Question for Physiotherapists
Patella dislocation
Welcome to Orthosports Question for Physiotherapists May 2024. This month Dr Doron Sher discusses Patella dislocation
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Case History 1 | A 30 year old elite volleyball player falls during a game and lands awkwardly. Her knee is bent and she is in significant pain. Your daughter is on her team so you happen to be there watching the game and go to her assistance.
You examine her and find that her patella is dislocated laterally. Taking a brief history from her you find out that this is her first dislocation. There is no neurovascular deficit at the foot and her hip is not irritable to movement. She does not have generalized ligamentous laxity or other predisposing factors for dislocation. While you are waiting for the ambulance to arrive you explain that you are going to attempt to gently straighten her knee to allow the patella to reduce itself. As you get close to full extension the patella reduces providing immediate significant pain relief.
She is now able to hobble to the sideline keeping her knee fully extended and can weight bear well enough to walk with assistance.
You arrange for her to have crutches and a zimmer splint and send her for an immediate xray and to the pharmacy for some analgesic medications. The xray shows normal bony morphology but due to the fact that she is an elite athlete you refer her for an MRI scan and Orthopaedic opinion.
Case History 2 | A 21 year old university student presents to you having dislocated her patella over the weekend. This happens about once a year if she goes dancing. The problem started when she was 15 years old but she was told not to have surgery at the time. Her clinical examination shows a small effusion but she already has fairly good movement of the knee with limited pain.
Her clinical examination shows generalized ligamentous laxity, internal femoral torsion and a positive patella apprehension sign. You arrange an xray to exclude an osteochondral injury. Since she has already failed to respond to non-operative treatment of splinting and physiotherapy you arrange an Orthopaedic opinion.
Patella dislocation usually results from a twisting injury or a direct blow to the knee with the joint in slight flexion. The injury is painful and may cause the patient to fall to the ground. The patella can reduce itself as the person tries to straighten their knee but more commonly is observed as a prominent bulge on the lateral margin of the knee. When the patella dislocates the knee is swollen and neither active nor passive movement is possible. The knee is usually in a flexed position when the patient presents for acute treatment.
Patella dislocation can be caused by (1) Abnormal forces on a normal patellofemoral joint OR by (2) Normal forces on an abnormal joint. Recurrence of the dislocation without surgery is common with more than half of the patients having significant activity restrictions. Having a dislocation doubles the risk of patellofemoral arthritis over 15 years. Teenagers are 5 times more likely to dislocate their patella than adults and females are more likely to dislocate than males.
Factors that may predispose to dislocation include:
- Generalised ligamentous laxity;
- A small lateral femoral condyle (relative to opposing tibial condyle);
- A small intercondylar groove;
- A small and / or high riding patella;
- A significant genu valgum deformity;
- Quadriceps weakness but it is possible to dislocate a ‘normal’ patella as well.
It is usually worthwhile trying a gentle reduction maneuver for an acute dislocation since the diagnosis is usually obvious. Simply straightening out the knee and (if necessary) applying a gentle medial force to the patella will reduce the joint and provide immediate pain relief for the patient. It is essential that all patients have an Xray including a skyline patella or Merchant view.
The “crossing sign” represents an abnormally elevated floor of the trochlear groove rising above the top of the wall of one of the femoral condyles, assessed on lateral radiographs. “Double contour” is a double line at the anterior aspect of condyles and is seen if the medial condyle is hypoplastic. The skyline view can show decreased trochlear depth and a large sulcus angle (>144º).
Once reduced the patient will usually have a haemarthrosis and be very tender at the medial edge of the patella where the soft tissue structures have torn. They will be reluctant to flex the knee and have a positive patella apprehension test.
If the dislocation has taken place in an otherwise normal knee and the patient is a regular sports participant it is becoming more common to reconstruct the structures that have been torn to allow a more reliable return to sport. If the patient leads a sedentary lifestyle I recommend immobilizing the knee in a firm supporting bandage and Zimmer splint for 3 weeks with the leg extended with full weight bearing allowed. Once the splint is removed, physiotherapy should be started immediately to strengthen the quadriceps muscles to try to prevent further dislocations.
If the dislocation takes place in an abnormal knee (recurrent dislocator) it is important to work out where the pathology is that is causing the dislocation. Non-operative treatments are always attempted first but surgery is often required. On the whole surgery works well to prevent further dislocations because skeletal and muscular components of the patellofemoral joint and extensor mechanism are realigned.
These days it is more common for patients to undergo a soft tissue reconstruction than a bony realignment procedure (MPFL medial patellofemoral ligament reconstruction) but there are certain cases where a bony procedure will be necessary.
https://kneedoctor.com.au/operations/mpfl-reconstruction/
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Previous Question for Physiotherapists:
Dec-2020 | Wrist Ganglions | Dr Kwan Yeoh |
Oct/Nov-2020 | Medial Meniscal Root Tears | Dr Doron Sher |
Sep-2020 | Lumbar Stress Fractures | Dr Paul Annett |
Aug-2020 | Frailty and Healthy Ageing | Dr John Best |
Jul-2020 | Thumb – Collateral Ligament Tear | Dr Kwan Yeoh |
Jun-2020 | Shoulder Instability | Dr Doron Sher |
May-2020 | Hallux Rigidus | Dr John Negrine |
Mar/Apr-2020 | Achilles Tendon Ruptures | Dr Todd Gothelf |
Feb-2020 | Distal Biceps | Dr Doron Sher |
Nov-2019 | Clavicle Fracture Internal Fixation | Dr Doron Sher |
Oct-2019 | Femoracetabular Impingement (FAI) | Dr Paul Mason |
Sep-2019 | Imaging for Acute ACL Injuries | Dr Doron Sher |
Aug-2019 | Joint Relocation | Dr Paul Annett |
Jul-2019 | Guyon canal surgery | Dr Kwan Yeoh |
Jun-2019 | Whats new in ACL reconstruction 2019 | Dr Doron Sher |
May-2019 | Cuneiform Fracture | Dr Todd Gothelf |
Apr-2019 | Flexor Tendon Injuries | Dr Kwan Yeoh |
Mar-2019 | Chronic Exertional Compartment Synd | Dr Paul Annett |
Feb-2019 | Achilles Tendon Rupture | Dr John Negrine |
Nov-2018 | Low Back Pain | Dr Paul Mason |
Sep-2018 | Concussion part 2 | Dr John Best |
Jul-2018 | Concussion part1 | Dr Paul Annett |
Jun-2018 | Thessaly & McMurray Test | Dr Doron Sher |
May-2018 | AC Joint | Dr Doron Sher |
Apr-2018 | Arthritis of the fingers | Dr Kwan Yeoh |
Feb-2018 | CLAVICLE fractures | Dr Doron Sher |
Oct-2017 | ACL Grafts | Dr Doron Sher |
Sep-2017 | Forefoot pain | Dr John Negrine |
Aug-2017 | Wrist Ganglion | Dr Kwan Yeoh |
Jul-2017 | Anterolateral Ligament Reconstruction | Dr Doron Sher |
Jun-2017 | Scapholunate ligament | Dr Kwan Yeoh |
Apr-2017 | Knee Brace – ACL Reconstruction | Dr Doron Sher |
Mar-2017 | Sesamoid fractures | Dr Kwan Yeoh |
Feb-2017 | Plantar Fasciitis | Dr Todd Gothelf |
Nov-2016 | Sternoclavicular Joint | Dr Doron Sher |
Oct-2016 | Proximal Humerus Fractures | Dr David Lieu |
Sep-2016 | Wrist Fractures | Dr Kwan Yeoh |
Aug-2016 | Patella Instability | Dr Doron Sher |
Jul-2016 | Snowboarders ankle | Dr Todd Gothelf |
May-2016 | Cortisone Injections | Dr Paul Annett |
Apr-2016 | Shoulder Instability_1 | Dr Ivan Popoff |
Mar-2016 | Exercise after TKR | Dr Doron Sher |
Dec-2015 | Scaphoid OA | Dr Kwan Yeoh |
Nov-2015 | Greater Tuberosity Fractures | Dr Doron Sher |
Oct-2015 | Stress Fractures | Dr Paul Annett |
Sep-2015 | Boxers Fractures | Dr Kwan Yeoh |
Aug 2015 | Resistance Training | Dr John Best |
July 2015 | LARS Ligament | Dr Ivan Popoff |
Jun-2015 | Distal Biceps | Dr Doron Sher |
May-2015 | Latarjet procedure | Dr Jerome Goldberg |
Apr-2015 | TFCC Questions | Dr Kwan Yeoh |
Mar-2015 | Acute Ankle Sprains | Dr Todd Gothelf |
Nov-2014 | PRPP | Dr Paul Annett |
Oct-2014 | Driving After Surgery | Dr Doron Sher |
Sep-2014 | Distal Biceps Rupture | Dr Doron Sher |
Aug-2014 | Ankle Sprain | Dr Todd Gothelf |
Jun-2014 | Patella Dislocation | Dr Doron Sher |
May-2014 | Shoulder Instability | Dr Todd Gothelf |
Apr-2014 | De Quervains | Dr Kwan Yeoh |
Mar-2014 | Acromio-clavicular joint injuries | Dr Todd Gothelf |
Feb-2014 | Chronic Knee Pain | Dr Paul Annett |
Dec-2013 | Foot and Ankle Questions | Dr John Negrine |
Oct-2013 | Rotator Cuff Repair | Dr Todd Gothelf |
Sep-2013 | ACL Reconstruction | Dr Doron Sher |
Jul-2013 | Slipped Upper femoral epiphysis | Dr Rod Pattinson |
May-2013 | Skiers thumb | Dr Kwan Yeoh |
Apr-2013 | Bakers_Cyst | Dr Ivan Popoff |
Mar-2013 | Tibial Osteotomy vs UKR | Dr Doron Sher |
Feb-2013 | ALIF success rate | Dr Andreas Loefler |
Jan-2013 | Lisfranc Injuries | Dr Todd Gothelf |
Nov-2012 | Anterior Spinal Fusions | Dr Andreas Loefler |
Oct-2012 | MCL Injuries | Dr Doron Sher |
Sep-2012 | Compartment Syndrome | DrPaul Annett |
Aug-2012 | Carpal tunnel | Dr Kwan Yeoh |
July-2012 | Anterior Process Calcaneus Fx | Dr Todd Gothelf |
Jun-2012 | Tenodesis vs Tenotomy | DrJeromeGoldberg |
May-2012 | Osteoarthritis in the young active patient | Dr Doron Sher |
Apr-2012 | Syndesmosis Sprain | Dr Todd Gothelf |
Mar-2012 | Triangular Fiocartilage Injuries | Dr Kwan Yeoh |
Jan-2012 | Shoulder Replacement Older Population | Dr Jerome Goldberg |
Dec-2011 | Wrist Fracture | Dr Kwan Yeoh |
Nov-2011 | Adductor Tendon Tear | Dr Paul Annett |
Oct-2011 | Navicular Pain | Dr Todd Gothelf |
Sep-2011 | OCD Lesion | Dr Doron Sher |
Aug-2011 | Metal on Metal Hip Replacements | Dr Andreas Loefler |
July-2011 | Femoral Neck Stress Fract (Pt 2) | Dr John Best |
Jun-2011 | Femoral Neck Stress Fractures | Dr John Best |
May-2011 | PCL Injury Part 2 | Dr Doron Sher |
Apr-2011 | PCL Injury Part 1 | Dr DoronSher |
Mar-2011 | Prolotherapy Autologous Blood Injections | DrPaul Annett |
Feb-2011 | Shoulder Impingement | Dr Todd Gothelf |
Dec-2010 | Does Chondral Grafting Work | DrDoron Sher |
Nov-2010 | Shoulder Immobilisation-Dislocation | Dr Jerome Goldberg |
Sep-2010 | SLAP Lesions Stable Shoulder | Dr ToddGothelf |
Jul-2010 | Ankle Sprains | Dr Todd Gothelf |
Jun-2010 | Dislocation After THR | Dr Peter Walker |
May-2010 | Acupuncture Muscle Strength Programmes | Dr Paul Annett |
April-2010 | Full Thickness Rotator Cuff Tears | Dr JeromeGoldberg |
Mar-2010 | Skiing after TKR | Prof Warwick Bruce |
Feb-2010 | Fractures of the Clavicle | Dr John Trantalis |
Jan-2010 | Osteoarthritis of the Knee | Dr Doron Sher |
Dec-2009 | Fifrth Metatarsal Fractures | Dr Todd Gothelf |
Nov-2009 | Partial Rotator Cuff Tears | Dr Todd Gothelf |