationProgram Details
Phase I
Focus: Protect graft site, restore A/PROM, decrease pain & inflammation, normalize gait. Improve Neuromuscular Control
and muscle performance
Precaution: Avoid pivoting, or twisting the knee, limit knee flexion to 90° for the first 4 weeks. Use axillary crutches with
brace locked at 0° during ambulation until adequate quad control is appreciated. Avoid undue pain and stress to surgical
site
Criteria to Advance to Phase II: No signs or symptoms of patella instability, knee ROM 90° or greater (after 4 weeks), full
knee extension, active quadriceps contraction, heel to toe gait pattern with unlocked brace, no assistance of crutches, and
minimal to no joint effusion. Pain less than 5/10
Range of Motion: Stationary bike with seat high, towel slides, ankle pumps
Muscle Performance: NMES with quad sets, Isometrics Hamstrings & Adductors. SLR with brace, 3 way SLR (Abduction,
adduction, extension), Standing Calf raise (single and bilateral), sidelying clams, Double leg bridges, CKC including 1/4
squats and leg press
Proprioception: Single limb balance wearing brace, stable surface
Abdominal Core: Transverse abdominis stabilization exercies
Stretching: Lateral Quad/Iliotibial Band, Hamstrings, gastroc/soleus
Manual Therapy: STM of injured limb: emphasis on quadriceps, hamstrings, lateral quad/ITB tract, PROM grade I/II
superior/inferior patella glides
Modalities: PRN, IFC estim with cryotherapy for swelling management
Home Program: daily pain free A/PROM to 90° knee flexion (4 weeks), basic LE strengthening with no open chained
activity at home59
60
Rehabilitation Program: Phase II
Phase of RehabilitationProgram Details
Phase II
Focus: Protect graft site, continue to restore ROM, and gait. Improve muscle performance by progressing CKC
exercises in single planes of motion.
Precaution: Avoid pivoting, or twisting the knee, Overstressing the surgical site, multiplanar movements, CKC
with deep knee flexion angles > 90° and wearing the brace during activity.
Criteria to Advance to Phase III: No signs or symptoms of patella instability, adequate quadriceps strength (i.e.
absense of extensor lag during SLR). Knee ROM 120° or greater, single limb balance 30 seconds or greater,
normal gait pattern with unlocked brace, minimal to no joint effusion
Range of Motion: Phase I activity continued
Muscle Performance: Phase I activity with the progression of CKC exercises: Form Squats, side stepping, 1/4
lunges in frontal and sagittal plane, 4 inch step ups, heel walking and toe walking
Proprioception: Single limb balance on unstable surface
Abdominal Core: Planks, side planks, etc.
Stretching: Phase I stretching continued; add adductors and hip flexors
Cardiovascular: Elliptical and stationary bike; Aquatic therapy if available
Manual Therapy: STM and Joint mobilizations as needed
Modalities: PRN, IFC estim with cryotherapy for swelling management
Home Program: Phase I and II activity with addition of cardiovascular conditioning with the elliptical trainer and
stationary bike
21
61
Rehabilitation Program: Phase III
Phase of RehabilitationProgram Details
Phase III
Focus: Restore FULL joint ROM, muscle performance, improve proprioception and introduce sport
specific/functional movements
Precaution: Avoid overstressing the surgical site, closed chain movements with deep knee flexion angles
(>90°) and post exercise swelling and pain
Criteria to Advance to Phase IV: No signs or symptoms of patella instability, minimal to no joint effusion,
improved quadricep strength to 75% of non-operative leg, normal knee ROM, clearance by surgeon, normal
jogging pattern while wearing brace
Range of Motion: as needed to restore full range of motion
Muscle Performance: Phase II activity with addition of multidirectional CKC exercises and Hamstring
strengthening. Sports specific activity including light jogging patterns (with brace) Non stressing plyometrics,
movement patterns with agility ladder
Proprioception: Single limb balance on BOSU
Abdominal Core: Planks, side planks, etc.
Stretching: Phase I stretching continued; Self myofascial release techniques
Cardiovascular: Elliptical and inclined treadmill, continuation of aquatic therapy
Manual Therapy: STM and Joint mobilizations as needed
Modalities: NONE
Home Program: Phase I and II activity with addition of cardiovascular conditioning with the elliptical trainer
and inclined treadmill
62
Rehabilitation Program: Phase IV
Phase of RehabilitationProgram Details
Phase IV
Focus: Returning to full sports activity
Precautions: Pain free activity and avoid post exercise joint effusion
Criteria to return to full activity: No signs or symptoms of patella instability, absence of joint
effusion, normal lower extremity strength, normal neuromuscular control with all sports specific
testing, clearance by surgeon
Range of Motion: Phase I-III as needed
Muscle Performance: Phase I-III as needed, Begin sports specific activity including low level
plyometrics, multidirectional agility drills and circuit training
Abdominal Core: Progressive Core strengthening exercises
Stretching: Phase I-III activities as needed with Dynamic Warm Up
Cardiovascular: Elliptical, stationary bike, progressive jogging
Manual Therapy: STM and Joint mobilizations as needed
Modalities: NONE
Home Program: Phase III-IV activity and addtion of jogging for cardiovascular jogging
63
22
64
References
65
1. Barton CJ, Lack S, Malliaras P, et al. Gluteal muscle activity and patellofemoral pain syndrome: a
systematic review. Br J Sports Med 2013;47(4):207–14.
2. Balcarek P, Jung K, Frosch KH, et al. Value of the tibial tuberosity-trochlear groove distance in patellar
instability in the young athlete. Am J Sports Med 2011;39(8):1756–61.
3. Diego CA, Gustavo B, et. Al. Medial Patellofemoral Ligament Reconstruction: A Longitudinal
Comparison of 2 Techniques with 2 and 5-Years Follow Up. Open Orthopedics Journal 2015. (9): 198-
203.
4. Fisher B, Nyland J, Brand E, Curtin B. Medial patellofemoral ligament reconstruction for recurrent
patellar dislocation: a systematic review including rehabilitation and return-to-sports efficacy.
Arthroscopy 2010; 26(10): 1384-94.
5. Howells NR, Barnett AJ, Ahearn N, Ansari A, Eldridge JD. Medial patellofemoral ligament
reconstruction: a prospective outcome assessment of a large single centre series. J Bone Joint Surg Br
2012; 94(9): 1202-8.
6. Lankhorst NE, Bierma-Zeinstra SM, van Middelkoop M. Factors associated with patellofemoral pain
syndrome: a systematic review. Br J Sports Med 2013;47:193–206.
7. Myer GD, Ford KR, Foss KD, et al. A predictive model to estimate knee-abduction moment: implications
for development of a clinically applicable patellofemoral pain screening tool in female athletes. J Athl
Train 2014;49(3):389–98.
8. Nakagawa TH, Serrao FV, Maciel CD, et al. Hip and knee kinematics are associated with pain and self-
reported functional status in males and females with patellofemoral pain. Int J Sports Med
2013;34(11):997–1002.
9. Nakagawa TH, Moriya ET, Maciel CD, et al. Trunk, pelvis, hip, and knee kinematics, hip strength, and
gluteal muscle activation during a single-leg squat in males and females with and without
patellofemoral pain syndrome. J Orthop Sports Phys Ther 2012;42(6):491–501.
10.Rothermitch MA, Glaviano NR, Hart JM. Patellofemoral Pain: Epidemiology, Pathophysiology, and
Treatment Options. Clin Sports Med 34 (2015) 313-327
References cont.
11.Shah JN, Howard JS, Flanigan DC, Brophy RH, Carey JL, Lattermann C. A systematic review of complications and failures associated with medial patellofemoral ligament reconstruction for recurrent patellar dislocation. Am J Sports Med 2012; 40(8): 1916-23.
12.Sillanpää PJ, Salonen E, Pihlajamäki H, Mäenpää HM. Medial patellofemoral ligament avulsion injury at the patella: classification and clinical outcome. Knee Surg Sports Traumatol Arthrosc 2014; 22(10): 2414-8.
13.Singhal R, Rogers S, Charalambous CP. Double-bundle medial patellofemoral ligament reconstruction with hamstring tendon autograft and mediolateral patelar tunnel fixation: A meta- analysis of outcomes and complications. Bone Joint J 2013; 95-B (7): 900-5.
14.Selfe J, Callaghan M, Ritchie E, et al. Targeted interventions for patellofemoral pain syndrome (TIPPS): classification of clinical subgroups. BMJ Open 2013; 3(9):e003795.
15.Willis RB, Firth G. Traumatic patellar dislocation: loose bodies and the MPFL. J Pediatr Orthop2012;32(Suppl 1): S47-51.
16.Lenschow S, Schliemann B, Gestring J, Herbort M, Schulz M, Koster C. Medial patellofemoral ligament reconstruction: fixation strength of 5 different techniques for graft fixation at the patella. Athroscopy2013. Apr;29(4):766-73. doi: 10.1016/j.arthro.2012.12.004
66