Will My Patrella Dislocate Again After a First Time
Knee Surg Sports Traumatol Arthrosc. 2014; 22(10): 2320–2326.
Render to sport subsequently patellar dislocation or following surgery for patellofemoral instability
Jacques Ménétrey
oneCentre de medicine de l'appareil locomoteur et du sport, Unité d'Orthopédie et Traumatologie du Sport (UOTS), Swiss Olympic Medical Center, Service de chirurgie orthopédique et traumatologie de fifty'appareil moteur, University Infirmary of Geneva (HUG) and Faculty of Medicine, University of Geneva, Rue Gabrielle-Perret-Gentil 4, 1211 Geneva, Switzerland
Sophie Putman
2Université Lille Nord-de-France, 59000 Lille, France
3Département universitaire de chirurgie orthopédique et de traumatologie, Hôpital Salengro, CHRU de Lille, rue Émile-Laine, 59037 Lille, French republic
Suzanne Gard
1Centre de medicine de l'appareil locomoteur et du sport, Unité d'Orthopédie et Traumatologie du Sport (UOTS), Swiss Olympic Medical Center, Service de chirurgie orthopédique et traumatologie de 50'appareil moteur, Academy Infirmary of Geneva (HUG) and Faculty of Medicine, Academy of Geneva, Rue Gabrielle-Perret-Gentil 4, 1211 Geneva, Switzerland
Received 2013 Nov 13; Accustomed 2014 Jul iii.
Abstract
Patellofemoral instability may occur in a immature population as a issue of injury during sporting activities. This review focuses on return to sport later on i episode of dislocation treated no operatively and equally well later on surgery for chronic patellofemoral instability. With or without surgery, but 2-thirds of patients return to sports at the aforementioned level as prior to injury. A loftier-quality rehabilitation programme using specific exercises is the primal for a safe return to sporting activities. To reach this goal, recovery of muscle forcefulness and dynamic stability of the lower limbs is crucial. The focus should exist directed to strengthen the quadriceps muscle and pelvic stabilizers, besides as lateral trunk muscle preparation. Patient teaching and regularly performed domicile exercises are other central factors that can atomic number 82 to a successful return to sports. The criteria for a safe return to sports include the absence of pain, no effusion, a complete range of motility, about symmetrical strength, and fantabulous dynamic stability.
Level of evidence IV.
Keywords: Patellofemoral, Return to play, Rehabilitation, Dislocation, Dynamic stability
Introduction
Patellar dislocation and patellofemoral instability may occur in a young population with varying activity levels. The overall recurrence rate of patellar dislocation after an initial event is close to 40 % [23]. In fact, patients who accept a primary patellar dislocation have a 17 % recurrence rate, and patients who sustain repeat patellofemoral joint dislocation have a 49 % recurrence rate [xiii]. Therefore, surgical treatment is more often than not recommended after a second dislocation [fourteen]. It is obvious that athletic patients take every bit a goal resumption of their sports activities at the same high level equally prior to the episode of dislocation. For less active patients, an increase in their level of activeness could be an attractive goal, equally strength and stability of the lower limb can prevent re-injury [eighteen]. Information well-nigh the functional capacity that allows for a safe render to sports after either primary dislocation or surgical stabilization is sparse. It is known that medial patellofemoral ligament (MPFL) reconstruction and rehabilitation improves the power to perform routine activities of daily living [8, 13], but it is less evident equally regards the ability to resume sports participation safely. Testing protocols are requested later patellar dislocation to assure a rubber return to sport (RTS), but data on this issue is currently express in the literature. Thus far, quantitative assessment was recommended, but as it will be shown in this article, qualitative measurement with a systematic video analysis has to be considered to better evaluate the dynamic stability of the knee.
This article focuses on objective patellofemoral instability and render to sport, addressing just those situations where one or more than episodes of dislocation have occurred or in cases where surgery for instability has been performed. It was attempted to answer the following 2 questions: (ane) How and when can patients safely render to sport after primary or recurrent patellar dislocation, or later on patellofemoral stabilization? (two) What validated evaluations can be utilized to make up one's mind readiness to return to sport? In our feel, return to sport can be compromised by pain, instability, weakness, and poor motor control.
Render to sport after nonsurgical handling
A safe return to sport implies that lesions of the human knee have healed and the injured lower limb has adequately recovered to face the demands of sporting activities. Successful return to sport implies: (ane) no early re-injury; (2) no further damage to the knee; (three) return to the preinjury or higher level; (iv) no limiting pain; (5) still playing after 5 years; and (6) no early on osteoarthrosis. A comprehensive return to sport decision-making process should be based upon: (one) clinical exam; (2) evaluation of laxity; (3) strength measurement; (4) neuromuscular evaluation; and (five) counselling with the physical conditioner and coach for professional person athletes. As regards the patellofemoral joint, the challenge is that the patella is a sesamoid bone enclosed within the extensor mechanism of the lower limb. Its function is closely associated with dynamic muscle activity while retaining its osseous and soft tissue static elements [26].
Atkin et al. [3] followed 74 patients (37 men, 37 women) after a first dislocation that was treated conservatively. Preinjury sports action was similar to that of patients with master anterior cruciate ligament (ACL) injury [10]. Patients were authorized to return to sports after they regained full passive range of move, had no effusion, and when quadriceps muscle strength was at least lxxx % of the noninjured limb. Patients regained range of motion later half-dozen weeks. Sports participation was limited during the first 6 months after injury, with difficulties in squatting and kneeling. At half-dozen months, 58 % of patients noted limitations in strenuous activity, but no recurrence was recorded. Sillampaa et al. [32] reported that the return to preinjury activeness level varied betwixt 44 % and sixty % regardless of the modality of treatment afterward the first dislocation.
Critical points in the rehabilitation for achieving a proper return to sport
There are few high-quality studies apropos rehabilitation after patellar dislocation [33], especially as regards the terminal phase of treatment before return to sport. At that place are no published randomized clinical trials, but only thoughts and recommendations as summarized in the review by Fisher et al. [13]. All the same, since the objectives are similar, a parallel situation exists with the information available in the literature concerning return to sport subsequently ACL reconstruction. In order to achieve a proper and safe resumption of sports activities, in that location are critical points to achieve during rehabilitation. The forcefulness of the lower limb muscles, peculiarly the quadriceps [vi, 36], and the gluteus medius is 1 key point [v]. Core strength is as well crucial every bit it plays an of import office in the stability of the lower limb. Indeed, if the trunk is not stable during cut manoeuvres, the loads applied to the knee are in valgus, thus generating a state of affairs where the patellofemoral articulation is at hazard of dislocation [xiii, 18].
To avoid re-injury, the stability of the lower limb must be mastered at the end of the rehabilitation programme. Cut manoeuvres, change of direction, and running on uneven ground are the three activities perceived to be the greatest risk factors for patellar dislocation [34]. Therefore, the last goal of the rehabilitation programme should be to focus on the stability of the lower limb past the use of specific exercises on different surfaces, including cutting manoeuvres, side hops, and sudden change of management.
During the final phase of the rehabilitation program, some other important factor to consider for a proper return to sport concerns sport-specific activities. While this may seem obvious, it is frequently overlooked. The athlete should be prepared for the specific loads and demands to exist experienced in their specific sport, including: (1) cut manoeuvres and pivoting exercises, performed for most of the squad sports; (ii) plyometric and landing strategies, emphasized in whatsoever sports with jumps; (3) 1-leg stability, particularly exercised for martial arts; and (4) proprioception, side stability, and landing capacities, which are stressed with skiers. Every bit previously mentioned, a parallel tin be made with return to sport later ACL reconstruction. Specific exercises to exist implemented for patients involved in soccer, basketball, alpine skiing, and American football take been described [7, 20, 37, 38].
Return to sports subsequently surgery for chronic patellofemoral instability
The same principles as mentioned above can be practical to patients after surgery for instability, regardless of the procedure performed. With respect to return to sport later medial patellofemoral ligament (MPFL) reconstruction, Fisher et al. [13] reviewed postoperative rehabilitation and the incidence of return to sport. They reported on only 2 studies [eleven, 25] concerning the rate of return to a specific level of sports and institute that 77 % of patients were able to resume sports at their preinjury level of operation. In a report by Ntagiopoulos et al. [29], 87 % of patients returned to their previous activities after isolated trochleoplasty, only the level of activity was not specified. Nelitz et al. [27] studied the outcome after combined trochleoplasty and MPFL reconstruction for recurrent dislocation in patients with astringent trochlear dysplasia. Twenty-eight patients at a minimum follow-up of 2-years were included in the report. I patient returned to sport at a higher level than preoperatively, sixteen returned at the same preoperative level, and simply six patients reported a return to a lower level of activity than before surgery. Overall, 60 % of patients returned to their previous activities. Unfortunately, there is no information in the literature about validated timelines for a safe render to sport after patellofemoral surgery, especially after tibial tubercle osteotomy. However, common sense recommends to await until the osteotomy is healed, and to delay the render until maximum recovery of musculus strength and dynamic stability.
Cartilage lesions represent a critical gene when functional recovery is considered. Treatment tin can vary according to the size of the lesion and the intrinsic stability of the patellofemoral articulation [12]. Factors to consider include size of the lesion, intrinsic healing capacity of the cartilage, and residual pain. Cartilage lesions are certainly not a favourable cistron for a safe return to high-impact and high-demanding sports activities. Clearly, a big cartilage lesion (>2 cmtwo) influences the prognosis for return to sport. However, there is no specific data in the literature that allows for solid recommendations.
Based on the current literature, the render to previous level of sports activities after an objective episode of instability is limited to 2-thirds of patients with or without surgery.
Discussion
Criteria for a safe return to sport
At that place is piffling in the current literature nearly return to sport after objective patellar instability, and thus, no clear criteria can be equally yet endorsed. Nonetheless, equally already mentioned, one can draw a parallel with the literature dedicated to return to sport post-ACL reconstruction [7, xx, 37, 38]. Based upon this literature and our feel, nosotros propose six clinical criteria to support our return to sport decision-making process. As regards timing, it is no longer a matter of weeks or months, but rather a matter of clinical and testing requirements that the patient should fulfil. These criteria are as follows: (1) no pain; (2) no effusion; (3) no patellofemoral instability; (4) a full range of motion; (v) virtually symmetrical force (85–90 %); and (6) excellent dynamic stability. These criteria can be applied in patients treated with or without surgery. Ideally, patients should satisfy these criteria at 6 weeks afterward a dislocation, and 3 months after surgery. Our protocol and criteria for return to sport are currently under evaluation. In 2013, the ISAKOS Sports Medicine Committee besides defined criteria for return to sport after surgery, and their criteria are very similar to ours (Tabular arrayi). Initially, the outset 4 criteria listed above are assessed by the surgeon, followed by measurement of quadriceps and hamstring muscle forcefulness in both legs with an isokinetic dynamometer. At this point, dynamic stability is assessed with the utilise of several functional tests and video recording. These tests typically use the patient's contralateral limb as the control or "normal", and a limb symmetry alphabetize (LSI) is thus calculated by computing side-to-side differences in the results. And finally, in light of the results, the surgeon and patient tin brand a well-documented determination with regards to render to sport. For force evaluation, especially in loftier-enervating sports (due east.g., alpine skiing, football game, basketball game, and handball), the patient should reach a LSI of at least 90 % in lodge to be cleared for return to sports [7, 20, 37, 38].
Table ane
From the ISAKOS Sports Medicine Commission, ISAKOS Consensus Meeting on Render-to-Play, London 2013. With the permission of Elisabeth Arendt, MD and François Kelberine, MD
| Criteria for a safe RTS after patellofemoral instability ISAKOS |
|---|
| If bony surgery is involved, consummate radiographic healing of bone |
| No complaints of knee pain or articulatio genus instability |
| Total or virtually full range of move |
| No knee effusion |
| Completed neuromuscular preparation/proprioception |
| Satisfactory core strength and endurance |
| Acceptable control with dynamic activities (east.1000., Star Excursion Residue Test) |
| Limb Symmetry Alphabetize > 85 % on hop tests, especially if resuming pivoting sports |
| Adequate performance with physiotherapist during sport-specific drills simulating the intensity and motion patterns of the athlete's given sport |
| Athlete demonstrates a psychological readiness to return to sport (eastward.yard., SANE score > lxxx/100) |
Testing exercises are mandatory to evaluate recovery and the competence of the injured or operated limb. There are many functional tests for the articulatio genus that have been used [17, 22, 31, 39] and appear to be reliable and valuable tools [40]. Later a thorough evaluation of the different tests that have been validated in the literature, we have selected the "single-leg squat", the "Star Excursion Balance Test" (SEBT), the "drop leap test", and the "side-hop test". These tests are ever performed after isokinetic measurements of the strength in both limbs.
Dynamic stability tin be evaluated with the single-leg squat (Fig.1a) and the SEBT (Fig.1b). In the unmarried-leg squat, the knee must stay above the foot without going into a valgus movement, and the pelvis has to remain stable without dropping or turning. This exercise is role of the rehabilitation programme and should be perfectly mastered [24]. In the SEBT, the knee has to stay aligned as the pelvis is moving [35]. The patient stands on one foot and reaches points around him like a clock quadrant [18, 28]. The results obtained are qualitative on the video analysis and too quantitative since distances reached during the SEBT can be noted and reported. This test is very useful for the evaluation of lower limb stability [9, 16, 21].
a Unmarried-leg squat to evaluate the dynamic stability of the lower limb, b Star Excursion Residue Test(SEBT) to evaluate the limb stability while reaching the maximum altitude around with the other leg
Many sports demand change in management and landing from jumps. If the limb cannot be maintained in good alignment and equally well properly decelerate, this may consequence in pain and gamble re-injury [thirty]. It is therefore of import to assess these parameters during the stage of return to sport. Driblet and jump is a uncomplicated test that provides valuable information virtually command of landing. The patient drops from a box 35 cm loftier, lands on both anxiety, and immediately jumps equally high as possible before landing a 2d fourth dimension. The symmetry of the reception, the alignment of both knees, deceleration, and the capacity for absorbing the shock are evaluated using video recording [4, 15, nineteen, 30]. In this case, the results are qualitative, just highly valuable. The side-hop exam consists in jumping on one leg between two lines at a altitude of 40 cm equally oft as possible in 30 southward (Fig.2). During this test, many aspects of physical conditioning tin be observed, including speed, agility, muscle coordination, limb alignment, body stability, and command in change of management. Here, the results are qualitative (video analysis) likewise as quantitative (number of jumps). All these tests are recorded and analysed using video assay software. They are and so shown to the patient, and the results discussed in club to outline a new set of exercises aimed at correction of whatever deficits noted. In this way, the training may evolve over time towards more sport-specific exercises with the aim to set the patient for return to sport. Arendt et al. have besides described a series of tests that can be used to evaluate patients with patellofemoral problems or post-obit cosmetic patellofemoral surgery [1, 2, 26]. They assessed core and trunk stability using prone plank, side plank, and single-limb exercises. For patients with patellofemoral issues, lower limb physical performance was evaluated with the stand up and achieve residual examination, SEBT, single-limb squat exam, and retro step-up/downward exam.
Side hop-test on lines 40cm away during thirty seconds. The torso and limb alignement is observed
From our point of view, patient teaching is a cardinal point. Very often, the patient has no thought virtually the importance of whole limb stability and is overly focused on the patellar problem. The use of video feedback is a very powerful tool for didactics. It is strongly recommended that patients regularly perform domicile exercises (Fig.iiia–eastward). Feel has shown that these self-administered exercises have been very useful to return the patient to sports.
Home practise plan: a Gluteus and hamstrings strengthening, b Myofascial release of ITB, c Rotational cadre stability, d Lunges with trunk rotation, east Single-leg squat
With all, we accept presented in that location still remains a lack of solid testify about the criteria to determine a safe return to sports after patellofemoral dislocation or surgery. Further work needs to be conducted in this field to better empathise the true adequacy of our functional testing, rehabilitation programme, and surgical procedures, to safely and durably bring our patient back to sports.
Determination
Patellar instability is a pathology that concerns a young active population. Fifty-fifty after a single dislocation, return to sports at the aforementioned level of functioning as before injury appears to be compromised. Analysis of the literature reveals that simply 2-thirds of patients return to sports at the aforementioned level. This can be considered a poor outcome with respect to the young age of the affected population. Return to sport may be encouraged and promoted using home self-administered exercises and by educating the patient about the importance of regaining musculus strength and dynamic stability. Finally, testing protocols for the RTS should include quantitative and qualitative criteria.
Correspondent Information
Jacques Ménétrey, Phone: +41-22-372-79 -11, Email: hc.eguch@yertenem.seuqcaJ.
Suzanne Gard, Email: hc.eguch@elevate.ennazuS.
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