Patella / Trochlea Lesion

stage 1 – proliferative phase (0-6 weeks)

primary goals

Do not overload the graft site with compression forces
Increase Tibial Femoral and Patella Femoral Mobility
Restore Quadriceps Control
Proximal Hip Girdle Strengthening
Emphasize PROM to tolerance early

brace

  • Hinged brace at 0-60 degrees for 3 weeks and then 0-90 degrees for 3 weeks for a total of 6 weeks controlled motion in brace

weight bearing

  • Begin touch-down immediately up to 30% of body weight with crutches for two weeks and increase by 30% every two weeks up to full weight bearing by 6-8 weeks
  • Bio-feedback with a bathroom scale can be used to help define 30%, 60% and 100% weight bearing.

range of motion (rom)

  • PROM – No AROM (extension) for 6 weeks
  • No Active Extension for 6 weeks – no resistance
  • CPM –
    • 6-8 hours per 24 hours – may/may not be broken into 2 hour segments
    • 0-60 degrees for 10 days
    • Then increase by 5 degree increments as tolerated to a goal of 90 degrees by 3 weeks
    • Remove the hinge brace while in CPM
  • Passive Manual ROM by therapist – minimum 90 degrees flexion by 3 weeks, 110 degrees by 6 six weeks, and full ROM by 12 weeks post-op – supine position

exercise therapy

  • Quad sets, SLR – include hip flexion, abduction and adduction, and extension
  • Standing resisted isometrics in full extension

physical therapy (the therapist)

  • Gentle multi-directional patella mobilization immediately after surgery
  • Cryotherapy and Ice Massage for swelling and pain control
  • E-Stim for VMO/Quadriceps muscle re-education/bio-feedback encouraged early after surgery if needed
  • Gentle deep tissue and skin massage/deep friction to hamstring insertions, suprapatellar quadriceps, medial/lateral gutters, and infrapatellar fat pad region at 2-3 weeks post-op
  • Whirlpool therapy (if available) recommended 2-3 weeks post-op to enhance motion
  • Passive Manual ROM by therapist – minimum 90 degrees flexion by 3 weeks, 110 degrees by 6 six weeks, and full ROM by 12 weeks post-op – supine position

comments

  • Avoid active open chain extension or repetitive active knee flexion between the range of  40-70 degrees due to increased patella femoral contact forces
  • Contact Physician if ROM not achieved within 20 degrees of goal.
  • No progression of this protocol until cleared by Physician at 6 weeks post-op
  • No leg presses or squats

stage 2 – transitional phase – (7-12 weeks)

brace

  • Hinged Brace is discontinued when at 100% weight bearing based on progressive criteria and once independent SLR is achieved

weight bearing

  • Full Weight bearing as tolerated

rom

  • Discontinue CPM
  • Gentle Active and Active Assist ROM flexion
  • Progress towards full ROM by 12 weeks

exercise therapy

  • Stationary bicycling without resistance for short intervals (5 min 2-3x/day) as tolerated
  • Isometrics
  • Strengthening of quadriceps, hamstrings and hip girdle (abductors/adductors/flexors/extensors) using elastic band isometrics and closed chain terminal knee extension 0-40 degrees only
  • Backward treadmill walking with safety bars recommended for reduced patella femoral compressive forces – no incline
  • Pool exercise using kickboard allowed – flutter/straight leg scissor kick only (no whip kick) – keep leg straight
  • No open chain strengthening permitted until 12 months after surgery
  • No leg extensions
  • No closed chain leg press or squatting for 9 months

physical therapy (the therapist)

  • Gentle multi-directional patella mobilization continued
  • Cryotherapy and Ice Massage
  • E-Stim for VMO/Quadriceps muscle re-education/bio-feedback
  • Gentle deep tissue and skin massage/deep friction to hamstring insertions, suprapatellar quadriceps, medial/lateral gutters, and infrapatellar fat pad continued
  • Whirlpool therapy (if available) recommended
  • Passive Manipulative ROM by therapist – minimum 90 degrees flexion by 3 weeks, 110 degrees by 6 six weeks, and full ROM by 12 weeks post-op

comments

  • This is a kissing lesion, so patella femoral contact stresses have to be minimized and ROM has to be maximized as the chance of adhesions, friction and consequent crepitation are significantly increased
  • Activity level should be modified if increased pain, catching, or swelling occurs
  • Progression of activity may resume once comfort level returns
  • No progression of this protocol until cleared by physician at 12 weeks post-op

stage 3 – remodeling phase – (13+  weeks)

brace

  • None

weight bearing

  • Full weight bearing

rom

  • Progress towards full ROM equal to contralateral side

exercise therapy

  • Stationary bicycling with very low resistance as tolerated
  • Treadmill forward/retro-walking, elliptical machine permitted
  • Pool exercise – flutter/straight leg scissor kick and running in water permitted
  • Continue gentle closed chain LE strengthening through functional range – caution with ROM between 40-70 degrees as patella enters joint
  • Full active flexion with resistance permitted
  • Open chain terminal extension with resistance not permitted

physical therapy (the therapist)

  • Continue multi-directional patella mobilization as needed
  • Continue cryotherapy and tissue mobilization for edema control
  • E-stim for VMO/quadriceps muscle re-education/biofeedback as needed
  • Tissue mobilization to scar, hamstring insertions, quadriceps, patella gutters and supra/infrapatellar regions

comments

  • Activity level should be modified if increased pain, catching or swelling occurs
  • Avoid activity/exercises with excessive patello-femoral compressive forces
  • Swelling is common in patellar implants as much as 9 months after ACI
  • No running or jumping permitted until 9-12 months after surgery
  • Continued improvement in comfort occurs for 2-3 years before maximal outcome is achieved
  • Bilateral half squats and leg presses with progressive weights after 9 months
  • Unilateral half squats and leg presses after 12 months
  • No pivoting sports should be done until after 12 months
  • Swelling is common in patellar implants as much as 9 months after ACI


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