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Patellar Instability

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Patellar Instability Females are at higher risk of having patellar instability. “YOUNG ATHLETES SUFFER PATELLAR DISLOCATIONS MORE COMMONLY THAN ANY OTHER AGE GROUP” 2 Patellar Instability PATELLAR INSTABILITY A PATIENT INFORMATION GUIDE The knee joint is made up of 3 bones: the femur for patellar instability. Some patients also have a (thigh bone), the tibia (shin bone) and the patella congenital condition in which the trochlear groove is (kneecap). Usually, the patella sits in the trochle- more “shallow”. In this situation, there is a loss of the ar groove, which is a groove at the distal end of the bony restraint to help hold the patella in place which femur. This forms the patellofemoral joint(figure 1). makes patellar dislocation more likely. There is also a Patellar instability is a condition that occurs when the tendency for patellar dislocation to run in families. kneecap comes out of the trochlear groove. Patellar When the patella dislocates, the soft tissue on subluxation occurs when the patella only partially the inner side of the patella may be stretched or torn, moves out of the trochlear groove. Dislocation of the including a ligament known as medial patellofemoral patella occurs when the patella moves completely out ligament (MPFL) which usually helps to hold the pa- of the trochlear groove. tella in place. Up to half of people who dislocate their Patellar dislocations are typically laterally where- patella will have further dislocations. They may also by the patella moves out of the groove towards the feel that the patella is unstable, even if it does not outer side of the knee joint. When they occur, they completely dislocate. are often associated with significant pain and swell- Young athletes suffer patellar dislocations more ing. Patellar dislocations are most commonly caused commonly than any other age group. Patients most by a twisting injury to the knee and less commonly at risk for patellar instability are 13 - 20 years of age. by a direct blow to the knee. Individuals with hyper- Females are also at higher risk for patellar instability. mobility (“loose jointedness”), are at increased risk WHAT IS A PATELLAR DISLOCATION? A patellar dislocation occurs when the patella (kneecap) moves out of it’s usual location in the knee joint. Figure 1. Front and side views of the knee Patellar Instability 3 PATELLAR DISLOCATION PATELLAR DISLOCATIONS can happen with a twisting injury to the knee with the involved leg planted on the ground such as during soccer or basketball. Less often, it can happen from a direct blow to the knee. ANATOMY: with articular cartilage. The patella is the largest sesamoid bone in the On either side of the patella, there is a broad body. A sesamoid bone is a bone that is embedded band of tissue which is known as the retinaculum. within a tendon. It is attached to the quadriceps The retinaculum does help provide a stabilizing tendon proximally and the patellar tendon distally. effect on the patella. The powerful muscles on the The patella sits in a groove in the femur known as front of the thigh, the quadriceps muscles, straight- the trochlear groove (Figure 2). The patella glides en the knee by pulling at the patellar tendon via the up and down the groove in the thigh bone (femur) patella. One of the quadriceps muscles, the vastus as the knee bends and straightens. The patella has medialis, pulls the patella inward (medially). An- a smooth coating (articular cartilage) on its under- other quadriceps muscle, the vastus lateralis, pulls side which allows it to slide easily in this groove. the patella outward (laterally). There is an impor- The trochlear groove on the femur is also covered tant ligament on the medial side of the knee known 4 Patellar Instability Figure 2 THE FIGURE BELOW SHOWS HOW THE as the MPFL (Medial Pa- the patella can sublux or KNEECAP NORMALLY tello Femoral Ligament) dislocate with seemingly “SITS” IN THE which acts as an impor- minor activities such as TROCHLEAR GROOVE tant stabilizer to lateral going up stairs or even OF THE FEMUR. patellar dislocation. The kneeling. MPFL is almost always Patellar dislocations stretched or torn when can also occur during the patella fully comes contact or non-contact out of the groove as in a situations in patients patellar dislocation. who may not have any of the above “predispos- CAUSES: ing factors”. An athlete Predisposing factors can dislocate his/her that increase the chance patella when the foot of the patella to sublux is planted and a rapid or dislocate include: change of direction or generalized ligamentous twisting occurs. This may laxity (loose jointedness), happen in sports such weakness of the medial as soccer, gymnastics or quadriceps muscles that basketball. Direct blows help to hold the kneecap to a knee can also cause in place, abnormal align- dislocations. This type ment of the bones of the of injury may occur in lower leg (genu valgus sports such as hockey or “knock kneedness”), or football. The force of a high riding kneecap these types of injuries is (patella alta) which typically much greater brings the patella above and usually causes more the groove, and trochlear severe damage to the dysplasia in which the knee especially to the “INITIALLY, PEOPLE WHO SUSTAIN trochlear groove is shal- restraining ligaments. A PATELLAR DISLOCATION WILL low. These predisposing Patients with traumatic factors allow the patella dislocations also have a COMPLAIN OF SUDDEN PAIN IN to slide more easily out higher incidence of as- THEIR KNEE AFTER A PLANT AND of the groove causing pa- sociated fractures in the tellar instability and may patellofemoral joint. TWIST TYPE OF INJURY” possibly cause recurrent instability of the patel- la. In these patients, Patellar Instability 5 Copyright Dalhousie Orthopaedics “THE GOALS OF TREATMENT ARE TO HAVE A STABLE PATELLA AND TO RESTORE NORMAL STRENGTH Diagnosis &Treatment AND FUNCTION IN THE KNEE.” Diagnosis: Imaging: In most cases, the patients will describe a twist- X-rays are generally recommended to see how ing episode where the patella dislocated and either the kneecap fits in its groove and to ensure that it is reduced on its own or someone had to put it back properly located. There are also several other bony in place for them. Following the injury, the patient landmarks that will be assessed such as the patellar may experience significant pain and swelling in height and possible tilting of the kneecap. X-rays their knee and they may have difficulty walking. In are also important to rule out any other associated some situations, the patient may have experienced injury to the bones of the knee such as a fracture patellar dislocations in the past. This is known as that may occur secondary to the patella dislocating. recurrent patellar instability. These patients may Other tests such as Magnetic Resonance Imag- or may not have the severity of the symptoms and ing (MRI) or CT scan are occasionally used to rule may need to be addressed differently than a patient out damage inside the knee. An MRI can be ob- experiencing a first-time incident. tained to evaluate the MPFL and determine where Physical examination of the knee may reveal it is torn. The MRI can also give a detailed look at that the patella is still dislocated. If this is the case, the cartilage surfaces and see if there are any other the patient will require a reduction of their patella injuries within the knee joint (meniscus, other liga- which may require sedation. Once the patella is ments). A CT scan may be ordered to determine the reduced there will be tenderness, usually on the bony alignment of the lower extremity and can help medial (inner) side of the knee where the medial with pre-operative planning in patients who have retinaculum and MPFL are located. There is often recurrent patellar dislocations. significant swelling in the knee (especially with a first time dislocation). A patellar apprehension Treatment: test where the patella is gently moved outward may The treatment goals are to prevent further epi- be performed. Quadriceps muscle atrophy usually sodes of patella dislocation, subluxations or feelings develops due to the knee injury. Range of motion of instability. The other goals are to restore nor- of the knee is often limited due to pain initially. The mal strength and function in the knee joint and to knee will be assessed for bone tenderness, joint line prevent further damage to the articular cartilage of tenderness and ligament stability. Known predis- the knee joint, which may lead to the development posing factors for patellar instability (especially in osteoarthritis in the future. patients with recurrent patellar instability) are often In order to reach these goals, there must be assessed such as generalized joint hypermobility, adequate healing of the ligaments and muscles in weakness in the muscles around the knee as well as the acute phase. Rehabilitation will then focus on the alignment of the lower extremity. strength, flexibility and neuromuscular control of the knee. Many patients benefit from seeing a physiotherapist initially to assist in attaining these goals. The treatment of patellar dislocations and patellar instability depends on the severity of the injury and other associated injuries. Each treatment plan should be individualized. Most first-time patellar dislocations are treated without surgery. This may include a short period of immobilization, which typically lasts 2 to 4 weeks in a long leg brace or cast. Following this, physiothera- py is initiated to regain the range of motion of your knee as well as to regain your strength, function and neuromuscular control of your knee. Stationary bicycling is an excellent way to regain mobility and strength in your knee in a safe manner.
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