KNEEtalk

The SPECIALIST'S OFFICE => The patello-femoral joint => Topic started by: Moribund on October 06, 2009, 12:05:19 AM

Title: What can I expect - MPFL tear
Post by: Moribund on October 06, 2009, 12:05:19 AM
Hi all,
I'm new to this forum - came across it while trying to research my knee problem.  I was practicing a martial art and had my knee dislocated.  Went for an MRI and just got the results.  They read "Findings suggest lateral dislocation of the patella with a complete tear of the medial patellofemoral ligament and associated bone marrow edema of the medial patella and lateral femoral condyle.  There is a strain of the popliteal muscle but no obvious tendon injuries'.

I haven't seen my doctor to go over the results yet, but to be honest (and I don't mean disrespect with this - it's just the way it is) the doctor has shown no interest in wanting to help me.  He looked at the knee for a total of 3 seconds from across his little examining room, did not touch, ask me how it happened, ask me where it hurt, have me move it around, etc - did nothing at all but prescribe an antiinflammatory and x-ray, then on the second visit (upon my insistence) an MRI.

I started physiotherapy and the physiotherapist has been very helpful - she explained a bit about the report results (which she called the MRI clinic to obtain for me) and her take on it is that the approach should probably be to try to rehabiltate with muscle strengthening exercises rather than surgery (which we are doing).

The knee is a bit painful but overall it doesn't bother me much.  I walk with a bit of a limp at times - other times no limp at all.  The big thing on my mind is what the odds are that I'll be able to strengthen it enough to go back to practicing martial arts (Aikido - lots of rolling, twisting, kneeling), how soon I should go back (I'd like to go right away but I'm guessing I shouldn't) and how to best prevent reoccurrence.  How many of you think this will eventually lead to surgery anyway?

Thanks in advance.
Title: Re: What can I expect - MPFL tear
Post by: crankerchick on October 06, 2009, 12:20:15 AM
Hi Moribund, sorry to have to welcome you to the club of kneegeeks, LOL. I think you will find answers to a lot of your questions, but the first thing that alarmed me about your post was your treatment by your doctor. Patella issues are very serious territory and not to be messed with by just any old doctor. Treatment like that would send me on to a new OS quicker than you can say 'see ya later!' Seriously, do not let anyone operate on your knee that you are not comfortable with and haven't done due diligence to ensure is a competent patello-femoral specialist.

That warning out of the way, on to your other questions. If the MPFL is torn, the options are generally repair your own if possible, reconstruct with a graft, or don't have surgery and focus on strengthening the muscles around.

So, some of my questions are:
- have you had any problems with this knee before?
- did the dislocation just "happen" or did someone like kick your or something tramautic? The reason I ask is because if your leg mechanics lend themselves to your patella wanting to dislocate, I think its fair to say (and there is literature to support this) that it is somewhat likely it will happen again.
- how is your rehab coming? does your knee and patella feel stable to you?

I've seen literature that suggests conservative treatment after the first dislocation and surgery if it happens again, but I've also seen literature that says the best results come by fixing it after the first occurence. There are people on here who have torn the MPFL and did not have surgery and are confident in doing sports after rigorous strengthening and wearing a brace, so the decision is highly personal.

I think a good patello-femoral specialist would be a good resource for helping you ascertain if surgery is a good option for you giving your desire to continue with martial arts. I think I'd rather have my MPFL than not, if it were me, but that is jsut me. THe first step is the MRI results, and the second step is getting a good opinion from a doctor that knows what he's talking about.
Title: Re: What can I expect - MPFL tear
Post by: doublemom on October 06, 2009, 06:23:42 AM
Ditto what cranker said... I'd be running away from that doctor super-fast and looking for a patellofemoral specialist who will be willing to go over your options with you.  You need to be able to make an educated decision about what to do, and with a doctor who will barely stay in the room with you, you won't know what all the pros and cons are of conservative versus surgical treatment. 

Andi
Title: Re: What can I expect - MPFL tear
Post by: Moribund on October 06, 2009, 05:29:15 PM
Thank you both for your posts.  I should have mentioned that the doctor I saw was not an OS - he's a general MD at a clinic, so definitely on my next visit (tomorrow) I will ask him to refer me to a knee specialist.
Answers to Crankerchick's questions - I don't have any history of problems with either of my knees.  I was bent over backwards with my weight on the right leg and the guy I was working with got a bit overzealous and kicked my knee sideways.  (He certainly didn't mean to pop the knee and obviously feels bad).  I felt the kneecap dislocate with an audible *pop*, then it went right back into place but there was quite a bit of pain.  It was about 30 minutes into a 90 minute practice and I'm pretty stubborn so I finished out the practice anyway.  It didn't stiffen right up until about 30 minutes after we finished up, then swelled up quite a bit.

Rehab so far has been all right (it's only been 3 weeks) but last night I started getting a clicking in the knee when coming down stairs, and I'm feeling a bit of locking (which is new).

Question - your last statement about how you'd rather have your MPFL than not - does this mean that with a tear like this, unless I have surgery it will never correct itself?  Sorry if that's a dumb question - I don't know much about this so my assumption at first was that the ligament would repair itself and that the purpose of the strength training was to help it along by preventing any further issues.  From your statement I'm deducing that maybe the strength training is to allow me to cope with the loss of the MPFL entirely?

Again, thanks for your help - it's nice to have a forum to ask these questions on.
Title: Re: What can I expect - MPFL tear
Post by: crankerchick on October 06, 2009, 06:17:23 PM
Well, so no past history of knee problems is good, hopefully that means your leg mechanics are such that your kneecap doesn't want to dislocate on its own, and you fall nicely into the "trauma" category and once you get this taken care of, you should be good.

Hopefully the clicking and locking clear up, although symptoms like that are sometimes indicative of a loose body engaging in the joint, so it is something you should take note of bring to the attention of the knee specialist.

I do not believe the MPFL can repair itself. There's a big difference in a strain/sprain and a full tear of ligaments. If its severed, it's gone and you either live without or have surgery. If its strained, then like MCLs, your doctor may say to treat it conservatively. If it's partially torn, I do not believe it can repair itself, but the tear maybe something you can live with without surgery. The first step is to just see the MRI results so you know everything you are dealing with.

An OS I saw told me that ligaments aren't like rubber bands, they don't just get stressed and go back into place. Once stressed, they stay stressed out. So even if its not fully torn, you still may have a reason to want to have surgery, or at least not rule it out in the future if you experience more dislocations.

It's such a hard choice. I would say take it one step at a time and see what your MRI says first. Then work on lining up a good specialist and go from there. IN the meantime you'll be doing physical therapy which is good regardless of where your path leads you, towards surgery or not.
Title: Re: What can I expect - MPFL tear
Post by: fraud_ninja on October 06, 2009, 07:39:28 PM
I completely dislocated my right kneecap when I was 12 and the left the following year when I was 13.  Whenever there is a complete dislocation, the MPFL is almost certainly always torn.  I experienced one more full dislocation to each kneecap in the year that followed.  However, in between I never really had any pain with my knees.  I was incredibly active in High School, I ran, danced, swam, and played any sport I wanted.  My knees never once bothered me in High School. 

It was not until I turned 20 and suffered another kneecap dislocation that I started to have problems.  Things got really bad after that and eventually led me to surgery, but my first surgery on my knees was not until 8 years after my first dislocation.  All total I have had 7 knee surgeries, and the problem of unstable kneecaps is now fixed.

Its hard to say if this was a freak incident or the beginning of a chronic problem.  Definately see a patella specialist.  Work hard on rehabbing the knee.  I am glad I did not have surgery after my first dislocation because it was not really a problem for me until much later.  I think that a person can be quite functional with a torn MPFL, it largely depends on the other factors going on in the knee.  There is a good chance that you will never have another problem again.  But these are things that only a patella specialist can tell you.  So, start there and see what happens.

Brianne
Title: Re: What can I expect - MPFL tear
Post by: doublemom on October 08, 2009, 05:05:38 AM
The clicking and locking could possibly a meniscal tear... I've had in meniscal tears in both knees, one with a pretty bad locking problem and a click from a soccer injury... plant foot, twist body in the other direction, and listen to knee snap!  The other was not a specific injury, but more degnerative.  It just had major grinding sounds and clicking, but no locking.  Just from my personal experience, the clicking and locking could be from meniscal tears, which is another thing to be sure to ask your OS about. 

Let us know how things go and what you decide to do.  Sorry you have had to join us on the KG boards, but it's a great place to be when you need help and support :)

Andi
Title: Re: What can I expect - MPFL tear
Post by: spurs27 on October 15, 2009, 05:43:00 PM
FIND A PATELLO-FEMORAL SPECIALIST!!!

Seriously, and I agree completely with Ninja (once again) and I was also quite functional for a while after my initial total dislocation, but it will most definitely get worse at some point down the road.  Alot has to do with age, physical activity level prior to injury, etc...

To answer your question about healing on it's own...the ligament will not reattach itself and heal on it's own.  By strengthening your knee through PT you can get away with not having the ligament repaired by building the muscles around your knee to hold it together and make up for the lack of an MPFL.  It takes alot of time and effort in the gym to do that though...like at least a hour in the gym everyday and maintaining that over time.

The surgery is not easy by any means but I think finding a good OS who specializes in the patellofemoral joint is key.  If you live in the greater NY/NJ area I can be of some assistance in finding one.  Just email me and I'll get back with you.

Best of luck,
Brian
Title: Re: What can I expect - MPFL tear
Post by: kdreamon on June 30, 2010, 10:21:17 AM
Hi Brian,

I read your posts of MPFL because I'm considering to take MPFL.
How's your knee now?

I live in NY.
Can you tell me your OS's name and hospital?

I'm looking forward to your reply.
Thanks.
Title: Re: What can I expect - MPFL tear
Post by: drmark on June 30, 2010, 03:37:37 PM
I am always trying to find atlhetes to do MPFL reconstructions on.  Damm, those lucky people with traumatic  injuries, normal TT-TGs, no patella alta, deep grooves, and normal rotation, are sent to physical therapy, retun to sports on their own and lleave me feeling hopeless, worthless, and useless.

Now, with the Twisted Sisters, I can always find work.

Mark Sanders MD FACS
Appointed as a PT specialist by Twisted Sisters.
Title: Re: What can I expect - MPFL tear
Post by: crankerchick on June 30, 2010, 04:00:42 PM
bwahaha  ;D

my still twisted leg seems hell bent on doing it's part to keep you with work. i second your appointment for specialist.
Title: Re: What can I expect - MPFL tear
Post by: fraud_ninja on June 30, 2010, 04:37:21 PM
Aww, poor Dr. Mark.  I promise you that if I should ever retear one of my MPFL's during one of my wild and crazy activities that I will let you reconstruct it.  haha! :)

FWIW, I'm a Twisted Sister, but I vow to remain twisted for the rest of my life.  Sorry.  ;D 

Brianne

P.S.  Do you have any recommendations for good biking trails in the North Texas area?  I'm moving to Texas in less than 6 weeks and I want some trails to hit as soon as I get there!
Title: Re: What can I expect - MPFL tear
Post by: drmark on June 30, 2010, 04:41:21 PM
http://www.tpwd.state.tx.us/publications/parkguide/?page=bike&lang=en
Title: Re: What can I expect - MPFL tear
Post by: fraud_ninja on June 30, 2010, 04:47:31 PM
AHHHH, that is perfect.  So excited.  Let's see, I get to Dallas on August 10...so I'll be hitting one of those trails on August 11th.  Sounds about right!
Title: Re: What can I expect - MPFL tear
Post by: The KNEEguru on June 30, 2010, 06:42:51 PM
These two links may be of interest -

http://www.kneeguru.co.uk/KNEEnotes/courses/realignment-osteotomy-knee-pain/dislocators-normal-anatomy-prior-dislocation (http://www.kneeguru.co.uk/KNEEnotes/courses/realignment-osteotomy-knee-pain/dislocators-normal-anatomy-prior-dislocation) - Dislocators with normal anatomy prior to dislocation- new section to Adrian Wilson's course - not quite finished, but may be useful.

http://www.kneeguru.co.uk/KNEEnotes/primers/whos-who-knee-surgery/whos-who-patellofemoral-surgery (http://www.kneeguru.co.uk/KNEEnotes/primers/whos-who-knee-surgery/whos-who-patellofemoral-surgery) - Who's Who in patellofemoral surgery? - this list is still being developed.

Title: Re: What can I expect - MPFL tear
Post by: aaa on June 30, 2010, 08:20:04 PM
very interesting .. thank you

i've tried to make sense of the medial patella ligaments and found this - http://www.wheelessonline.com/ortho/medial_patellofemoral_ligament

the VMO is described to 'fuse' with the MPFL.  So is the MPFL purely a ligament, or have muscle/tendon like property as well?


Title: Re: What can I expect - MPFL tear
Post by: drmark on June 30, 2010, 11:43:34 PM
The MPFL is a seperate and distinct structure from the vastus medialis obliquis.  The former is a ligament and the latter a muscle/tendon unit.  They are easily seperated in the dissection room and in surgery.

To get back to my earlier point, I just can't remember when I did surgery to repair/reconstruct an MPFL as an isolated issue.  Most recurrent dislocations occur resultant from developmental abnormalities.  A single traumatic dislocation in an otherwise normal individual rarely become recurrent and requires surgery.

Mark Sanders MD FACS
Title: Re: What can I expect - MPFL tear
Post by: aaa on July 01, 2010, 02:53:38 AM
i have to wonder if i might fall into this case, although rare

i had no knee issues whatsoever until my kneecap was forcibly knocked out of place, it happened as i was about to land from getting a rebound in basketball and my knee was loose for a second while bracing for the impact to hit the floor, just at the moment someone decided to streak across perpendicular to me, and grab the ball from my hands, and in the processes thrusted their chin into my kneecap. 

I even ran up the CN Tower in Toronto maybe a year or so before the injury (many small staircases and turns) and my knees didn't ache at all.  muscles burned,  joints were solid,

when my kneecap dislocated, it looked like it was down near the hamstrings, it was brutal, i think i did a 360 from the impact before landing as well.  the guy who hit me had a huge bruise on his shin and thought he had broken it.  It was out for an hour and a half until the doctor finally saw me and put it in place.  I was put in an immobilizer for 4 weeks and sent home with no instructuctions.  I was taken out of the immobilizer and then I could not walk right ever since.  Its been over 2 years. Even a single leg extension was near impossible for several months, i felt severe pressure on the lateral kneecap.

Now several years later, I had the lateral release, its helped quite a bit so far and i'll keep working at it since its only 2+ months post-op, but i have to think MPFL recon or repair sounds like it may have helped too.

Title: Re: What can I expect - MPFL tear
Post by: fraud_ninja on July 01, 2010, 03:05:51 AM
Dave,

Often people are unaware of knee cap problems until they have the initial dislocation. This was true for me.  My knees never bothered me for a second and then I dislocated my right kneecap when I was 12.  I had no problems afterward for another 8 years.  I dislocated my left kneecap at 13 and had no problems with it until after I had my right TTT. 

Its possible that you are one of those rare cases, but there is only one way to know for sure.  Seeing a patella specialist who has the knowledge and takes enough time to check for the conditions noted by Dr Mark will tell you for sure. 

I have a pretty twisted left femur...38 degrees where 15 degrees is considered 'normal'.  Before my CT scan revealed my femoral anterversion I never knew I had it.  In fact, I read some posts on this forum about femoral anteversion and I thought 'thank God I do not have that."

Knees are not like cars.  You cannot keep replacing the parts until you get them back in working order.  Its so, so important to spend the extra time on the front end.  You can never get it back once you commit to major surgery.

Brianne
Title: Re: What can I expect - MPFL tear
Post by: Jennifer34 on July 01, 2010, 04:07:53 AM
Dr. Mark,

I had a MPFL in March (3 months ago) with donor ligament.  How long does it take to fully recover from this surgery to the point that I can go back to running, hiking, cross country skiing safely without further injury.

My surgeon says up to 12 months, which seems kind of long.  Is this a realistic time frame?

thanks