Hi Doug,
I have been reading your blog and have found it extremely informative, so
thank you! I have struggled with recurrent patellar dislocations of my
left knee since I was 10 years old (I am now 24 and it has gone out upwards
of 30 times) and recently had surgery to try and correct the situation. The
problem as far as I understand it is that I have extremely shallow grooves
and my patella sits on the outer edge of my groove (the deeper edge).
Because it's not in the groove, it obviously sIips out of place often. I
was told by my orthopedic surgeon that he tightened the ligaments on the
inside of my knee and moved my patella slightly to the inside to try and
prevent further dislocations. Obviously without a full reconstruction of my
joint, I am dependent on my muscles to keep my kneecap in place. In place
of the exercises my physical therapist has been giving me (short arc quads
are one example), what exercises would you suggest to try and keep my
kneecap from sliding out of place? Any suggestions you might have would be
GREATLY appreciated.
Thank you!
H
Thanks for your question. A couple of things first before I go over the basics:
- Make sure you talk about your concerns with your therapist. Ask him or her the same question you asked me.
- I cannot give you specific advice so what I describe in this blog is for educational purposes.
With a shallow groove, you'll want to optimize your lower extremity biomechanics. This means excellent motion and strength in the hip, especially external rotators, and good control of the foot. Yes, you need strong quadriceps too but a dislocating patella is a problem during weight bearing; not while lying on your back or sitting in a chair.
But, the solution is more than a series of exercises. You have to develop a fluid, elegant motion through the trunk, hip, knee and ankle. All of the joints should work together and when this happens you'll feel more in control of your knee. This though depends upon your joint strength, flexibility, timing, and awareness.
I tell my students (and clients), "Give your intention your attention." Being aware of how your body moves in and out of positions, what seems to be working and when, can help reduce the incidence of subluxations or dislocations (and this is my experience - not a scientific study). How to do that - increase awareness and adjust to it - is beyond what I can tackle in this post but methods such as Feldenkrais, Alexander, Pilates, and Yoga offer insights and strategies on how to improve movement.
One example of "Give your intention your attention" is how you walk. We all have the same bones, joints, ligaments, muscles yet none of us walk exactly the same way. Some people sling their feet out in front of them with such force that the knee snaps into its end position with the force of a slamming door. Others, slink along shuffling their feet as if at any moment gravity will suck them to the ground. For a chronically locating patella, you want your feet to strike the ground softly with the knee joint stopping short of full extension. It is an acquired, practiced form of walking. It will not feel natural for some time.
But first, there are things I would want to know:
- Is your foot overly pronated? If so, you may need at least off the shelf orthotics such as Superfeet.
- What is the strength of your hip abductors and external rotators? Measure this in both a supine position and in standing.
- What is your Single Leg Squat Load Tolerance? You need to know this in order to get the correct dosage for your drills.
- What is your Single Leg Step Down Load Tolerance? Often this is below body weight not because of pain but either a sense of impending dislocation or inability to control movement of the leg.
- What is your ankle dorsiflexion range of motion (and this should be talocrural motion not motion of the ankle and forefoot combined)? If you're limited, then when you walk or squat or go up and down stairs, you'll drive the tibia into internal rotation too soon and force the patella out of the groove.
- What is your hip extension range of motion? You need about 20 degrees of hip extension to produce the 5 to 10 degrees of internal and external rotation that normally occur during the gait cycle. A lack of extension can shift when in the gait cycle the rotation motions occur and can contribute to a poorly tracking patella.
The training program is then built with these things in mind. If you have flexibility limitations, I would address those. So, for the ankle, I would add some long duration, low load flexibility drills but I would "lock" the forefoot by placing a wedge under the navicular bone to prevent early pronation during the stretch. For the hip, you have to make sure that the stretching does not also include the lumbar spine and you'll have to keep the knee relatively straight or run the risk of forcing the patella out of the groove. Most of the common stretches people use for hip extension are for the iliopsoas and rectus femoris muscle and you would want to concentrate more on the iliopsoas since this does not require any knee bend. The image to the right usually works well since the lower back will be slightly flexed by the maximum hip flexion of the opposite leg.
For strength training, the goal is of course strength but even more important is resting tension level of the muscle. If you think of muscles as springs, you want a tight, tough spring attached to your patella. I often use single leg squats but with hyperirradiation or what we call a "sizzler". Hyperirridation is an application of neurophysiologic law called Sherrington's Law of Irradiation. What this law states is that as neighboring muscles contract, the primary working muscle contracts as well. So, the more you tighten muscles around the knee - the hamstring, the hip muscles, and even the abdominals, the more your quadriceps will tighten. You can feel this easily by making a fist. Clench as hard as you can. Now, tighten ALL of the muscles in your arm. Notice that the harder you tighten the fist and other arm muscles, the tighter your fist becomes. Now, keeping this tension in the arm, straighten your elbow but fight against your self at the same time by maintaining the tension in the arm. As you do this, you'll notice that the muscles in your chest and abdomen will contract. So, with any squat exercise, you add a "sizzler". You tighten the hamstrings, hips, calf muscles and "fight" against the motion.
The benefit of this kind of training is that you'll increase your squat strength but will also increase the resting tension level. Your leg will feel tighter.
In addition to squats in supine (which are often at first done on a Total Gym because most people cannot tolerate body weight forces), I also use squats in a side lying position and will add weight to just above the knee (the weight bearing leg will be the leg on top). This increases the work load for the hip rotators and abductors yet respects your Single Leg Squat Load Tolerance.
On a treadmill, I would use walking forward, sideways, backwards while adding a "sizzler".
In addition to lower extremity training, I add core training:
- Plank
- Side plank
- Pull ups
- Push ups
- Yes, the last two are upper body drills as well but they happen ot be great core drills.
I work on step down function using a small step - 6 inches or less - and in an anti-gravity device (pulley, etc). I adjust the load on the leg so that you (the client) can control the motion and feel confident. This drill is as much motor learning as anything else. You have to gain confidence in controlling the leg. To increase the muscle work, add a sizzler.
These are some of the basics. Probably the three biggest mistakes I've made are not testing the leg correctly to identify the load level, not appreciating how to alter movement and create a more fluid motion, and not making the program demanding enough. This is a muscle training program and you (and your leg) should be tired when you finish it.
