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Offline fsugirl

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VMO - Don't ignore it!!
« on: July 10, 2014, 02:00:13 PM »
Vastus Medialis Oblique (VMO)

Working this area is SO important in your rehabilitation, so if you're not familiar with it, I suggest you research it now!  I heard about it several times on these boards... people mentioned it to me when I talked about some of the issues I was having (pain, popping, etc.)... but I didn't pay too much attention because I thought, "I exercise; I should be fine."  Wrong!  I thought if I was working my quads at the gym - squats, leg extensions, leg press, etc... and doing a lot more than the average walking... etc. that certainly I was working all the muscles in my quads - wrong.  I also thought that some of the exercises we were doing in PT were for regaining my extension and that if my extension was good I didn't need to continue them.... I also thought that a lot of the PT exercises did not need to be continued if I had a regular, full body workout plan... again - wrong.  All the while I had these silly thoughts, I also noted that the inner portion of my quad was not developing like the rest and was bothered by the fact that it still looked so puny and even a little flabby in that area, while the rest was getting back to 'normal'.  FINALLY... my little brain thought, "Hmm.... Maybe I should look further into that 'VMO talk'"....
DUH!!!  That's exactly what was going on!  I was doing exercises that target the rest of the quad (even cycling/riding the recumbant bike), but not the VMO and VERY likely my patella is not tracking properly!
Maybe YOUR OS or PT is talking to you about this, but mine didn't!  I remember my PT trying to get my muscle to 'fire' in PT (without success!), but she didn't really say anything more about it - uggh.
So..... My advice to all.......

KNOW ABOUT THE VMO & MAKE SURE YOU ARE WORKING/REHABBING IT!!!!!!

& My apologies to YOU if you tried to tell me this and I ignored you. :/
3/17/12 patella fracture
3/22 ORIF - 3 screws, wire, immobilizer
4/2 - sutures removed, crutches, nwb
4/30 new brace-locked, referral for pt ~20/25ROM, pwb
5/9 started pt 30ROM
5/18 45ROM
5/25 50ROM-brace to 30
6/1 60ROM-brace to 50
7-MUA
More PT
Dynasplint fullROM
10/30-PT release
4/30/14-HW remova

Offline MDAL

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Re: VMO - Don't ignore it!!
« Reply #1 on: July 10, 2014, 02:09:12 PM »
True that VMO work took a huge focus when I was doing my rehab with the physio.

Care to share examples of exercises you did? Links to example video or image better....

Offline mjeffrey

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Re: VMO - Don't ignore it!!
« Reply #2 on: July 10, 2014, 07:29:48 PM »
Hi fsugirl
I agree completely. I had a similar issue with the VMO and strengthening helped alot.
 
In my 20's while running I got knee pain and so gave it up. In my 30's more than 20 yrs ago I got knee pain while mountain biking and the OS diagnosed a problem with the cartilage under the knee cap caused by VMO weakness, PT didn't help it (in retrospect I don't think the PT knew what she was doing) and so I stopped mountain biking.
In my 50's I started mountain biking again and started to get knee pain but I also read that it may be due to quadriceps insufficiency (weakness or lack of stamina).
http://www.amazon.com/Treat-Your-Own-Knees-Reissue-ebook/dp/B00L0M4F7G/ref=la_B002LPYUBM_1_3?s=books&ie=UTF8&qid=1405013955&sr=1-3.
In particularly the VMO is often the problem.
So I started exercising the VMO with leg extensions (since this exercise seemed to make them work the most for me). To target the VMO it is important to do them the right way which is pretty easy, just experiment slightly with the angle of the foot, a bit to the left, a bit to the right, so you see a good contraction in the VMO - for me it is about 10 degrees with the foot outwards. And, the bodybuilding trick, focus on the VMO and contract it consciously, thinking about every rep (don't think about the football score or going home) think about the exercise and work the muscle with your brain.

You should do one warm-up set of 8 repetitions (at 70% of the full weight) and then 3 sets of 8 repetitions at the full weight (some people prefer 10, some 12 but don't go more than 12). At least a minute between sets and at least a day between exercises. Write down what you do each day (it is easy to forget and the log is motivating).

Start slowly, it should be relatively easy the first week to get used to the movement (unless you are experienced) and then gradually increase the weight. At 4 weeks it should start to get challenging and you should start to feel the "burn" on the last reps of each set. Muscles may feel sore the next day. Eat properly after the exercise, calorie restriction does not help to gain strength/muscle.

I found that after 2 weeks of this, my pain decreased and a few weeks later disappeared and only comes back if I am a bit lax (they aren't my favourite exercise).

I can only suggest this for people without some trauma to the knee, an injury is different and I can't give any useful advice but would be happy to hear some :).

After a trauma getting the VMO to function again is really difficult. On my injured leg, mine does not yet, even with the Compex electrical stimulator it does not get a good contraction. And I don't do leg extensions with any weight so far since they are far too painful but I do use the Compex EMS and do the isometric exercise in the link below. This is the one from the book above, again focusing on the muscle contracting is important.
 
https://www.google.com/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&cad=rja&uact=8&docid=UdLIR20rx4cyOM&tbnid=9MQKFJKfNpNb3M:&ved=&url=http%3A%2F%2Fcari-brokenknee.blogspot.com%2F&ei=HNO-U4TxDcH-Odn6gNgJ&bvm=bv.70138588,d.ZGU&psig=AFQjCNE73ehRjE2ZzQVTt3bOBLuzxYfQIA&ust=1405101182110448

Hope it helps,
;)

Mark

2004
20 Feb: Comminuted patella fracture, 4 K wires, Cercalge, Figure of 8
11 Mar: Staples remove Flex 50
22 Apr: Control Xray, flex 80, progress stalled
09 May: MUA: flex 120 on CPM machine
04 Jun: regained flex 120 after losing 10 degrees
23 Jun: Started "running", Flex 135
06 Jul: Flex 140, control scan for hardware removal scheduled for 4 Aug
2014:
20 Feb: Comminuted patella fracture, 4 K-wires, Cercalge, Figure of 8
11 Mar: Staples removed Flex 50
22 Apr: Control Xray, flex 80, progress stalled
09 May: MUA: flex 120, 3 weeks CPM
23 Jun: Slow Running, Flex 135
06 Jul: Flex 140
08 Aug: Hardware removed
10 Sep: full flexion

Offline fsugirl

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Re: VMO - Don't ignore it!!
« Reply #3 on: July 11, 2014, 09:15:54 PM »
I do plan to respond to this; I just came here to do that & ended up spending time responding to another post instead... and now ran out of time.  More later...  :)
3/17/12 patella fracture
3/22 ORIF - 3 screws, wire, immobilizer
4/2 - sutures removed, crutches, nwb
4/30 new brace-locked, referral for pt ~20/25ROM, pwb
5/9 started pt 30ROM
5/18 45ROM
5/25 50ROM-brace to 30
6/1 60ROM-brace to 50
7-MUA
More PT
Dynasplint fullROM
10/30-PT release
4/30/14-HW remova

Offline Madyakker

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Re: VMO - Don't ignore it!!
« Reply #4 on: July 12, 2014, 10:51:09 PM »
Im glad you posted this since I had never heard of it. Am busy looking it up as we speak. I definitely think it has been a big problem for me I still struggle to lift my lower leg and cannot hold it up after I have lifted it. I have been doing leg extensions but haven't done anything at different angles before, must try that tomorrow.
15/12/13 Kayak accident trap under by leg diag. depr. lateral TPF
20/12/13 ORIF 8 screws
21/12/13 Vasovagal episode
22/12/13 Walk + frame
24/12/13 Home
02/1/14 stiches out vasovagalattack sono physio
16/1/14 1st phys  crutches
27/2/14 PWB
20/3/14 FWB
29/4/14 no crutch occ stick
08/5/14 1st step up

Offline lostpirate

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Re: VMO - Don't ignore it!!
« Reply #5 on: July 13, 2014, 02:25:23 AM »
The VMO is HUGE! Not having it up to par with the rest of my muscles is part of what turned a 1 year recovery into a 3 year one! EVERYTHING revolves around the VMO! I struggled and struggled until I got a 2nd opinion with a OS that sent me straight back to therapy with therapist the was very experienced with knee injuries. He got my VMO caught up with the rest of my muscles and once he did my recovery really took off! I have preached about the VMO for years here because I don't want to see anyone go through what I did. You have to make sure you are concentrating on it in therapy. It's the lynch pin on which everything depends on.
5/2/09..Broken right patella
5/4/09..Surgery. 2 pins and wire
6/5/09..Began PT (60 degrees ROM)
6/12/09..Began walking out of immobilizer
6/29/09..2 month check up (130 degrees ROM)
7/12/09..Full ROM
7/22/09..Shifting pin
8/14/09..pin removed
11/10/09..All hardware removed

Offline fsugirl

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Re: VMO - Don't ignore it!!
« Reply #6 on: July 14, 2014, 05:12:00 PM »
Lostpirate - unfortunately, you are one of those I ignored. :(  Not you, specifically - I have always appreciated your posts!!  Your hardware removal posts are the ones that finally 'sealed the deal' for me on that decision. :)  I just wasn't listening very closely to all of the VMO talk, for some stupid reason.

Regarding what exercises to do - I have just been looking online and starting this myself, so I'm not quite in a position yet to say 'what works'.  Mark - thanks for your contributions!  I had not heard about doing the leg extensions that way, but it definitely makes sense as I have started adding seated leg lifts (with no weight) to my regular calisthenics.  The other exercise I'm doing (that we did in PT, but I didn't continue because I thought it was for extension) is rolling up a towel and putting it behind my knee, while sitting on the floor, and pushing down on the towel so that my foot comes off the floor, holding it for 10 seconds each time... for about 10 times.  I figured I would start with the 'easy' stuff and then work myself into the harder exercises.
Otherwise - another very important acknowledgement and change I've made is in the way I go down stairs.  Again - I'm kicking myself for not thinking about how this was probably hurting me more than helping me.... which is why I wrote this post - in case anyone else finds him/herself in this position... doing the same things...
Anyway....
When I go down stairs (which I do a LOT - at work & at home) I go down normal on my good leg & then I kinda hop on the bad one, as if to get past it and back onto the good one.  Therefore, I'm not putting much weight on that leg... & NOT working it... NOT working on the balance (which is related to VMO strenghening)!  I realized this because I read that 'step ups' were a good exercise for the VMO....
As I was going up & down my stairs, I started paying closer attention, thinking, "How can I make sure I am working my VMO when I'm doing this?".... and then I realized... FIRST - you need to start actually using your muscles! Uggh.  So.... now I"m concentrating more when I'm going up & down stairs to make sure I'm not 'cheating'.  Funny thing is - now that I'm doing this, I find myself thinking, "If anyone is watching me, they probably think I'm regressing" - which reminds me that it is probably one of the reasons I started doing this... I went a lot faster this way... and, therefore, probably looked more 'normal' or 'ok' that way.

So - yes - here's to more concentration on the VMO!!!
(& listening closer to the wisdom of folks like lostpirate!;) )
3/17/12 patella fracture
3/22 ORIF - 3 screws, wire, immobilizer
4/2 - sutures removed, crutches, nwb
4/30 new brace-locked, referral for pt ~20/25ROM, pwb
5/9 started pt 30ROM
5/18 45ROM
5/25 50ROM-brace to 30
6/1 60ROM-brace to 50
7-MUA
More PT
Dynasplint fullROM
10/30-PT release
4/30/14-HW remova

Offline charlottekatt

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Re: VMO - Don't ignore it!!
« Reply #7 on: July 15, 2014, 02:46:49 PM »
Dagnabbit FSU gal : )

You just made me rethink stairs 1000%.   I read this post, went and skittered up n down some stairs and durned if I'm not doing the same thing.  Stairs are the one thing my PT did not evaluate, just took my word on  (PT facility is a one story building so he really didn't have much choice).  To his credit... he had me walk ramps, and up n down corridors, watching like a hawk and adding exercises to address weaknesses/bad habits etc. 

Soo...resolving  hereon (forthwith, yadda yadda).... to-do-with-my-left-leg-as-I-do-with-my-right-leg  with good faith and to the best of my ability*

* in empty stairwells, and hopefully with no one watching the security cams!
------------------------
2/23/14 - Fractured Patella - Transverse/Displaced - Immobilized
2/25/14 - Doc appt, surgery scheduled
3/4/14 - ORIF  - 2 pins, Tension band - cylinder cast NWB
3/11/14 - Follow-up - NWB
3/21/14 - Cast off.  ROM Brace locked in full extension - NWB
4/4/14 - Brace, Full extension - NWB 70% healed
4/11/14 - Physical Therapy start - 38 ROM
4/14/14 - 48 ROM
4/17/14 - 60 ROM
4/21/14 - 78 ROM
4/24/14 - 90 ROM
4/25/14- Doc appt, w/wean from brace instructions/wean from crutches instructions
4/28/14 - 105 ROM
5/1/14 - 110 ROM
5/5/14 - 112 ROM
5/6/14 - Started bike trainer (10/15 min/day)
5/08/14 - 120 ROM
5/12/14 - 125 ROM
5/14/14 - 130 ROM
5/19/14 - 137 ROM - started walking home from work (1.5 miles)
5/25/14 - 4 mile bike ride (flat)
5/27/14 - 142 ROM
7/7/14 - 150 ROM - Graduated from PT

Offline mjeffrey

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Re: VMO - Don't ignore it!!
« Reply #8 on: July 16, 2014, 08:43:06 PM »
@fsugirl your description of going down stairs made me smile because I do exactly the same!

Quote
I go down normal on my good leg & then I kinda hop on the bad one, as if to get past it and back onto the good one.

Thanks for the post I'm going to try to improve as well. My PT pulled me up for walking badly recently as well. So easy to fall into bad habits (when the good ones hurt).
2014:
20 Feb: Comminuted patella fracture, 4 K-wires, Cercalge, Figure of 8
11 Mar: Staples removed Flex 50
22 Apr: Control Xray, flex 80, progress stalled
09 May: MUA: flex 120, 3 weeks CPM
23 Jun: Slow Running, Flex 135
06 Jul: Flex 140
08 Aug: Hardware removed
10 Sep: full flexion

Offline fsugirl

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Re: VMO - Don't ignore it!!
« Reply #9 on: July 17, 2014, 06:27:51 PM »
Sorry to be the one to bring you to that realization, but SO glad my post helped! That was my intent! :)

I love this, Charlottekat!
"Soo...resolving  hereon (forthwith, yadda yadda).... to-do-with-my-left-leg-as-I-do-with-my-right-leg  with good faith and to the best of my ability*

* in empty stairwells, and hopefully with no one watching the security cams!"

So...
Another 'duh' moment I had recently...
I have these shoes called Chung Shi.  They have a 20% lift in the front, forcing you to walk heel-to-toe, as we are supposed to, claiming to increase muscle activity (which I felt they did when I wore them).  I wore them all the time before my injury, but I was afraid to put them on after... because you do have to think... and balance... and I was definitely afraid of falling... and/or more injury to my knee.  I thought I might not ever put them on again.
However...
Now that I've been doing all of this thinking about the VMO and balance, I thought - hey! what about those Chung Shis?!  Maybe I should start wearing them again... they might actually be really good for me...  Hmmm...
I did a little research and - sure enough - studies have found that wearing them INCREASES VMO activity!  So, guess what I'm wearing now on my daily walks?! :)
3/17/12 patella fracture
3/22 ORIF - 3 screws, wire, immobilizer
4/2 - sutures removed, crutches, nwb
4/30 new brace-locked, referral for pt ~20/25ROM, pwb
5/9 started pt 30ROM
5/18 45ROM
5/25 50ROM-brace to 30
6/1 60ROM-brace to 50
7-MUA
More PT
Dynasplint fullROM
10/30-PT release
4/30/14-HW remova

Offline Madyakker

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Re: VMO - Don't ignore it!!
« Reply #10 on: July 19, 2014, 07:26:35 PM »
I'm struggling with these exercises. I can for instance do a leg raise but I cant get my leg to turn out to the side very much at all (The physio did say that my hip is inhibited which I do exercises for) and when I do then I cannot feel the VMO at all even to just contract it. How do you know if you are feeling in the right place? I have compared with the good leg but there just isn't anything at all on the bad one. Any advice?
15/12/13 Kayak accident trap under by leg diag. depr. lateral TPF
20/12/13 ORIF 8 screws
21/12/13 Vasovagal episode
22/12/13 Walk + frame
24/12/13 Home
02/1/14 stiches out vasovagalattack sono physio
16/1/14 1st phys  crutches
27/2/14 PWB
20/3/14 FWB
29/4/14 no crutch occ stick
08/5/14 1st step up

Offline mjeffrey

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Re: VMO - Don't ignore it!!
« Reply #11 on: July 20, 2014, 02:02:07 PM »
The "towel" exercise described by fsugirl is good when other exercises are too difficult. I've had 4 PTs and each of them had me do it. Jim Johnson also recommends it as a proven exercise for quad strength in his book:
http://www.amazon.com/Treat-Your-Own-Knees-Responsiveness-ebook/dp/B004HYHP1C

Also take a look at the FAQ for bone breaks (at the top of this board).

Quote
What is the VMO muscle and what can I do to strengthen it (This is one of the most common problems that hinder people in recovering from a fractured patella)?
See -
http://www.kneeguru.co.uk/KNEEtalk/index.php?topic=54126.0
http://www.sportsinjuryclinic.net/cybertherapist/front/knee/vmo.php

I found that when I didn't have any contraction in the VMO at the beginning, short "twitches" at the start of a session helped it "wake up" and then I could do longer contractions (only managed a few seconds at the start). To twitch, make the contraction for just a fraction of a second and release it. Gradually it will be possible to hold it for longer.
 
It's a weird feeling in the beginning to ask the muscle to do something and nothing happens (had the same with my biceps a few years back after a shoulder injury).

Try putting your hand on the muscle or push your fingers into it to get feedback on what helps the contraction - I think this helps the body re-learn how to contract the muscle.

p.s. make sure you do the exercises on BOTH legs. You need strong quads anyway and the other leg is also getting less exercise than normal.
I also have the impression, but no proof,  that the good leg helps "teach" the bad one).
I lot of people seem to re-injure themselves knees with another fall and that can be caused by weak quads, so aim to work the good one as well.

Do you have PT sessions? What does your PT say?
2014:
20 Feb: Comminuted patella fracture, 4 K-wires, Cercalge, Figure of 8
11 Mar: Staples removed Flex 50
22 Apr: Control Xray, flex 80, progress stalled
09 May: MUA: flex 120, 3 weeks CPM
23 Jun: Slow Running, Flex 135
06 Jul: Flex 140
08 Aug: Hardware removed
10 Sep: full flexion

Offline mjeffrey

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Re: VMO - Don't ignore it!!
« Reply #12 on: July 20, 2014, 02:08:56 PM »
Oh and I forgot to mention proprioception exercises. This helps give your knee stability and i don't think I'd be running (albeit for a very short time) at the moment without them.

Equipment is great to have (balance boards, bosu balls etc) but just as good is to balance on one leg with it slightly bent and balance for 30 seconds. Once you can do that, do it with your eyes closed. Was/is really difficult for me, even with my good leg :-)
2014:
20 Feb: Comminuted patella fracture, 4 K-wires, Cercalge, Figure of 8
11 Mar: Staples removed Flex 50
22 Apr: Control Xray, flex 80, progress stalled
09 May: MUA: flex 120, 3 weeks CPM
23 Jun: Slow Running, Flex 135
06 Jul: Flex 140
08 Aug: Hardware removed
10 Sep: full flexion

Offline Madyakker

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Re: VMO - Don't ignore it!!
« Reply #13 on: August 04, 2014, 09:32:28 PM »
I have been trying these for the last 2 weeks whilst away on holiday and I am happy to say that I am finally getting somewhere. :) I had been trying the twitches first and can now "find" the muscle. At the same time my physio had been trying some PNF stretches on my hip and sent me away with one of those to try which has worked wonders and I can now turn my knee out to the side at last. I cant believe to only took 2 weeks to sort that out it was incredibly fast. I only wish my ROM problems could be solved as quickly.
I have been trying the towel exercise and I must admit that I do struggle with that still but I can now lift my leg straight(ish) with my foot turned out. I have to warm the muscle up first but it will be it if I warm it up with a few straight leg lifts first. The thing I struggle with now is keeping my leg straight whilst I lift it. It starts off straight but bends as I start to lift it. I will mention it to the physio next time I see her but I guess her answer will probably be that I need more practice and to keep trying.
Next thing to try is the proprioception exercises I guess.
Wish me luck.
15/12/13 Kayak accident trap under by leg diag. depr. lateral TPF
20/12/13 ORIF 8 screws
21/12/13 Vasovagal episode
22/12/13 Walk + frame
24/12/13 Home
02/1/14 stiches out vasovagalattack sono physio
16/1/14 1st phys  crutches
27/2/14 PWB
20/3/14 FWB
29/4/14 no crutch occ stick
08/5/14 1st step up

Offline morgana

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Re: VMO - Don't ignore it!!
« Reply #14 on: August 07, 2014, 04:19:54 AM »
Fascinating read  fsugirl  as the number of times this thread has been looked at shows!  Thanks for starting it!  And many thanks to everyone who added info to it!
5-26-08 Severely comminuted bicondylar fracture-right tib plat - locking plate & 6 screws  Bicycle Accident
nwb for 12 weeks
6-12 started pt
7-21 added swimming
8-25 pwat with walker
9-02 four prong cane
10-07 cane
10-15 cane as needed,slight limp
10-27 OS:next visit 10-2009















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