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Health Policy & Clinical Effectiveness Program Evidence-Based Care Guideline for Conservative Management of patellar instability and dislocation in children and adults aged 8-25 Guideline 44 James M. Anderson Center for Health Systems Excellence Introduction References in parentheses ( ) Evidence level in [ ] (See last page for definitions) Evidence-Based Care Guideline Lateral patellar dislocations/subluxations and lateral patellar instability are conditions that can result in short- Conservative Management of Lateral Patellar term and long-term anterior knee pain, functional Dislocations and Instability disability and potentially degenerative joint changes (Smith 2010b [1b], Fithian 2004 [2a], Atkin 2000 [3b]). Both In children and young adults aged 8-25 yearsa conditions are often managed with a non-surgical, Publication date: March 18, 2014 conservative approach that entails physical therapy care (Stefancin 2007 [1b]). While a variety of expert opinion and Target Population review articles have been published with suggestions for physical therapy interventions for lateral patellar Inclusions: Children or young adults: dislocation and patellar instability, higher level studies With history of lateral patellar dislocation, specifically investigating rehabilitation interventions for subluxation or general patellar instability in one or these conditions are limited. Consequently, optimal both knees who are going to be conservatively physical therapy strategies have not yet been determined managed (Smith 2010b [1b]). Therefore, the purpose of this guideline Ages 8-25 years is to provide a comprehensive description of evaluation and intervention strategies for conservative management Exclusions: Children or young adults: of lateral patellar instability. Following surgical patellar stabilization techniques This guideline was developed based on a synthesis of With Neuro-developmental conditions associated current evidence relative to the non- surgical, with patellar instability or dislocation (e.g. cerebral conservative management and treatment of lateral palsy, Down Syndrome) patellar dislocations and patellar instability in children, adolescents, and young adults. Each article from the Target Users literature search was individually appraised through a formalized process (described in detail on pages 27-28). Include but are not limited to: Where evidence was insufficient or limited, statements were formulated through a consensus process from a Athletic Trainers panel of physical therapists. The consensus-based Nurse Practitioners statements regarding progression of injured patients Other healthcare professionals through the identified treatment phases are based on an Physical Therapists understanding of current evidence and a consideration of the active, passive, and static stabilizers of the Physicians and physician assistants patellofemoral joint, the biomechanical principles Patients, families, and coaches relative to joint kinematics and kinetics, and the expected healing properties of the surrounding tissues. For the purposes of this guideline, “primary patellar dislocation” (PPD) will be used to refer to an acute lateral patellar dislocation or subluxation injury that a Please cite as: Lateral Patellar Instability Management occurs without prior history of dislocation or subluxation Team, Cincinnati Children's Hospital Medical Center: in the involved knee. “Recurrent patellar instability” Evidence-based clinical care guideline for Conservative (RPI) will be used to refer to multiple episodes of lateral Management of Lateral Patellar Dislocations and Instability, patellar subluxation or dislocation that are either http://www.cincinnatichildrens.org/svc/alpha/h/health- insidious in onset or subsequent to a previous primary policy/ev-based/Conservative Management of Lateral Patellar traumatic dislocation episode. In general, there is much Dislocations and Instability.htm, Guideline 44, pages 1-30, overlap between PPD and RPI with regard to incidence, Date.. hyperlink the document mechanisms of injury, prognosis, treatment and Copyright © 2014 Cincinnati Children's Hospital Medical Center; all rights reserved. Page 1 of 30 Evidence-Based Care Guideline for Conservative Management of patellar instability and dislocation in children and adults aged 8-25 Guideline 44 outcomes. However, for clarity purposes, it can be Risks and Limitations for the patients in following this helpful to discuss PPD and RPI separately in some guideline include: cases. Therefore, distinct aspects and recommendations Underlying concomitant tissue damage such as for each condition will be discussed separately chondral lesions that can lead to long-term pain or throughout the guidelines when appropriate. loose bodies in the joint may lead to limitations or Objectives of this guideline include: difficulties with full implementation of these guidelines To guide and promote consistency in the delivery of optimal evidence-based physical therapy Pre-disposing anatomical abnormalities may services for non-surgical, conservative reduce a patient’s chances for long-term success of management of PPD and RPI the implementation of these guidelines to reduce lateral patellar instability To promote long-term joint integrity and maximize healing To reduce impairment Background To enhance function Patellofemoral joint stability is sustained through To maintain and improve patient and family complex and dynamic interactions among static, passive satisfaction and quality of life and active anatomical restraints and healthy To minimize risk for re-injury biomechanics at the knee (Balcarek 2011 [4b], Senavongse 2005 [4b], Mulford 2007 [5b], Beasley 2004 [5b]). Due to these Benefits and Expected Outcomes for the patient after complex relationships, any anatomical variations, following this guideline: abnormal biomechanical tendencies, or a combination of Full range of motion (ROM) both active and both may compromise patellofemoral joint stability. In passive in the involved knee order to better understand the etiology of lateral PPD Ability to participate with self-report of pain less and RPI, it is helpful to review the general anatomic and than or equal to 2 out of 10 on Numeric Rating biomechanical characteristics of a normal, healthy knee. Scale with activities of daily living (von Baeyer 2009 In a normal, healthy knee, the medial patellofemoral [4b], Williamson 2005 [5a]) ligament (MPFL) serves as a passive stabilizer of the Ability to participate with self-report of pain less patella against lateralization during the first 20-30 than or equal to 2 out of 10 on Numeric Rating degrees of knee flexion and helps guide the patella into Scale in all age-appropriate gross motor skills (von the trochlear groove (Philippot 2012b [4b], Amis 2003 [5b]). Baeyer 2009 [4b], Williamson 2005 [5a]) Beginning around 20-30 degrees of knee flexion, the Ability to participate with self-report of pain less patella engages within the trochlear groove of the femur, than or equal to 2 out of 10 on Numeric Rating which provides additional static support against Scale in all desired recreational activities (von lateralization of the patella (Smith 2010b [1b], Philippot 2012b Baeyer 2009 [4b], Williamson 2005 [5a]) [4b], Mulford 2007 [5b]). As the knee moves toward 90 A minimum of 4+/5 strength for all core and lower degrees of flexion, the MPFL is further supported by extremity musculature bilaterally including hip other passive restraints including the patellar tendon, flexors and extensors, hip abductors and medial patellomeniscal ligament (MPML), and the adductors, hip internal and external rotators, knee medial patellotibial ligament (MPTL) (Philippot 2012b flexors and extensors, ankle dorsiflexors and [4b]). plantarflexors, lateral and medial ankle musculature An active contraction of the quadriceps muscle group, which has fascial connections to the MPFL via the Ability to demonstrate safe and proper alignment vastus medialis oblique (VMO), is frequently identified of trunk, hips, knees and feet while performing as a potential active stabilizer for the patella that helps walking, lunging, squatting, jumping and running guide the patella appropriately into the trochlear groove activities (Brunet 2003 [4b], Farahmand 1998 [4b], Amis 2003 [5b]). In addition to the quadriceps muscle group acting as an active stabilizer, dynamic coordinated muscle Copyright © 2014 Cincinnati Children's Hospital Medical Center; all rights reserved. Page 2 of 30 Evidence-Based Care Guideline for Conservative Management of patellar instability and dislocation in children and adults aged 8-25 Guideline 44 activations proximally at the trunk, pelvis and hip, and Reportable injury event distally at the ankle and foot, can also influence the Pain stability of the patellofemoral joint (Souza 2010 [4b], Powers Inability to bear weight on involved limb 2003 [4b], Powers 2010 [5a]). Complaints of instability/giving way Table 1: Primary Stabilizers for Patellofemoral Joint Moderate to large effusion Type of Stabilizer Primary Examples Decreased ROM Passive MPFL Impaired muscle activation and strength Trochlear Groove Congruency MPML Limited ability to participate in ADLs and MPTL recreational activities Active Quadriceps muscle group PPD Prognosis Coordinated Multi- Trunk Although in many cases, conservative management of Joint Muscle Pelvis PPD has been shown to be successful, patellar re- Activity Hip dislocation and recurrent instability symptom rates Ankle Foot associated with PPD for all ages have been reported up
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