Conservative treatment of patellofemoral subluxation * JACK H. From the
HENRY,† M.D., University
AND JACK W. CROSLAND, M.D., San Antonio, Texas Center, San Antonio, Texas
Health Science
The
purpose of this study was to try to determine the efficacy of conservative treatment in patellofemoral subluxation, and to find what factors, if any, predisposed to failure of this conservative treatment. A review of the literature revealed that very little attention had been paid to conservative treatment of subluxation as most authors were concerned with &dquo;dislocating or slipping patella.&dquo; However, Hugh Owen Thomas’ &dquo;cured&dquo; a girl with a bilateral lesion by weekly percussion and irritation of the lateral femoral
condyle
to
produce a deeper groove.
Orr2 and Pearson’3 described a poroplastic felt &dquo;knee cap&dquo; prevent recurrent dislocation of the patella.
to
MacAusland and Sargent,4 used a split knee cap pad held in place with a Jones knee brace. This was combined with &dquo;stimulative treatment,&dquo; i.e., baking and massage to give tone to the relaxed ligaments and exercises to strengthen muscles for postural strength. Whitman foot braces were prescribed for pronated feet.
Ober’s’ conservative treatment included a Thomas lift under the heel and a felt pad lateral to the patella. He also suggested exercises for the vastus medialis and sartorius. Ober also noted that conservative treatment would help in many instances, but was quick to point out that early operative treatment should be performed to avoid arthritic changes and trauma from falls. Even though these authors wrote of conservative treatment, Dickson~summed up the current feeling: &dquo;Conservative treatment with braces and support has given temporary relief, but has never been successful in effecting a cure.&dquo; Heywood found that in 15% of the patients in his series, &dquo;symptoms ceased, never to recur, after physio-therapy had developed the quadriceps.&dquo; These patients were &dquo;young adults,&dquo; in whom the patella went through a period of dislocation about the time of skeletal maturation. This, in part, *
Presented at the Third Annual
Meeting of the American OrthoDiego, California, July 5 to 9,
paedic Society for Sports
Medicine, San
1977. -f~ Address requests for Antonio, Texas 78229.
reprints
12
to:
8038
Wurzbach, Suite 570, San
agrees with current concepts that sufficient
growth can relieve
symptoms. In this series of patients, the diagnosis of patellofemoral subluxation was made by history and physical examination. The multiplicity&dquo;&dquo; of described x-rays and the variability of the contracting quadriceps caused us not to depend on x-ray criteria. The history usually revealed that the patient’s knee was giving way and additional questioning revealed that the knee gave way when cutting away from the affected side; i.e., the femur was internally rotated on a tibia that was fixed in external rotation. Characteristically, there was no physical contact that produced the giving way. Occasionally, the patient remembered that the patella &dquo;slid over&dquo; and that he felt a &dquo;click&dquo; (sometimes called &dquo;locking&dquo;), but the subsequent normal range of motion after the injury helped rule out true locking. The history of an effusion that occurred within 12 hr was common. If the effusion was aspirated, the fluid was serosanguinous, but it usually resolved in 7 to 10 days if no internal derangement had occurred. The patient often complained of &dquo;weakness&dquo; of the leg, especially when running, cutting, and stair climbing. The physical examination revealed a high-riding patella or patella alta, which Smillie’° thinks is the most consistent sign. Hughston&dquo;, 12 noted the lateral tilt to the patella and has named this the &dquo;grasshopper eye patella.&dquo; The oblique head of the vastus medialis was dysplastic and a &dquo;dimple&dquo; could be palpated medially. The vastus lateralis was often hypertrophied. Evidence of previous Osgood-Schlatter disease as exemplified by a large tibial tubercle and long patella tendon was often present. The fat pad was large, and this, along with the high patella, produced what has been called the &dquo;camelback&dquo; sign. The knee was flexed 30° to prevent longitudinal motion of the patella and subluxation was attempted. Apprehension of the patient was considered a sign of recurrent subluxation, or Fairbanks sign. Peripheral tenderness around the patella represented inflammation of the retinaculum or tendinitis, tenderness posteriorly! on the patellar facets or pain on longitudinal
transverse grating chondromalacia. Postural deformities, including genu valgum, recurvatum, pronated feet, and exces-
and
sive femoral neck anteversion, were also noted. In the group of patients reviewed, the conservative treatment consisted of an elastic knee bandage with a horseshoe-shaped felt pad to be used in running or sports, and an exercise regimen. 14 The exercises consisted of straight leg raises with the patient in the supine position, leg abduction with the patient in the lateral decubitus position, and hip flexion with the patient
sitting. Weight as tolerated was added as 30 repetitions could be performed. The exercises were repeated three times a day for a 6-week period and then the patient was re-assessed. If sympbetter, exercises were discontinued and used on an interim basis if symptoms recurred. The length of follow-up ranged from 2 to 5 years, with an average of 3.1 years. Table 1 shows the distribution of followup. There was no significant difference in the result 6 weeks after initiation of treatment and 2, 3, 4, or 5 years after initiation of treatment. One hundred forty-five patients returned for evaluation and examination. There were 71 males and 74 females in this group, closely approximating a 1:1sex ratio. The right and left knees were involved equally, both knees being symptomatic in 17% of the cases. In the patients with both knees symptomatic, 61% were males and 39% females. The age range was from 11 to 55. The average age of the male was 20 and the female 25. The average age of the entire group was 23. The patient makeup is shown in Figure 1 with the shaded areas representing the female population. In patients over the age of 30, there was a 3:1 female to male ratio. The symptoms are listed in decreasing frequency in Table 2. The signs are listed in decreasing frequency in Table 3. The average Q angle for this group of patients was 19.6°, with a range from 10 to 35°. The Q angles were normally distributed
toms were
regard to both sex and age. A breakdown of the range is shown in Table 4. The results were classified as successful if the patient became asymptomatic or if he was still somewhat symptomatic, but was able to participate in all desired activities. Unsuccessful results or failure implied no subjective improvement. Of the 145 patients who were re-examined after conservative treatment, 110 (76%) said that they were better. When asked if exercises helped, all 76% answered affirmatively. When asked about braces, only 64% thought this adjunct had helped; 7.7% also noted they changed activities because of their knees. Thirty-five patients (24%) of the group said they were no better after conservative treatment. Of this group, 11admitted exercises helped and 15admitted braces helped; even though the patients felt they were no better after treatment than before. Twelve required surgical correction. An evaluation of the signs and symptoms failed to reveal any factors that would predict failure of conservative treatment. The signs and symptoms were normally distributed in the successful and unsuccessful groups. Furthermore, in examining the failure group which consisted of 19 females (average age 29) and 16 males (average age 18), it was found that 31 % of the failures were males under 20 and 29% were females over 30, together comprising 60% of the failure group. From the study of these patients, it would appear there are no specific signs or symptoms that would indicate whether or
with
TABLE2
Symptoms ~
. .....-
TABLE 1
Follow-up
TABLE3
Signs
TABLE 4
Q angle
Fig.
1. Distribution
of patient population by age and sex. 13
patient subjectively would respond favorably to conservative treatment. The authors were left with the impression that most patients did get some subjective relief of symptoms. It is concluded, therefore, that conservative therapy does have a place in the treatment of subluxation of the patella and the symptomatic patient should be given a trial of exercises and/or bracing before surgical intervention is carried out. not a
REFERENCES 1. Cole WH, Williamson GA: Chronic recurrent dislocation of the patella. JAMA 102: 357-360, 1934 2. Orr HW: A review of the surgical treatment of congenital dislocation, recurrent dislocation, or slipping patella. Clin Orthop 3: 3-7, 1954 3. Pearson CY: Aftertreatment of lateral dislocation of the patella by a new form of knee cap. Lancet, 1: 1884 4. MacAusland WR, Sargent AF: Recurrent dislocation of patella. Surg Gynecol Obstet 35: 35-41, 1922 5. Ober FR: Recurrent dislocations of the patella. Am J Surg 43:
497-500, 1939 6. Dickson JA: Recurrent dislocation of the patella. Surg Clin North Am: 997-1000, 1936 7. Heywood AWB: Recurrent dislocation of the patella. A study of its pathology and treatment in 106 knees. J Bone Joint Surg 43B:
508-517,1961 8. Insall J, Salvati E: Patella position in the normal knee joint. Radiology 101: 101-104, 1971 9. Merchant AC, Mercer RL, Jacobsen RH, et al: Roentgenographic analysis of patellofemoral congruence. J Bone Joint Surg 56A:
1391-1396, 1974 10. Smillie IS: Ligamentous injury and subluxation of the patella. J Bone Joint Surg 41B: 214, 1959 11. Hughston JC, Stone MM: Recurring dislocations of the patella in athletes. South Med J 57: 623-628, 1964 12. Hughston JC: Subluxation of the patella. J Bone Joint Surg 50A:
1003-1026, 1968 13. Wiles P, Andrews PS, Devan MD: Chondromalacia of the J Bone Joint Surg 38B: 95-113, 1956 14. Nicholas JA: Personal communication
patella.
EDITORIAL COMMENT Dr. Robert H. Larson: The following discussions are of the preceding articles by Dr. DeHaven et al. and Dr. Henry and Dr. Crosland. Conservative care has been recognized for some time as being beneficial in a great number of patellar problems. The statistical evaluation of patients done by Dr. DeHaven et al. and Dr. Henry and Dr. Crosland confirm the successful results in 70 to 80%. There is another value in a trial of conservative treatment and that is it gives one the chance to re-examine and re-evaluate both the patient and the extensor mechanism problem, so that a more thorough assessment of the basic mechanics is possible should a surgical procedure be required. When surgical treatment is necessary, there are many types of procedures attesting to the problems with each. The extensor mechanism is a complicated dynamic apparatus. Static adjustments necessary at the time of surgery may not function as desired in the dynamic action after surgery. If one can rehabilitate and strengthen the extensor mechanism to relieve the patient’s complaints symptomatically, one need not fear the problems which may develop from operative intervention.
14
As has been
mentioned, chondromalacia is a pathologic clinical one. When used as a clinical diagnosis, it is often a &dquo;wastebasket.&dquo; I think it is best to be more specific in diagnosis of extensor mechanism problems, relating them either to instability (subluxation or dislocation), patellar tendinitis, or patellar compression syndrome. Chondromalacia may be merely an end stage in a malalignment problem, or may be related to a specific incident of injury. One of the modalities of conservative treatment is the use of orthotic supports, which I believe, in some cases, may be beneficial in that it does change the way the patella tracks through the patellofemoral groove. Their use may relieve some of the irritation in those having discomfort from repetitive activity. I wholeheartedly agree in the conservative approach (nonoperative) as the initial management in most patients with patellar femoral problems.
diagnosis,
not
a
Dr. Bernard R. Cahfll: The excellent papers by Dr. DeHaven al. and Dr. Henry and Dr. Crosland confirm the suspicion of clinicians; that conservative therapy in patellar dysfunction is successful in most cases and gives a scientific precedence for the continuation of this practice. In those patients who require surgery, the preoperative attempts at conservative therapy seem to speed rehabilitation of the extremity and so this is another justification for its continued use. Although their methods of rehabilitating the knee are somewhat different, both groups of authors correctly conclude that conservative therapy can be curative in various types of patellar dysfunction in the athlete. et
Dr. Jack C. Hughston: Dr. Henry and Dr. Crosland have written to me asking me to give some discussion to their concepts of conservative treatment. We had the pleasure of having Jack Henry working with us here in our clinic and visiting with us at other times, thus he knows our strong feelings regarding an initial attempt at conservative treatment for subluxation of the patella, as well as for an initial acute dislocation of the patella. A good friend of mine was present when we made the first presentation of &dquo;Patella Subluxation in Athletes&dquo; at the Southern Medical Meeting in Miami; when I saw him at a subsequent meeting I year later he told me how great it was that we had brought this energy to the recognition of orthopaedists and that as a result he had operated on x number of cases this past year, whereas he had failed to recognize them prior to the presentation. His stated number of operations for subluxation of the patella in 1 year exceeded the number of operations that we had done for this condition in the previous 10 years. Needless to say, I was shocked and thus the reason for the emphasis we have subsequently placed on the rehabilitative nonoperative treatment of this condition in our seminars and meetings. I am glad to see Jack Henry and Jack Crosland come out with a well documented, well studied series of cases specifically relating to the use of conservative treatment of this condition rather than an operation as the desired initial attempt at correction of the patient’s disability.
HENRY,† M.D., University
AND JACK W. CROSLAND, M.D., San Antonio, Texas Center, San Antonio, Texas
Health Science
The
purpose of this study was to try to determine the efficacy of conservative treatment in patellofemoral subluxation, and to find what factors, if any, predisposed to failure of this conservative treatment. A review of the literature revealed that very little attention had been paid to conservative treatment of subluxation as most authors were concerned with &dquo;dislocating or slipping patella.&dquo; However, Hugh Owen Thomas’ &dquo;cured&dquo; a girl with a bilateral lesion by weekly percussion and irritation of the lateral femoral
condyle
to
produce a deeper groove.
Orr2 and Pearson’3 described a poroplastic felt &dquo;knee cap&dquo; prevent recurrent dislocation of the patella.
to
MacAusland and Sargent,4 used a split knee cap pad held in place with a Jones knee brace. This was combined with &dquo;stimulative treatment,&dquo; i.e., baking and massage to give tone to the relaxed ligaments and exercises to strengthen muscles for postural strength. Whitman foot braces were prescribed for pronated feet.
Ober’s’ conservative treatment included a Thomas lift under the heel and a felt pad lateral to the patella. He also suggested exercises for the vastus medialis and sartorius. Ober also noted that conservative treatment would help in many instances, but was quick to point out that early operative treatment should be performed to avoid arthritic changes and trauma from falls. Even though these authors wrote of conservative treatment, Dickson~summed up the current feeling: &dquo;Conservative treatment with braces and support has given temporary relief, but has never been successful in effecting a cure.&dquo; Heywood found that in 15% of the patients in his series, &dquo;symptoms ceased, never to recur, after physio-therapy had developed the quadriceps.&dquo; These patients were &dquo;young adults,&dquo; in whom the patella went through a period of dislocation about the time of skeletal maturation. This, in part, *
Presented at the Third Annual
Meeting of the American OrthoDiego, California, July 5 to 9,
paedic Society for Sports
Medicine, San
1977. -f~ Address requests for Antonio, Texas 78229.
reprints
12
to:
8038
Wurzbach, Suite 570, San
agrees with current concepts that sufficient
growth can relieve
symptoms. In this series of patients, the diagnosis of patellofemoral subluxation was made by history and physical examination. The multiplicity&dquo;&dquo; of described x-rays and the variability of the contracting quadriceps caused us not to depend on x-ray criteria. The history usually revealed that the patient’s knee was giving way and additional questioning revealed that the knee gave way when cutting away from the affected side; i.e., the femur was internally rotated on a tibia that was fixed in external rotation. Characteristically, there was no physical contact that produced the giving way. Occasionally, the patient remembered that the patella &dquo;slid over&dquo; and that he felt a &dquo;click&dquo; (sometimes called &dquo;locking&dquo;), but the subsequent normal range of motion after the injury helped rule out true locking. The history of an effusion that occurred within 12 hr was common. If the effusion was aspirated, the fluid was serosanguinous, but it usually resolved in 7 to 10 days if no internal derangement had occurred. The patient often complained of &dquo;weakness&dquo; of the leg, especially when running, cutting, and stair climbing. The physical examination revealed a high-riding patella or patella alta, which Smillie’° thinks is the most consistent sign. Hughston&dquo;, 12 noted the lateral tilt to the patella and has named this the &dquo;grasshopper eye patella.&dquo; The oblique head of the vastus medialis was dysplastic and a &dquo;dimple&dquo; could be palpated medially. The vastus lateralis was often hypertrophied. Evidence of previous Osgood-Schlatter disease as exemplified by a large tibial tubercle and long patella tendon was often present. The fat pad was large, and this, along with the high patella, produced what has been called the &dquo;camelback&dquo; sign. The knee was flexed 30° to prevent longitudinal motion of the patella and subluxation was attempted. Apprehension of the patient was considered a sign of recurrent subluxation, or Fairbanks sign. Peripheral tenderness around the patella represented inflammation of the retinaculum or tendinitis, tenderness posteriorly! on the patellar facets or pain on longitudinal
transverse grating chondromalacia. Postural deformities, including genu valgum, recurvatum, pronated feet, and exces-
and
sive femoral neck anteversion, were also noted. In the group of patients reviewed, the conservative treatment consisted of an elastic knee bandage with a horseshoe-shaped felt pad to be used in running or sports, and an exercise regimen. 14 The exercises consisted of straight leg raises with the patient in the supine position, leg abduction with the patient in the lateral decubitus position, and hip flexion with the patient
sitting. Weight as tolerated was added as 30 repetitions could be performed. The exercises were repeated three times a day for a 6-week period and then the patient was re-assessed. If sympbetter, exercises were discontinued and used on an interim basis if symptoms recurred. The length of follow-up ranged from 2 to 5 years, with an average of 3.1 years. Table 1 shows the distribution of followup. There was no significant difference in the result 6 weeks after initiation of treatment and 2, 3, 4, or 5 years after initiation of treatment. One hundred forty-five patients returned for evaluation and examination. There were 71 males and 74 females in this group, closely approximating a 1:1sex ratio. The right and left knees were involved equally, both knees being symptomatic in 17% of the cases. In the patients with both knees symptomatic, 61% were males and 39% females. The age range was from 11 to 55. The average age of the male was 20 and the female 25. The average age of the entire group was 23. The patient makeup is shown in Figure 1 with the shaded areas representing the female population. In patients over the age of 30, there was a 3:1 female to male ratio. The symptoms are listed in decreasing frequency in Table 2. The signs are listed in decreasing frequency in Table 3. The average Q angle for this group of patients was 19.6°, with a range from 10 to 35°. The Q angles were normally distributed
toms were
regard to both sex and age. A breakdown of the range is shown in Table 4. The results were classified as successful if the patient became asymptomatic or if he was still somewhat symptomatic, but was able to participate in all desired activities. Unsuccessful results or failure implied no subjective improvement. Of the 145 patients who were re-examined after conservative treatment, 110 (76%) said that they were better. When asked if exercises helped, all 76% answered affirmatively. When asked about braces, only 64% thought this adjunct had helped; 7.7% also noted they changed activities because of their knees. Thirty-five patients (24%) of the group said they were no better after conservative treatment. Of this group, 11admitted exercises helped and 15admitted braces helped; even though the patients felt they were no better after treatment than before. Twelve required surgical correction. An evaluation of the signs and symptoms failed to reveal any factors that would predict failure of conservative treatment. The signs and symptoms were normally distributed in the successful and unsuccessful groups. Furthermore, in examining the failure group which consisted of 19 females (average age 29) and 16 males (average age 18), it was found that 31 % of the failures were males under 20 and 29% were females over 30, together comprising 60% of the failure group. From the study of these patients, it would appear there are no specific signs or symptoms that would indicate whether or
with
TABLE2
Symptoms ~
. .....-
TABLE 1
Follow-up
TABLE3
Signs
TABLE 4
Q angle
Fig.
1. Distribution
of patient population by age and sex. 13
patient subjectively would respond favorably to conservative treatment. The authors were left with the impression that most patients did get some subjective relief of symptoms. It is concluded, therefore, that conservative therapy does have a place in the treatment of subluxation of the patella and the symptomatic patient should be given a trial of exercises and/or bracing before surgical intervention is carried out. not a
REFERENCES 1. Cole WH, Williamson GA: Chronic recurrent dislocation of the patella. JAMA 102: 357-360, 1934 2. Orr HW: A review of the surgical treatment of congenital dislocation, recurrent dislocation, or slipping patella. Clin Orthop 3: 3-7, 1954 3. Pearson CY: Aftertreatment of lateral dislocation of the patella by a new form of knee cap. Lancet, 1: 1884 4. MacAusland WR, Sargent AF: Recurrent dislocation of patella. Surg Gynecol Obstet 35: 35-41, 1922 5. Ober FR: Recurrent dislocations of the patella. Am J Surg 43:
497-500, 1939 6. Dickson JA: Recurrent dislocation of the patella. Surg Clin North Am: 997-1000, 1936 7. Heywood AWB: Recurrent dislocation of the patella. A study of its pathology and treatment in 106 knees. J Bone Joint Surg 43B:
508-517,1961 8. Insall J, Salvati E: Patella position in the normal knee joint. Radiology 101: 101-104, 1971 9. Merchant AC, Mercer RL, Jacobsen RH, et al: Roentgenographic analysis of patellofemoral congruence. J Bone Joint Surg 56A:
1391-1396, 1974 10. Smillie IS: Ligamentous injury and subluxation of the patella. J Bone Joint Surg 41B: 214, 1959 11. Hughston JC, Stone MM: Recurring dislocations of the patella in athletes. South Med J 57: 623-628, 1964 12. Hughston JC: Subluxation of the patella. J Bone Joint Surg 50A:
1003-1026, 1968 13. Wiles P, Andrews PS, Devan MD: Chondromalacia of the J Bone Joint Surg 38B: 95-113, 1956 14. Nicholas JA: Personal communication
patella.
EDITORIAL COMMENT Dr. Robert H. Larson: The following discussions are of the preceding articles by Dr. DeHaven et al. and Dr. Henry and Dr. Crosland. Conservative care has been recognized for some time as being beneficial in a great number of patellar problems. The statistical evaluation of patients done by Dr. DeHaven et al. and Dr. Henry and Dr. Crosland confirm the successful results in 70 to 80%. There is another value in a trial of conservative treatment and that is it gives one the chance to re-examine and re-evaluate both the patient and the extensor mechanism problem, so that a more thorough assessment of the basic mechanics is possible should a surgical procedure be required. When surgical treatment is necessary, there are many types of procedures attesting to the problems with each. The extensor mechanism is a complicated dynamic apparatus. Static adjustments necessary at the time of surgery may not function as desired in the dynamic action after surgery. If one can rehabilitate and strengthen the extensor mechanism to relieve the patient’s complaints symptomatically, one need not fear the problems which may develop from operative intervention.
14
As has been
mentioned, chondromalacia is a pathologic clinical one. When used as a clinical diagnosis, it is often a &dquo;wastebasket.&dquo; I think it is best to be more specific in diagnosis of extensor mechanism problems, relating them either to instability (subluxation or dislocation), patellar tendinitis, or patellar compression syndrome. Chondromalacia may be merely an end stage in a malalignment problem, or may be related to a specific incident of injury. One of the modalities of conservative treatment is the use of orthotic supports, which I believe, in some cases, may be beneficial in that it does change the way the patella tracks through the patellofemoral groove. Their use may relieve some of the irritation in those having discomfort from repetitive activity. I wholeheartedly agree in the conservative approach (nonoperative) as the initial management in most patients with patellar femoral problems.
diagnosis,
not
a
Dr. Bernard R. Cahfll: The excellent papers by Dr. DeHaven al. and Dr. Henry and Dr. Crosland confirm the suspicion of clinicians; that conservative therapy in patellar dysfunction is successful in most cases and gives a scientific precedence for the continuation of this practice. In those patients who require surgery, the preoperative attempts at conservative therapy seem to speed rehabilitation of the extremity and so this is another justification for its continued use. Although their methods of rehabilitating the knee are somewhat different, both groups of authors correctly conclude that conservative therapy can be curative in various types of patellar dysfunction in the athlete. et
Dr. Jack C. Hughston: Dr. Henry and Dr. Crosland have written to me asking me to give some discussion to their concepts of conservative treatment. We had the pleasure of having Jack Henry working with us here in our clinic and visiting with us at other times, thus he knows our strong feelings regarding an initial attempt at conservative treatment for subluxation of the patella, as well as for an initial acute dislocation of the patella. A good friend of mine was present when we made the first presentation of &dquo;Patella Subluxation in Athletes&dquo; at the Southern Medical Meeting in Miami; when I saw him at a subsequent meeting I year later he told me how great it was that we had brought this energy to the recognition of orthopaedists and that as a result he had operated on x number of cases this past year, whereas he had failed to recognize them prior to the presentation. His stated number of operations for subluxation of the patella in 1 year exceeded the number of operations that we had done for this condition in the previous 10 years. Needless to say, I was shocked and thus the reason for the emphasis we have subsequently placed on the rehabilitative nonoperative treatment of this condition in our seminars and meetings. I am glad to see Jack Henry and Jack Crosland come out with a well documented, well studied series of cases specifically relating to the use of conservative treatment of this condition rather than an operation as the desired initial attempt at correction of the patient’s disability.
