Things we should not do after patella fracture

Tibial plateau fractures, femoral fractures, fractured patella
mtsarpilot
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Things we should not do after patella fracture

Post by mtsarpilot »

There have been a number of questions lately about what "healed" really means to us post-patella fracture folks. Other comments about leg press on weight machines, and so on. I learned a lot of new things last week with a new OS that I thought I'd explain to the forum for everyone's benefit.

First, I'll explain what happened that brought this on. Back in July I was doing great. Completed the endurance bike ride I was targetting, did some hiking, no problems, life was great. I got home from vacation and was planning to do a backpack trip with friends so decided to do a simple test first to make sure the knee would be happy. I put 45 pounds in a pack and did a 3 mile hike with about 1500 feet of climbing then descent. The next day I could barely walk. My knee blew up like a grapefruit. It took nearly 3 weeks before I could comfortably turn a bike pedal again. Since then it has been inflamed internally all the time.

After that 3 week episode I began strengthening again. Using the leg press on my weight bench. Doing leg extensions. Doing squats and lunges. Etc. Each time, the knee would inflame internally, feeling tight, pressure, hot, uncomfortable, painful, etc.

I decided to go see the sports medicine OS figuring I'd talk to a guy who was also an athlete and would understand what I was trying to accomplish and wanted to still do in my life. This is the doctor I happened to ski with last February, so I knew how aggressive an athlete he is. What a fantastic visit. He explained everything that is going on, and also explained how to keep strengthening without causing the inflamation. Here's the theory:

After a patella fracture, the back of the patella will never be smooth. Even though the OS smoothed it as part of the hardware removal surgery, it is not going to be smooth like it was. There will be vains of harder bone in the areas where the breaks healed, like veins of harder rock you see through softer rock (at least here in the Rocky Mountains that is).

When the knee is bent more than 45 degrees or so, the back of the patella is now riding in the groove of the femoral condyle. To straighten the leg, the quad pulls using the patella as a fulcrum to lever the lower leg up to straight. The further bent the knee is, the harder that patella is pullled into the femoral condyle with greatly increasing force. Picture how the knee works and this will make sense to you.

With a healthy patella, all this works great. But with a patella that is rough and has ridges on the underside, that force is now grating into the soft tissue on the femoral condyle and the back of the patella. This causes that soft tissue to inflame. The short term result is discomfort, pain, hot feeling, feeling of "fullness" as the OS described it, inflamation, etc.. The long term results is wearing away that soft tissue to the point of generating condromellachia (spelling??), arthritis, and the eventual knee replacement.

This explains why doing lunges and squats make it hurt. Leg presses, leg extensions, all this is bad stuff to a recovered patella fracture. Fifi mentioned that it hurts after doing these things ... that is why. Stepping down such as stairs or hiking downhill with a backpack on, is a lot of quad muscle pulling across that patella. That's why a lot of down stairs can cause discomfort.

"So then how do I strengthen the quads more without doing these exercises" was my next question. He said simply to do them but not go past 40 degrees. Increase the weight such that it works the muscles hard in that 0 to 40 range and you'll do just as much strengthening of the quads. For the leg press, bring the weight up with both legs, then take the good leg away and just do presses from straight to 35 degrees and back to straight. For leg extensions, same thing. Bring the weight up with both legs, then take the good leg away and do the extensions from 0 to 35 degrees. Set the weight such that after 3 sets of 10 - 15 reps your quads are burning. He also said to rotate the foot outwards about 20 degrees such that the VMO is facing straight upwards. That will engage the VMO more and help it develop.

For squats, stand on the injured leg, and just squat down far enough that the knee eclipses your view of your toes then go 1 or 2 more inches, then back up. As you get stronger, hold weight in your hands. You'll get the quad burning quickly.

The reason to stay below 40 degrees is that 40 degrees is about the point at which the patella begins riding in the groove of the femoral condyle, and starts getting used in the lever manner. Don't get into that point, and you don't jam it into the femoral condyle, and you avoid the problem altogether.

I have started doing exercises this way and it has been wonderful. Far less discomfort and the inflamation is slowly going down :D

I have also noticed that when I'm sore, 15 minutes of ice on the knee turns a lot of the discomfort off. I just keep a few cold packs in the freezer to toss on the knee. It works great.

Last portion of the discussion with the OS was around things I should no longer do in life. Telemark skiing was #1 on the list. That's about the worst possible force in the above described manner as you can create. Bummer, but I'll give it up if it means many more years of knee use. Anything lunges is next. You can see where this is going. Use good judgment. It's all a tradeoff. The more you stress that soft tissue now, the sooner it will deteriorate, and the sooner you'll have arthritic problems. Pick your battles wisely. Do the things you love, drop those that are not as important to you. BTW, bicycle is a good thing. Although you go well beyond 90 degrees, the stress in the knee is much lower than you'd imagine because a majority of your weight is born on the saddle, not the pedals and your knee. But you should use lower gears and spin instead of forcing the pedals around in bigger gears.

OK, this is getting too long. I hope this is helpful to others. Give me a shout with questions.

Joel
9/05 - Patella fracture - 5 pieces in rock climbing fall, ORIF, 3 screws & figure 8 wire
5/06 - HW Out
7/06 - Back to full activity
7/09 - Custom brace created to support knee during activity
11/15 - Surgery to clean up meniscus, remove osteophytes, attempt to get more life out of knee
11/16 - TKR
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Re: Things we should not do after patella fracture

Post by lizl »

Well, Joel, you've done it again! :) :D ;D ::) You provided fantastic insight that will help us all.

I grimmace every time I hear my knee crunch when going up a staircase, because I know that friction is doing its damage gradually. I do not have a smooth movement, so I often still sidestep going down stairs. I also had some trimming on both menisci, so I'm very protective of the joint.

Your advice to pick your battles is right on. I am now working as a REALTOR, and I do not preview unfinished basements, for instance. Sometimes even when I have a client present, I do not go down if the basement is unfinished. For one thing, the client can make the trip faster without me and for another, I figure that every staircase I avoid buys my knee some time for the future. Today, I previewed an expensive house that I will be showing this weekend. Much to my chagrin, the master bedroom has a tight little spiral staircase leading up to a dressing room loft/closet area!!! I made the trip up today, but there is another entrance to that level, so I will take that this weekend. I was just so clumsy on that twisty thing, and I certainly don't want my awkwardness to over-emphasize how ridiculous the darned staircase really is!

Did you get the message from your sports doc (maybe between the lines) that some degree of trouble is an inevitable part of the future for most/many repaired patellas?

Thanks again for the great info!

LizL
2003: 1/28-29Fell on wet floor,broke kneecap
ORIF(hdwr&immob)
Post-op drug reaction
3/4-5/13 brace
3/21-8/28PT
12/19Hardware removal,scope,partial meniscectomies
2004: More PT
lost job
Settledw/WC Oct
2005: Personal injury lawsuit--reschedulings,failed mediation
2006: settled out of court in March
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Re: Things we should not do after patella fracture

Post by Richie392 »

Thanks for this advice, Joel! I tryed some of the exercises you described and it really works on the VMO. :-*

Cheers,
Richard
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Re: Things we should not do after patella fracture

Post by mtsarpilot »

Hi Lizl,
lizl wrote: Well, Joel, you've done it again! :) :D ;D ::) You provided fantastic insight that will help us all.
I try :) We are all learning about this together and every one of us is providing insights that help the next. That's the great value of this forum. I happen to be one of those people that is going to push the bounds to their limits. Both as a nature of my personality (the folks that work with me know that all to well) and as a result of the athletic endevours that I enjoy. So I'll be learning lots that can be shared. I hope it is helpful.
lizl wrote: Did you get the message from your sports doc (maybe between the lines) that some degree of trouble is an inevitable part of the future for most/many repaired patellas?
Not even between the lines. It was a direct portion of the conversation. I go into OS visits with a long list of questions to talk about so I don't forget anything. This was one of them.

There is no doubt that some degree of trouble is inevitable. To what degree is hard to tell. Each person is different. The amount and level of stress is different based on the activities done. The level of damage on the back of the patella is also different. In my case I asked him straight up "am I looking at a knee replacement in my future". His answer was that it was possible, but it's possible I won't have to. Much of it depends on that point about choosing your battles wisely. If the things you choose to do are more stressful and repetative then they will do more damage. My case is made more complex because of the number of breaks I had, and because the OS that did the hardware removal (same one that fixed me) was not clear on the post-operative report. In one paragraph he said the knee has grade 3 chondromelacia (grade 4 is bone on bone) and in another paragraph he wrote that this was a pristine knee. That's a complete contradiction, so the OS could not give me advice as to what the knee really looks like inside (and the operative OS has moved away and would not remember 6 months later anyway). The scope photos showed cracks in the soft tissue though, so we know it is not pristine :(

One thing he mentioned was that in 10 years there will be newer knee treatment techniques yet again. Maybe they'll be able to resurface and not have to replace if the bones are still good for example and it's just soft tissue surface damage.

Hard to tell what your popping is from. He had me step up onto a stair height stool and he listened to and felt my knee as I was doing that. A datapoint he could work with. If you are popping and having problems going up stairs, you might want to see an OS to find out what is happening and what you can do to help resolve it since stairs are a part of your everyday life. If you need to do a set of stairs when showing or previewing a house, one thing to consider is to do them like we did when we were immobilized - one step at a time stressing the good leg only. It's slower, but it works. I too still go down stairs a little sideways. I now notice that stair treads are not as long as my foot. Twisting the foot sideways a little enables me to get the ball of the foot onto a stair tread which helps in walking down them. I the stair tread is elongated, I can go down them straight on.

I'll certainly be pushing the bounds with the amount of cycles of the knee on a bicycle, and stress on it with things like rock climbing, skiing, and hiking. I'm just going to be careful about it, but I can't stop living life the way I want. As the OS said - you can give it up now or you can give it up later. But if you wait till later at least you got to do the things you enjoyed. If you give them up now, you don't even get to enjoy them any longer. Pick your battles wisely and extend it as long as you can. Maybe it could be fine for a lot longer than you think. I like his point of view. But then again, he is an avid athlete and a kindred spirit. That's why I chose him to go see.

Joel
9/05 - Patella fracture - 5 pieces in rock climbing fall, ORIF, 3 screws & figure 8 wire
5/06 - HW Out
7/06 - Back to full activity
7/09 - Custom brace created to support knee during activity
11/15 - Surgery to clean up meniscus, remove osteophytes, attempt to get more life out of knee
11/16 - TKR
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Re: Things we should not do after patella fracture

Post by fifi1974 »

Hi Joel,

Thanks for this great post! I shall have a go at the squats tonight. I've been trying to limit my jumping/ major squatting exercises to water aerobics, as I guess that is a lot easier on joints. But I feel like it is all a bit of a careful balancing act between strengthening the muscles and protecting the joint, so will def try these ideas.
Oh and a quick q re cycling, if you might happen to know the answer: when you say that the saddle takes most of the weight, does that mean it is a bad idea for the knee to stand and pedal, as when going up-hill? Should I just try going up in a lower gear?

I'm attending a friend's wedding next weekend and have bought a pair of perilous shoes! That feels a bit foolhardy now...

Fi
14/7/05 fell and broke right patella
15/7/05 ORIF (in France)
19/7/05 leave hospital and return to UK.
7/9/05 brace removed!
18/10/05 Finally start proper PT. ROM at about 105
10/03/06 Discharged by OS
14/03/06 Discharged by PT (8 months to the day after fall)
Hardware removal???
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Re: Things we should not do after patella fracture

Post by mtsarpilot »

Fifi,

The primary point about the saddle is that when you are pushing down on the pedals, you are not having to lift your weight while the knee is in the 110 bent position like would be happening during lunges, squats, or telemark skiing. Standing on bike pedals is probably not as good as sitting and spinning in a lower gear, but also not all that horrible. When you are standing, the leg motion is more akin to a StairMaster. Your knee is not bent nearly as far as when you are sitting. I stand on climbs often and don't seem to be getting any adverse response out of it. Your mileage may vary (quite literally on a bike) ;D

Cycling shorts are a great idea if you are going to do any reasonable amount of time on a bike. Regular shorts will chaff your legs after riding for a while. Nothing foolhardy about buying some.

Have fun at the wedding.

Joel
9/05 - Patella fracture - 5 pieces in rock climbing fall, ORIF, 3 screws & figure 8 wire
5/06 - HW Out
7/06 - Back to full activity
7/09 - Custom brace created to support knee during activity
11/15 - Surgery to clean up meniscus, remove osteophytes, attempt to get more life out of knee
11/16 - TKR
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Re: Things we should not do after patella fracture

Post by cah7 »

Joel - Thanks so much for the info on exercise do's and don't's. That was a big help for me. I am an avid downhill skier and hiker and have been struggling to build my quads (especially that pesky VMO) back up so that I feel strong enough to participate in those sports again. (And I'm not as young as I used to be - spent my 50th birthday last year in the hospital with this whole mess.) I have been trying to find the balance between pushing too hard and causing inflammation and irritation to the joint and yet gaining muscle strength - your suggestions really make sense. I have been doing a lot of biking (both road and at the gym) and working out at the gym with weights, etc. The biking feels great, but some of the exercises I do, extensions especially, seem to cause more discomfort. And I know I sometimes try to do too much because I want so badly for my leg to be strong again. I'm going to try modifying what I'm doing with squats, leg presses, extensions, etc. While I want to get the joint strong again, I certainly don't want to cause more damage/irritation in the process. (My knee has been through plenty already!)

I do , however, want to be able to hike and ski again - even if I have to modify both activities somewhat in order to take care of my knee. I agree with your viewpoint - I'm not willing to give those things up altogether, but I understand that there also needs to be some balance in order to avoid any problems for as long as possible. I used to be a runner, but on the advice of my OS here have given that up in order to "save" my knee for skiing and hiking. I had to skip last year's ski season as my leg wasn't strong enough yet, but plan to ski this year, even if it's only easy runs and shorter time out on the slopes.

In light of all of your information and experiences so far, what do you think of backpacking vs. hiking? I'm wondering whether carrying the weight of a full pack (as opposed to a light pack for a day hike) will be too much for my knee? (So far I have only tried easy short day hikes............ok except for rocky/uneven downhills which are still very difficult for me.)

And here's to the hope that they make some great medical advances with knee problems in the coming years!

Cathy
7/30/05 fell backpacking in Russia patella fracture
7/31-8/5 ORIF& postop infection Russian hospital
8/5-8/13  flew home-hospital in States
8/13 out of hospital NWB straight immobilizer
9/21 Bledsoe brace
9/26 PWB
10/17 no crutches
11/1 wrap brace,PTstarts
11/28 back to work
1/31/06 PT ends
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Re: Things we should not do after patella fracture

Post by mtsarpilot »

Cathy,

I fully understand your desire to ski and hike in your future. Two activities I love and have back into my life. I'm only 6 years behind you in age. We have a lot of years of fun still ahead of us.

I'm not sure how backpacking will go over on the knees to actually answer your question. I'll give you insight into my experiences so far and we can draw some assumptions from there.

Prior to my vacation in California, a couple friends suggested I use trekking poles when hiking to take strain off the knees. I took along my backcountry ski poles as a test case. We did many day hikes on that vacation, the longest being 9 miles with about 3000 feet of climbing then descending. I had an estimated 20 pounds in my pack. The knee did great. No discomfort at all. The poles made a huge difference on both the steep ups and downs. It took a while to get a good technique with the poles, but once I had it, they were great. I'd occassionaly do a test and hand the poles to my son to see if I really felt any difference without them. Yes indeed, it was noticeable.

When I got home I bought a nice set of carbon fiber light weight poles and use them on all hikes now.

A few days after getting home is when I did the backpack test with 45 pounds (using poles). That is when the knee inflamed. So I know the line is somewhere between 20 and 45 pounds.

I have done many hikes since then with 30 to 35 pounds of climbing gear in my pack. I have found that if I wear my DonJoy brace while hiking, the knee is much happier. I don't know if it's the support of the brace or the guidance it gives to the patella, but it is definately helping out. No problems with the knee after these hikes, some of which have been quite steep.

I have not tried 45 pounds with the brace on the knee to see if the brace solves the problem. I don't need to know the answer so bad as to cause the 3 weeks of down time again if the answer is no.

So the conclusions I have drawn for myself: Moderate weight and wear the brace when hiking works fine on my knee. I hope by next summer to be able to pull off a full backpack load. I'll keep using the brace until I find it is not necessary. When I asked the OS about using the brace his response was "if it feels good, do it".

I think hiking will be just fine. Backpacking will have to be tested. Be careful of how much you are stepping up or down with the injured leg, as that is where the stress comes in. The poles can transfer a lot of that load to your biceps and triceps which helps the leg a lot. You need to get the upper body in condition to do this kind of workload, but that's a good thing. Upper body is normally not heavily involved in hiking. Now you can distribute the workload across more muscles.

Give it a try and see how it works for you.

Joel
9/05 - Patella fracture - 5 pieces in rock climbing fall, ORIF, 3 screws & figure 8 wire
5/06 - HW Out
7/06 - Back to full activity
7/09 - Custom brace created to support knee during activity
11/15 - Surgery to clean up meniscus, remove osteophytes, attempt to get more life out of knee
11/16 - TKR
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Re: Things we should not do after patella fracture

Post by kimmyxs »

Joel, as usual you provide a wealth of information. I no longer backpack. I loved it when I was young, but the pounding I took in the Grand Canyone when I was 25 or 26 made me rethink the entire concept I do daypack on occasion. I wanted to do the Appalchian Trail, but with my knee issues, I am rethinking that. I think I will stay with moderate bike riding.

I was just released from PT. My PT warned me to watch the depth of lunges and squats - but she didn't give me the reason. I wish now that I had asked. I am one of the few people to ever bring in a bowling ball to get over the fear of lunging with the weight of the ball. It helped me get past the fear of the knee cap popping back out, but the depth of the lunge at release is less than it was before. All in all, I actually think that this injury will slow me down a bit and it may end up helping me. Who knew!

I am now 16 weeks post injury - 14 after surgery. Last week I some of the swelling Joel mentioned, but this week I am fine. I was lucky to only lose half an inch of quad - largely because I was pretty stubborn and did stretching as much as I could as soon as I could. I also build muscle pretty easily. That pesky VMO has been the focus of most of my work. This week I will begin back at the gym. I may even be able to bike ride outdoors if the weather stays nice. I still have worries, I still hate going down stairs, and the thought of wearing heels frightens me. And yes, I am bone on bone, but I am hoping to put off the TKR as long as possible. I was hoping for at least another 7 years (I woudl be 55 then), but it may not be possible. I have learned to take each day as it comes.
6/03/89 - First Knee Cap Disclocation
7/05/89 - Returned to work
6/17/06 - Tramatic Knee Cap Dislocation and Vertical Fractured Patella
6/28/06 - ORIF - Screws - no wires
8/24/06 - Ditched the brace - start PT
9/20/06 - First spinning
1/15/07 - screw removal, LR , VMO Advanc  & patella cleanupl
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Re: Things we should not do after patella fracture

Post by favouritesearcher »

Joel,

I'm really impressed with your post; its a really interesting read.

One question I have: What do you do for patellar tendon stretches? My PT gave me one where I lay on my back with my knee bent at about 90 degrees and a hand towel behind it, and use the hand to lever the lower leg up and down. I suspect this isn't good for a knee (though the stress on the joint is only the weight of the bottom half of the leg), even though my leg can't get by without having this stretch done.

Thanks again.

John
Mar 04 - Tibial spine avulsion fracture (skiing). Open surgery to fix, 1 screw.  Max passive ROM 20-75, active ROM 30-45
Aug 04 - Diag. severe arthro. Scar tissue clean up (LOA, removal of scar tissue).
Feb 05 - Discharged from surgeon's care. ROM 3-125.
Apr 05 - Discharged from physio. Same ROM
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Re: Things we should not do after patella fracture

Post by mtsarpilot »

John,

I'm not sure I'm correctly picturing what your PT told you to do. It sounds like you are using the towel to pull on the leg trying to pull it beyond the point of current restriction. That is basically the way you have to go at ROM increase. You have to find the right mechanism to push against the limitation to get it to break free or loosen up.

From your signature, it looks like you have plateau'd at about 125 degrees. There can be many causes for the ROM limitation. Sounds like you had scar tissue that was acting as a limiter and was removed in surgery. At this point, your limiters could be more scar tissue or adhesions, tightened and shrunk muscles, or tightened/shortened tendons. All of this is a natural result of the injury and healing. You have to continue to put pressure against the limitation to get it to slowly stretch. This is a slow process, not something that will happen overnight. Your PT has given you one approach. Everyone seems to find different body positions and mechanism that work for them. Be creative and look for a mechanism that works for you. It changes as the leg gets more ROM.

125 to 140 went much slower for me. Keep working it and give it time. Don't go to the point of pain, but you should feel a good bit of resistance and discomfort because you are pulling against a physical restriction inside your leg.

Good Luck,

Joel
9/05 - Patella fracture - 5 pieces in rock climbing fall, ORIF, 3 screws & figure 8 wire
5/06 - HW Out
7/06 - Back to full activity
7/09 - Custom brace created to support knee during activity
11/15 - Surgery to clean up meniscus, remove osteophytes, attempt to get more life out of knee
11/16 - TKR
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Re: Things we should not do after patella fracture

Post by jvendi4321 »

What can we do?
Well breaking the patella is much different than just a rupture of the tendon. The hardware seems to be the main problem with the pain and constant swelling. I liked what you sad about only doing things in a limited manor. Easier said than done! :)

A visit last Wednesday gave me the bad news of another 6 months of hardware. he called the swelling below the knee tendinitis. A little concerned with the tendons I was told. 18 months of hardware>>>> I miss the quality of life that I had, and at 54 wonder about the future. Will I be able to play with par again?

I know that being on my feet 6-7 hours a day at work and then more work around the homestead, makes for a sore knee. RICE.....well advil 3 times a day, ice at least once after work, and a good 1 hour nap, (start work at 3:30 am) with the leg raised gets me through each day......

Good post by all........thanks
patella tendon rupture Right Knee Feb 97. Slip on icy stairs
Fractured Left Patella, 4 screws and wire to repair, oct. 2005. Bowling, foot stuck to floor
cancer survivor 1990, malignant melanoma,a stage 4, very lucky I am.......:)
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Re: Things we should not do after patella fracture

Post by kimmyxs »

Now I remember why I am afraid to begin bowling again. I had forgotten that you broke your patella bowling. I admit, that I am going bowling on Tuesday with my league. I may not be able to finish 3 games, but hey...

I ended up with tendonitis in my left knee from the extra pressure on the knee while recuperating. Honestly, this weekned I have felt my old self again. I wore nice shoes to a Toastmasters event, I am able to move up and down the stairs at home, and I haven't felt the need for ice as often. I am lucky that I have a go to meetings kind of job. I can sit when I facilitate JAD sessions if needed and everyone understands. I try not to overdo anything, but I know that bowling will be the tell all for me.

I am lucky that I didn't have wires. My OS hates them and just used screws, but that leads to pretty conservative recovery - PT only once he feels that the patella could take it. I am honestly glad. I know that the last 15 degrees in ROM will come with time - I hope anyway.

6/03/89 - First Knee Cap Disclocation
7/05/89 - Returned to work
6/17/06 - Tramatic Knee Cap Dislocation and Vertical Fractured Patella
6/28/06 - ORIF - Screws - no wires
8/24/06 - Ditched the brace - start PT
9/20/06 - First spinning
1/15/07 - screw removal, LR , VMO Advanc  & patella cleanupl
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Re: Things we should not do after patella fracture

Post by jvendi4321 »

Be very carefull with that bowling! Such a dangerous sport. :o

have fun.....
patella tendon rupture Right Knee Feb 97. Slip on icy stairs
Fractured Left Patella, 4 screws and wire to repair, oct. 2005. Bowling, foot stuck to floor
cancer survivor 1990, malignant melanoma,a stage 4, very lucky I am.......:)
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Re: Things we should not do after patella fracture

Post by cah7 »

Joel - Just wanted to report in that I have been following the exercise advice in your post for the last couple of weeks and notice that it really seems to be helping. I have adjusted the way I do extensions, leg presses, squats, etc. so that there is not as high a degree of bend in the knee/force on the joint and at the same time have adjusted the weight so that I can still feel my quads getting a good workout. Now it feels as if its just the muscles working without pressuring the joint. My knee feels much better - don't have the soreness and inflammation that would usually come after an exercise session. I no longer feel that I'm further irritating the joint as I try to build muscle. The suggestion to rotate the foot outward is helping, also - it really feels as if I am giving the VMO a better workout.
Thanks for your help!
Cathy
7/30/05 fell backpacking in Russia patella fracture
7/31-8/5 ORIF& postop infection Russian hospital
8/5-8/13  flew home-hospital in States
8/13 out of hospital NWB straight immobilizer
9/21 Bledsoe brace
9/26 PWB
10/17 no crutches
11/1 wrap brace,PTstarts
11/28 back to work
1/31/06 PT ends
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