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Dr. Laith M. Jazrawi Chief, Division of Sports Medicine Associate Professor Department of Orthopaedic Surgery Rehabilitation Protocol for Patellar Realignment 333 38 th St. ▪ New York, NY 10016 ▪ (646) 501 7047 ▪ newyorkortho.com The knee consists of four bones that form three joints. The femur is the large bone in your thigh, and a9aches by ligaments and a capsule to your ;bia, the large bone in your shin. Next to the ;bia is the fibula, which runs parallel to the ;bia. The patella, commonly called the knee cap, is embedded in the quadriceps and patellar tendonand ar;culates with the front of the femur. This is the patellofemoral joint. The patella acts as a pulley to increase the amount of force that the quadriceps muscle can generate and helps direct the force in the desired upward direc;on.1 The patella sits in a groove on the end of the femur called the trochlear groove. This groove varies in depth from person to person. While the knee exes (bends), the patella travels down the groove and as the knee extends (straightens) it moves up the groove. As the patella travels up and down in the femoral groove it maintains a congruent boney alignment. This patellar movement in the femoral groove is oGen referred to as patellar tracking. There are several structures that work together to keep the patella aligned and stabilized in the femoral groove properly, specifically to prevent the patella from excessive lateral movement. The lateral aspect of the trochlear groove is normally about 1 cm higher than the medial which helps to keep the patella in the trochlear groove by providing a bu9ress on the lateral side (Figure 1).2 This provides the main resistance to lateral patellar transla;on (which is the most common direc;on of displacement), especially beyond 20 degrees of knee exion.3 People who have a shallow trochlea are more suscep;ble to patellar instability. Proper stabiliza;on of the patella is also affected by the soG ;ssue structures (ligaments and muscles) surrounding the knee. The medial patellofemoral ligament (MPFL) is a con;nua;on of the deep re;naculum and vastus medialis oblique (VMO) muscle fibers (inner por;on of the quadriceps muscle) on the inside of the knee. These structures provide a significant force (near 60% total) against lateral displacement of the patella, as their force is directed inward or medially.2,4 The MPFL is the primary restraint to lateral displacement of the patella during the first 20-30 degrees of knee exion.3 This ligament is a passive stabilizer and extends from the upper inner side of the patella to medial aspect of the femur.

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Page 1: Rehabilitation Protocol for Patellar Realignment · Rehabilitation Protocol for Patellar Realignment 333 38th St. New York, NY 10016 (646) 501 7047 newyorkortho.com! The knee consists

Dr. Laith M. Jazrawi Chief, Division of Sports Medicine Associate Professor Department of Orthopaedic Surgery

Rehabilitation Protocol forPatellarRealignment

333 38th St. ▪ New York, NY 10016 ▪ (646) 501 7047 ▪ newyorkortho.com!

Thekneeconsistsoffourbonesthatformthreejoints.Thefemuristhelargeboneinyourthigh,anda9achesbyligamentsandacapsuletoyour;bia,thelargeboneinyourshin.Nexttothe;biaisthefibula,whichrunsparalleltothe;bia.Thepatella,commonlycalledthekneecap,isembeddedinthequadricepsandpatellartendonandar;culateswiththefrontofthefemur.Thisisthepatellofemoraljoint.Thepatellaactsasapulleytoincreasetheamountofforcethatthequadricepsmusclecangenerateandhelpsdirecttheforceinthedesiredupwarddirec;on.1Thepatellasitsinagrooveontheendofthefemurcalledthetrochleargroove.Thisgroovevariesindepthfrompersontoperson.Whilethekneeexes(bends),thepatellatravelsdownthegrooveandasthekneeextends(straightens)itmovesupthegroove.Asthepatellatravelsupanddowninthefemoralgrooveitmaintainsacongruentboneyalignment.ThispatellarmovementinthefemoralgrooveisoGenreferredtoaspatellartracking.Thereareseveralstructuresthatworktogethertokeepthepatellaalignedandstabilizedinthefemoralgrooveproperly,specificallytopreventthepatellafromexcessivelateralmovement.Thelateralaspectofthetrochleargrooveisnormallyabout1cmhigherthanthemedialwhichhelpstokeepthepatellainthetrochleargroovebyprovidingabu9ressonthelateralside(Figure1).2Thisprovidesthemainresistancetolateralpatellartransla;on(whichisthemostcommondirec;onofdisplacement),especiallybeyond20degreesofkneeexion.3Peoplewhohaveashallowtrochleaaremoresuscep;bletopatellarinstability.Properstabiliza;onofthepatellaisalsoaffectedbythesoG;ssuestructures(ligamentsandmuscles)surroundingtheknee.Themedialpatellofemoralligament(MPFL)isacon;nua;onofthedeepre;naculumandvastusmedialisoblique(VMO)musclefibers(innerpor;onofthequadricepsmuscle)ontheinsideoftheknee.Thesestructuresprovideasignificantforce(near60%total)againstlateraldisplacementofthepatella,astheirforceisdirectedinwardormedially.2,4TheMPFListheprimaryrestrainttolateraldisplacementofthepatelladuringthefirst20-30degreesofkneeexion.3Thisligamentisapassivestabilizerandextendsfromtheupperinnersideofthepatellatomedialaspectofthefemur.

Page 2: Rehabilitation Protocol for Patellar Realignment · Rehabilitation Protocol for Patellar Realignment 333 38th St. New York, NY 10016 (646) 501 7047 newyorkortho.com! The knee consists

Rehabilitation Protocol forPatellarRealignment

333 38th St. ▪ New York, NY 10016 ▪ (646) 501 7047 ▪ newyorkortho.com!

Thepatellomeniscalligamentandre;naculumalsocontributeover20%oftherestrainingforce.Theseligamentscanbeinjuredandtornwithanini;alacutetrauma;cpatellardisloca;on(kneecapquicklygoingoutofplaceduringasportrelatedmovement).Themostcommonmechanismforanini;aldisloca;onisaforcefulinwardrota;onofthekneeonaplantedfoot.Theradiographbelowisthatofa12yearoldboyintheemergencyroomaGersuchaninjury(Figure2).OGen;mesthepatellawillgobackintoplace(orrelocatetothegroove)asthekneeisgentlystraightened.Inthiscasethepa;entwasunabletostraightenhiskneeandhispatellaremaineddislocatedlaterally.Noteontheradiographthatthereisnooverlapofthefemurandpatella.Anindividualcanalsohaveatrauma;cinstability.Inthissitua;ontheinstabilityismorelikelytobeapar;aldisloca;onorsubluxa;onandnotcreatedbyalargeforcefulone;meinjury.Peoplewithatrauma;cinstabilityusuallyhavepredisposingfactorsthataltertheirnormalpatellartracking.Thealignmentofthepelvisandfemurcanaffectpatellartracking.Thealignmentofthepelvisandfemurcanbestructurallyalteredbasedonapar;cularindividual’sangleofthequadricepsmuscle,alsoknownas“Qangle”.The“Qangle”isformedbythesuperiorlineofthequadricepspull(fromthehip)andthepatellartendon(inser;onontothefrontofthe;bia)astheyintersectatthepatella(Figure3).2Thealignmentofthepelvisandfemurcanalsobefunc;onallyalteredinaweightbearingposi;onduetohipweaknessorpronated(flat)feet.

Page 3: Rehabilitation Protocol for Patellar Realignment · Rehabilitation Protocol for Patellar Realignment 333 38th St. New York, NY 10016 (646) 501 7047 newyorkortho.com! The knee consists

Rehabilitation Protocol forPatellarRealignment

333 38th St. ▪ New York, NY 10016 ▪ (646) 501 7047 ▪ newyorkortho.com!

Patellofemoralstresssyndrome(kneecappain)andpatellarinstabilityresultfromadevia;oninthenormaltrackingofthepatella.MostoGenabnormaltrackingresultsinlateralposi;oningofthepatella(towardtheoutsideoftheknee).Lateraldisplacementcanoccurfromthefemurrota;nginwardorthepatellabeingpulledoutward.Thiscanhappenasaresultofinjuryorrepe;;vestress.Instabilitycanoccurasamildsubluxa;on(slightlossofjointalignment),orasacompletedisloca;on(Figure2).Patellardisloca;ontypicallyinvolvesastrongquadricepscontrac;oncombinedwithaflexedandvalguskneeposi;onandaninternallyrotatedfemurrela;vetothe;bia.2InsportsthisoGenoccurswhenanathleteplantshis/herfoottopivotandthekneeturnsinwardwhiletheupperbodyandhipsareturningoutward.Annualincidenceofpatellardisloca;onsinpeopleunder16yearsofagewasfoundtobe43per100,000.Thisincidencelowersto31per100,000intheseconddecadeoflife,followedby11per100,000inthethirddecade,andevenfurtherto1.5-2per100,000inthosebetween30-59yearsofage.2Peoplewithrecurrentdisloca;onsofthepatellaoGenhaveanatomicalvaria;onsormalalignmentincludingpatellaaltaorahigherquadriceps“Qangle”(Figure3),whichpredisposethemtoinstability.3,4.Patellaaltadescribesahigh-ridingpatellawhichengagesthetrochlealaterinflexionthannormal,givingthepatellalessboneystability.4Manyop;onsexistfortrea;ngpatellarinstability.Rehabilita;onistypicallyrecommendedfollowinganini;aldisloca;on;howeverrecurrentdisloca;onisreportedtobeashighas48%withnon-opera;vetreatment.2Opera;vetreatmentistypicallyperformedonthosewithanunderlying,predisposinganatomicalvaria;ons/malalignmentasnotedabove.Opera;vetreatmentisalsoperformedonpeoplewhohavehadreoccurringdisloca;ons,astheseindividualstypicallyhavecon;nuedapprehensionandprogressivejointdamage.Specificopera;vetreatmentisselectedbasedonthepar;cularneedsoftheindividualincluding:extentofmalalignment,individual’sage,levelofac;vity,ligamentousinjury(MPFL)andjointcondi;on.Examplesofproceduresusedinclude:proximalrealignment,MPFLrepairorreconstruc;on,lateralrelease,anddistalrealignment.

Page 4: Rehabilitation Protocol for Patellar Realignment · Rehabilitation Protocol for Patellar Realignment 333 38th St. New York, NY 10016 (646) 501 7047 newyorkortho.com! The knee consists

Rehabilitation Protocol forPatellarRealignment

333 38th St. ▪ New York, NY 10016 ▪ (646) 501 7047 ▪ newyorkortho.com!

Proximalrealignmentaltersthemedial-lateralposi;onofthequadricepsmuscletothepatellathroughappropriatemanipula;onofthe;ssuesatorabovethelevelofthepatella.Anincisionismadeoverthekneeandspecificproceduresinclude:lateralre;nacularrelease(lengtheningthestructuresontheoutsideofthepatella),VMOadvancementandMPFLrepairandreconstruc;on(shorteningthemuscleorligamentsontheinsideofthepatella).2Thisprocedureissome;mesdoneincombina;onwithadistalrealignmentprocedure.DistalrealignmentisoGendonetoreducethe“Qangle”.Thisisperformedthroughanincisionoverthekneeinwhichaninstrumenttocutthe;bialtubercle(theboneyprominenceonthetopofthe;biawherethepatellartendona9aches)isused.Thisiscalledanoteotomy.Thebasicpurposeofthistypeofosteotomyistomovethe;bialturberclemedially(towardtheinside).Thetypeofosteotomyperformedwilldeterminehowmuchofthisbonewillbecut.Becauseofthisdifferencetherewillalsobesubsequentdifferencesinwhenthesepa;entscanbeginweightbearing.Thepatellartendonandbonewhichwascutisthenmovedmediallywhichalterstheposi;onofthepatella.Theboneisrea9achedinthisnewposi;ontothe;biawithscrews(Figure4).Aqualitypost-opera;verehabilita;onprogramisessen;altohavingasuccessfuloutcomefromapatellarstabiliza;onprocedure.Thegoalsofrehabilita;onwillini;allyfocusonprotec;onforhealing,mobilityandrangeofmo;on.AGerthisearlyphasetherewillbeastrongemphasisonstrengtheningthroughouttheen;relegandcore.Inthefinalstagesrehabilita;onthefocuswillbeoncontrolofsportspecificmovements,suchaschangeofdirec;onandrota;onalmovements.


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