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Author Topic: Rehab Exercises for Maltracking  (Read 5425 times)

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Offline Powerpaul99

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Rehab Exercises for Maltracking
« on: July 21, 2002, 08:55:24 PM »
 ???

Hi all,

Just what are the correct exericses for PFS and patellar maltracking. There seems to be so much divided opinion about which exercises provide the correct rehab.

For example straight-leg raises are meant to be a good rehab exercise, but surely if you have a muscular imbalance (ie lateral over medial) then this will not help your problem. Others argue that the quadriceps muscles work in concert and it's simply not possible to focus on one, but if this was the case then surely it wouldnt be possible to get a muscular imbalance would it?

I can understand stretching to be good in nearly all cases. Does anyone have any views on which exericses are the best for a laterally tracking patella or in general for building up the knee. Thanks.



« Last Edit: August 19, 2002, 05:28:41 PM by admin »

Offline Heather M.

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Re: Proper Rehab Exercises
« Reply #1 on: July 21, 2002, 10:01:36 PM »
Paul,

Check out the exercise and rehab section on the forum--there are some good ideas.

As for quad imbalance, it's my understanding that the four different muscles that make up the quadriceps group CAN become imbalanced, and this will lead to poor tracking in some people.  Most people have a  weak VMO or inner quad muscle, leading to lateral tracking.  You need a proper assesment from an OS and/or physical therapist to see which muscles are weak in your leg and what you need to do.

You're right about straight leg raises in a sense:  if you lie down and just lift your leg, it won't do much good.
Proper form is EVERYTHING for these PFS exercises.  You must point your toe, clench your quad muscles, THEN lift to the height of your other bent knee, hold for 5 seconds, lower, RELEASE the contraction, then repeat.  After a full set (10-30, depending on your strength) then you need to flex your foot instead of keeping it pointed and repeat the whole thing.  Believe me, it works, but only if you contract the quad before lifting.  I had quad atrophy after surgery and my kneecap actually started to track all over the place.  After about a week of dedicated PT, I could start to see muscle definition in my thigh, and the knee stabilized.  

When you get stronger, you can build up to wall squats with a ball, which really build the VMO (inner quad) muscle as well.  Some people have more severe mal-tracking that just won't be addressed by therapy--I was one of them.  I had a lateral release, and while it has so far prevented further dislocations and damage to the cartilage, it has come with TONS of complications that are actually worse than the original problem.

I strongly recommend getting a good PT who specializes in knees to get started on the right PT regimen, with proper form and accessories.

Good luck, and surf around the exercise section of the web page www.kneeguru.co.uk

Heather
Scope #1: LR, part. menisectomy w/cyst, chondroplasty
#2-#5: Lysis of adhesions/scar tissue, AIR, patellar tendon debridement, infections, MUA, insufflation
#6: IT band release / Z-Plasty, synovectomy, LOA/AIR, chondroplasty
2006 Arthrofibrosis, patella baja
http://www.flickr.com/photos/hmaxwell

Offline snowcat

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Re: Proper Rehab Exercises
« Reply #2 on: July 22, 2002, 01:58:17 AM »
Hey Heather--thanks for the great tip about pointing the toe when doing the straight-leg raises.  I tried that and felt it in my VMO a lot more!  My latest stint on crutches helped my IT Band calm down but left my knee cap slipping and sliding all over the place!!  :P  

I've also been instructed to rotate my foot outward (so the toe is pointing at 2:00) and then do the straight leg raise.  However, these bothered the lateral side of my knee, so I don't do them.  Powerpaul, you might want to consult with a physical therapist and ask which method seems best for you!
5/00: partial lateral menisectomy (R)
7/01: LR, partial lateral menisectomy, cyst draining (R), followed by ongoing problems with illiotibial band syndrome & adhesions
6/04: Much better!

Offline Heather M.

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Re: Proper Rehab Exercises
« Reply #3 on: July 22, 2002, 04:04:08 AM »
Snowcat,

I can't tolerate turning my foot out, either.  Too much pain at the lateral release site and where the cyst was removed...

So my PT came up with this:

Sit on a high chair, barstool, whatever.  Your legs need to dangle, feet pointing forward.  Contract your quad muscle gently with your legs bent at 90 degrees, then slowly straighten your leg(s) as much as you comfortably can.  Stop when you feel the pull (and you will, especially on the lateral side).  Hold for 5 seconds, lower slowly with a controlled motion.

Repeat these with your toes turned inward like you're pigeon-toed, and if you can with the toes turned out to 2 o'clock.  Turning your toes inward will work internal thigh muscles you never knew you had.

Try to start with only five per day, and only do one of the three toe positions until you're sure you can tolerate them all.  For some reason, it doesn't hurt as much as leg raises.

Hope this helps.  It only took me a year of rehab to get these exercises.....

Heather
Scope #1: LR, part. menisectomy w/cyst, chondroplasty
#2-#5: Lysis of adhesions/scar tissue, AIR, patellar tendon debridement, infections, MUA, insufflation
#6: IT band release / Z-Plasty, synovectomy, LOA/AIR, chondroplasty
2006 Arthrofibrosis, patella baja
http://www.flickr.com/photos/hmaxwell

Offline Powerpaul99

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Re: Proper Rehab Exercises
« Reply #4 on: July 22, 2002, 09:24:57 PM »

Thanks for the response all. Very useful

Im under the impression that after years of treadmill running my left kneecap has become tilted as one end seems to protrude out slightly when flexed. After piecing together all the bits of evidence, I ve come to the conclusion that after running one time, my medial retinaculum just loosened, causing the tilt.  Does anyone know of cases where a kneecap can actually be straightened/rectified by pure PT alone. I have been to numerous physios and tried taping, inner quad training etc but little effect so far.  It seems to me so far that the most crucial element is the flexibility of the patella ligaments, (therefore patellar mobilizations are effective) followed by VMO training. Would be interested to hear views on this. Thanks Paul.

Offline Heather M.

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Re: Proper Rehab Exercises
« Reply #5 on: July 23, 2002, 08:22:07 PM »
Paul,

I had kind of the opposite experience to the theory you postulated--my patellar ligaments etc. were extremely loose after 3 dislocations and countless subluxations, and nothing I did could 'tighten' them.  My OS pushed my kneecap over to the lateral side a good 2 inches, then asked me if it hurt.  I said no.  He replied, "Well it should, because I'm a fraction away from dislocating your knee."  That's how easy it was to pop the patella out of place.

As the KNEEGURU explained in another post, I had a structurual problem because my knee was sitting off in a groove it had created on the lateral part of my knee.  Rehab and keeping my legs in general good shape worked for a while (about 18 years from diagnosis), but since this is a degenerative thing, time eventually won out.  I deliberately avoided the surgery for as long as possible, because I had been warned it would be ugly and possibly lead to further work.  Then I pinched off a piece of meniscus in an unusual place (anterior horn of lateral meniscus) and developed a cyst.  After that, a scope was done to trim the meniscus, and my doctor discovered grade IV chondromalacia from all the years of maltracking.

By the way, everything they told me about lateral release was correct--it was a brutal surgery to recover from (not in terms of pain, per se, but in terms of rehab and gait re-educuation) and has caused lots of additional problems.  While it did stop all dislocations/subluxation, it's left me with scar tissue, painful swelling in lateral gutter area, tenidinitis/IT band syndrome...I could go on.  What I can't do is get over the fact that I'm almost one year post-op and WAY worse than I was before the surgery.

I really don't know what I would advise with respect to lateral release.  I know that if I had continued without surgery, my patella's articular cartilage would have worn away, and then I'd be in a whole new world of hurt (and I'd be in the arthritis section of this page).  But I'm hurting in a different way, now....  I guess my point would be to make sure you are really debilitated and facing severe problems before taking on the patellar tracking surgeries.  Despite having only three tiny incisions on my knee, they did TONS of work and it's been really difficult to recover.  It's not quite the "snip-snip" in and out the doctors make it out to be.

Good luck.

Heather
Scope #1: LR, part. menisectomy w/cyst, chondroplasty
#2-#5: Lysis of adhesions/scar tissue, AIR, patellar tendon debridement, infections, MUA, insufflation
#6: IT band release / Z-Plasty, synovectomy, LOA/AIR, chondroplasty
2006 Arthrofibrosis, patella baja
http://www.flickr.com/photos/hmaxwell

Offline Kris

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Re: Proper Rehab Exercises
« Reply #6 on: July 24, 2002, 03:18:38 AM »
My therapist uses the same exercise and stretch routine with PFS patients as she does with many ACL patients and also those that have had the lateral release.  Good or bad, I don't know.  I ended up having the lateral release surgery anyway, so I'm not sure if it worked.  As far as the straight leg lifts, she instructs patients to do them on all for sides correctly with toe pointed only on the stomach lying one.  The others are flexed, and the back lying one is flexed and turned (only a little bit) outward.  She also had my doing a lot of bungee exercises with the different colored tubing which seemed to help the most.  She called them TKE, but I'm not exactly sure what the name is or means.  The Bungee tubing is placed in a door securely and then the other end is around the knee just above the bending point of the knee.  The tubing is then stretched until you feel resistence and then you bend the knee and bring it back making sure nothing is hyperextending.  As for stretching, I only had one.  The one where you lay on the back, cross the leg over and pull it with your opposite hand until you feel the stretch in the outer leg area and not in the glutes.  
Right  LR on 2/8/02,  7/11/03, and 11/5/05
Left leg LR on 5/02, 4/05
Right achilles tendon lengthened on 2/01.   Synvisc injections on 2/17/03. 
Cortisone on 12/03 and 3/04, 12/05. 
Proximal Reallignment Right 5/23/05
R Microfracture 5/19/06
PFJR 6/20/07