Clinical Protocols 2) Patellofemoral Dysfunction

Evidence-based Clinical Protocols 2) Patellofemoral Dysfunction

CLINICAL EDITORS Morgan Boyle, III, MEd, ATC Steve Jacoby, ATC

EDITOR Terry McLaughlin, MS, ATC

CONTRIBUTORS

Tab Blackburn, PT, ATC Terry Giove, PT Woody Goffinett, ATCs Steve Hoffman, PT, ATC Drew Hurley, ATC/L Ginger Kurmann, PT, ATC Terry Malone, PT, ATC John Stemm, MEd, PT, ATC Sarah Sydor, ATC Steve Tippett, PT, ATC Kim VanFleet, MS, ATC/L Michael Voight, PT, ATC Gary Wilkerson, Ed.D, ATC

FN: 03-027 EVIDENCE-BASED CLINICAL PROTOCOL FOR table of contents REHABILITATION OF PATELLOFEMORAL DYSFUNCTION

INTRODUCTION...... 2-1 REHABILITATION GOAL...... 2-2 REHABILITATION PROGRAM CONSIDERATIONS...... 2-2 DEFINITIONS...... 2-2

POST-INJURY/PRE-SURGERY PHASE GOALS (To progress to Phase I) ...... 2-3

PHASE I: Reduction of Acute Symptoms GOALS (To progress to Phase II)...... 2-3 CLINICAL EVALUATION...... 2-3 CLINICAL TREATMENT OPTIONS ...... 2-5 SUPERVISED PROGRAM...... 2-7 HOME PROGRAM ...... 2-8 REPORTS...... 2-8

PHASE II: Range of Motion and Initial Strengthening GOALS (To progress to Phase III)...... 2-9 CLINICAL EVALUATION...... 2-10 CLINICAL TREATMENT OPTIONS ...... 2-11 SUPERVISED PROGRAM...... 2-13 HOME PROGRAM ...... 2-14 REPORTS...... 2-14

PHASE III: Initial Weight-bearing and Intermediate Strengthening GOALS (To progress to Phase IV) ...... 2-15 CLINICAL EVALUATION...... 2-16 CLINICAL TREATMENT OPTIONS ...... 2-17 SUPERVISED PROGRAM...... 2-19 HOME PROGRAM ...... 2-21 REPORTS...... 2-22

PHASE IV: Return to Activity GOALS...... 2-23 CLINICAL EVALUATION...... 2-24 CLINICAL TREATMENT OPTIONS ...... 2-25 SUPERVISED PROGRAM...... 2-27 HOME PROGRAM ...... 2-29 REPORTS...... 2-30

STABILITY INDEX...... 2-31

REFERENCES ...... 2-33

The information contained in this manual is presented by Biodex Medical Systems as part of our commitment to provide continuing service to medical professionals and to the community at large.

IMPORTANT: READ BEFORE PROCEEDING

Suggested courses of rehabilitation for any specific conditions are meant as references of generalized program models, and are not intended as precise prescriptions for individual treatment. The data is a compilation of information based on the work of acknowl- edged experts that have been published in respected journals.

We believe it is representative of current trends in scientifically derived and clinically proven principles and methods of rehabilitation medicine. Much of the published information that we review, however, is based on research and case studies involving very specific patient or test subject populations. Many research subjects, for instance, are highly-trained and well conditioned athletes prior to treatment, or are chosen because they have no known medical problems other than the condition involved in the study. It should therefore be noted that the application of any published methods should be done with extreme care and should be based on sound clinical judgment after thorough evaluation of the individual patient’s capabilities, limitations, and overall medical condition. In the presence of any doubt, or question, regarding the efficacy of initiating a procedure, seek advise from appropriate sources and/or consult with the patient’s physician.

Please send any comments or concerns to:

c/o Clinical Education Biodex Medical Systems, Inc. 20 Ramsay Rd. Shirley, NY 11967-4704

A special thanks goes to Terry McLaughlin, MS, ATC, Steven Jacoby, ATC and Morgan Boyle III, MEd, ATC, for their assistance in the organization of this protocol.

• Basic anatomy and function of the patellofemoral joint and associated structures

• Mechanism of injuries

• Healing process following initial injury

• Methods to optimize: Patient compliance (assess potential; establish realistic goals) Reduction of pain and edema Increases in ROM Increases in strength, power, and endurance Improvement of agility (balance; proprioception)

• Appropriate allocations of resources and time to individual patient program

• Means of evaluating individual and overall program effectiveness

DEFINITIONS:

Goals: Specific improvements which must be met in order for patient to progress to next phase.

Clinical Evaluation: Evaluations that are only to be performed by certified and/or licensed ATC, PT or OT, in association with supervising physician’s diagnosis.

Clinical Treatment Options: Treatment options that should only be performed under the supervision of certified and/or licensed clinicians.

Supervised Program: Rehabilitation program that should be done only under the direction of appropriately qualified personnel (i.e. Certified Strength and Conditioning Specialist).

Home Program: Rehabilitation program that after proper instruction by supervising clinician, can be done by patient without supervision.

Reports: Test reports are to be completed at the end of each phase to ensure progress to the next phase is indicated.

2-2 INTRODUCTION PHASE I reduction of acute symptoms

GOALS:

• Mentally prepare patient for rehabilitation

• Education of patient to understand the problems of PF dysfunction

• Identify specific needs of patient and potential problems

• Restore normal flexibility

• Decrease joint effusion 4

• Maintain ankle ROM and strength

• Full knee PROM

• Decrease pain at rest to 0* *Analog pain scale of 0-10

• Normalize gait deviations and correct biomechanical faults Step Symmetry

• Identify contributory factors to condition Vastus Medialis (VMO): Vastus Lateralis (VL)

• Increase VMO:VL strength ratio to 50%

• OKC Proprioception < 40% deficit bilaterally Open Kinetic Chain (OKC)

• Isometric strength: QUAD < 30% deficit HAM < 30% deficit

• Stability Index*: 70% of Normative value for bilateral stance *Note: See page 36 for normative values

CLINICAL EVALUATION:

• General patient history and observation

• Pain scale: 19 Severity, location, duration, quality, radiation

• Edema: Degree and character of swelling Patella ballottement test; mid-patella circumferential measurement

• Active and Passive range of motion

• Patella assessment: Physical exam palpation and radiographs

• Neurological assessment: Myotomes, dermatomes and reflexes for L2 – S1

• Clinical tests: Supine hamstring flexibility measurement Ober test (IT Band tightness) 21 Thomas test (Rectus femoris tightness) Plica test

• Palpation/Observation: 17 Identify VMO dysplasia Biofeedback ratio

• Goniometry: 12 Knee flexion/extension (0-135º knee flexion) active and passive

• Patella assessment/mobility: Radiological: Patella alto (congenital formation) Insall and Salvati method, independent of the knee flexion angle, the length of the patella tendon should be equal to the longest (diagonal) length of the patella ligament. Patella baja (post surgical condition). 13

Palpable: Tested with knee flexion at 30º-45º of knee flexion over a pillow or examiners knee. The patella should glide one half its width medially & laterally. 14

Physical: 18 Medical/lateral tilt Inferior/superior tilt Medial/lateral glide Internally/externally rotated

TEST: Biodex Gait Trainer evaluation Gait symmetry A-angle Q-Angle Foot biomechanics

*NOTE: The treatment of patellofemoral pain (chondromalacia patella or patellofemoral syndrome) has been shown to be more successful when foot orthoses are used in conjunction with other treatment modalities.3

TEST: Bilateral Isometric knee extension/flexion evaluation Device: Biodex Multi-Joint System Pad Placement: Normal Setup: 60º of knee flexion Mode: Isometric Sets and Duration: 1 x 10 reps x 5 seconds each Recommendations: Must be performed pain free and without crepitis

TEST: Biodex Open Kinetic Chain (OKC) Proprioception Device: Biodex Multi-Joint System Passive and Active Joint position sense Pattern: Knee extension/flexion Mode: Passive and Isokinetic Sets and Reps: 1 x 5 each target angle Target angles: 90º/60º/30º Recommendations: There should be no incidence of pain or inhibition with movement

2-4 PHASE I: REDUCTION OF ACUTE SYMPTOMS CLINICAL TREATMENT OPTIONS:

• Rehabilitation process education: Introduce patient to clinic/staff Describe rehabilitation process Define goals to the patient

• Patellofemoral bracing or strapping 15 NOTE: It has been noted in the literature that by strapping the knee, you will increase not only the force output both concentrically and eccentrically, but decrease the perceived amount of pain.

This was not noted for the bracing. Bracing increased eccentric force and decreased pain, but no concentric changes were noted. 6

• Avoid Weight-bearing ADL's which compromise articular surface 7

• Correct lower extremity biomechanical with ambulation training

• Reduce joint effusion/manage pain: P.R.I.C.E.

• Patella mobilizations for hypomobility PRN: Medial, superior and inferior glides Stress medially to stretch lateral retinaculum

• Cardiovascular training: Device: Biodex BioStep® Semi-Recumbent Elliptical Mode: Isokinetic Duration: 10 min Speed: 120 deg/sec Intensity: 70% Maximum Heart Rate (MHR)

Device: Biodex Upper Body Cycle Mode: Isokinetic Duration: 5-7 min Speed: 90 deg/sec Intensity: 70% Maximum Heart Rate (MHR)

• Isometric strengthening: Device: Biodex Multi-Joint System Mode: Isometric Pattern: Knee Ext/Flex Setup: 90º/60º/30º/0º Sets and Reps: 2 x 10 x 10 sec hold each Recommendation: Use electrical stimulation to increase motor unit recruitment.6

• Quadriceps re-education for disuse atrophy: Device: "Quad sets" with Electro Neuromuscular Stimulation (ENS) and biofeedback. 27 Enhance VMO:VL ratio towards uninvolved level (normal is 1:1) Sets and Reps: 3 x 10 –12 Duration: 10 sec hold Repeat: 3-4 times daily

Device: Biodex Multi-Joint System Pattern: Knee FLEX/EXT Pad Placement: Normal ROM: 45º of flexion to full extension Mode: Passive Speed: 10 deg/sec Pause: 10 sec in extension Duration: 10 min. Recommendations: Set torque limits to half of limb weight. Instruct patient to maintain constant movement of 10 deg/sec. Patient should perform a "Quad set" during pause. Use electrical stimulation to increase motor unit recruitment. 6

• Weight-bearing Proprioception/Stability: Device: Biodex Balance System Stance: Bilateral (Two feet) Eyes: Open Setup: Dynamic Balance Training Stability level: 8 (most stable) progress to 6 (less stable) Duration: 3 bouts of 30 sec (progress to 5 bouts as tolerated) Recommendations: Utilize Biodex Unweighing System if patient is able to partially weigh bear (PWB) during exercise. Unweigh patient up to 60% of body weight. Patient should be instructed to hold handrails during initial training.

• Weight-bearing Proprioception: Device: Biodex Multi-Joint System Passive and Active Joint position sense Pattern: Knee FLEX/EXT Mode: Passive and Isokinetic Sets and Reps: 3 x 5 each target angle Target angles: 90º/60º/30º Recommendations: There should be no incidence of pain or inhibition with movement

• Flexibility program: 23 Hamstrings seated IT band Supine over the table Quadriceps Gastrocnemius/Soleus Hold each stretch for 20 sec repeat 5-6 times NOTE: May have to hold some quad stretching if the patient has medial/adductor patella facet syndrome.

2-6 PHASE I: REDUCTION OF ACUTE SYMPTOMS SUPERVISED PROGRAM:

(frequencies prescribed on individual basis)

• Reduce swelling and manage pain: P.R.I.C.E.

• Patellofemoral bracing/strapping

• Muscle re-education for disuse atrophy Biofeedback Electrical Stimulation (EMS) as prescribed

• Cardiovascular Training: Device: Biodex BioStep® Semi-Recumbent Elliptical Mode: Isokinetic Duration: 12 min Speed: 110 deg/sec Intensity: 75% MHR

Device: Biodex Upper Body Cycle Mode: Isokinetic Duration: 7-10 min Speed: 80 deg/sec Intensity: 75% MHR

Device: Biodex Rehabilitation Treadmill Speed: 2.0 mph Incline: O% Position: Straight ahead walking Time: 5-7 min Intensity: 65-75% MHR

• Flexibility: Hamstrings seated IT band Supine over table rectus femoris/quads Gastrocnemius/Soleus Hold each stretch for 20 sec repeat 5-6 times

• Muscle Re-education and strengthening: Leg Raises: FLEX/EXT/ADD Hold from initiating abduction leg raises due to possible tight lateral structures and weak medial musculature. 9 Seated Isometrics 90, 75, and 60º of knee flexion 1 Sets and Reps: 3 x 10 each angle

• Control pain and edema: P.R.I.C.E. Modalities/Medications as prescribed

• Range of Motion (ROM) exercises: PROM knee FLEX/EXT with contralateral limb Sets and Reps: 3 x 10 Repeat: 4x/day

• Strengthening "Quad sets" at 0º and 90º of knee flexion Sets and Reps: 1x 10 Hold contraction: 10 seconds Repeat: 2x/day

Mini squats: Sets and Reps: 3 x 10 Repeat: 2x/day Recommendations: Stand between two chairs, feet shoulder width apart, keeping the patella over the second metatarsal. Squat down to 30º knee flexion and slowly return to standing.

• Flexibility training: (static stretch only) Quadriceps Hamstrings IT band Gastrocnemius/Soleus Sets and duration: 5-6 x 20 seconds Repeat: 2x/day

REPORTS:

• Analog pain scale

• Range of Motion

• Cardiovascular fitness level

• Biodex Bilateral OKC proprioception test

• Biodex isometric bilateral comparison QUAD/HAM @ 60 deg/sec

• Biodex Gait Trainer evaluation

• Biodex Stability Index

2-8 PHASE I: REDUCTION OF ACUTE SYMPTOMS PHASE II range of motion & initial strengthening

GOALS:

• Decrease pain and inflammation

• Increase flexibility with pain-free PROM and AROM

• Decrease symptoms with ADL’s

• Restore full AROM

• Restore normal patellar mobility

• Increase cardiovascular conditioning

• Increase VMO:VL ratio to > 75%

• OKC Proprioception < 25% deficit

• Isometric QUAD/HAM strength < 10% deficit

• Isokinetic QUAD/HAM strength < 30% deficit

• Stability Index: Bilateral stance < 25% deficit from normative goal

• Pain scale: Severity, location, duration, quality, radiation

• Edema: Degree and character of swelling Patella ballottement test; mid-patella circumferential measurement

• Goniometry: 12 Knee flexion/extension (0-135º knee flexion) active and passive

• Biofeedback evaluation: Vastus medialis:lateralis (VMO:VL) ratio 16

TEST: Bilateral Isometric knee FLEX/EXT evaluation Device: Biodex Multi-Joint System Pad Placement: Normal Setup: 30º/60º/90º of knee flexion Mode: Isometric Sets and Duration: 1 x 10 reps x 5 seconds each Recommendations: Must be performed pain free and without crepitis

TEST: Bilateral Isokinetic knee FLEX/EXT evaluation Device: Biodex Multi-Joint System Pad Placement: normal Setup: pain free ROM Mode: Isokinetic Sets and Reps: 1 x 5 @ 180 deg/sec 1 x 15 @ 300 deg/sec Recommendations: ROM should be limited to avoid crepitis and allow for safe speed training.

TEST: Bilateral OKC Proprioception test Device: Biodex Multi-Joint System Passive and Active position sense Pattern: Knee FLEX/EXT Mode: Passive and Isokinetic Sets and Reps: 1 x 3 each target angle Target angles: 90º/60º/30º Recommendations: There should be no incidence of pain or inhibition with movement

TEST: Stability Index 24 Device: Biodex Balance System Stability level: Level 6 Trials and Duration: 3 x 30 seconds Eyes: open Recommendation: Prepare to support patient during test. Instruct patient to use handrails as needed.

2-10 PHASE II: RANGE OF MOTION AND INITIAL STRENGTHENING CLINICAL TREATMENT OPTIONS:

• Reduce joint effusion/manage pain: P.R.I.C.E.

• Patella mobilizations: Medial, superior and inferior glides

• Patellofemoral bracing/strapping

• Cardiovascular Training: Device: Biodex BioStep® Semi-Recumbent Elliptical Mode: Isokinetic Duration: 15 min Speed: 120 deg/sec Intensity: 75% MHR

Device: Biodex Upper Body Cycle Mode: Isokinetic Duration: 10 min Speed: 90 deg/sec Intensity: 75% MHR

• Retroambulation: 8 Device: Biodex Rehabilitation Treadmill Speed: 2.0 mph Incline: 12% Duration: 10 min

• Postural Control Exercises

• Strengthening: Device: Biodex Multi-Joint System Mode: Isometric Pattern: Knee Ext/Flex Setup: 90º/60º/30º/0º Sets and Reps: 2 x 10 x 10 sec hold each Recommendation: With poor "quad set", use electrical stimulation to increase motor unit recruitment.

Device: Biodex Multi-Joint System Pattern: knee FLEX/EXT Mode: Isokinetic Pad Placement: normal Setup: Pain-free ROM and limit crepitis Speeds: 180 and 300 deg/sec in both directions27 Sets and Reps: 3 x 15 (progress to 20-30)

• Strengthening (Cont): Device: Biodex Multi-Joint System Closed Chain Attachment Pattern: Leg press Mode: Isokinetic Setup: 0-45º Speeds: 60 deg/sec Sets and Reps: 3 x 10

3 plane SLR Sets and Reps: 3 x 15-20 (progress to 30)

Weight-bearing exercises: 4" One-legged step-ups Wall squats Leg press Mini-squats with physioball between knees to increase EMG output from the VMO* Sets and Reps: 2 x 10 each (progress to 3 x 15) ROM: 0º-45º *NOTE: The VMO takes its origin from the adductor longus and magnus.12 Weight-bearing exercises should be performed in a pain-free ROM and without crepitus. At the same time, the patella should at not go anterior to the toes.

• Weight-bearing Proprioception: Device: Biodex Balance System Stance: Bilateral (Both feet) Level: Level 6 progressing to level 4 Sets and Duration: 3 x 30 seconds (progress to 3 min continual) Eyes: open (progress to closed) Training method: Trace circles on screen (A-D), color in circles (A-B) Recommendations: Have patient progress to using no hands

• Non-weight-bearing Proprioception: Device: Biodex Multi-Joint System Passive and Active position sense Pattern: Knee EXT/FLEX Mode: Passive and Isokinetic Sets and Reps: 3 x 10 each target angle Hold: 10 seconds Target angles: 90º/60º/30º

2-12 PHASE II: RANGE OF MOTION AND INITIAL STRENGTHENING SUPERVISED PROGRAM:

(Frequencies prescribed on individual basis)

• Reduce swelling and manage pain: P.R.I.C.E.

• Patellofemoral bracing/strapping

• Muscle re-education for disuse atrophy Biofeedback Electrical Stimulation (EMS)

• Cardiovascular Training: Device: Biodex BioStep® Semi-Recumbent Elliptical Mode: Isokinetic Seat height: normal Pedal length: normal Duration: 15 min Speed: 120 deg/sec Intensity: 65-80% MHR

Device: Biodex Upper Body Cycle Mode: Isokinetic Duration: 7-10 min Speed: 90 deg/sec Intensity: 65-80% MHR

Device: Biodex Rehabilitation Treadmill Direction: Retroambulation Speed: 2.0 mph Incline: 12% Position: Straight ahead walking Time: 10 min Intensity: 65-70% MHR

• Muscle Re-education and strengthening: Leg raises with ankle weights Sets and Reps: 3 x 15 each direction Hold from initiating abduction

Seated Isometrics 90º knee flexion up to greatest extended position without pain or crepitus Sets and Reps: 3 x 15 each angle

Wall squats with ball between knees Sets and Duration: 2 x 20 seconds (progress to 5 sets)

Calf raises Sets and Reps: 3 x 10 (progress to 20) Instruct patient to perform raise with both feet. Initial raises should be done from flat surface and progress to 4" step. (Frequencies prescribed on individual basis)

• Flexibility: Hamstrings seated IT band Supine over table rectus femoris/quads Gastrocnemius/Soleus Hold each stretch for 20 sec repeat 5-6 times

• Control pain and edema: P.R.I.C.E. Modalities/Medications as prescribed

• Electro Neuromuscular Stimulation (ENS) as directed

• Range of Motion (ROM) exercises: PROM knee EXT/FLEX with contralateral limb Sets and Reps: 3 x 10 Repeat: 4x/day

• Strengthening "Quad sets" at 0º and 90º of knee flexion Sets and Reps: 1x 10 Hold contraction: 10 seconds Repeat: 2x/day

Mini squats Sets and Reps: 3 x 10 Repeat: 2x/day Recommendations: Stand between two chairs, feet shoulder width apart, keeping the patella over the second metatarsal. Squat down to 30º knee flexion and slowly return to standing.

3-way SLR Sets and Reps: 3 x 10 Repeat: 2x/day Resistance: begin with none and progress to 3-5 pounds Recommendations: Continue to hold abductor leg raises.

• Flexibility training: (static stretch only) Quadriceps Hamstrings IT band Gastrocnemius/soleus Sets and duration: 5-6 x 20 seconds Repeat: 2x/day

• Cardiovascular training 30 min at 65-80% MHR 3-4x /week

REPORTS:

• Analog pain scale

• Range of Motion

• Cardiovascular fitness level

• Biodex Bilateral OKC proprioception test

• Biodex isometric bilateral comparison QUAD/HAM @ 60º

• Biodex isokinetic bilateral comparison QUAD/HAM @ 180 and 300 deg/sec (as tolerated)

• Biodex Gait Trainer Exercise Summary

• Biodex Stability Index

2-14 PHASE II: RANGE OF MOTION AND INITIAL STRENGTHENING initial weight-bearing & PHASE III intermediate strengthening

GOALS:

• Decrease pain and inflammation

• Increase flexibility with pain-free PROM and AROM

• No pain with ADL’s

• Restore full AROM

• Restore normal patellar mobility

• Increase cardiovascular conditioning

• Restore normal VMO:VL firing sequence

• Increase VMO:VL ratio to 100%

• Isometric QUAD/HAM strength = bilaterally or WNL

• Isokinetic QUAD/HAM strength < 15% deficit

• OKC Proprioception < 15% deficit

• Stability Index: Bilateral stance < 15% deficit from normative goal

• Evaluate muscle hypertrophy

• Pain scale: Severity, location, duration, quality, radiation

• Edema: Degree and character of swelling

• Goniometry: Knee FLEX/EXT (0-135º knee flexion) active and passive

• Biofeedback evaluation: VMO:VL ratio NOTE: Current research trends point to VMO/VL ratios in time-based evaluations. However, this was noted through fine wire electrode EMG. Clinically the most applicable means is through surface EMG VMO/VL ratio.

TEST: Bilateral Isometric knee EXT/FLEX evaluation Device: Biodex Multi-Joint System Pad Placement: Normal Setup: 30º/60º/90º of knee flexion Mode: Isometric Sets and Duration: 1 x 10 reps x 5 seconds each Recommendations: Must be performed pain free and without crepitis

TEST: Bilateral Isokinetic knee FLEX/EXT evaluation Device: Biodex Multi-Joint System Pad Placement: normal Setup: pain free ROM Mode: Isokinetic Sets and Reps: 1 x 5 @ 180 deg/sec, 1 x 15 @ 300 deg/sec Recommendations: ROM should be limited to avoid crepitis and allow for safe speed training.

TEST: Stability Index Device: Biodex Balance System Stability level: Level 6 Trials and Duration: 3 x 30 seconds Eyes: open Recommendation: Prepare to support patient during test. Instruct patient to use handrails as needed.

TEST: Bilateral OKC Proprioception test Device: Biodex Multi-Joint System Passive and Active position sense Pattern: Knee EXT/FLEX Mode: Passive and Isokinetic Sets and Reps: 1 x 3 each target angle Target angles: 90º/60º/30º/15º

2-16 PHASE III: INITIAL WEIGHT-BEARING & INTERMEDIATE STRENGTHENING CLINICAL TREATMENT OPTIONS:

• Reduce pain and edema P.R.I.C.E. Electro Neuromuscular Stimulation (ENS)

• Continue with patellofemoral bracing/strapping

• Strengthening: Device: Biodex Multi-Joint System Pattern: knee EXT/FLEX concentric/concentric Mode: Isokinetic Pad placement: normal Setup: Pain-free ROM and no crepitus Speeds: 180-500 deg/sec in both directions Sets and Reps: 5 x 10 (progress to 10 x 10) Recommendations: Have patient perform velocity spectrum

Device: Biodex Multi-Joint System Pattern: knee EXT/FLEX concentric/eccentric Mode: Passive Pad placement: normal Setup: Full extension to 60º of flexion Speeds: 60 deg/sec Sets and Reps: 2 x 10 (progress to 3 x 15) Resistance: Initial torque levels should be based on concentric and isometric test results. Recommendations: Instruct patient to contract quadriceps into extension and to resist movement into flexion. There should be no pain or crepitus with this movement.

Weight-bearing strengthening exercises: Mini-squats with physioball between knees to increase EMG output from the VMO*. Sets and Reps: 3x15 each ROM: 0º-90º (secondary to joint reaction forces) 8" One-legged step-ups and step-downs Leg presses Single leg calf raises Sets and Reps: 3 x 10 each Wall squats with physioball behind back Sets and Duration: 2 x 30 seconds

Isotonic strengthening:

Device: Recumbent Squat Foot position: tibia parallel to the ground Sets and Reps: 3 x 12

*NOTE: This exercise should be performed in a pain-free ROM and with no crepitus. Also, the patella should at no time go anterior to the toes.

Isotonic strengthening (Cont): PNF patterns on Cable Column to increase resistance

• Weight-bearing proprioception:

Device: Biodex Balance System Stance: Unilateral Level: Level 4 progressing to level 2 Sets and Duration: 3 x 30 seconds (progress to 3 min continual) Eyes: Closed Training method: Trace circles on screen (A-D), color in circles (A-B) Recommendations: Have patient progress to using no hands

• Non-weight-bearing proprioception: Device: Biodex Multi-Joint System Passive and Active position sense Pattern: Knee FLEX/EXT Mode: Passive and Isokinetic Sets and Reps: 3 x 5 each target angle Hold: 10 seconds Target angles: 90º/75º/60º/45º/30º/15º/0º Recommendations: There should be no incidence of pain or inhibition with movement.

• Cardiovascular training: Device: Biodex BioStep® Semi-Recumbent Elliptical Mode: Isokinetic Duration: 15 min Speed: 100 deg/sec Intensity: 65-80% MHR

Device: Biodex Upper Body Cycle Mode: Isokinetic Duration: 10 min Speed: 80 deg/sec Intensity: 65-80% MHR

Device:Biodex Rehabilitation Treadmill Direction: Forward Jogging on Speed: 4.5 mph Incline: 0% Duration: 5-10 min

Aquatic Therapy 15-20 min

• Flexibility training: Quadriceps Hamstrings IT band Gastrocnemius/Soleus Sets and duration: 5-6 x 20 seconds

2-18 PHASE III: INITIAL WEIGHT-BEARING & INTERMEDIATE STRENGTHENING SUPERVISED PROGRAM:

(Frequencies prescribed on an individual basis)

• Reduce swelling and manage pain: P.R.I.C.E.

• Patellofemoral bracing/strapping

• Cardiovascular Training: Device: Biodex BioStep® Semi-Recumbent Elliptical Mode: Isokinetic Duration: 15 min Speed: 100 deg/sec Intensity: 65-80% MHR

Device: Biodex Upper Body Cycle Mode: Isokinetic Duration: 10 min Speed: 80 deg/sec Intensity: 65-80% MHR

Device: Biodex Rehabilitation Treadmill Direction: Retroambulation Speed: 2.5 mph Incline: 12% Position: Straight ahead walking Time: 15 min Intensity: 65-85% MHR

Device: Biodex Rehabilitation Treadmill Direction: Forward jogging Speed: 3-5 mph Incline: 0% Duration: 5-15 min

• Strength training: Leg raises Sets and Reps: 3 x 15 each direction

Knee extension (concentric/eccentric quadriceps) Sets and Reps: 3 x 12-15 Recommendations: Perform the exercise in pain free ROM

Wall squats with ball between knees Sets and Duration: 2 x 20 seconds (progress to 5 sets)

Single-leg calf raises Sets and Reps: 3 x 10 (progress to 20)

(Frequencies prescribed on an individual basis)

• Strength training (Cont): Device: Recumbent Squat Foot position: tibia parallel to the ground Weight: begin with 3-4 plates and progress as tolerated Sets and Reps: 3 x 12 NOTE: This exercise should be performed in a pain-free ROM and with no crepitus. It is imperative that the patella does not travel medially and /or laterally during the motion. Also, the patella should at no time go anterior to the toes.

• Flexibility training: (static stretch only) Quadriceps Hamstrings IT band Gastrocnemius/Soleus Sets and duration: 5-6 x 20 seconds

2-20 PHASE III: INITIAL WEIGHT-BEARING & INTERMEDIATE STRENGTHENING HOME PROGRAM:

• Control pain and edema: P.R.I.C.E. Modalities/Medications as prescribed

• Strengthening Active knee extension Sets and Reps: 3 x 10-12 Resistance: Start with a 5 pound cuff weight and progress to 10 pounds Repeat: 2x/day Recommendations: Pain-free ROM and with no crepitis

Mini squats Sets and Reps: 3 x 15 -20 Repeat: 2x/day Recommendations: Stand between two chairs, feet shoulder width apart, keeping the patella over the second metatarsal. Squat down to 45º knee flexion and slowly return to standing.

3-way SLR Sets and Reps: 3 x 10 Repeat: 2x/day Resistance: 3-5 pounds Recommendations: Continue to hold abductor leg raises if lateral structures remain inflexible or VMO is deficient.

Wall Sit Sets and Duration: 2 x 30 sec Repeat: 3x/day Position: 45º

Heel raises Position: Both feet (progress to single) Sets and Reps: 3 x 15 Repeat: 2x/day

• Flexibility training: (static stretch only) Quadriceps Hamstrings IT band Gastrocnemius/soleus Sets and duration: 5-6 x 20 seconds Repeat: 2x/day

• Cardiovascular training 30 min at 65-80% MHR 3-4x/week

• Analog pain scale

• Range of Motion

• Cardiovascular fitness level

• Biodex Bilateral OKC proprioception test

• Biodex isometric bilateral comparison QUAD/HAM @ 60º

• Biodex isokinetic bilateral comparison QUAD/HAM @ 180 and 300 deg/sec (as tolerated)

• Biodex Gait Trainer Exercise Summaries

• Biodex Stability Index

2-22 PHASE III: INITIAL WEIGHT-BEARING & INTERMEDIATE STRENGTHENING PHASE IV return to activity

GOALS:

• Decrease pain and inflammation

• Maintain flexibility with pain-free PROM and AROM

• Maintain pain-free with all activities

• Maintain full AROM

• Maintain normal patellar mobility

• Increase cardiovascular conditioning

• Maintain normal VMO:VL firing sequence

• Maintain VMO:VL ratio at 1:1

• Isokinetic QUAD/HAM strength < 10% deficit

• Isokinetic QUAD concentric/eccentric strength < 85% bilaterally

• OKC Proprioception < 10% deficit

• Stability Index: Bilateral stance < 10% deficit from normative goal

• Single leg hop, 6 meter timed hop and crossover hop < 15% deficit lower extremity 19

• Evaluate muscle hypertrophy

• Pain scale: Severity, location, duration, quality, radiation

• Edema: Degree and character of swelling

• Goniometry: Knee FLEX/EXT (0º-135º knee flexion) active and passive

• Biofeedback evaluation: Vastus medialis:lateralis (VMO:VL) ratio 16

TEST: Bilateral Isokinetic knee FLEX/EXT evaluation Device: Biodex Multi-Joint System Pad Placement: normal Setup: Full pain-free ROM Mode: Isokinetic Sets and Reps: 1 x 5 @ 180 deg/sec 1 x 15 @ 300 deg/sec Recommendations: ROM should be limited to avoid crepitis and allow for safe speed training.

TEST: Stability Index Device: Biodex Balance System Report: Stability Index Stability level: Level 4 Trials and Duration: 3 x 30 seconds Eyes: open Recommendation: Prepare to support patient during test. Instruct patient to use handrails as needed.

TEST: Bilateral OKC Proprioception test Device: Biodex Multi-Joint System Passive and Active position sense Pattern: Knee FLEX/EXT Mode: Passive and Isokinetic Sets and Reps: 1 x 3 each target angle Target angles: 90º/60º/30º/15º Recommendations: There should be no incidence of pain or inhibition with movement.

TEST: Hop tests Single leg hop, 6 meter hop and crossover hop tests Trials: Average of three Take off: On the involved extremity Landing: On the involved extremity

2-24 PHASE IV: RETURN TO ACTIVITY CLINICAL TREATMENT OPTIONS:

• Reduce pain and edema P.R.I.C.E.

• Continue with patellofemoral bracing/strapping PRN

• Flexibility training: Quadriceps Hamstrings IT band Gastrocnemius/Soleus Sets and duration: 5-6 x 20 seconds

• Cardiovascular training Device: Biodex BioStep® Semi-Recumbent Elliptical Mode: Isokinetic Duration: 20 min Speed: 100 deg/sec Intensity: 80-85% MHR

Device: Biodex Upper Body Cycle Mode: Isokinetic Duration: 20 min Speed: 80 deg/sec Intensity: 80-85% MHR

Device: Biodex Rehabilitation Treadmill Direction: forward jogging/running Speed: 5.0 mph as tolerated Incline: 0% as tolerated Duration: 10-15 min

Device: Fitter Duration: 10-12 min

• Proprioceptive Neuromuscular Facilitation (PNF) patterns for the Lower Extremity: Device: Cable Column Sets and Reps: 3 x 10-15 Recommendations: Perform hip adduction only if VMO:VL ratio is 1:1 and has no complaints of increased signs or symptoms. NOTE: Should perform exercises on involved and uninvolved side

• Weight-bearing Proprioception Device: Biodex Balance System Stance: Unilateral Level: Level 2 progressing to Level 1 Sets and Duration: 3 x 30 seconds (progress to 3 min continual) Eyes: Closed Training method: Trace circles on screen (A-D), color in circles (A-B) Recommendations: Have patient progress to using no hands

• Weight-bearing/Partial weight-bearing isotonic strengthening: Device: Functional Squat System or Isotonic Squat Foot position: tibia parallel to the ground Weight: use weight as tolerated Sets and Reps: 3 x 12 NOTE: This exercise should be performed in a pain/crepitus free ROM. It is imperative that the clinician ensures that the patient’s patella should at no time go anterior to the toes.

Device: Mini-squats with physioball Pattern: 60º/75º/90º of knee flexion Sets and Reps: 3 x 12 each

Device: Cable Column Pattern: Single leg mini squats Sets and Reps: 3 x 12

Device: Recumbent Squat Pattern: Plyometrics Foot position: Begin in center of platform (progress to various positions throughout) Weight: 3 plates to begin, progress as tolerated Sets and Reps: 3 x 12 NOTE: This is an alternative to standing plyometrics. The clinician may want to utilize the squat system for increased control of patient movement. Assure proper foot position as well as the foot slipping off the edge of the platform.

Lateral step-down Sets and Reps: 3 x 12 Recommendations: Perform step-down from 4" height and progress to 8"

Wall Seats with ball between knees Sets and Reps: 3 x 12 with 10 sec hold Recommendations: Instruct patient to push heels into ground and to pull toes up while performing this exercise.

Heel raises (Seated and Standing) Sets and Reps: 3 x 20-25

2-26 PHASE IV: RETURN TO ACTIVITY CLINICAL TREATMENT OPTIONS (cont):

• Isokinetic Strengthening: Device: Biodex Multi-Joint System Pattern: Knee flexion/extension Concentric/Concentric training Pad placement: normal Setup: crepitus/pain free ROM Mode: Isokinetic Speeds: 180-450 deg/sec in both directions Sets and Reps: 3 x 10 Recommendations: Progress to 30 seconds at each speed instead of reps.

Device: Biodex Multi-Joint System Pattern: Knee extension Concentric/Eccentric training Pad placement: normal Setup: 60- 0º of knee flexion Mode: Passive Speeds: 60 deg/sec Sets and Reps: 3 x 8-10 Recommendations: Instruct patient to actively contract quadriceps into extension and to resist movement into flexion. Once patient has understanding of eccentric muscle contractions, change mode to Reactive Eccentric and set torque limits based on test values.

• Functional Program: Plyometric program 11 Return to sport progression

SUPERVISED PROGRAM:

(Frequencies prescribes on an individual basis)

• Patellofemoral brace/strap to facilitate pain free exercise

• Strengthening program: Isotonic Progressive Resistance Exercises (PREs) Hip adduction, abduction, flexion and extension Sets and Reps: 3 x 12-15 Resistance: 10-12 Ib Recommendations: Perform on both involved and uninvolved lower extremities

Knee extension (concentric/eccentric quadriceps) Sets and Reps: 3 x 12-15 Resistance: 10-12 Ib Recommendations: Should have full pain free ROM

Knee flexion (concentric/eccentric hamstrings) Sets and Reps: 3 x 12-15 Resistance: 10-12 Ib Recommendations: Should have full pain free ROM

Device: Recumbent Squat Foot position: tibia parallel to the ground Sets and Reps: 3 x 12 Weight: as tolerated NOTE: This exercise should be performed pain-free and with no crepitis. At the same time, the patella should at no time go anterior to the toes.

• Cardiovascular training: Device: Biodex BioStep® Semi-Recumbent Elliptical Mode: Isokinetic Seat height: normal Pedal length: normal Duration: 20 min Speed: 100 deg/sec Intensity: 80% MHR

Device: Biodex Upper Body Cycle Mode: Isokinetic Duration: 20 min Speed: 80 deg/sec Intensity: 80% MHR

Device: Biodex Rehabilitation Treadmill Direction: Forward Speed: 4-8 mph Incline: as needed Duration: Vary depending on sport/activity Note: Perform exercises as per athletic competition as well as different patterns (i.e., cross-over steps, side-steps)

Slide Board Duration: 10-12 min Fitter Duration: 8-12 min Aquatic therapy Sport/activity specific exercises and conditioning techniques

2-28 PHASE IV: RETURN TO ACTIVITY HOME PROGRAM:

• Reduce pain and edema: P.R.I.C.E.

• Strengthening: Active knee FLEX/EXT Sets and Reps: 3 x 15 Resistance: Start with a 10 pound cuff weight and progress to 15 pounds Recommendations: Pain-free ROM and with no crepitis

3-way SLR Sets and Reps: 3 x 15 Repeat: 2x/day Resistance: 3-5 pounds Recommendations: Continue to hold abductor leg raises if lateral structures remain inflexible or VMO is deficient.

Wall Sit Sets and Duration: 2 x 45 sec Repeat: 2x/day Position: 45º

Heel raises Position: Both feet (progress to single) Sets and Reps: 3 x 20-25 Repeat: 2x/day

• Flexibility training: (static stretch only) Quadriceps Hamstrings IT band Gastrocnemius/soleus Sets and duration: 5-6 x 20 seconds Repeat: 2x/day

• Cardiovascular training 30 min at 65-80% MHR 3-4x /week Sport specific drills and conditioning techniques

• Functional progression: 5 15 heel raises Walking at fast pace Jumping on both legs Hopping on the involved leg Jog straight and curves Run straight at 1/2 speed, 3/4 speed, and then full speed Run large figure - 8's (20 yards) at 1/2, 3/4, and full speed Run small figure - 8's (10 yards) at 1/2, 3/4, and full speed Cross-over run in both directions Run on uneven terrain Run up, down, and sideways on hills Cutting (wearing athletic shoes on asphalt) at 1/2, 3/4, and full speed NOTE: Patients can progress through each step only if asymptomatic

• Analog pain scale

• Range of Motion

• Cardiovascular fitness level

• Biodex Bilateral OKC proprioception test

• Biodex isometric bilateral comparison QUAD/HAM @ 60º

• Biodex isokinetic bilateral comparison QUAD/HAM @ 180 and 300 deg/sec

• Biodex isokinetic bilateral comparison QUAD/HAM Concentric/Eccentric comparison

• Biodex Gait Trainer evaluation

• Biodex Bilateral and Unilateral Stability Index

2-30 PHASE IV: RETURN TO ACTIVITY BIODEX BALANCE SYSTEM stability index

NORMATIVE VALUES:

Age (yrs) Stability Index Standard Deviation (+/–)

17-35 1.54 .72

36-53 2.13 .90

54-71 2.57 .78

72-89 2.70 .80

Females are more stable than males:

All ages Stability Index Standard Deviation

Females 1.94 .80

Males 2.70 .08

Values were collected by J.A. Finn, et al, Stability Performance Assessment among Subjects of Disparate Balancing Abilities. Southern Connecticut State University.

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2-34 REFERENCES EVIDENCE BASED CLINICAL PROTOCOL FOR patellofemoral dysfunction THE MANAGEMENT OF:

post Injury: phase I: phase II: Reduction of Acute Symptoms Range of Motion and Initial Strengthening

goals: • Mentally prepare patient for rehabilitation • Decrease pain and inflammation • Education of Pt to understand the problems of • Increase flexibility with pain free PROM and AROM PF dysfunction • Restore normal patellar mobility • Identify specific needs of patient and • Increase cardiovascular conditioning potential problems • Increase VMO: VL ratio to > 75% • Decrease pain and edema • OKC Proprioception < 25% deficit • Maintain ankle ROM and strength • Isometric QUAD/HAM strength < 10% deficit • Full knee PROM • Isokinetic QUAD/HAM strength < 30% deficit • Increase VMO:VL strength ratio to 50% • Stability index: Bilateral stance < 25% deficit • OKC Proprioception < 40% deficit of uninvolved side • Isometric strength QUAD/HAM < 30% deficit • Normalize gait deviations and correct biomechanical faults • Identify contributory factors • Stability Index

clinical • General patient history and observation • Verify home program compliance • Pain scale: location, quality and duration • Degree and character of edema evaluations: • Degree and type of edema • Pain scale: location, quality and duration • Range of motion: active and passive • ROM testing: AROM and PROM (0-135 degrees) • Goniometry (0-135 degrees) • TEST : Biodex bilateral isometric • Patella assessment (radiographs, palpation, physical) QUAD/HAM @ 30, 60, 90 deg • Neurological assessment: myotomes, dermatomes • TEST : Biodex bilateral isokinetic and reflexes QUAD/HAM @ 180/300 deg/sec • TEST : Biodex bilateral isometric test 3 position • TEST : Biodex bilateral proprioception QUAD/HAM QUAD/HAM (30, 60,90) OR • TEST : Biodex Balance System bilateral stance • TEST : Biodex bilateral isokinetic test QUAD/HAM @ 300 deg/sec • TEST : Biodex OKC proprioception test • TEST : Biodex Balance System bilateral stance • TEST : Biodex Gait Trainer assessment

clinical • Rehabilitation process education • Reduce edema / inflammation • Patellar bracing or strapping • Reduce spasm / pain treatment • Reduce pain and edema • Patellar mobilizations options: • Patellar mobilization • Patellofemoral bracing/strapping • Correct biomechanical dysfunction/ • ROM: AAROM QUAD/HAM ambulation training • Postural control • Flexibility training • Strengthening exercises: • Muscle re-education of QUADS - Biodex multi-angle isometric QUAD/HAM • Strengthening: Multi-angle isometrics - Biodex isokinetic QUAD/HAM @180/300 deg/sec • WB Proprioception: Biodex Balance System bilateral stance • Non-WB Proprioception: Biodex MJS • Cardiovascular training: Biodex UBC, SRC • WB Proprioception: Biodex Balance System bilateral stance • WB and partial WB Exercises: - Wall squats, step-ups - Biodex CC Attachment • Cardiovascular training: Biodex UBC, LBC or Treadmill

supervised • Control edema and manage pain • Control pain and edema • Patellofemoral bracing/strapping • Muscle re-education program: • Muscle re-education • Strengthening: Hip, knee, lower leg & ankle* -EMS, isometrics • Flexibility: Hip, knee, lower leg and ankle • Flexibility training • Cardiovascular training: Biodex UBC, LBC or Treadmill • Cardiovascular training: Biodex UBC or LBC

*NOTE : No hip adduction with knee exercises home • Control pain and edema • Control pain and edema • ROM exercises • Flexibility: Hip, knee, lower leg and ankle program: • Flexibility training • Non-WB strengthening: Hip, knee, lower leg & ankle* • EMS • Cardiovascular training: 20-30 min. 3-4 x/wk • Non-WB strengthening exercises • Cardiovascular training *NOTE : No hip adduction with knee exercises

reports: • Range of motion • Range of motion • Pain scale • Pain scale • Cardiovascular fitness level • Cardiovascular fitness level • Biodex bilateral OKC proprioception test • Biodex bilateral OKC proprioception test • Biodex isometric OR isokinetic bilateral comparison • Biodex isometric AND isokinetic bilateral comparison • Biodex Balance System bilateral stance test • Biodex Balance System bilateral stance test • Biodex Gait Trainer Evaluation EVIDENCE BASED CLINICAL PROTOCOL FOR patellofemoral dysfunction THE MANAGEMENT OF:

phase III: phase IV: Initial Weight-bearing and Return to Activity Intermediate Strengthening

goals: • Full pain free ROM • Pain-free with activity • No effusion • No effusion and full ROM • No complaints of palpable tenderness • Maintain normal patellar mobility • Restore normal VMO: VL ratio • Activity specific tests WNL • Restore normal patellar mobility • Increase cardiovascular conditioning • Increase flexibility • Isokinetic strength QUAD/HAM < 10% deficit • Isokinetic strength < 15% deficit • Isokinetic strength con/ecc (quads only) • Isokinetic strength (con/ecc) < 15% deficit (quad only) < 85% deficit • Isometric strength = bilaterally or WNL • Functional hop test < 15% deficit • OKC Proprioception < 15% deficit • OKC Proprioception < 10% deficit • Stability Index: Unilateral stance < 15% deficit • Stability index: unilateral stance < 10% deficit • Maintain VMO:VL ratio • Maintain VMO:VL firing sequence

clinical • Muscle hypertrophy • ROM: active and passive • Pain scale: location, quality and duration • Muscle hypertrophy evaluations: • ROM: full AROM and PROM (0-135 degrees) • Pain scale • Biofeedback of VMO: VL ratio • Edema • TEST : Biodex bilateral isokinetic test • Goniometry (0-135 degrees) QUAD/HAM (60, 180, 300) • TEST : Functional hop test • TEST : Biodex OKC proprioception active and passive • TEST : Biodex bilateral isokinetic • TEST : Biodex Balance System unilateral stance QUAD/HAM (60, 180, 300) • TEST : Biodex Bilateral isometric multi angle • TEST : Biodex OKC proprioception (30, 60, 90) (passive, isokinetic) • TEST : Biodex Balance System unilateral stance • Functional activity evaluation

clinical • Reduce pain and edema • Reduce pain and edema • Patellofemoral bracing/strapping - PRN • ROM exercises treatment • ROM: active, passive and static • Strengthening: • Strengthening: - Biodex isokinetic QUAD/HAM @ options: - Biodex isokinetic (60, 180, 300) QUAD/HAM (60, 180, 300) - Isotonics WB and Non-WB - WB and Non-WB isotonics - Isotonics for lower extremity (no hip AD ) - Biodex isokinetic con/ecc - Biodex isokinetic con/ecc QUAD @ 60 deg/sec QUAD @ 60/180 deg/sec - Hip and ankle isotonics (no hip AD) • Non-WB proprioception: Biodex M-JS • OKC Proprioception training: Biodex M-JS • WB proprioception: Biodex Balance System • CKC Proprioception: Biodex Balance System unilateral stance unilateral stance • Flexibility Training • Cardiovascular training: Biodex UBC, Treadmill • Cardiovascular Training (UBC, TM) • Flexibility training • Functional Program

supervised • Control pain and edema • Control pain and edema • Strengthening: Hip, knee, lower leg and ankle* • Strengthening: Hip, knee, lower leg and ankle program: • Flexibility: Hip, knee, lower leg and ankle • Flexibility: Hip, knee, lower leg and ankle • Cardiovascular training: Biodex UBC, LBC or Treadmill • Cardiovascular training: Biodex UBC, LBC or Treadmill *NOTE : No hip adduction with knee exercises • Initiate interval sports program

home • Control pain and edema • Control pain and edema • Flexibility: Hip, knee, lower leg and ankle • Flexibility: Hip, knee, lower leg and ankle program: • Non-WB and WB strengthening: Hip, knee, • WB strengthening: Hip, knee, lower leg and ankle lower leg and ankle* • Cardiovascular training: 20-30 min. 3-4 x/wk • Cardiovascular training: 20-30 min. 3-4 x/wk • Initiate interval sports program

*NOTE : No hip adduction with knee exercises

reports: • Range of motion • Range of motion • Pain scale • Cardiovascular fitness level • Cardiovascular fitness level • Biodex bilateral OKC proprioception test • Biodex bilateral OKC proprioception test • Biodex isokinetic bilateral comparison • Biodex isometric (60 degrees) AND isokinetic (60, 180, 300 deg/sec) bilateral comparison (180 and 300 deg/sec) • Biodex Balance System unilateral stance test • Biodex Balance System unilateral stance test • Biodex Gait Trainer Evaluation • Biodex Stability Index • Patellofemoral Outcome Report • Biodex Gait Trainer Evaluation