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Alignment or overuse problems of the knee structures can lead to strain, irritation, and/or injury of the quadriceps muscle and tendon. This produces pain, weakness, and swelling of the knee joint.

These problems can affect people of all ages but the majority of patients with overuse injuries of the knee (and specifically quadriceps tendonitis) are involved in soccer, volleyball, or running activities.

This guide will help you understand:

• how the problem develops
• how doctors diagnose the condition
• what treatment options are available

What is the quadriceps muscle/tendon, and what does it do?

The patella (kneecap) is the moveable bone on the front of the knee. This unique bone is wrapped inside a tendon that connects the large muscles on the front of the thigh, the quadriceps muscles, to the lower leg bone.

The large quadriceps muscle ends in a tendon that inserts into the tibial tubercle, a bony bump at the top of the tibia (shin bone) just below the patella. The tendon together with the patella is called the quadriceps mechanism. Though we think of it as a single device, the quadriceps mechanism has two separate tendons, the quadriceps tendon on top of the patella and the patellar tendon below the patella.

Tightening up the quadriceps muscles places a pull on the tendons of the quadriceps mechanism. This action causes the knee to straighten. The patella acts like a fulcrum to increase the force of the quadriceps muscles.

The long bones of the femur and the tibia act as level arms, placing force or load on the knee joint and surrounding soft tissues. The amount of load can be quite significant. For example, the joint reaction forces of the lower extremity (including the knee) are two to three times the body weight during walking and up to five times the body weight when running.

How does this problem develop?

Quadriceps tendonitis occurs most often as a result of stresses placed on the supporting structures of the knee. Running, jumping, and quick starts and stops contribute to this condition. Overuse injuries from sports activities is the most common cause but anyone can be affected, even those who do not participate in sports or recreational activities.

There are extrinsic (outside) factors that are linked with overuse tendon injuries of the knee. These include inappropriate footwear, training errors (frequency, intensity, duration), and surface or ground (hard surface, cement) being used for the sport or event (such as running). Training errors are summed up by the rule of toos. This refers to training too much, too far, too fast, or too long. Advancing the training schedule forward too quickly is a major cause of quadriceps tendonitis.

Intrinsic (internal) factors such as age, flexibility, and joint laxity are also important. Mal-alignment of the foot, ankle, and leg can play a key role in tendonitis. Flat foot position, tracking abnormalities of the patella, rotation of the tibia, and a leg length difference can create increased and often uneven load on the quadriceps mechanism. Any muscle imbalance of the lower extremity (from the hip down to the toes) can impact the quadriceps muscle and affect the joint. Individuals who are overweight may have added issues with load and muscle imbalance leading to quadriceps tendonitis.

Strength of the patellar tendon is in direct proportion to the number, size, and orientation of the collagen fibers that make up the tendon. Overuse is simply a mismatch between load or stress on the tendon and the ability of that tendon to distribute the force. If the forces placed on the tendon are greater than the strength of the structure, then injury can occur. Repeated microtrauma at the muscle tendon junction may overcome the tendon’s ability to heal itself. Tissue breakdown occurs triggering an inflammatory response that leads to tendonitis and even partial tears.

Chronic quadriceps tendonitis is really a problem called tendonosis. Inflammation is not present. Instead, degeneration and/or scarring of the tendon has developed. Chronic tendon injuries are much more common in older athletes (30 to 50 years old).

What does the condition feel like?

Pain from quadriceps tendonitis is felt in the area at the bottom of the thigh, just above the patella. The pain is most noticeable when you move your knee. The more you move your knee, the more tenderness develops in the area of the tendon attachment above the kneecap.

There may be swelling in and around the quadriceps tendon. It may be tender or very sensitive to touch. You may feel a sense of warmth or burning pain. The pain can be mild or in some cases the pain can be severe enough to keep the runner from running or other athletes from participating in their sport. Stiffness of the knee is common when you first get up in the morning (or after a long period of rest or inactivity), and during and after exercise.

How is quadriceps tendonitis diagnosed?

When you first visit First Choice Physical Therapy, diagnosis begins with a complete history of your knee problem followed by an examination of the knee, including the patella. There is usually tenderness with palpation of the inflamed tissues at the insertion of the tendon into the bone. We will assess you knee for range of motion, strength, flexibility and joint stability.

Our Physical Therapists will look for intrinsic and extrinsic factors affecting the knee (especially sudden changes in training habits). Potential problems with lower extremity alignment are identified. We will also check to see if the quadriceps tendon is partially torn or ruptured. Weakness of the extensor mechanism is a sign of such an injury.

You may be referred to a physician if a more serious pathology is suspected or your symptoms are not responding to Physical Therapy.

What treatment options are available?

Prevention of future injuries through patient education is a key component of our treatment program. This is true whether conservative care or surgical intervention is required. Modification of intrinsic and extrinsic risk factors is essential.

Non-surgical Rehabilitation

At First Choice Physical Therapy, the initial treatment for acute quadriceps tendonitis begins by decreasing the inflammation in the knee. Our Physical Therapist may suggest relative rest and anti-inflammatory medications, such as aspirin or ibuprofen, especially when the problem is due to overuse. Acetaminophen (Tylenol®) may be used for pain control if you can’t take anti-inflammatory medications for any reason.

Relative rest is a term used to describe a process of rest-to-recovery based on the severity of symptoms. If you have pain at rest, strict rest is required and possibly a short time of immobilization in a splint or brace. When pain is no longer present at rest, then a gradual increase in activity is allowed so long as the resting pain doesn’t come back.

Physical Therapy can help in the early stages by decreasing pain and inflammation. When you begin your Physical Therapy program, we may initially use ice massage, electrical stimulation, and ultrasound to limit pain and control (but not completely prevent) swelling. Some amount of inflammatory response is needed for a good healing response.

Our Physical Therapist will prescribe stretching and strengthening exercises to correct any muscle imbalances. Eccentric muscle strength training helps prevent and treat injuries that occur when high stresses are placed on the tendon during closed kinetic chain activities. Eccentric contractions occur as the contracted muscle lengthens. Closed kinetic chain activities means the foot is planted on the floor as the knee bends or straightens.

We often recommend flexibility exercises designed for the thigh and calf muscles. Specific exercises are used to maximize control and strength of the quadriceps muscles. We will show you how to ease back into jumping or running sports using good training techniques. Off-season strength training of the legs, and particularly the quadriceps muscles is advised.

Bracing or taping the patella can help you do exercises and activities with less pain. Most braces for patellofemoral problems are made of soft fabric, such as cloth or neoprene. You slide them onto your knee like a sleeve. A small buttress pads the side of the patella to keep it lined up within the groove of the femur. An alternative to bracing is to tape the patella in place. Our Physical Therapist can apply and adjust the tape over the knee to help realign the patella. The idea is that by bracing or taping the knee, the patella stays in better alignment within the femoral groove. This in turn is thought to improve the pull of the quadriceps muscle so that the patella stays lined up in the groove. Patients report less pain and improved function with these forms of treatment.

Our Physical Therapists may also recommend special shoe inserts, called orthotics, to improve knee alignment and function of the patella. Proper footwear for your sport is important.

Coaches, trainers, and Physical Therapists can work together to design a training program that allows you to continue training without irritating the tendon and surrounding tissues. Remember to warm up and stretch before exercise. Some experts recommend a cool down and stretching after exercise as well. Know your limits and don’t overdo it.

Use ice after activity if indicated by pain or swelling. Icing should be limited to no more than 20 minutes to avoid reflex vasodilation (increased circulation to the area to rewarm it causing further swelling). Heat may be used in cases of chronic tendinosis to stimulate blood circulation and promote tissue healing.

Whenever you have to miss exercising for any reason or when training for a specific event, adjust your training schedule accordingly. Avoid the “too” training errors mentioned earlier.

Quadriceps tendonitis is usually self-limiting. That means the condition will resolve with rest, activity modification, and Physical Therapy. Recurrence of the problem is common for patients who fail to let the quadriceps tendon recover fully before resuming training or other aggravating activities.

Although recovery time varies among patients, Physical Therapy for about four to six weeks is usually recommended. The aim of our treatment is to calm pain and inflammation, to correct muscle imbalances, and to improve the function of the quadriceps mechanism.

With the First Choice Physical Therapy rehabilitation program, many patients are able to return to their previous level of activity without recurring symptoms.

Post-surgical Rehabilitation

Many surgeons will have their patients take part in formal Physical Therapy after knee surgery for patellofemoral problems. More involved surgeries for patellar realignment or restorative procedures for tendon tissue require a delay before going to therapy. Rehabilitation may be slower to allow the tendon to heal before too much strain can be put on the knee.

When you begin your Physical Therapy program, treatments are designed to help control the pain and swelling from the surgery. Our Physical Therapist will choose exercises to help improve knee motion and to get the quadriceps muscles toned and active again. Muscle stimulation, using electrodes over the quadriceps muscle, may be needed at first to get the muscle moving again.

As your program evolves, more challenging exercises are chosen to safely advance the knee’s strength and function. The key is to get the soft tissues in balance through safe stretching and gradual strengthening.

At First Choice Physical Therapy our goal is to help you keep your pain under control, ensure you place only a safe amount of weight on the healing knee, and improve your strength and range of motion. When your recovery is well under way, regular visits to our office will end. Although we will continue to be a resource, you will be in charge of doing your exercises as part of an ongoing home program.

X-rays may be ordered on the initial visit to your doctor. An X-ray can show fractures or the presence of calcium deposits in the quadriceps muscle but X-rays do not show soft tissue injuries. In these cases, other tests, such as ultrasonography or magnetic resonance imaging (MRI), may be suggested. Ultrasound uses sound waves to detect tendon tears. MRIs use magnetic waves rather than X-rays to show the soft tissues of the body. This machine creates pictures that look like slices of the knee. Usually, this test is done to look for injuries, such as tears in the quadriceps. This test does not require any needles or special dye and is painless.

Surgery is rarely needed when a wide range of protective measures, relative rest, ice, support, and rehab are used. If nonsurgical treatment fails to improve your condition, then surgery may be suggested. Surgery is designed to stimulate healing through revascularization (restoring blood supply). Weak, damaged tissue is removed and the injured tendon is repaired. Tissue remodeling through surgery can restore function.

Arthroscopic procedures can usually be done on an outpatient basis. This means you can leave the hospital the same day. If your problem requires a more involved surgical procedure where bone must be cut to allow moving the quadriceps tendon attachment, you may need to spend one or two nights in the hospital.

The patella, or kneecap, can be a source of knee pain when it fails to function properly.

Alignment or overuse problems of the patella can lead to wear and tear of the cartilage behind the patella. Chondromalacia patella is a common knee problem that affects the patella and the groove that the patella slides in over the femur (thigh bone). The kneecap together with the lower end of the femur is considered the patellofemoral joint.

Chondromalacia is the term used to describe a patellofemoral joint that has been structurally damaged, while the term patellofemoral pain syndrome (PFPS) refers to the earlier stages of the condition where structural damage has not yet occurred. Symptoms are more likely to be reversible with PFPS.

This guide will help you understand:

• what parts of the knee are affected
• how this condition develops
• how health care professionals diagnose the condition
• what treatment options are available
• what First Choice Physical Therapy’s approach to rehabilitation is

What is the patella, and what does it do?

The patella (kneecap) is the moveable bone on the front of the knee. This unique bone is wrapped inside a tendon that connects the large muscles on the front of the thigh, the quadriceps muscles, to the lower leg bone. The large quadriceps tendon together with the patella and patellar ligament is called the extensor mechanism. Though we think of it as a single device, the extensor mechanism has two separate tendons, the quadriceps tendon on top of the patella, which connects the quadriceps muscle to the top of the patella, and the patellar tendon below the patella, which connects the lower portion of the patella to the shinbone (tibia).

Tightening up the quadriceps muscles places a pull on the tendons of the extensor mechanism. This action causes the knee to straighten. The patella acts like a fulcrum to increase the force of the quadriceps muscles.
The underside of the patella is covered with articular cartilage, the smooth, slippery covering found on joint surfaces. This covering helps the patella glide (or track) in a special groove made by the thighbone, or femur. This groove is called the femoral groove.

Two muscles of the thigh attach to the patella and help control its position in the femoral groove as the leg straightens. These two muscles are part of the quadriceps group and are called the vastus medialis obliquus (VMO) and the vastus lateralis (VL). The VMO runs along the inside of the thigh, and the VL lies along the outside of the thigh. If the timing between these two muscles is off or one is stronger than the other then the patella may be pulled off track and rubbing will occur on the articular cartilage on the back of the patella.

What causes this problem?

Problems commonly develop when the patella suffers repetitive wear and tear. The underlying cartilage begins to degenerate, a condition common in young athletes. Soccer players, snowboarders, cyclists, rowers, tennis players, ballet dancers, and runners are often affected but anyone whose knees are under great stress during any work or sport activity is at increased risk of developing chondromalacia patella.

Wear and tear can develop for several reasons. Both acute injury to the patella, such as a fall, or chronic friction between the patella and the femur, such as during jumping, can generate symptoms of patellofemoral pain syndrome. Degeneration leading to chondromalacia may also develop as part of the aging process, similar to putting a lot of miles on a car, where eventually the car parts wear out.

The main cause of a gradual onset of PFPS, which can lead to chondromalacia patella, is a problem in the way the patella tracks within the femoral groove as the knee moves. Physical and biomechanical changes alter the stress and load on the patellofemoral joint and cause excessive stress on the back of the patella.

The quadriceps muscle helps control the patella so it stays within the femoral groove. If part of the quadriceps is weak for any reason, a muscle imbalance can occur. When this happens, the pull of the quadriceps muscle may cause the patella to pull more to one side than the other. This in turn causes more pressure on the articular cartilage on one side than the other. In time, this pressure can damage the articular cartilage leading to chondromalacia patella. Muscles that are too tight in the lower extremity, such as the quadriceps muscle itself, or the muscles at the back of the leg or calf (hamstrings and gastrocnemius respectively) can also cause increased pressure on the back of the kneecap leading to early wear and tear.

A similar tracking problem occurs when the timing of the quadriceps muscles is off. As mentioned above, two of the quadriceps muscles that attach to the kneecap control the side-to -side motion.  These are the VMO (the muscle running down the inside of the thigh) and the VL (the muscle that runs down the outside part of the thigh.) People with patellofemoral problems sometimes have problems in the timing between the VMO and the VL.  Ideally, the smaller VMO fires microseconds earlier than the VL to keep the patella centred.  If the VL contracts first it tends to pull the patella toward the outside edge of the knee. The result is abnormal pressure on the articular surface of the patella.

Another type of imbalance may occur due to differences in how the bones of the knee are angled. These differences, or anatomic variations, are something people are born with. The angle between the thighbone and the shinbone is referred to as the “Q angle”. Some people are born with a greater than average Q angle. Women also tend to have a greater Q angle than men, due to their wider hips. The patella normally sits at the center of this angle within the femoral groove. When the quadriceps muscle contracts, the knee straightens, pushing the patella slightly to the outside of the knee. In cases where the Q angle is increased, the patella tends to shift outward with greater pressure. This leads to a similar pressure imbalance as when the VL is stronger than the VMO:  As the patella slides through the groove, it places more pressure on outside edge of the patella, leading to damage of the underlying articular cartilage.

Anatomic variations in the bone shapes themselves can also occur which contribute to the development of chondromalacia patella. For instance, one side of the femoral groove can be smaller than the other. This creates a situation where the groove is too shallow, usually on the outside part of the knee. People who have a shallow groove sometimes have their patella slip sideways out of the groove, causing a patellar dislocation. This is not only painful when it occurs, but it can damage the articular cartilage underneath the patella. If this occurs repeatedly, degeneration of the patellofemoral joint occurs fairly rapidly.

Another anatomic variation can be the patellar position. If the patella sits in an abnormal position, such as quite high or low, it also changes how the patella glides over the femur, and can lead to greater wear and tear on the articular cartilage. In addition, the patella may be very mobile in some individuals.  A hypermobile patella does not stay firmly in the femoral groove as the knee straightens and bends so it is at a greater risk of wearing on the cartilage as it moves around, and can possibly skip out of the femoral groove (subluxation or dislocation).

Weakness of the muscles around the hip can also indirectly affect the patella and can lead to patellofemoral joint pain as well as wear and tear on the cartilage of the patella. The muscles of the hip control the position of the knee. A weakness of the muscles that pull the hip out and away from the other leg, or turn the thigh outward (hip abductor  and external rotator muscles,) can lead to imbalances in the alignment of the entire leg including the knee joint. This causes abnormal tracking of the patella within the femoral groove and eventually pain around the patella. This misalignment is accentuated when jumping and running, or when descending stairs. Many patients are confused when their Physical Therapist begins exercises to strengthen and balance the hip muscles, but there is a very good reason that their therapist is focusing on this area.

Finally, the position of the foot plays a large part in maintaining the alignment of the knee and tracking of the patella in the femoral groove. The foot position is also partially controlled by the muscles of the hip and knee, but also by the muscles on the bottom of the foot and the muscles that run from the inside of your shin bone down underneath your foot. If any of these muscles are weak, your arch can drop downwards which causes your knee to rotate inwards. Anatomical variations in the bones of one’s foot may cause flat-footedness, and the result on the knee is the same.

What does chondromalacia patella feel like?

The most common symptom is pain underneath or around the edges of the patella. Often the pain radiates to the medial side of the kneecap whereas others experience vague pain in the knee that isn’t centered in any one spot.
The pain is made worse by any activities that load the patellofemoral joint, such as running, hill walking, or going up and down stairs. Kneeling or squatting is often too painful to even try. Keeping the knee bent for long periods, such as when sitting in a car or during a movie may also cause pain.

Sometimes there may be a sensation like the patella is slipping or giving way on activities such as jumping or running. Most often this is thought to be a reflex response to pain and not because there is any instability in the kneecap. As mentioned above, however, in some cases where the femoral groove is shallow or the patella is particularly mobile, the patella can sublux, but most often, the reflexive response to pain is to blame for the sensation.

The knee may grind, or you may hear a crunching sound when you squat or go up and down stairs. If there is a considerable amount of wear and tear, you may feel popping or clicking as you bend your knee. These sounds are caused by the uneven surface of the underside of the patella rubbing against the femoral groove. The knee may swell with heavy use and become stiff and tight. This stiffness can be because of fluid accumulating inside the knee joint, sometimes called ‘water on the knee’. This swelling is not unique to chondromalacia patella but sometimes occurs when the knee becomes irritated.

How do health care professionals diagnose the problem?

The history and physical examination are usually enough to suspect the diagnosis of chondromalacia patella. Your Physical Therapist at First Choice Physical Therapy will question you about your activity level, where precisely the pain is, when the pain began, what you were doing when the pain started, and what movements aggravate or ease the pain.  Chondromalacia patella generally begins insidiously (gradual onset) but it can also be instigated by a trauma to the knee, such as a fall onto the kneecap or a hard knock to the knee such as during a collision in sport.

Next your Physical Therapist will do a physical examination of the knee and entire lower extremities. They will palpate, or touch, around the knee and particularly along the patella to determine the exact location of pain. They will also move your kneecap to determine how mobile it is and may even try to illicit pain by rubbing on the underside of your patella if your patella is mobile enough to allow this. Your Physical Therapist will look for other factors such as bony alignment (Q-angle,) muscle flexibility, mobility of the patella, and joint laxity that may be contributing to your knee pain. They will want to look at how you stand and your foot position, and may ask to watch you walk, squat, jump or run. Your Physical Therapist will also check the strength and lengths of the muscles surrounding and affecting the knee joint such as the quadriceps, hamstrings, calves, hip flexors and buttocks muscles. All of these muscles, if weak or tight, can contribute to the forces applied to the knee joint and to the development and ongoing pain of chondromalacia patella.

Your Physical Therapist will check if they can illicit pain by providing resistance while you straighten your knee. This action generally reproduces the pain associated with chondromalacia patella because it puts pressure on the painful cartilage on the back of the patella and thus helps to confirm the diagnosis.

First Choice Physical Therapy provides services for Physical Therapy in Lynn Haven and Panama City Beach.

X-rays may be ordered on the initial visit to your doctor. An X-ray can help determine if the patella is properly aligned in the femoral groove. Several X-rays taken with the knee bent at several different angles can help determine if the patella seems to be moving through the femoral groove in the correct alignment. The X-ray may show the wear and tear between the patella and femur, but only when the problem has been there for a while and the wear and tear is significant.

Other tests, such as magnetic resonance imaging (MRI), may be suggested. The MRI machine uses magnetic waves rather than X-rays to show the soft tissues of the body. This machine creates pictures that look like slices of the knee. It used to be that this test was only done to look for injuries such as tears in the menisci or ligaments of the knee but recent advances in the quality of MRI scans have enabled doctors to see the articular cartilage on the scan and determine if it is damaged. This test does not require any needles or special dye and is painless.

In some cases, investigative arthroscopy may be needed to make the definitive diagnosis when there is still a question about whether chondromalacia patella is causing your knee problem. Arthroscopy is an operation that involves placing a small fiber-optic TV camera into the knee joint. This camera allows the surgeon to directly look at the structures inside the joint.  They can see the condition of the articular cartilage on the back of your patella from the inside, rather than guessing at the condition of it from the outside. The vast majority of patellofemoral problems are diagnosed without resorting to investigative arthroscopy. Arthroscopy is generally reserved to diagnose knee pain not identified by other means.

Interestingly, there is no clear link between the severity of symptoms and X-ray or arthroscopic findings. This means that you can have severe pain but not much will show up on the investigations. The contrary can also occur; severe damage but little pain.  For this reason, most often health care professionals rely upon the history, symptoms, and results of the physical examination to determine chondromalacia patella as the cause of your pain rather than just the results of investigative tests.

What treatment options are available?

Nonsurgical Rehabilitation and Treatment

Non-operative treatment is the usual treatment for this problem. You may require 4-6 weeks of Physical Therapy treatment, and then several more months of a home stretching and strengthening program to treat your chondromalacia patella. Getting the pain and inflammation under control is the first step. The overall goals for a rehab plan are to provide pain relief or pain control, improve muscle function and flexibility, improve knee alignment, and avoid further wear and tear.

The initial treatment for chondromalacia patella at First Choice Physical Therapy will aim to decrease the inflammation and pain in your knee. Simply icing the knee can often assist with the inflammation and relieve a great deal of the pain. In cases of chronic pain (lasting longer than 3 months), heat may be more useful in decreasing pain. Your Physical Therapist may also use electrical modalities such as ultrasound or interferential current to decrease the pain and inflammation. Massage, particularly for the quadriceps muscle, may also be helpful. During the initial stages of treatment, where the knee is still quite painful, a relative rest from activity may be required. This means that those activities that bother your knee the most may need to be stopped or decreased for a specific amount of time to allow your knee pain to settle down.  In many cases, however, you may still be able to partake in a moderate amount of activity. Your Physical Therapist will advise you on the appropriate amount of rest from activity that will be needed in your specific case. For some patients a complete cessation of all activities is required in order to get the pain and inflammation under control.

Your physician may suggest anti-inflammatory medications, such as aspirin or ibuprofen, as another means of combating the inflammation and pain. Acetaminophen or paracetamol may be suggested for pain control if you can’t take anti-inflammatory medications for any reason.

Once the initial pain and inflammation has calmed down, your Physical Therapist will focus on improving the flexibility, strength, and alignment around the knee joint and entire lower extremity. Static stretches for the muscles and tissues around the knee (particularly the quadriceps and iliotibial band on the outside of the knee) will be prescribed by your Physical Therapist early on in your treatment to improve flexibility. Again, any tightness in the muscles or tissues around the knee can increase the pull on the patella and affect alignment during walking, running or jumping so it is important to address this immediately.

Strength imbalances will also affect the alignment of the knee and can cause muscles to tighten which put more pressure on the knee and can contribute to the cause of chondromalacia patella. Your Physical Therapist will determine which muscles in your individual case require the most strengthening. Strength in both the knee and the hip (which controls the knee position) are very important.  In most cases your Physical Therapist will prescribe exercises that strengthen the medial quadriceps muscle (VMO) as this muscle is prone to weakness around the knee, and as described above, when it is not strong enough, the pressure behind the kneecap increases.  Your Physical Therapist will also focus on the particular timing of contraction of this muscle to ensure that it fires when needed to guide the patella properly along the femoral groove.

The muscles of the hip (gluteals) that work to align the knee over top of the foot also have a tendency to be weak so specific attention will be paid to them in the rehabilitation process.

When you have gained enough strength in the knee and hip muscles, your Physical Therapist will incorporate advanced exercises that force the knee and hip to recruit the correct muscles while under tension and at a quicker rate.  When bending the knee in activities such as running, jumping or stair climbing and descending, the knee muscles and ligaments are placed under load while they are stretching (eccentric load.) This load can be tremendous and translates to heavy loads on the back of the kneecap. In order to prepare the patella to take this load once you return to activity your Physical Therapist will prescribe ‘eccentric’ muscle strengthening. Bending the knee quickly into a squatting position and then stopping rapidly (drop squats) encourages the patella (and entire knee joint) to adapt to the force that will eventually be needed to return to physical activity, and to recruit the proper muscles with the proper timing. When appropriate, weights can be added to simulate the increased body weight that the knee endures during running and jumping. Your Physical Therapist may ask you to do this exercise on a board slanting downwards (approximately 25 degrees) which has been shown to improve the recruitment of the required knee muscles. In addition, an electrical muscle stimulator may be used on the quadriceps muscle during the activity, which encourages improved recruitment of the muscle, particularly the VMO. All exercises should be completed with minimal or no pain and advancing the exercises should be done only at the discretion of your Physical Therapist. Once these exercise are mastered, your Physical Therapist may add even more advanced jumping and landing exercises from a height or on different surfaces.

As part of your treatment your Physical Therapist may use a hands-on technique to mobilize your kneecap and improve its flexibility if it is stiff.  In cases where the patella does not move well, improved movement can assist in decreasing the resistance that the VMO needs to work against and make tracking of the patella easier to control.
Taping the kneecap may also help you to do exercises and activities with less pain. Your Physical Therapist may even teach your how to tape your own knee so you can do it for sporting activities that you are still engaging in. Taping over a longer time frame will cause irritation to the skin and can be cumbersome, therefore if the taping helps, a brace, which performs a similar function, may be suggested. Braces used for chondromalacia patella are made of soft fabric, such as cloth or neoprene, and work to encourage proper alignment of the patella as it glides down the knee. There are small buttress pads in the brace that sit on the side of the patella to keep it lined up within the groove of the femur. Patients commonly report less pain and improved function with both taping and bracing.

As mentioned above, proper alignment of your entire lower extremity is paramount to decreasing the overall stress that is placed on the patella and knee in general. In addition to strengthening, stretching, hands-on treatment, and taping, foot orthotics may be useful to assist with alignment.  Strengthening of the muscles of the shin and foot can help with the foot alignment, but often this is not enough to fully correct the problem, and foot orthotics are required.  Alignment of the foot in turn then encourages proper alignment up the lower extremity chain. Your Physical Therapist can advise you on whether orthotics would be useful for you, and also on where to purchase them.
A critical part of our treatment for chondromalacia patella at First Choice Physical Therapy includes specific education on returning to full physical activity. Bending and straightening the knee occurs often even in everyday activities such as walking or stair climbing so a patella that is recovering from injury can easily be aggravated.  Returning you back to normal physical activity at a graduated pace is crucial to avoid repetitive pain or a chronic injury. Your Physical Therapist will advise you on the acceptable level of activity at each stage of your rehabilitation process and assist you in returning to your activities as quickly but as safely as possible.

With a well-planned rehabilitation program and adherence to suggested levels of rest and activity modification, most people respond very well to the treatment we provide for chondromalacia patella at First Choice Physical Therapy. If, however, your knee pain is not responding to the treatment then we may suggest that you consult an orthopaedic surgeon as surgery may be necessary in your case to resolve your pain.

If nonsurgical treatment fails to improve your condition, surgery may be suggested. The procedure used for patellofemoral problems varies. In severe cases a combination of one or more of the following procedures may be necessary.

Arthroscopic Method

Arthroscopy is sometimes useful in the treatment of patellofemoral problems of the knee. Looking directly at the articular cartilage surfaces of the patella and the femoral groove is the most accurate way of determining how much wear and tear there is in these areas. Your surgeon can also watch as the patella moves through the groove, and may be able to decide whether or not the patella is moving normally. If there are areas of articular cartilage damage behind the patella that are creating a rough surface, special tools can be used by the surgeon to smooth the surface and reduce your pain. This procedure is sometimes referred to as ‘shaving the patella.’

Cartilage Procedure

In more advanced cases of patellar arthritis, surgeons may operate to repair or restore the damaged cartilage. The type of surgery needed to repair articular cartilage is based on the size, type, and location of the damage. Along with surgical treatment to fix the cartilage, other procedures may also be done to help align the patella so less pressure is placed on the healing cartilage.

Lateral Release

If your patella problems appear to be caused by a misalignment problem, a procedure called a lateral release may be suggested. This procedure is done to allow the patella to shift back to a more normal position and relieve pressure on the articular cartilage. In this operation, the tight ligaments on the outside (lateral side) of the patella are cut, or released, to allow the patella to slide more towards the center of the femoral groove. These ligaments eventually heal with scar tissue that fills in the gap created by the surgery, but they no longer pull the patella to the outside as strongly as prior to the surgery. This helps to balance the pull from the quadriceps muscles and equalize the pressure on the articular cartilage behind the patella.

Ligament Tightening Procedure

In some cases of severe patellar misalignment, a lateral release alone may not be enough. For problems of repeated patellar dislocations, the tendons on the inside edge of the knee (the medial side) may have to be tightened as well.

Bony Realignment

If the misalignment is severe, the bony attachment of the patellar tendon may also have to be shifted to a new spot on the tibia (shin bone.) Remember that the patellar tendon attaches the patella to the tibia just below the knee. By moving a section of bone where the patellar tendon attaches to the tibia, surgeons can change the way the tendon pulls the patella through the femoral groove.

The surgeon removes a section of bone where the patellar tendon attaches on the tibia. This section of bone is then reattached on the tibia closer to the other knee.
Usually, the bone is reattached onto the tibia using screws. This procedure shifts the patella to the medial side. Once the surgery heals, the patella should track better within the center of the groove, spreading the pressure equally on the articular cartilage behind the patella.

Arthroscopic procedures to shave the patella or a simple lateral release can usually be done on an outpatient basis, meaning you can leave the hospital the same day. If your problem requires the more involved surgical procedure where bone must be cut to move the patellar tendon attachment, you may need to spend one or two nights in the hospital.

Patients undergoing a patellar shaving usually begin rehabilitation at First Choice Physical Therapy right away. More involved surgeries for patellar realignment or restorative procedures for the articular cartilage may require a delay before starting at First Choice Physical Therapy just to give the tissues a short time to begin the healing process before they are stressed. Rehabilitation will be slower with a realignment or restorative procedure as the bone and cartilage needs more time to heal before too much strain can be put on the knee.
Your first few appointments at First Choice Physical Therapy will focus on helping to control the pain and swelling from the surgery. Icing the knee frequently will assist with the inflammation and relieve a great deal of the pain. Your Physical Therapist may also use electrical modalities such as ultrasound or interferential current to decrease the pain and inflammation. Massage, particularly for the quadriceps muscle, may also be helpful in the early stages after surgery.

One of the first exercises your Physical Therapist will prescribe will be some gentle range of motion exercises for your knee to gradually regain full movement. This should be done within a pain free range of motion, however, movement will be encouraged even if it causes a slight bit of discomfort as the movement itself can greatly assist with dispersing any inflammation as well as improving the overall level of pain. A stationary bicycle can be very useful in the initial stages of gaining range of motion in the knee, so if able, you will be encouraged to use one.  Even if you are unable to fully rotate the pedals, the back and forth motion on the bike is an excellent method of slowly encouraging the knee to regain its full range of motion.

Your Physical Therapist will begin to add some gentle strengthening exercises as well for your knee. Initially these may only involve isometric exercises, where you tighten and hold the quadriceps muscle without actually moving the knee itself. Gradually though, the strengthening exercises will be advanced and will address any deficits in strength that your Physical Therapist has identified as contributing factors to the initial development of your chondromalacia patella.

As you recover from the direct effects of the surgery, your Physical Therapist will begin to add in exercises to your program similar to that listed under non-surgical rehabilitation. Flexibility of the knee and hip will be addressed, as well as the strength, and the overall alignment of these joints during your rehabilitation exercises and everyday activities. Eccentric exercises will be added as soon as they are appropriate, and exercises specific to the sport you enjoy will also be incorporated as soon as it is safe to do so

When you are well under way with your rehabilitation, regular visits to First Choice Physical Therapy will end. Your Physical Therapist will continue to be a resource, but you will be in charge of doing your exercises as part of an ongoing home program. Generally rehabilitation at First Choice Physical Therapy after surgery for chondromalacia patella goes extremely well and clients can return without difficulties to the activities they enjoy participating in. If however, your pain is lasting longer that your therapist thinks it should or you are not progressing as rapidly as we would expect, we will ask you to follow up with your surgeon to ensure that there are no complicating factors impeding your rehabilitation.

Alignment or overuse problems of the knee structures can lead to strain, irritation, and/or injury of the quadriceps muscle and tendon. This produces pain, weakness, and swelling of the knee joint.

These problems can affect people of all ages but the majority of patients with overuse injuries of the knee (and specifically quadriceps tendonitis) are involved in sports such as soccer, volleyball, running activities, or other repetitive jumping activities.

This guide will help you understand:

• how the problem develops
• how health care professionals diagnose the condition
• what treatment options are available
• what First Choice Physical Therapy’s approach to rehabilitation is

What is the quadriceps muscle/tendon, and what does it do?

The patella (kneecap) is the moveable bone on the front of the knee. This unique bone is wrapped inside a tendon that connects the large muscles on the front of the thigh, the quadriceps muscles, to the lower leg bone.

The large quadriceps muscle ends in a tendon that inserts into the tibial tubercle, a bony bump at the top of the tibia (shin bone) just below the patella. The quadriceps tendon (on the top of the patella) together with the patella and the patellar tendon (on the bottom of the patella) is called the quadriceps mechanism.

Tightening up the quadriceps muscles places a pull on the tendons of the quadriceps mechanism. This action causes the knee to straighten. The patella acts like a fulcrum to increase the force of the quadriceps muscles.

The long bones of the femur and the tibia act as lever arms, placing force or load on the knee joint and surrounding soft tissues. The amount of load can be quite significant. For example, the joint reaction forces of the lower extremity (including the knee) are two to three times the body weight during walking and up to five times the body weight when running.

How does this problem develop?

Quadriceps tendonitis occurs most often as a result of repetitive stresses placed on the supporting structures of the knee. Running, jumping, and quick starts and stops contribute to this condition. Overuse injuries from sports activities are the most common causes of quadriceps tendonitis but anyone can be affected, even those who do not participate in sports or recreational activities.

There are both extrinsic factors (those not related to the body) and intrinsic factors (those pertaining to the body) that can contribute to the development of quadriceps tendonitis. Extrinsic factors include inappropriate footwear, training errors such as doing too much too quickly, or for too long, and inappropriate sport training/playing ground being used.
Intrinsic factors such as age, flexibility, and joint laxity are also important. Misalignment of the foot, ankle, and leg can play a key role in tendonitis. Factors such as a flat foot position, tracking abnormalities of the patella, rotation of the tibia, and a leg length difference can create increased and often uneven load on the quadriceps mechanism. Any muscle imbalance of the lower extremity (from the hip down to the toes) can impact the quadriceps muscle and affect the joint. Individuals who are overweight may have added issues with load and muscle imbalance leading to quadriceps tendonitis.

Strength of the patellar tendon is in direct proportion to the number, size, and orientation of the collagen fibers that make up the tendon. Overuse is simply a mismatch between load or stress on the tendon and the ability of that tendon to distribute the force. If the forces placed on the tendon are greater than the strength of the structure, then injury can occur. Repeated microtrauma at the musculotendinous junction may overcome the tendon’s ability to heal itself. As a result issue breakdown occurs triggering an inflammatory response that leads to tendonitis and even partial tears.

Chronic quadriceps overuse leads to a problem called tendonosis. Unlike with tendonitis, inflammation is not present in tendonosis. Instead, degeneration and/or scarring of the tendon has developed due to long-term wear and tear. Chronic tendon injuries are much more common in older athletes (30 to 50 years old).

What does quadriceps tendonitis feel like?

Pain from quadriceps tendonitis is felt in the area at the bottom of the thigh, just above the patella. The pain is most noticeable when you move your knee. The more you move your knee, the more tenderness develops in the area.

There may be swelling in and around the quadriceps tendon and the tendon may be tender or very sensitive to touch. You may feel a sense of warmth or burning pain. The pain can be mild or in some cases the pain can be severe enough to keep the runner from running or other athletes from participating in their sport. Stiffness of the knee is common when you first get up in the morning (or after a long period of rest or inactivity), as well as during and after exercise.

How do health care professionals diagnose the problem?

Diagnosis begins with a complete history of your knee problem followed by an examination of the knee, including the patella. Your Physical Therapist at First Choice Physical Therapy will ask you questions about where precisely the pain is, when the pain began, what you were doing when the pain started, and what movements aggravate or ease the pain.  As mentioned above, extrinsic factors such as training history as well as type of footwear are important for your therapist to inquire about. The history alone will often lead your Physical Therapist to the suspicion of quadriceps tendonitis.

Next your Physical Therapist will do a physical examination of the knee and entire lower extremities. They will palpate, or touch, around the knee and particularly along the quadriceps tendon to determine the exact location of pain. Your Physical Therapist will look for the individual intrinsic factors mentioned above, such as alignment and flexibility that may be affecting your knee. They will assess the stability of the knee joint to determine if the laxity of the ligaments and tissues surrounding the knee joint are contributing to the problem.

Your Physical Therapist may want to look at how you stand, your foot position, or watch you walk, squat, or jump. Your Physical Therapist will also check the strength and lengths of the muscles surrounding and affecting the knee joint such as the quadriceps, hamstrings, calves, hip flexors and buttocks muscles. All of these muscles, if weak or tight, can contribute to the forces applied to the knee joint and lead to the development of quadriceps tendonitis. Providing resistance while you straighten your knee generally reproduces the pain associated with quadriceps tendonitis so this will also be tested. Weakness during this straightening motion or on squatting on one leg may cause your Physical Therapist to suspect a partially torn or ruptured quadriceps tendon. Often a divot in the contour of the tendon can be felt if the tendon is even partially torn and an investigative exam is generally then done to confirm the diagnosis.

Diagnostic Tests

X-rays may be ordered on the initial visit to your doctor. An X-ray can show fractures or the presence of calcium deposits in the quadriceps muscle but X-rays do not show soft tissue injuries. If a soft tissue injury is suspected, such as a quadriceps tendon tear or rupture, other tests, such as ultrasonography or magnetic resonance imaging (MRI), may be required. Ultrasound uses sound waves to detect tendon tears. MRIs use magnetic waves rather than X-rays to show the soft tissues of the body. An MRI  machine creates pictures that look like slices of the knee. This test does not require any needles or special dye and is painless.

What treatment options are available?

Nonsurgical Rehabilitation

Quadriceps tendonitis is usually self-limiting. That means the condition will run its course and resolve with the appropriate rest, activity modification, and  Physical Therapy. Recurrence of the problem is common for patients who fail to let the quadriceps tendon recover fully before resuming training or other aggravating activities.

The initial aim of treatment for acute quadriceps tendonitis at First Choice Physical Therapy is to decrease the inflammation and pain in the knee. Simply icing your knee can assist with the inflammation and relieve a great deal of the pain. In cases of chronic tendonitis, heat may be more useful in decreasing pain. Your Physical Therapist may also use electrical modalities such as ultrasound or interferential current to help decrease the pain and control the amount of inflammation. Some mild inflammation is actually needed in order for the injury to heal.  Massage, especially for the quadriceps muscle, may also be helpful.

Medication to ease the pain or inflammation can often be very beneficial in the overall treatment of quadriceps tendonitis. Your Physical Therapist may suggest you see your doctor to discuss the use of anti-inflammatories or pain-relieving medications in conjunction with your Physical Therapy treatment.  Your Physical Therapist may even liaise directly with your doctor to obtain their advice on the use of medication in your individual case.

As inflammation of the quadriceps tendon most often occurs due to repetitive activity, rest is an important part of the treatment.  ‘Relative rest’ is a term used to describe a process of rest-to-recovery based on the severity of symptoms. If you are experiencing pain while doing nothing (resting) it means the injury is more severe and your Physical Therapist will advise a period of strict rest and possibly even a short time of immobilization in a splint or brace to prevent any repetitive knee flexion/extension. When pain is no longer present at rest, then a gradual increase in activity is permitted so long as there is no return in resting pain.

Once the initial pain and inflammation has calmed down, your Physical Therapist will focus on improving the flexibility, strength, and alignment around the knee joint and the entire lower extremity. Static stretches to increase the flexibility of the muscles and tissues around the knee (particularly the quadriceps and iliotibial band on the outside of the knee) will be prescribed by your Physical Therapist early on in your treatment. Again, any tightness in the muscles or tissues around the knee can increase the pull on the quadriceps tendon or affect alignment during walking, running or jumping so it is important to address this immediately. Dynamic stretching (rapid motions that stretch the tissues quickly) will also be taught and will be incorporated into your rehabilitation exercise routine as part of your warm-up once you return to doing more aggressive physical activity. Dynamic stretches are used to prepare the tissues for activity whereas static stretches focus more on gaining flexibility.

Strength imbalances will also affect the alignment of the knee and can cause muscles to tighten. Your Physical Therapist will determine which muscles in your individual case require the most strengthening. Strength in both the knee and the hip (which controls the knee position) are very important.  When bending the knee, the quadriceps tendon is placed under load while it is stretching. This load can be tremendous especially when jumping or landing. In order to prepare the healing tendon to take this load, your Physical Therapist will prescribe ‘eccentric’ muscle strengthening. Eccentric contractions occur as the muscle lengthens and the tendon is put under stretch.  Bending your knee quickly into a squatting position and then stopping rapidly (drop squats) encourages the knee to adapt to the force that will eventually be needed to return to physical activity. When appropriate, weights can be added to simulate the increased body weight that the knee endures during running and jumping. Your Physical Therapist may even ask you to do this exercise on a board slanting downwards (approximately 25 degrees) which has been shown to also increase the force through the tendon. In addition, an electrical muscle stimulator on the quadriceps may be used which encourages improved recruitment of the quadriceps muscle. All exercises should be completed with minimal or no pain and advancing the exercises should be done at the discretion of your Physical Therapist as not to flare up the healing tendon.

In addition to stretching and strengthening the knee, bracing or taping the patella or the quadriceps tendon itself can help you do exercises and activities with less pain. Your Physical Therapist can educate you on which brace would be most appropriate for you. Most braces for knee tendonitis problems are made of soft fabric, such as cloth or neoprene. These braces work by encouraging proper alignment of the patella in the femoral groove and/or by distributing the force on the quadriceps tendon which is,  in turn, improves the functioning of the quadriceps mechanism. An alternative to bracing is the use of tape. Your Physical Therapist can tape your knee for you and can also teach you how to do it for yourself. Taping is an easy and cost-effective way to determine if a brace will decrease your pain before actually investing in one. Patients commonly report less pain and improved function with both taping and bracing.

Proper alignment of your entire lower extremity is paramount to decreasing the overall stress that is placed on your quadriceps tendon. In addition to strengthening and stretching, foot orthotics may be useful to correct your foot position, which encourages proper alignment up the lower extremity chain. Your Physical Therapist can advise you on whether orthotics would be useful for you, and also on where to purchase them.
A critical part of our treatment for quadriceps tendonitis at First Choice Physical Therapy includes education on returning to physical activity. Bending and straightening your knee occurs often even in everyday activities such as walking or stair climbing so a quadriceps tendon that is recovering from injury can easily be re-aggravated.  Returning to your normal physical activity at a graduated pace is crucial to avoid repetitive tendonitis pain or a chronic injury. Advice from your Physical Therapist on the acceptable level of activity at each stage of your rehabilitation process will be invaluable, and will assist you in returning to your activities as quickly but as safely as possible.

With a well-planned rehabilitation program, adherence to suggested levels of rest and activity modification, and by addressing the intrinsic and extrinsic factors that are modifiable, most patients are able to return to their previous level of activity without recurring symptoms. If, however, your pain continues and does not respond to conservative treatment, your Physical Therapist may refer you back to your doctor or to an orthopaedic surgeon so you may discuss whether surgery may be an option for treatment.

Surgery is rarely needed for quadriceps tendonitis. If nonsurgical treatment fails to improve your condition, however, then surgery may be suggested. Surgery is designed to stimulate healing through revascularization (restoring blood supply). More severe cases may require the attachment of the quadriceps tendon to be moved in order to alter the biomechanics of the quadriceps mechanism. During the surgical procedure weak, damaged tissue is removed and any injured tendon is also repaired.

Arthroscopic revascularization procedures can usually be done on an outpatient basis (you can leave the hospital the same day.) If your problem requires a more involved surgical procedure such as moving the quadriceps tendon attachment, you may need to spend one or two nights in the hospital.

What should I expect after treatment?

Patients will benefit greatly from partaking in Physical Therapy at First Choice Physical Therapy after quadriceps tendon surgery.  More involved surgeries for patellar realignment or restorative procedures for tendon tissue usually require a delay before starting therapy in order to give the tissues a short time to begin the healing process before they are stressed. Rehabilitation will also be slower with a more involved surgery, as more time is needed to allow the tendon to heal even more before too much strain is put on the knee. Your surgeon may want you to wear a brace for the initial period after your surgery to protect the knee. Once rehabilitation begins, you will be able to remove the brace to do your exercises while you are at the clinic and when you are at home. Complete removal of the brace will be dictated by your surgeon and Physical Therapist, and will occur once your thigh muscles are strong enough to support the leg, and once your reaction time is quick enough to protect the knee if you should slip.

Your first few appointments at First Choice Physical Therapy after surgery will focus on controlling the pain and swelling from the surgery. Icing the knee frequently will assist with the inflammation and relieve a great deal of the pain. Your Physical Therapist may also use electrical modalities such as ultrasound or interferential current to decrease the pain and inflammation. Massage, particularly for the quadriceps muscle, may also be helpful in the early stages post-surgically.

One of the first exercises your Physical Therapist will prescribe will be some gentle range of motion exercises for your knee to gradually regain full movement. This should be done within a pain-free range of motion, however, movement will be encouraged even if it causes a slight bit of discomfort as the movement itself can greatly assist with dispersing any inflammation as well as improving the overall level of pain. A stationary bicycle can be very useful in the initial stages of gaining range of motion in the knee, so if able, you will be encouraged to use one.  Even if you are unable to fully rotate the pedals, the back and forth motion on the bike is an excellent method of slowly encouraging the knee to regain its full range of bending and straightening.

When appropriate your Physical Therapist will begin to add some gentle strengthening exercises for your knee. Initially these may only involve isometric exercises, where you tighten and hold the quadriceps muscle without actually moving the knee itself. Isometric exercises can be done almost immediately within the limits of discomfort.  A muscle stimulator may be used on the quadriceps at this point to encourage the muscle fibers to contract.  Gradually your therapist will advance your strengthening exercises.

The more advanced exercises will address any deficits in strength that your Physical Therapist has identified as a contributing factor to the initial development of your quadriceps tendonitis.

As you recover from the direct effects of the surgery, your Physical Therapist will begin to add in similar exercises to your program as those listed under non-surgical rehabilitation. Flexibility of the knee and hip will be addressed, as well as the strength, and the overall alignment of these joints during your rehabilitation exercises and everyday activities. Eccentric exercises will be added as soon as they are appropriate, and exercises specific to the sport you enjoy will also be incorporated as soon as it is safe to do so

When you are well under way with your rehabilitation, regular visits to First Choice Physical Therapy will end. Your Physical Therapist will continue to be a resource, but you will be in charge of doing your exercises as part of an ongoing home program. Generally, rehabilitation at First Choice Physical Therapy after surgery for quadriceps tendonitis goes extremely well and clients can return without difficulties to the activities they enjoy participating in. If however, your pain is lasting longer that your therapist thinks it should or you are not progressing as rapidly as they would expect, your therapist will ask you to follow up with your surgeon to ensure that there are no complicating factors impeding your rehabilitation.

An Osgood-Schlatter lesion involves pain and swelling in the small boney bump on the front of the tibia (shinbone), right below the kneecap. It primarily occurs in children and adolescents. The problem affects the area where bone growth occurs. Too much stress on the growing bone causes the pain and swelling. The pain often worsens with activity and eases with rest. Fortunately, the condition is not serious and it is usually only temporary.

Osgood-Schlatter Disease is the most frequent cause of knee pain in children between the ages of 10 and 15. The problem used to occur mostly in boys but with more girls playing sports, boys and girls are now affected equally. Being that girls’ skeletons begin to mature earlier than boys, girls tend to have this condition when they are one to two years younger than boys. Kids who play sports have this condition 20 percent more often than non-athletes. In addition, the lesion seems to run in families; when one child is affected, there’s a 30 percent chance a sibling will have it, too.

This guide will help you understand:

• why the condition develops
• how health care professionals diagnose the condition
• what treatment options are available

What part of the knee is affected?

The Osgood-Schlatter lesion affects the tibial tuberosity. The tibial tuberosity is the bump on the top of the tibia (shinbone) where the patellar tendon connects. Tendons connect muscles to bones. The patellar tendon stretches over the top of the patella (kneecap). The patellar tendon connects the large quadriceps muscle on the front of the thigh to the tibial tuberosity. As the quadriceps muscle works, it pulls on the patellar tendon and extends (straightens) the knee joint.

A small bursa sometimes develops where the patellar tendon meets the tibial tuberosity. A bursa is a normal structure that often forms in areas where friction occurs, such as between muscles, tendons, and bones. A bursa is a thin sac of tissue filled with fluid. The fluid lubricates the area and reduces friction.  If too much friction occurs, however, the bursa can swell and become a problem itself.

How did this problem develop?

Osgood-Schlatter lesions fit into a category of bone development disorders known as osteochondroses. (Osteo means bone, and chondro means cartilage.) In normal development, specialized bone growth centers (called growth plates) change over time from cartilage to bone. The growth centers expand and finally unite. This is how bones grow in length and width. Bone growth centers are located throughout the body.

Children with bone development problems in one area are likely to develop similar problems elsewhere. For example, among young athletes with growth plate problems in the back of the heel (Sever’s Syndrome), about two-thirds also develop an Osgood-Schlatter lesion. Children who have an Osgood-Schlatter lesion also have a small chance of problems at the top of the patellar tendon, where it attaches to the bottom tip of the kneecap. This condition is known as Sinding-Larsen-Johansson disorder.

The main cause of Osgood-Schlatter lesions is too much tension in the patellar tendon.

The tension can come from overuse from sports activity and from growth spurts. Usually both happen together and both put extra stress on the tibial tuberosity.

During growth spurts, the tendon may not be able to keep up with the growth of the lower leg and the tendon ends up being relatively too short. The tendon constantly pulls at the tibial tuberosity. Tension from sports activity comes from overuse during the activities. When the quadriceps muscle on the front of the thigh works, it pulls on the patellar tendon. The tendon in turn pulls on the tibial tuberosity. If the tension is too great and occurs too often while the bone is developing, it can pull the growth area of the tibial tuberosity away from the growth area of the shinbone.
A bump can form at the tibial tuberosity because the separated growth plates keep growing and expanding. The area between the bone fragments fills in with new tissue, either cartilage or bone. The new tissue causes the tibial tuberosity to become enlarged and painful.

Another possible contributing factor to Osgood-Schlatter lesions is abnormal alignment in the legs.  Kids who are knock-kneed or flat-footed seem to be prone to developing this condition as these postures form a sharper angle between the thigh bone/quadriceps muscle and the patellar tendon. This angle is called the Q-angle. A large Q-angle puts more tension on the patellar tendon and bone growth plate of the tibial tuberosity, increasing the chances for an Osgood-Schlatter lesion to develop. A high-riding patella, called patella alta, is also thought to contribute to development of Osgood-Schlatter lesions.

What does an Osgood-Schlatter lesion feel like?

In an Osgood-Schlatter lesion, the tibial tuberosity is often enlarged and painful. It hurts when bumped. It also hurts when pressure is put on it, such as when kneeling. Activities like running, jumping, climbing, and kicking may hurt because of the tension of the patellar tendon pulling on the tibial tuberosity.

Symptoms generally go away gradually over a period of one to two years and can be managed in that time with Physical Therapy. The condition, however, may leave a permanent, painless bump below the knee and the area may always be tender when pressure is applied to it. Many adults who had a lesion as a child still have pain when kneeling on that knee.

Complications can occur if the area between the bone fragments fills in with cartilage rather than bone. Normally, the bone growth plates join together with solid bone in between. If cartilage fills in the space, the condition is called a nonunion.

How do health care professionals diagnose the condition?

Diagnosis begins with a complete history of your child’s knee problem followed by an examination of the knee and related joints.  Most often your Physical Therapist at First Choice Physical Therapy can make the diagnosis of Osgood Schlatter Disease from the history and physical examination.  Your Physical Therapist will ask your child questions about where precisely the pain is, when the pain began, what they were doing when the pain started, and what movements aggravate or ease the pain.  They will also inquire about pain elsewhere in the body such as in the hips, heels, or lower back.  If your child is active in sport, they will inquire about which sports they are involved in, and how much and how often they are participating.  They will also want to know if any siblings have also suffered from knee pain and what the nature of the problem was.  The history alone will often lead your Physical Therapist to the suspicion of Osgood Schlatter Disease.

Next your Physical Therapist will do a physical examination of both your child’s painful and non-painful knee, and examine the entire lower extremities for factors contributing to the problem. Your therapist will palpate, or touch, around the knee and particularly along the patellar tendon and at the tibial tuberosity to determine the exact location of pain and to note any swelling. They will assess the stability of the knee joint to determine if the laxity of the ligaments and tissues surrounding the knee joint are contributing to the problem.
In order to assess your child’s individual alignment your Physical Therapist may want to look at how they stand, observe their foot position, or watch them walk, squat, or jump. Your Physical Therapist will also check the strength and lengths (flexibility) of the muscles surrounding and affecting the knee joint such as the quadriceps, hamstrings, calves, hip flexors and buttocks muscles. All of these muscles, if weak or tight, can contribute to an imbalance of forces applied to the knee joint and may contribute to the development of Osgood Schlatter Disease. Providing resistance while your child straightens their knee often reproduces the pain associated with Osgood Schlatter Disease so this will also be tested. Severe weakness during this straightening motion or while squatting on one leg may cause your Physical Therapist to suspect a more serious injury affecting the tibial tuberosity.

What can be done for the problem?

Nonsurgical Treatment

Generally the passing of time allows the pain from Osgood-Schlatter Disease to dissipate. It takes one to two years for the bone growth plates of the tibial tuberosity to grow together and form one solid bone. When this occurs, symptoms usually go away completely.  As the pain is most often related to the closing of the growth plates, the age of your child when the pain begins can contribute to how long the pain lasts overall.

Your doctor may prescribe anti-inflammatory medicine to help reduce swelling.
Working with a Physical Therapist at First Choice Physical Therapy can also help to reduce swelling, manage pain levels, aid in activity modification, and assist in developing proper alignment to decrease the stress applied to the painful knee.

Cortisone injections are commonly used to control pain and inflammation in other types of injuries. However, a cortisone injection is usually not appropriate for Osgood-Schlatter lesions. Cortisone injections haven’t shown consistently good results for this condition.

There is also a high risk that the cortisone will cause the patellar tendon to rupture.

What can be expected from treatment?

Nonsurgical Rehabilitation

With nonsurgical rehabilitation at First Choice Physical Therapy, the goal is to reduce pain and inflammation, and decrease the overall stress applied to the knees.  Fortunately, most Osgood-Schlatter lesions get better with Physical Therapy treatment and the passing of time as the bones mature.  The foremost aim of treatment at First Choice Physical Therapy is to decrease the inflammation and pain in the knee. Simply having your child ice their knee can assist with the inflammation and relieve a great deal of the pain. In cases of chronic pain, heat may be more useful in decreasing pain. Your Physical Therapist may also use electrical modalities such as a low-dose ultrasound or interferential current to help decrease the pain and control the amount of inflammation. Massage for the quadriceps, hamstrings, and calf muscles may also be used.

In some cases, your child may need to stop sporting activities for a short period, which allows the pain and inflammation to calm down.  If the bone has completely separated then it is necessary to completely avoid sports.  Fortunately it is not common that the bone completely separates, so not all athletes need to entirely avoid sports.  Patients who do require a rest usually don’t need to avoid sports for a long time, and often a relative rest is adequate.  Taking a relative rest means decreasing the intensity or frequency of certain activities but not eliminating them completely. Your Physical Therapist will advise you regarding whether or not your child needs to cease or decrease their activity.  Pain that is intense enough to continue during the night, is constant, causes a limp while walking, or needs to be regularly relieved with over the counter pain medication is considered severe enough that activities need to be ceased for a defined period of time.  In only very severe cases is bracing or casting recommended for periods of up to 6 weeks in order to give the chance for the pain and inflammation in the knee to calm down.

In some cases your Physical Therapist may try using some tape on your child’s knee.  Taping the knee or kneecap can help guide the tissues into an improved alignment, which then relieves some pressure on the painful area at the tibial tuberosity.

Orthotics, or shoe inserts, may also be suggested.  The foot is the bottom of the lower extremity chain therefore putting the foot into proper alignment frequently takes pressure off of the knee, and can relief all or some of your child’s pain.  Other types of braces, such as those that help to align the knee cap or add padding to the front of the knee can sometimes also be helpfulin reducing the tension and force transmitted to the tibial tubercle. Your Physical Therapist at First Choice Physical Therapy can discuss these options with you and your child.

Once the initial pain and inflammation has calmed down, your Physical Therapist will focus on improving the flexibility, strength, and alignment around the knee joint and the entire lower extremity. Static stretches to increase the flexibility of the muscles and tissues affecting the knee (particularly the quadriceps, hamstrings, hip flexors, calf, and iliotibial band on the outside of the knee) will be prescribed by your Physical Therapist early on in your child’s treatment. Any tightness in the muscles or tissues around the knee can increase the pull on the patellar tendon and the tibial tuberosity, which affects alignment during walking, running or jumping. Dynamic stretching (rapid motions that stretch the tissues quickly) will also be taught and will be incorporated into your child’s rehabilitation exercise routine as part of their warm-up if they are continuing to engage in physical activity. Dynamic stretches are used to prepare the tissues for activity whereas static stretches focus more on gaining overall flexibility.

Strength imbalances will also affect the alignment of the knee and can cause muscles to tighten, which in turn may cause increased stress on the patellar tendon and tibial tuberosity. Your Physical Therapist will determine which muscles in your child’s case require the most strengthening. Strength in both the knee and the hip (which controls the knee position) are very important.  Increased strength and endurance can affect the ability to maintain one’s alignment, and will directly affect the amount of pressure transferred to the tibial tuberosity.  Strengthening a knee that is painful can be difficult therefore it is important to follow the strict instructions of your Physical Therapist regarding increasing or decreasing the load of the exercise. Overdoing an exercise can cause more harm than good in the case of Osgood Schlatter Disease.  In some cases your Physical Therapist may use a muscle stimulator on your child’s knee to help recruit the proper muscles around the joint.

Over time, when the knee becomes less painful your therapist will add eccentric exercises to your child’s rehabilitation routine. Eccentric contractions occur as the muscle lengthens and the tendons and their attachment points are put under stretch.  For instance, when bending the knee, the quadriceps muscle, the patellar tendon, and its attachment point at the tibial tuberosity are all under load while stretching. This load is tremendous especially when deep squatting, jumping or landing from a jump.  Even going down stairs puts significant load through the tissues. Eccentric exercises prepare the tissues to take these heavy types of loads.  Exercises that simulate going down stairs or jumping will be prescribed.  Drop squats, where your child bends their knee quickly into a squatting position and then stops rapidly, are commonly used to encourage the knee to adapt to the force that is needed to return to physical activity.  Again, in dealing with pain from Osgood Schlatter Disease, any discomfort should be strictly heeded.  When appropriate, weights can be added to the exercises to simulate the increased body weight that the knee endures during running and jumping.  As with all the exercises, proper alignment and technique is extremely important in order to avoid flaring up the knee or creating a secondary injury. Your Physical Therapist will be strict about having your child maintain good technique, and will ask you, as the parent, to also monitor this.

In addition to flexibility and strength exercises your Physical Therapist will also add a proprioceptive, or balance component to your child’s rehabilitation program.  With any injury or whenever pain is present, the receptors in your joints that are responsible for knowing where your body is in space decline in function.  Without adequate proprioception, the muscles and joints are not used efficiently and the chance of sustaining another injury is increased.  Exercises such as mini squats on a soft mat or standing on a wobbly surface are simple exercises that improve proprioception, and will also improve muscle strength and overall endurance.

All exercises given will be required to be completed not only in the clinic but also as part of a home program.  Many children and adolescents can reliably do a small list of independent Physical Therapy exercises, however at First Choice Physical Therapy we always encourage you, as the parent, to closely monitor the child’s technique and exercise frequency at home in order to get the most out of the treatment we provide.

Surgery is not considered for an Osgood-Schlatter lesion unless bone growth is complete and symptoms are still bothersome despite nonsurgical treatments. Even under these circumstances, surgery is rarely recommended.

When surgery is needed, however, the usual operation involves removing the raised area of the tibial tuberosity, the bursa, and the irritated tissue nearby. The surgeon makes a small incision down the front of the lower knee, just over the tibial tuberosity. The patellar tendon is split in half. Retractors are used to pull the skin and the patellar tendon apart, which makes it easy for the surgeon to see and work on the tibial tuberosity. The surgeon uses an osteotome to cut away the raised area of the tibial tuberosity. Care is taken while removing the bursa and nearby tissue.

The retractors are removed. The cut edges of the patellar tendon are brought together. Scar tissue eventually binds the edges back together. To complete the operation, the surgeon stitches up the skin.

After surgery for Osgood Schlatter Disease rehabilitation at First Choice Physical Therapy can begin as soon as your child’s surgeon recommends it.  Some surgeons may want your child to rest the knee for a period before doing any rehabilitation while others will be keen to have your child begin gentle rehabilitation almost immediately.  When rehabilitation begins depends on the surgeon’s personal experience, the technique used, and other factors specific to your child’s individual case.  In every case, however, vigorous activities or exercise will need to be avoided for about six weeks after surgery. Athletes will not be allowed to take part in high-level sports for two to three months.

After surgery your child will likely be required to use crutches for a short period. Your Physical Therapist at First Choice Physical Therapy will ensure your child knows how to safely use their crutches both on level ground and on stairs.  Your Physical Therapist will advise your child as soon as it is appropriate to walk without the crutches.  In order to do this, your child must be able to walk well without any limp at all.  Walking with a limp can cause a host of other problems in the joints of the lower extremity and the back so heeding advice from your Physical Therapist on the right timing for your child to go without crutches is imperative.

The first few appointments after surgery at First Choice Physical Therapy will focus on helping to control the pain and swelling from the surgery itself. Icing the knee frequently will assist with the inflammation and relieve a great deal of the pain. Your Physical Therapist may use electrical modalities such as low-dose ultrasound or interferential current to decrease the pain and inflammation. Massage for the muscles of the leg or around the knee may

One of the first exercises your child’s Physical Therapist will prescribe will be some gentle range of motion exercises to help the knee to gradually regain full movement. These exercises should be done within a pain free range of motion, however, movement will be encouraged even if it causes a slight bit of discomfort as the movement itself can greatly assist with dispersing any inflammation as well as improving the overall level of pain. A stationary bicycle can be very useful in the initial stages of gaining range of motion in the knee, so if able, your child will be encouraged to use one.  Even if they are unable to fully rotate the pedals, the back and forth motion on the bike is an excellent method of slowly encouraging the knee to regain its full range of motion, and to get the swelling moving.

Next your Physical Therapist will begin to add some gentle strengthening exercises for the knee. Initially these may only involve isometric exercises, where your child is required to tighten and hold the quadriceps muscle on the top of the thigh without actually moving the knee itself. Gradually though, the strengthening exercises will be advanced and will address any individual deficits in strength that your Physical Therapist has identified around the knee, and hip area, which controls the knee position.  Eccentric exercises, as explained above under non-surgical treament, will also eventually be added in order to prepare your child’s knee for the rigorous bending involved in both everyday and sporting activities.

As a final component to your child’s rehabilitation, your therapist will also prescribe proprioceptive exercises.  These exercises help to improve the ability of the joint to know where it is in space and encourage the muscles to work together to control the knee joint.  As with all rehabilitation exercises, your therapist will closely monitor the technique used and the alignment of your child’s knee as they do the exercises in order to ensure that they are not compensating in any way, which can lead to ongoing pain or a secondary injury.

When you’re child is well under way with their rehabilitation, regular visits to First Choice Physical Therapy will end. Your Physical Therapist will continue to be a resource, but with your supervision, your child will be in charge of doing their exercises as part of an ongoing home program. Generally rehabilitation at First Choice Physical Therapy after surgery for Osgood Schlatter Disease goes extremely well and children can eventually return without difficulties to the activities they enjoy participating in. If, however, your child’s pain is lasting longer that your therapist thinks it should or your child is not progressing as rapidly as your therapist would expect, they will ask you to follow up with your child’s surgeon to ensure that there are no complicating factors from the surgery that are impeding rehabilitation.

Bipartite patella is a congenital condition (present at birth) that occurs when the patella (kneecap) is made of two bones instead of a single bone. Normally, the two bones would fuse together as the child grows but in bipartite patella, they remain as two separate bones. About one per cent of the population has this condition. Boys are affected much more often than girls. When this condition is discovered in adulthood it is often an “incidental finding” meaning that when your health care professional was investigating another problem around the knee, the bipartite patella is discovered.

This guide will help you understand:

• what parts of the knee are involved
• how this condition develops
• how health care professionals diagnose this condition
• what treatment options are available
• what First Choice Physical Therapy’s approach to rehabilitation is

What is the patella and what does it do?

The knee is the meeting place of two important bones in the leg, the femur (the thighbone) and the tibia (the shinbone). The patella (kneecap) is the moveable bone that sits in front of the knee. This unique bone is wrapped inside a tendon that connects the large muscles on the front of the thigh, the quadriceps muscles, to the lower leg bone.

What causes this condition?

In development the patella starts out as a piece of fibrous cartilage. It only turns into bone or ossifies as part of the growth process. Each bone has an ossification center. This is the first area of the structure to start changing into bone.

Most bones (including the patella) only have one primary ossification center. In some cases, however, a second ossification center is present. Normally, these two centers of bone will fuse together during late childhood or early adolescence. If the bones do not ossify together, then the two pieces of bone remain connected by fibrous or cartilage tissue. This connective tissue is called a synchondrosis.

In the patella the most common location of the second bone is the supero-lateral (upper outer) corner of the patella but the bone can be at the bottom of the patella or along the side of the kneecap.

Injury or direct trauma to the synchondrosis can cause a separation of this weak union between the two bones, which then leads to inflammation. Repetitive micro trauma can have the same effect. The cartilage has a limited ability to repair itself. The increased mobility between the main bone and the second ossification center further weakens the synchondrosis resulting in painful symptoms.

What does bipartite patella feel like?

Most of the time, there are no symptoms. Sometimes there is a bony bump or place where the bone sticks out more on one side than the other. If inflammation of the fibrous tissue between the two bones occurs, then painful symptoms develop directly over the kneecap. The pain is usually described as a dull ache. There may be some swelling.

Movement of the knee can be painful, especially when bending the joint. Atrophy of the quadriceps and misalignment of the patella can lead to patellar tracking problems. Squatting, stair climbing, weight training, and strenuous activity will all aggravate the knee causing increased symptoms. For the runner, running down hill in particular causes increased pain, tenderness, and swelling.

How will my health care professional diagnose this condition?

Most of the time, this condition is seen on X-rays of the knee that are taken for some other reason. This is referred to as an incidental finding. Sometimes, it is mistaken for a fracture of the patella but since the problem usually affects both knees, an X-ray of the other knee showing the same condition can confirm the diagnosis.

If, due to the proper mechanism of injury being present, a fracture is suspected, then MRIs or bone scans are useful if the fracture doesn’t show up on the X-rays. The presence of fibrocartilaginous material between the two bones on MRI helps confirm a diagnosis of bipartite patella. An MRI can also show the condition of articular cartilage at the patellar-fragment interface. The lack of bone marrow edema helps rule out a bone fracture. CT scans will show the bipartite fragment but are not as helpful as MRIs because bone marrow or soft tissue edema does not show up, so it’s still not clear from CT findings whether the symptoms are from a fragment or a fracture.

What treatment options are available?

Most of the time, no treatment is necessary because most people who have a bipartitepatella, probably don’t even know it. However if an injury occurs and/or painful symptoms develop, then treatment may be needed.

Nonsurgical Treatment

Conservative care involves rest, over-the-counter nonsteroidal antiinflammatory drugs (NSAIDs) such as ibuprofen, and rehabilitation at First Choice Physical Therapy.
If there has been a separation of the synchondrosis this can be treated with immobilization for four to six weeks. The knee is placed in full extension using a cast, knee immobilizer, or dynamic patellar brace.

An immobilizer is a removable splint. It’s usually only taken off to wash the leg and remains in place the rest of the time. The dynamic brace immobilizes the knee in an extended (straight-leg) position with limited flexion (up to 30 degrees). The brace reduces pain by decreasing the pull on the patella from the quadriceps muscle. Once healing occurs and the cast or brace is no longer needed, then rehabilitation at First Choice Physical Therapy should begin. Once the X-ray shows complete ossification of the two bone fragments, then you should be able to return to your regular activities providing you have also met your rehabilitation goals.

What should I expect during treatment?

Nonsurgical Rehabilitation

If you have developed symptoms from bipartite patella then rehabilitation at First Choice Physical Therapy can be very useful.  If you have been immobilized then your rehabilitation can begin once your immobilizer has been removed.

During your first visit to First Choice Physical Therapy your Physical Therapist will begin by educating you on activity modification and implementing a period of active rest so that your symptoms calm down. Taking an active rest means decreasing your activity intensity or duration such that you are not aggravating your knee. It means that you can do some activity as long as it does not stir up your knee symptoms. Some activities, however, may need to be completely avoided or replaced by less stressful ones. In most cases avoiding movements such as deep flexion of the knee during activities such as squatting will be advised.  Avoiding excessive use of the stairs, as well as resisted weight training will also advised. Often activities such as cycling (with the bike seat high to avoid excessive knee flexion) or cardiovascular activities in the pool can be continued as long as they do not bring on symptoms.  If symptoms continue even once you have modified your activity then a complete rest from the activity is the next step.

Your Physical Therapist may use electrical modalities such as ultrasound or interferential current to help ease your pain or decrease any swelling that may exist. Ice or heat over the knee can also help with these symptoms.  Your therapist can advise you whether ice or heat would be best in your individual case, and you should then also apply this at home.

Your Physical Therapist may use tape or a flexible brace to assist with your symptoms. The aim of this treatment is to help guide the kneecap through its proper range of motion while you move the knee during your rehabilitation exercises and during everyday activity.  If either the tape or the flexible brace helps your symptoms, your therapist can teach you how to use and apply them yourself on a daily basis.  Often a short period where your pain is reduced can allow your symptoms to subside as well as allow a period where strengthening exercises can be most advantageous.

Once your symptoms begin to subside your Physical Therapist will start you on some gentle stretching exercises in order to ensure you maintain your full knee range of motion.  If you have been immobilized by a brace or cast then your leg may be particularly stiff into bending.  Gentle stretches for the quadriceps muscle, which is on the top of the thigh, will be prescribed. There are several modifications of a quadriceps stretch that can be taught if the stretch brings on your symptoms, so be sure to tell your Physical Therapist if you are experiencing any pain at all while stretching.  In addition to stretching the quadriceps, your therapist may also prescribe other related stretches such as ones for the hip flexors which are at the front of the hip, the hamstrings on the back of the thigh, the buttocks muscles, the calf, or the tensor fascia latae, which is on the upper and outer side of the hip.  All of these muscles, if tight, can alter the biomechanics of the knee and put undue stress on the kneecap.

Your Physical Therapist will also prescribe strengthening exercises for your knee and lower extremity.  It is very important that only the necessary forces are put through your knee in order to avoid future problems with the joint. In order to do this, you need adequate strength in your quadriceps and buttocks muscles, which are the main controllers of the knee position.  Your therapist will assess both your lower extremity alignment as well as the strength of the muscles in your lower extremities, which help to maintain your alignment. If there are other muscles, aside from your quadriceps and buttocks muscles that require strengthening, exercises for these muscles will also be prescribed.  If strengthening your knee brings on your symptoms and your exercises can not be modified enough to relieve the symptoms then your Physical Therapist may suggest that you do strengthening exercises in a hydrotherapy pool rather than on the land.  The hydrostatic properties of the water along with the warmth of the water often makes it easier to exercise and to do so with less pain.  As soon as possible, though, your exercises should be progressed to land-based exercises as these more closely simulate everyday activities.

As soon as you are able your therapist will progress your strengthening activities so that you incorporate more advanced exercises for your knee. Exercises such as jumping, squatting, stair climbing or descending, or working with heavier lower extremity weights will be added as your Physical Therapist feels your knee can tolerate it. Exercise bands, exercise machines, or free weights may be used for additional resistance during the exercise.  As stated previously, it is crucial that you do not overload your knee such that you cause any symptoms. Your Physical Therapist will be the key to monitoring and advancing your rehabilitation program in order for you to improve as quickly as possible without causing any undue stress on the knee.

The ability to know where your knee is in space without looking at it is called proprioception. Any injury or pain associated with a joint will decrease the joint’s proprioceptive ability. A period of immobilization will add to this decline. Your therapist will prescribe exercises for your proprioception to help your knee function at its peak. Adequate proprioception also assists in avoiding future injuries. Exercises such as balancing on one leg or on an unstable surface such as a wobbly board or a foam disc work your proprioception. Closing your eyes during these exercises challenges your proprioception even further.  Advanced proprioceptive exercises may involve hopping, jumping and landing from a height, or moving rapidly from side to side.  As with stretching and strengthening exercises, any pain during proprioceptive exercises should be heeded.  Eventually exercises that mimic your everyday activities and sporting interests will be added in order to maximally challenge your knee as well as prepare you to return to your regular activity.

It is crucial that proper alignment and technique is maintained throughout all exercises, therefore your Physical Therapist will continually draw your attention to your form. The knee is a joint that is particularly sensitive to poor alignment, which causes undue tension on the joint and eventually leads to pain and early wear down of the joint.  If necessary, your therapist may suggest the use of foot orthotics or arch taping in order to assist your lower extremity alignment. Lower extremity alignment begins from the ground up, therefore poor foot alignment immediately affects the position and tension on the knee.

In addition to range of motion, strength, and proprioceptive exercises at First Choice Physical Therapy, we also highly recommend maintaining the rest of your body’s fitness with regular exercise while you rehabilitate your knee.  An upper body bike is a good cardiovascular activity that will not flare up your knee. A stationary bike is also a good cardiovascular activity you can trial, as it generally does not flare up the knee if done with a few simple modifications. Keeping the resistance low on the bike and putting the bike seat up higher than usual help to ensure that you do not experience pain in your knee.  If the stationary cycle or other land based activities are too difficult, often a cardiovascular activity in the pool can be performed without irritating your knee.  In addition to a cardiovascular activity, weights for your upper extremities and unaffected leg are also strongly encouraged. Advanced exercises such as the stepper or elliptical machines may be used once your knee has recovered to an acceptable level.  Running is generally the final activity added to your rehabilitation and cardiovascular program due to the extreme force it exerts through your knee and body in general.  Your Physical Therapist at First Choice Physical Therapy can provide a program for you to maintain your general fitness while you rehabilitate your knee, and can advise you on the best time to advance your cardiovascular exercises without stirring up symptoms.

Most patients with bipartite patella respond well to a period of immobilization and/or rehabilitation along with activity modification.  If, however, there is no improvement after three months of conservative care, then surgery is considered.

If conservative care with immobilization is not successful in alleviating swelling and pain, then surgery may be suggested. When the bipartite fragment is small, then the surgeon can simply remove the smaller fragment of bone. When the bipartite fragment is larger and also contains part of the joint surface, the surgeon may decide to try and force the two fragments to heal together or fuse. The connective tissue between the two fragments is removed first and the two bony fragments are then held together or stabilized with a metal screw or 
pin. This technique is called internal fixation. The two fragments of bone eventually heal together or fuse, creating a solid connection between the two fragments. Although successful in reuniting the patella, the procedure may require several weeks of immobilization. As a result, knee stiffness may occur. Physical Therapy at First Choice Physical Therapy is then required once the bones have healed in order to regain motion as well as strength, endurance, and proprioception.

Another potential surgical treatment option is a procedure called a lateral 
retinacular release. The vastus lateralis tendon (a part of the large quadriceps muscle
 of the thigh) exerts a constant lateral pull on the patella. In patients with bipartite patella this pull is usually on the bone of the bipartite fragment of the upper, outer patella. Simply cutting the vastus lateralis attachment reduces the constant pull on the bony fragment. Healing of the two bony fragments may occur as a result of the decreased tension.

Rehabilitation after surgery for bipartite patella should begin as soon as your surgeon indicates that it is safe to do so.  What has been done in surgery will determine whether you need a period of immobilization or rest before beginning rehabilitation.  Each surgeon will set his or her own specific restrictions regarding when to begin treatment at First Choice Physical Therapy based on what was done during the surgical procedure, their personal experience, and whether your tissues are healing as expected.

You may be required to use crutches for a short period after your surgery. If you are still using crutches by the time we first see you at First Choice Physical Therapy, your Physical Therapist will ensure you are using the crutches safely, properly, and confidently, and that you are abiding by your weight bearing restrictions if you have been given any. We will also ensure that you can safely use your crutches on stairs. If you are no longer using crutches, or once you no longer need them, your Physical Therapist will focus on normal gait re-education so you are putting only the necessary forces through your surgical side with each step, and are not compensating in any way.  Until you are able to walk without a significant limp, we recommend that you continue to use crutches, or at least one crutch or a cane/walking stick. Improper gait can lead to a host of other pains in the knee, hip and back so it is prudent to use a walking aid until near normal walking can be achieved. Your First Choice Physical Therapy Physical Therapist will advise you regarding the appropriate time for you to be walking without any walking aid at all.

During your first few appointments at First Choice Physical Therapy your Physical Therapist will focus on relieving any pain and inflammation that you may be lingering from the surgical procedure itself. We may use modalities such as ice, heat, ultrasound, or electrical current to assist with decreasing any pain or swelling you have around the surgical site or anywhere down the leg. In addition, your Physical Therapist may massage your leg and ankle to improve circulation and help decrease pain and swelling.
The next part of our treatment will focus on regaining the range of motion in your knee.

Your Physical Therapist at First Choice Physical Therapy will prescribe a series of exercises that you will practice in the clinic and also learn to do as part of a home exercise program. Range of motion in the knee generally comes back very quickly after surgery for bipartite patella, but it still depends on exactly what your surgeon has done inside your joint, how much swelling is present, and how controlled your discomfort is. During the range of motion exercises you may experience a small amount of discomfort at the end ranges of motion initially.  Despite this discomfort it is still important to perform the range of motion exercises prescribed because moving the joint also helps to move the swelling, get fresh blood to the healing area, and provide nutrition to the surface of the joint.

Only mild discomfort, however, is permissible. Any sharp or moderate discomfort should be heeded. An exercise bike at this stage of your rehabilitation is very useful to assist in gaining back knee range of motion. Even if you are unable to fully rotate the pedals of the bike, using it is still encouraged.  Performing the simple back and forth motion forces fluid through the joint, which helps to move the swelling and bring fresh blood to the healing tissues.

In regard to range of motion the goal after surgery for bipartite patella is to regain full bending and extending of your knee joint. Without this full range of motion, areas of the joint surface cartilage can become weak and start to wear down.  In addition, without full range of motion the biomechanics of the knee do not function as they have been designed to, and this also contributes to early wearing down of the joint.

In addition to you yourself doing range of motion exercises your Physical Therapist may mobilize your knee joint to assist in regaining motion. This hands-on technique encourages the knee to move gradually into its normal range of motion. Mobilization of the knee (including the patella) may be combined with therapist-assisted stretching of any tight muscles around the surgical site.

As soon as possible your Physical Therapist will also prescribe strengthening exercises for your knee and lower extremity. These exercises will focus on your quadriceps muscle as well as the muscles of your hip, in particular your gluteal muscles.  Gluteal exercises are particularly important, as the hip is the main controller of the position of the knee.  The goal of all strengthening exercises will be to regain enough strength and endurance to be able to properly control the alignment of the knee and lower extremity during your everyday and sporting activities.  The muscles at the back of your thigh, the hamstrings, as well as your calf muscles, may also require strengthening post surgically.  In addition, your therapist may also prescribe exercises for your core area, which also plays a part in maintaining proper alignment of the lower extremities.

After a knee surgery the quadriceps muscle becomes very low in tone and difficult to activate voluntarily, despite no injury to the muscle itself or the nerve that innervates it.  This phenomena is termed reflexive inhibition, and it is said to occur in response to several factors including the initial knee injury itself, the swelling in the joint, the reaction of receptors in the knee joint, pain, joint immobilization, and the surgical intervention itself. Reflexive inhibition of the quadriceps muscle after surgery occurs even if you had highly defined thigh muscle tone prior to the surgery. This decrease in tone, if prolonged, will contribute to poor recovery after a knee surgery; therefore exercises to get the quadriceps muscles activated are crucial.  It is often noted that the more tone you had prior to the surgery, the quicker the tone returns post surgically. For this reason doing a pre-operative exercise program is highly recommended!

The initial strengthening exercises that your Physical Therapist prescribes after an arthroscopic surgery might be as simple as sitting and tightening the quadriceps or buttocks muscles without moving the joint (this type of exercises is termed isometric).

Your therapist may use an electrical muscle stimulator to assist you in contracting the muscles, particularly the quadriceps muscle.  As soon as you are able it is important for you to move from the seated position and perform weight-bearing exercises in a functional position, such as standing or squatting.  Exercises that work the muscles while in a weight bearing position most effectively assist with daily activities such as walking and stair climbing.  Exercises such as squatting, or slowly stepping up or down a step are excellent exercises to encourage the dual activation of both the quadriceps and hamstrings muscles, as well as the muscles of the hip and calf.

Your Physical Therapist may again use an electrical muscle stimulator to assist your muscles to contract while you perform these functional exercises.  Exercises may also include the use of exercise band, exercise machines, or free weights to provide some added resistance for your thigh and hip.  As soon as you are able, and your knee will safely tolerate it, your therapist will advance your exercises to include quicker movements, such as hopping.

They will also encourage more repetitions of each exercise in order to help regain muscle endurance.  If you have access to a pool, your Physical Therapist may suggest you go to the pool to do your exercises. The buoyancy of the water along with the warmth of the water (provided it is a heated pool) can assist greatly in providing comfort to the knee joint and often allows you to exercise through greater ranges of motion during early rehabilitation.

As a result of any injury or surgery, the receptors in your joints, ligaments, and other tissues that assist with balance and proprioception (the ability to know where your body is without looking at it) decline in function. A period of immobility and reduced weight bearing will add to this decline. If your balance and proprioception has declined, your joints and your limb as a whole will not be as efficient in their functioning and the decline may contribute to further injury in the future. As a final component of our treatment your Physical Therapist at First Choice Physical Therapy will prescribe exercises for you to regain your balance and proprioception. These exercises might include activities such as standing on one foot or balancing on an unstable surface such as a wobbly board or a soft plastic disc.  Advanced exercises will include agility type movements such as hopping on one foot or jumping side to side.

As your range of motion, strength, and proprioception improve, your therapist will advance your exercises to ensure your rehabilitation is progressing as quickly as your body allows. As soon as it is safe to do so, your Physical Therapist will add more aggressive exercises such as running, jumping to or from a height, or exercises that mimic the sports and recreational activities that you enjoy participating in.  During all of your exercises you therapist will pay particular attention to your technique to ensure that you are not using any compensatory patterns or are developing bad habits in regard to how you use your knee and lower extremity.  If you do not pay close attention to how you use your joint and limb post-surgically poor patterns which existed due to pain pre-surgery often continue to occur even once the source of your pain has been eliminated by surgery.  The advice from your Physical Therapist at First Choice Physical Therapy is crucial regarding correcting your movement patterns and developing new, efficient patterns during your daily activities.

Aside from directly rehabilitating the knee after surgery, at First Choice Physical Therapy we also highly recommend maintaining the rest of your body’s fitness with regular exercise while your knee is recovering.  Cardiovascular exercise can begin very early post-surgically.  If you are not yet able to use a normal stationary cycle then an upper body bike can be used instead, or your surgeon may approve of you doing gentle aerobic exercises in a pool as an alternative.  A stationary bike, however, is often the best cardiovascular activity once your range of motion and pain levels allow it.  Weights for the upper extremities and your other leg are also strongly encouraged.  Advanced exercises such as the stepper or elliptical machines may be used once your knee has recovered to an acceptable level.  Running is not advised until well into your rehabilitation program as your lower extremity requires both the strength and endurance to tolerate the heavy demands that running puts on the knee joint as well as on the rest of the body.  Your Physical Therapist at First Choice Physical Therapy can provide a program and advice for you to maintain your general fitness while you recover from your surgery.

Usually, the removal of a bipartite patella fragment, fusion of the fragments, or a lateral release are relatively simple surgeries with prompt relief of pain and a quick recovery. Many athletes can expect full range of motion, a stable knee, and a fairly rapid return to normal activity within one to two months with proper rehabilitation. Unfortunately runners and athletes who have had an extended time of immobility, muscle weakness and atrophy, loss of normal joint motion, and patellar tracking problems may require a longer rehabilitation program and a slower return to activity.

When you are well under way with your rehabilitation program, regular visits to First Choice Physical Therapy will end.  Your therapist will continue to be a resource for you as your recovery continues, but you will be in charge of doing your exercises as part of an ongoing home program.

Generally the rehabilitation after arthroscopic knee surgery responds very well to the Physical Therapy we provide at First Choice Physical Therapy.  If for some reason, however, your pain continues longer than it should, your range of motion is slow to return, or your general therapy is not progressing as your Physical Therapist would expect, we will ask you to follow-up with your surgeon to confirm that the knee is tolerating the rehabilitation well and to ensure that there are no complications that may be impeding your recovery.

A contusion is the medical term used for a ‘bruise.’ Contusions can be minor, like the one you get after clumsily hitting your thigh on the edge of the coffee table, to major ones like the contusion you may get across your chest or down your leg after a significant motor vehicle accident.  Whatever the size, that red, blue, purple, green or brown rainbow that appears is a sure sign of injury to the tissues below or near the area.

This guide will help you understand:

• what causes a contusion
• why bruises are different *colours*
• how contusions are diagnosed
• what First Choice Physical Therapy’s approach to rehabilitation is
• what complications may occur

What causes a contusion?

A contusion can result from a blow (or repetitive blows) to a specific part of your body, or can result from you hitting your body against a fixed object or the ground.  When this occurs, injury occurs to the muscle fibers as well as the capillaries (which are small blood vessels) and blood leaks out of the injured cells into the surrounding areas beneath the skin.  The injury does not break the skin.

How quickly a bruise develops depends on how forceful the trauma is that causes the injury.  If you simply pinch a bit of skin in a zipper, you may see the bruise develop quickly, within a few minutes or within the hour, as the injury is close to the surface.  In more forceful traumas, like during a fall or getting hit by an object such as a sports stick or helmet, the bruising may not come out for a few hours or even a couple of days.  It should be noted that bruising could occur farther from an injury than you would think, as well. It is not uncommon to see bruising around your ankle after an injury or surgery to the hip or knee, or to see bruising in your hand after a shoulder injury. Gravity carries the escaped blood to the lowest point of the limb, hence showing up in the hanging hand or foot.  It should also be noted that severe contusions on the abdomen or back could also injure the internal organs.

The size of the bruise you incur depends on what actually caused your injury, as well as how much force was involved in the injury. The larger the object you run into, the bigger the potential contusion.  Evidently the more force involved in the blow, also the bigger the potential contusion.

What does a contusion feel like?

For most people, the feeling of a bruise need not be explained. What should be noted, however, is that one may feel like an area is bruised, and yet there is no objective sight of it.  As mentioned above, the bleeding caused by trauma can be deep, and for this reason, the skin may not look bruised initially, but can feel tender. The classic bruise will likely make its way to the surface hours or days later, or the bruising may show up, as discussed above, farther away from the site of the trauma rather than right under the traumatized area.

What does the *colour* of a bruise mean?

The *colour* of a bruise depends on how fresh the injury is, or its stage of healing.  Typically a new bruise will begin red, as fresh new blood is leaked into the surrounding tissues, which is rich in both oxygen and hemoglobin (a protein that contains iron).  Sometimes the red stage isn’t noticed, as the area of impact isn’t looked at immediately.  Not long after the blood has leaked out of the injured capillaries, the blood loses its oxygen, and the blood becomes darker, which turns the skin *colour* blue or purple. Over a few days the bruise may turn an even deeper purple *colour* or may even look black.  This occurs due to the red blood cells being broken down and hemoglobin (and iron) being released into the surrounding tissues.

As your contusion begins to heal, a variety of other *colour*s may appear. Healing contusions begin to turn green as the hemoglobin in the tissues begins to convert to other chemicals.  As the hemoglobin nears its final breakdown the bruise will turn yellow. Eventually the body absorbs the last of the damaged tissue and the skin returns to its normal *colour*ing.

It should be noted that most bruises are multi*colour*ed as different areas of the tissue are damaged at different intensities and with different forces.  The worst of the damage, however, will be noted in the dark purple or black areas.

How do health care professionals diagnose the problem?

Generally the presence of a contusion can be diagnosed by the patient themselves when they see it.  Your health care professional may palpate (feel) around the contused area to see if there are any areas of hardness developing within the contused area, which can mean a complication is developing (see Complications below).
In most cases of contusions no further investigations are required, however, in cases where the extent of the damage to the injured area is in question, an ultrasound, magnetic resonance image (MRI) test, a computed tomography (CT) scan, or an x-ray may be ordered.  These tests can help to determine whether the original injury has caused a significant or full tear of the muscle in the area, damage to an internal organ, or even a fracture to a local bone.

In cases where extensive bruising is occurring more than it should from the expected insult (ie: a large bruise from a small bump) or where bruising occurs more easily than it should, your health care professional may suggest you be investigated for systemic conditions which make bruising more likely such as hereditary blood diseases (ie: hemophilia).  Some medications can also make bruising more likely (ie: blood thinners).  Your health care professional will inquire regarding any general health conditions or medications you are on in order to determine if you have any specific reasons why you may be bruised or bruising more easily that normal.

What will my doctor do when I see them?

Depending on when exactly you get to see your doctor regarding your contusion, in most cases they will simply suggest immediate first aid to assist your bruise (rest, ice, compression, and elevation). In more severe cases if you are having difficulty moving your limb or dealing with significant pain they may suggest a painkiller type of medication, whether it be over the counter or prescription.  In these cases the degree of damage of the tissue or bone may also be in question, so as mentioned above, your doctor may request further examination through an ultrasound, x-ray, computed tomography (CT) scan or MRI in order to determine the status of the soft tissue or underlying bone.  Associated injury to a local nerve may also need to be ruled out.

The path of rehabilitation for your contusion will depend on when exactly you see your Physical Therapist.  The earlier you can get in to see your therapist, the more they can help!

In the initial stages of healing of a contusion, the RICE principle still applies: Rest, Ice, Compression, and Elevation.

Your therapist will discuss with you how much rest you need and how much activity you can continue to do with your healing contusion. Resting doesn’t necessarily mean sitting around doing nothing at all. Rest means to make a relative decrease in the activities that you have normally been doing or at least those activities that you know irritate your contused muscle.  That being said, some gentle stretching and movement of the contused muscle also helps to encourage the fluid and damaged tissue to move out of the area and assists the newly forming scar tissue to align in the correct direction.  Your therapist will discuss how much rest you need and will prescribe the proper stretching and strengthening exercises for your stage of healing.  If you have just incurred your injury, you may only be asked to slowly and gently move the muscle into its full range of motion, and work to isometrically tighten the muscle (squeeze and tighten the muscle without moving the actual joint near it).  Some severe contusions may require complete rest for a short period of time; minimal movement over this time will allow the recovery process to begin without causing further pain or damage.

If your injury is already well on its way to recovery, your therapist may prescribe more aggressive stretching called dynamic stretching. Dynamic stretching is used to prepare your muscle for the repetitive and more aggressive movements needed for everyday activity and sport. Dynamic stretching involves moving your limbs repetitively and with controlled speed into their end range of motion so that the muscles get put on full stretch.  If you are at the end stages of recovery from your contusion then your strengthening will be more aggressive as well.  You may be asked to jump, squat, or move your limbs or torso aggressively and quickly in order to prepare the contused muscle to return to the repetitive and arbitrary movements that come with everyday life or sport.

Again, depending on how far along the healing of your injury is once you seek Physical Therapy, your therapist may or may not encourage ice.  If you have just sustained your contusion (or within the last 48 hours), applying ice is essential to cut down on any unnecessary swelling and secondary injury to the tissues surrounding the main injury.  Even if the injury occurred more than a couple of days ago, icing can still be extremely useful for the same purpose.  If the injury has occurred a few weeks back or is long-standing, your therapist may suggest using heat on the injured area.  Heat, when applied at the proper stage, can also help to decrease pain and assist recovery.  A combination of ice and heat may also help. Your Physical Therapist can give specific advice regarding when it is best to use ice or heat for your individual injury, and can advise you on the best amount of time to keep the ice or heat on during each session.

If your contusion is in an area that is easy to apply a compression wrap to (ie: calf, forearm, thigh) then your therapist will advise that you the compress the area.  Compressing an injury with a wrap of some sort is emerging in current research as one of the most important things one can do, particularly in the early stages of recovery. Compressing the injured area can limit any excess swelling and bruising in the area and help to contain the area of secondary injury.  Some swelling of an injury is actually required for the healing process to occur, but excess swelling can damage surrounding cells and inhibit the local muscles from working well.  If the injured area gets more painful once you wrap it or if it feels too constricted, it is imperative to remove the wrap and re-wrap it a bit looser.

In the later stages of healing of a contusion, a compression wrap can continue to be useful both to limit any ongoing swelling, but it can also help to add a physical support to the injured muscle as you start to rehabilitate it.  Your therapist may also suggest using tape (even from early on in the healing process of your contusion) in order to add some compression and limit swelling and bruising.

If feasible, elevating the injured area helps to drain any of the swelling related to your injury. Obviously there are some areas that sustain a contusion that can’t easily be elevated, but if you have injured an area in your limbs, elevation can assist gravity to move the swelling and bruising back towards your heart so it can re-circulate the fluid into your system.  For this reason, where possible, it is best to elevate your limb above your heart in order to help the most. If it was a contusion on your thigh or calf for example, you could lie on the couch and stack pillows up to put your leg on, or lie on the floor and put your leg up on the couch.  The upper extremity is harder to elevate for a long period, but even if you can rest the limb level with your heart whenever possible, it will assist the recovery of your contusion.  When the area is not elevated, gravity pulls the swelling downwards into your limb and your body has to rely only on the pumping action of your muscles to get the fluid out.  Since your muscles aren’t working as much or as hard due to the injury in the area, this process for removing the swelling and bruising can be slow.  The force of gravity is the same reason that one sometimes gets bruised in an area that seems unrelated to the originally injured area (gravity pulls the swelling downwards).  For instance, it is not uncommon to see ankle bruising after a hip or knee injury or surgery, or bruising at the back of the thigh when the original injury was on the top of the thigh.

In addition to rest, ice (and/or heat), compression and elevation, your Physical Therapist may use a variety of other modalities on your contusion in order to speed its recovery. Hands on techniques such as massage or stretching may be useful, or electrical modalities such as ultrasound, muscle stimulation, laser or interferential current (IFC).

If you have a severe contusion of your lower limb or torso you may require the use of crutches in order to get around.  Your Physical Therapist can recommend crutches where needed and teach you how to use them. The general rule regarding when to use crutches after a lower limb or torso contusion is such that if you are limping when walking without crutches, then you should use crutches to get around.  Crutches (or a cane/stick) should continue to be used until your injury heals enough so that you are able to walk without limping when not using the walking aid.

What kinds of complications can occur from a contusion?

In rare cases complications may result as a contusion heals.  Incurring a complication is more common when dealing with a severe rather than mild contusion, as severe contusions also cause more significant muscle fiber damage.  Factors that may affect the risk of developing a complication include stretching the contused muscle too aggressively and too early on, not having an appropriate time for the contusion to heal before returning to activity, or massaging directly over the contused area too aggressively. Receiving early advice from your Physical Therapist and strictly following the advice in regards to your stretching, strengthening, and return to activity regime will significantly decrease your chances of developing a complication.

Hematoma

In more severe contusions, hematomas (blood clots) can develop as a complication within the healing muscle.  A hematoma is felt as a hard lump in the muscle fairly early on in the recovery process. The development of a hematoma can delay recovery time, but the hematoma, in most cases, will eventually be reabsorbed back into the tissue, and a full recovery will be made.

Myositis Ossificans (MO)

With some severe contusions myositis ossificans may develop. This condition occurs most often with contusions of the quadriceps muscle (also known as corked thigh in some parts of the world) but can occur in any severely contused muscle. With myositis ossificans damaged muscle fibers turn into bone (ossify) but the exact mechanism of this conversion remains unclear.  MO will also cause a lump in the healing tissue, similar to a hematoma, but the calcification of the muscle will not be felt or show up on x-ray usually any earlier than 4 weeks after the injury, which distinguishes it from a hematoma.  Being too aggressive in early rehabilitation or returning to activity too early may be related to developing MO.
See First Choice Physical Therapy’s Guide to Myositis Ossificans: http://www.honsbergerphysio.com/Injuries-Conditions/Muscle-Injury/Muscle-Injury-Issues/Myositis-Ossificans/a~8610/article.html

Compartment Syndrome

Another rare complication of a severe contusion in the upper or lower limbs, can be a compartment syndrome.  When a severe contusion occurs there is a lot of local swelling and blood in the area, which has nowhere to escape to.  The force of the extra fluid in the area can put pressure on the other local muscles and arteries and can cause severe damage or death to the muscles by cutting off their blood supply.  Symptoms of a compartment syndrome occurring after a severe contusion include a sudden, new and excessive pain or ache in the injured area, pins and needles or tingling, difficulty moving the body part, and tightness on palpation of the area.  An acute compartment syndrome requires emergency medical attention in order to decompress the compartment, restore blood supply to the tissues, and ensure no muscle death occurs in the affected area.

Contusions can occur for a variety of different reasons but the larger the force and the bigger the object that one makes contact with determines the extent of the damage.  As contusions heal they go through a classic array of *colour*ing which relates to their stage of healing, although many contusions are a variety of *colour*s due to different areas within the same bruise having different levels of damage.  Receiving early Physical Therapy advice and treatment can be very useful in ensuring a quick and uncomplicated recovery of your contusion.

To better understand how knee problems occur, it is important to understand some of the anatomy of the knee joint and how the parts of the knee work together to maintain normal function.

First, we will define some common anatomic terms as they relate to the knee. This will make it clearer as we talk about the structures later.

Many parts of the body have duplicates. So it is common to describe parts of the body using terms that define where the part is in relation to an imaginary line drawn through the middle of the body. For example, medial means closer to the midline. So the medial side of the knee is the side that is closest to the other knee. The lateral side of the knee is the side that is away from the other knee. Structures on the medial side usually have medial as part of their name, such as the medial meniscus. The term anterior refers to the front of the knee, while the term posterior refers to the back of the knee. So the anterior cruciate ligament is in front of the posterior cruciate ligament.

This article will help you understand:

• what parts make up the knee
• how the parts of the knee work

The important parts of the knee include:

• bones and joints
• ligaments and tendons
• muscles
• nerves
• blood vessels

Bones and Joints

The knee is the meeting place of two important bones in the leg, the femur (the thighbone) and the tibia (the shinbone). The patella (or kneecap, as it is commonly called) is made of bone and sits in front of the knee.

The knee joint is a synovial joint. Synovial joints are enclosed by a ligament capsule and contain a fluid, called synovial fluid, that lubricates the joint.

The end of the femur joins the top of the tibia to create the knee joint. Two round knobs called femoral condyles are found on the end of the femur. These condyles rest on the top surface of the tibia. This surface is called the tibial plateau. The outside half (farthest away from the other knee) is called the lateral tibial plateau, and the inside half (closest to the other knee) is called the medial tibial plateau. The patella glides through a special groove formed by the two femoral condyles called the patellofemoral groove.

The smaller bone of the lower leg, the fibula, never really enters the knee joint. It does have a small joint that connects it to the side of the tibia. This joint normally moves very little.

Articular cartilage is the material that covers the ends of the bones of any joint. This material is about one-quarter of an inch thick in most large joints. It is white and shiny with a rubbery consistency. Articular cartilage is a slippery substance that allows the surfaces to slide against one another without damage to either surface. The function of articular cartilage is to absorb shock and provide an extremely smooth surface to facilitate motion. We have articular cartilage essentially everywhere that two bony surfaces move against one another, or articulate. In the knee, articular cartilage covers the ends of the femur, the top of the tibia, and the back of the patella.

Articular Cartilage

Ligaments and Tendons

Ligaments are tough bands of tissue that connect the ends of bones together. Two important ligaments are found on either side of the knee joint. They are the medial collateral ligament (MCL) and the lateral collateral ligament (LCL).

Ligaments

Inside the knee joint, two other important ligaments stretch between the femur and the tibia: the anterior cruciate ligament (ACL) in front, and the posterior cruciate ligament (PCL) in back.

Other Important Ligaments

The MCL and LCL prevent the knee from moving too far in the side-to-side direction. The ACL and PCL control the front-to-back motion of the knee joint.

The ACL keeps the tibia from sliding too far forward in relation to the femur. The PCL keeps the tibia from sliding too far backward in relation to the femur. Working together, the two cruciate ligaments control the back-and-forth motion of the knee. The ligaments, all taken together, are the most important structures controlling stability of the knee.

Two special types of ligaments called menisci sit between the femur and the tibia. These structures are sometimes referred to as the cartilage of the knee, but the menisci differ from the articular cartilage that covers the surface of the joint.

Knee Ligaments

Menisci

The two menisci of the knee are important for two reasons: (1) they work like a gasket to spread the force from the weight of the body over a larger area, and (2) they help the ligaments with stability of the knee.

Imagine the knee as a ball resting on a flat plate. The ball is the end of the thighbone as it enters the joint, and the plate is the top of the shinbone. The menisci actually wrap around the round end of the upper bone to fill the space between it and the flat shinbone.

The menisci act like a gasket, helping to distribute the weight from the femur to the tibia.

Without the menisci, any weight on the femur will be concentrated to one point on the tibia. But with the menisci, weight is spread out across the tibial surface. Weight distribution by the menisci is important because it protects the articular cartilage on the ends of the bones from excessive forces. Without the menisci, the concentration of force into a small area on the articular cartilage can damage the surface, leading to degeneration over time.

Meniscus of the Knee

In addition to protecting the articular cartilage, the menisci help the ligaments with stability of the knee. The menisci make the knee joint more stable by acting like a wedge set against the bottom of a car tire. The menisci are thicker around the outside, and this thickness helps keep the round femur from rolling on the flat tibia. The menisci convert the tibial surface into a shallow socket. A socket is more stable and more efficient at transmitting the weight from the upper body than a round ball on a flat plate. The menisci enhance the stability of the knee and protect the articular cartilage from excessive concentration of force.

Taken all together, the ligaments of the knee are the most important structures that stabilize the joint. Remember, ligaments connect bones to bones. Without strong, tight ligaments to connect the femur to the tibia, the knee joint would be too loose. Unlike other joints in the body, the knee joint lacks a stable bony configuration. The hip joint, for example, is a ball that sits inside a deep socket. The ankle joint has a shape similar to a mortise and tenon, a way of joining wood used by craftsmen for centuries.

Knee Ligament Summary

TendonsTendons are similar to ligaments, except that tendons attach muscles to bones. The largest tendon around the knee is the patellar tendon. This tendon connects the patella (kneecap) to the tibia. This tendon covers the patella and continues up the thigh.

There it is called the quadriceps tendon since it attaches to the quadriceps muscles in the front of the thigh. The hamstring muscles on the back of the leg also have tendons that attach in different places around the knee joint. These tendons are sometimes used as tendon grafts to replace torn ligaments in the knee.

Meniscus of the Knee

Muscles

The extensor mechanism is the motor that drives the knee joint and allows us to walk. It sits in front of the knee joint and is made up of the patella, the patellar tendon, the quadriceps tendon, and the quadriceps muscles. The four quadriceps muscles in front of the thigh are the muscles that attach to the quadriceps tendon. When these muscles contract, they straighten the knee joint, such as when you get up from a squatting position.

The way in which the kneecap fits into the patellofemoral groove on the front of the femur and slides as the knee bends can affect the overall function of the knee. The patella works like a fulcrum, increasing the force exerted by the quadriceps muscles as the knee straightens. When the quadriceps muscles contract, the knee straightens.

The hamstring muscles are the muscles in the back of the knee and thigh. When these muscles contract, the knee bends.

Nerves

The most important nerve around the knee is the popliteal nerve in the back of the knee. This large nerve travels to the lower leg and foot, supplying sensation and muscle control. The nerve splits just above the knee to form the tibial nerve and the peroneal nerve. The tibial nerve continues down the back of the leg while the peroneal nerve travels around the outside of the knee and down the front of the leg to the foot. Both of these nerves can be damaged by injuries around the knee.

Nerves Around the Knee

Blood Vessels

The major blood vessels around the knee travel with the popliteal nerve down the back of the leg. The popliteal artery and popliteal vein are the largest blood supply to the leg and foot. If the popliteal artery is damaged beyond repair, it is very likely the leg will not be able to survive. The popliteal artery carries blood to the leg and foot. The popliteal vein carries blood back to the heart.

The knee has a somewhat unstable design. Yet it must support the body’s full weight when standing, and much more than that during walking or running. So it’s not surprising that knee problems are a fairly common complaint among people of all ages. Understanding the basic parts of the knee can help you better understand what happens when knee problems occur.

Hip surgeries such as total joint replacement and hemiarthroplasty require the surgeon to open the hip joint capsule. This puts the hip at risk of dislocating after surgery. Patients follow special precautions after surgery about which hip positions and movements need to be avoided to keep the hip from dislocating. While you are in the hospital, your health care team will remind you often about the need to follow these hip precautions. Once you get home, you will have to remember to follow these rules until your surgeon approves motion beyond these limits of movement.

This guide will help you understand:

• why hip precautions are needed
• which precautions you should use and when to use them
• ideas you can use at home to protect your hip joint

Which parts of the hip joint are affected by a dislocation?

The hip joint is one of the true ball-and-socket joints of the body.

Ball and Socket

The hip socket is called the acetabulum and forms a deep cup that surrounds the ball of the upper thighbone, called the femoral head. The ball and socket is surrounded by a soft-tissue enclosure called the joint capsule.

Joint Capsule

The hip itself is surrounded by the thick muscles of the buttock on the back of the hip and the upper thigh muscles on the front.

Muscles

When the surgeon opens the hip joint capsule on the front edge, the procedure is called an anterior approach.

Opening the Hip Joint

Opening the joint from the back part of the joint is called a posterior approach.

Why are precautions needed to prevent a hip dislocation?

The joint capsule and ligaments keep the ball joint centered in the hip. When these soft tissues are cut during hip surgery, there is a greater risk for the ball to be forced out of the socket and dislocated after surgery while the soft tissues of the hip heal. The hip precautions you’ll learn are used to keep your hip in safe positions. To do this, you need to avoid certain movements and positions. In this way, the ball will be less likely to push against the healing tissues and be forced out of the socket. Most surgeons prefer to have you use these precautions for at least six to twelve weeks after surgery until the healing tissues gain strength.

Dislocation of an artificial hip is uncommon but may occur within the first three months after surgery. The problem usually starts with a popping or slipping sensation. If the ball dislocates, you will be unable to put weight on the affected limb and will most likely experience discomfort in your hip. You should contact your orthopedic surgeon immediately and probably have someone take you to the emergency room. Putting the hip back in the socket will probably require medication given intravenously to relax the hip muscles and allow your surgeon to put the hip back into place.

Most patients will have an opportunity to work with First Choice Physical Therapy physical or occupational therapist before having hip joint surgery. However, patients sometimes require emergency surgery, such as after a hip fracture, and are not able to have preoperative therapy instruction.

Our therapist will go over specific precautions with you in the preoperative visit and will drill you often to make sure you practice them at all times for six to 12 weeks after surgery.

Your health care team will remind you often about these precautions. They sometimes place a sign by your hospital bed as a reminder. You’ll continue to review and use these precautions until your surgeon gives the approval for you to stop using them.

What are the precautions I should know and use to keep my hip from dislocating?

The positions and movements you’ll need to avoid after surgery depend on whether your surgeon opens the joint from the front (anterior approach) or the back (posterior approach).

Anterior Approach

The main positions and movements to avoid after an anterior approach include bending the hip back, turning your hip and leg out, or spreading your leg outward.

• Don’t stretch your hip back. Walk with short steps. Taking a longer step when leading with your nonoperated hip stretches the surgical hip back.

• Don’t kneel only on one knee. Kneeling only on the surgical hip stretches the hip back. Use both knees when you must kneel down.

• Don’t turn your foot out. Place a pillow next to your hip and leg to keep your leg from turning or rolling out while lying on your back in bed.

• Don’t twist your body away from your operated hip. This means don’t stand with your toes pointed out. Keep the toes of your affected leg pointed forward when you stand, sit, or walk. If you turn your body away from your surgical hip without pivoting your foot, your hip will be placed in an unsafe position. Remember to lift and turn your foot as you turn.

What arrangements should I consider in my home to help protect my hip from dislocating?

You may require special equipment at home to keep your hip in safe positions. Following are ideas for different areas of your home.

Bathroom

Several items can be used to increase your safety in the bathroom. For instance, a toilet seat can be elevated with a raised commode seat to keep your hip from bending too far when sitting down. Getting on and off the commode may be easier with the help of handrails or grab bars securely fastened near by. For accessing your bathtub or shower, you may need one or more grab bars. For additional safety and comfort, be sure to obtain an adjustable tub or shower bench. When you first try the bench, be sure your knees are positioned slightly lower than your hips. In this way, you’ll be sure to keep your hip from bending more than ninety degrees while sitting down.

Furniture

To prevent your hip from bending beyond ninety degrees, you may need to elevate your couch, chair, or recliner. A good rule of thumb is to have a seat height that is at least twenty inches above the floor. If you find that your furniture is too low, consider using a platform under your chair or couch to raise it to the desired height. Using four-by-four blocks may be helpful, but be sure that the chair or couch is safe and steady before you sit down.

Shelves and Cupboards

To avoid excessive bending and lifting, arrange your shelves and cupboards with frequently used items at waist to shoulder height. For lighter items on lower shelves, be sure to have your grabber handy to keep from bending over too far at the hip.

If you are able to see our Physical Therapist before surgery, we’ll begin going over your hip precautions then. After surgery, our Physical Therapist will begin working with you right away and may see you one to three times each day in the hospital until you are safe to go home.

You are advised to continue using your hip precautions until your surgeon says you may discontinue following them.