Take it slow, assess the whole structure when treating patella dislocation
NFL quarterback Patrick Mahomes suffered a painful and debilitating patella dislocation this past week. Reports indicate that he may miss just three weeks from this injury.
Before returning back to the playing field, an aggressive and thorough rehab program is vitally important. If he returns too quickly, he is more susceptible to a repeat injury or a compensatory injury secondary to applying excessive forces to other structures. It has been found that the incidence of recurrent dislocation after the first dislocation occurs can be as high as 40%.
Typical treatment of patella dislocations — when a loose fragment is not present — is immobilizing the knee for a short period of time, typically one week to 10 days. This allows time for swelling and pain to reduce. The repair process is initiated with slow mobilization of the knee and the patellofemoral joint, and full recovery can usually be expected within a 3-6 week period.
However, if there is a history of a previous patellar dislocation, the recovery progress will be lengthened significantly. Conservative management of patella dislocations consisting of rest, appropriate hip and thigh muscle strengthening, and the use of a patellar stabilization brace is appropriate. Supplements with joint support and anti-inflammatory properties such as MSM, glucosamine, Chondroitin, and hyaluronic acid can be hugely beneficial in supporting the recovery process.
Those suffering this injury should have a complete musculoskeletal structural evaluation starting with the feet and working up the kinetic chain. Identifying all of the structural deficits is paramount in preventing a repeat injury or sustaining a new injury.
Contact and non-contact injuries
Although Mahomes’ injury was due to contact, there is a reason why most lower-extremity injuries are non-contact in nature. Many of these injuries have to do with technical errors in the foot. When the foot strikes the ground, it is designed to absorb and disperse energy at impact, as well as ensure proper lower extremity alignment. This is accomplished if the foot has a viable plantar vault, proper support of the medial longitudinal arch, lateral longitudinal arch and transverse arches.
If this vault is compromised, then the foot collapses causing a myriad of negative reactions from the foot to the neck. As the foot pronates, the tibia rotates medially and the knee is forced into a valgus position. This creates shear forces pulling the patella laterally. If the forces extend beyond the capacity of the stabilizing architecture, then the patella will dislocate laterally. Therefore, any athlete suffering a patella dislocation injury requires an examination of the feet, preferably a laser 3D weight-bearing image. This will provide value information for determining the need for a custom-made orthotic.
In this case, knee stability should be the focus. Stabilizing the feet will minimize the effect of an existing pronation deformity, which will in turn help align the lower extremity and allow the patella to track vertically like it is designed to do. A pes planus, or flexible pes planus deformity, will cause medial tibial rotation as well as a dynamic genu valgus deformity during weight bearing impact loading. This increased Q-angle at the knee will make the knee more susceptible to injury.
Increasing quad-hamstring co-contraction strength will also provide dynamic stability of the knee, thus reducing mechanical stress on the intrinsic supportive ligamentous structures of the knee. Maximum co-contraction between the quadricep and hamstring occurs at 30 degrees of knee flexion. Therefore, a single leg stance with 30 degree knee bend exercise focusing on keeping the knee aligned with the second toe should be incorporated into the rehab program. This will increase hamstring and quadricep co-contraction intensity, which will provide much greater stability for the knee. Quadricep exercises focusing on isolating the vastus medialis oblique (VMO) are paramount.
The VMO will help stabilize the knee and help keep the patella from tracking laterally, thus helping to prevent a reoccurrence of a lateral patella dislocation. A stabilizing support should be worn in order to co-manage the athlete with an orthopedic surgeon is in the best interest of the athlete. Advanced imaging such as an MRI will be warranted to determine the extent of the injury. In some cases, a surgical consultation is necessary.
Increased injury risk
If an athlete suffering a patella dislocation similar to Mahomes’ returns to play too quickly, his/her risk of injury increases dramatically. The areas at greatest risk are the stabilizing ligaments of the involved knee as well as the ligaments of the uninvolved knee.
Compensatory loading will occur unconsciously. Therefore, if the stress loading exceeds the capacity of those structures, failure, resulting in injury, will occur.
Return to play from a patella dislocation should be determined by functional testing. The following is a short list of “non-negotiables” when it comes to return to play rehab guidelines:
- Full range of motion of the knee should be accomplished.
- Walk with a normal gait, without a limp (no evidence of quadricep shut down).
- Run forward and backwards without pain.
- Run “figure 8s” and perform 90-degree cuts without pain or signs of compensation.
- Perform a single leg hop which is symmetrical when compared to the non-injured side.
- A duck walk should be performed symmetrically, pain free and without evidence of compensatory recruitment.
Making a proper return to play
Returning an athlete to the field or court not only puts them at greater risk for re-injury but also increases their risk for other injuries. A recent example is NBA all-star Kevin Durant, who was rushed back too quickly this past summer from a calf injury and ended up tearing his Achilles tendon.
Proper rehab not only ensures the safe return to activity but is also provides the athlete with the confidence needed to get back on the field or court. The psychological aspect of treating the injured athlete can be one of the most important but challenging aspects of the rehab process. So, as you address the injured athlete, help them maximize their true potential by focusing on getting both their body and mind ready for competition.
KURT JUERGENS, DC, CCSP has been in private practice since 1989 and has had extensive post-graduate training in sports medicine. Juergens owns and operates Juergens Chiropractic & Sports Rehab Center in Houston, Texas. He graduated Summa Cum Laude from Texas Chiropractic College. In 1992 he was selected to be a member of the U.S. Olympic Track and Field Trials Sports Medicine team. He has also served on the sports medicine teams for the NCAA Track & Field Championships, and the ATP World Tour’s Tennis Masters Cup and U.S. Clay Court Championships. Juergens continues to treat high school, college, and professional athletes in all fields from all over the world, and lectures regularly for his profession on topics related to sports rehabilitation. He represents Foot Levelers and can be contacted at drjuergens.com.