Subluxation of the Patella

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1 Subluxation of the Patella Alexandra Zaldivar December 15, Course, Los Angeles

2 Abstract After reading information from the Internet and anatomy books, it becomes very clear why pilates is an incredibly effective treatment for an injury such as patellar subluxation. The Internet informed me on what muscle groups should be focused on to help strengthen the knee and create balance to prevent such an injury from occurring again. The Internet also provided suggestions on what other kind of treatment may help reduce swelling and inflammation of the knee such as Aleve, ice and electrical stimulation. The anatomy books gave me an understanding as to why certain muscles should be focused on during the treatment of patellar subluxation. Knowing which of these muscles are important and how they function makes it easier as a pilates instructor to pick beneficial exercises and stretches. Understand how a problem originates, also helps in teaching a client how to make changes in their every day lives that will secure a lasting effect.

3 Table of Content Page 4 : Diagram and anatomical description of Patella Page 5 : Diagram and anatomical description of the Q Angle Page 6 : Introduction and Case Study Page 7 : Conditioning Program Page 8 : Muscle Focuses Page 9 : Reasons for selected Program and desired Results Page 10 : Conclusion

4 Anatomical Description and Diagram The patella is connected to the femur and tibia and sits inside the intercondylar groove; muscles, ligaments and tendons connect it. The quadriceps, hamstrings, and calf muscles are the main muscles that affect the patella and it s tracking. All the muscles must work appropriately for the patella to stay in alignment and function properly.

5 This is a diagram of the Q angle. This is the angle between the quadriceps and the patella tendon. The greater this angle is, the more susceptible one is to patellar subluxation.

6 Since I myself have experienced and been treated for this injury, I will discuss the treatment and rehabilitation for a subluxation of the patella. Having my knee sublux three times in the past and receiving different treatments each time give me a understanding of what treatments work and which don t. I ve experienced the positive effects of pilates and know which exercises truly target the muscles that need the most work. Being consistent in doing exercises and taking care of this already sensitive area is extremely important in maintaining a healed injury. Doing a case study, from there creating a conditioning program, then explaining why and how this program should be beneficial is important to do with clients so they understand the goal behind keeping up with the treatment. I m using myself, Alexandra Zaldivar, for this case study. In my 21 years, I have experienced subluxation of the patella three times while dancing. Each time, my patella would shift externally and laterally when pressure was exerted on it going from a bent position to straight. The first time I experienced patellar subluxation was on stage at a dance competition when I was fourteen years old. In the process of standing from a kneeling position, my patella dislocated. Once carried off stage, I lay down with my legs straighten out and after a minute or two the patella shifted back into place on its own. I do not recall going to a physical therapist after this first incident. I simply iced the knee and stayed off it for a couple weeks. Once I began taking dance classes again, I wore a knee brace to provide a bit more stability and confidence. This injury surfaced a second time while I was taking a dance class at California State University of Long Beach. Again, I was getting up from the floor and patellar subluxation occurred. I knew exactly what happened this time

7 and didn t try to continue the motion of standing. I, instead, threw myself to the floor and straightened my knee at fast as possible. This time I did see a physical therapist provided through CSULB. This therapist mostly massaged and treated my knee with electrical stimulation. The only exercise I remember consistently practicing was leg lifts while sitting, trying to contract and engage the quadriceps. I didn t take a break after this injury, I simply had the therapist tape up my knee to keep the patella in place and continued taking dance classes, though limiting myself to less demanding exercises. After studying pilates, I now see that the treatment I was receiving at CSULB was not sufficient and didn t produce long term results. The third most recent time this injury resurfaced was in May of Yet again, I was taking a dance class and my patella subluxed while I was going from a kneeling position to standing. I threw myself to the ground; straighten my leg out as quickly as possible. Upon returning home to California, I went to a physical therapy clinic in which I was introduced to pilates as part of the rehabilitation process. At this clinic the treatment consisted of a massage followed by multiple strengthening exercises and finished with ice and electric stimulation. This treatment has proved the most effective and encouraged me to pursue teaching pilates as a career. With the knowledge I have now, I will analyze my body and the injury I experienced through a pilates teacher s eyes. Since the patella shifted laterally, I need to work on the pronation of the foot, strengthen the gluteus medius and vastus medialis oblique, while stretching the hamstring, vastus laterialis, and iliotibial band. Having flat feet otherwise known as pronation of the foot, puts pressure on the knee since the knee shifts internally as a result of the foot placement. This puts

8 pressure on the inside of the knee and pulls on the outside of the patella. The gluteus medius stabilizes the pelvis since it s originates from the ilium and inserts into the lateral surface of the greater trochanter of the femur. A weak gluteus medius keeps the femur from tracking correctly. The vastus medialis connects to the patella and pulls on it to keep it in the center of the intercondylar groove. When this muscle is weak, the patella is more susceptible to dislocation. The hamstring may be tight pulling on the back of the knee causing misalignment and stress on the patella. When the vastus lateralis and iliotibial band are tight they pull on the patella and when the vastus medialis is weak this results in discomfort and pressure in the knee. Chrondromalacia, fraying and damage to the cartilage, may occur after a injury such as this since the patella stops sitting right in the intercondylar groove thus causing the grinding in the joint. A person may be suseptiable to this kind of injury due to the Q angle which is the angle at which the femur crosses with the patella. Knowing which muscles need the most work, I can now set up a conditioning regimen that will help prevent further injury. Since we need to focus on stabilizing the pelvis, we will start with a Pelvic Curl, which strengthens the abs and the hamstrings. Next Chest Lifts and Chest Lifts with Rotation, we want to provide a fully stable body and the core and vital in stabilizing the legs. Leg Circles will teach the pelvis to stay stable simultaneously strengthening the abs. Foot Work on the Reformer strengthens the hamstrings and quads and indicates whether or not tracking of the feet and knees is correct. Abdominals could be done on the Reformer doing Hundred and Coordination to maintain the pelvic stability and strength. Hip Work will help with the femur

9 alignment so I d give them a short series, just Frog, Circles, and Openings. The Spinal Articulation section must be carefully selected since pushing through the legs may feel scary and puts pressure on the knees. Since I m flexible, I ll give the Kneeling Lunge Stretch. This may be too much pressure on the knee, depending on how soon after the injury this exercise is attempted. Next, in order to stretch the iliopoas, which is often tight in dancers, I d teach Down Stretch on the Reformer. Too keep the legs and gluts engaged while doing the Arm Work I d teach the Arms Standing Series on the Cadillac. Exceptional focus must go into the Leg Work to help ensure a stable knee. I d work on the Gluteals Side Lying Series with two-pound weights then in addition Leg Press Standing on the Wunda Chair, which targets the vastus medials. To keep the legs semi-engaged, I d give the Side Kneeling Stretch for Lateral Flexion. For Back Extension I d use the Double Leg Kick returning to the Mat in order to simultaneously target the hamstrings while working the back. My main focus with this conditioning program would be to teach proper alignment of the foot which then leads to correct alignment of the ankle, knee and hip, strengthen the gluteus medius and the vastus medialis and stretch out the hamstrings, vastus lateralis, and iliotibial band. If the foot is out of proper alignment during something as simple as walking, the rest of the leg will suffer misalignments and perhaps more injuries. The gluteus medius and the vastus medialis muscles are incredibly important in patellar tracking. When they are weak the knee is prone to a lateral angulation called genu valgum. This position of the leg is very unstable and makes the knee susceptible to dislocation. Strength within these two particular muscles is vital to a stable leg, especially when pressure is constantly being put on it.

10 The hamstring, vastus lateralis, and iliotibial band all need to be stretched and loosened up. When these three muscles are putting extra force on a knee that already has weak muscles, the chances of dislocation become even higher. I would probably also suggest rolling out the IT band with a foam roller on the client s time outside the studio. Over all stability within the core will provide a stable pelvis, which in turn helps with proper alignment of the femur. Sometime wearing a knee brace or McConnell taping of the knee helps the patella to stay in place allowing the client to focus on strengthening the muscles that will eventually support the knee on their own. When inflammation occurs, taking anti-inflammatory drugs helps along with icing the knee to reduce swelling. Eventually, the goal would be that the client is strong enough to not need a brace, taping or constant antiinflammatory drugs. In order to treat a patella dislocation or subluxation, rest, physical therapy, and exercise are all very important components in the healing process. As a pilates instructor, I must first learn about my client s past injuries, past treatment and lifestyle in order to create a program that will be beneficial to him or her. Upon gaining this knowledge and understanding, I must learn about the injury and what muscles, tendons, ligaments, and bones are affected or affect the given injury. Once I know which muscles are weak, strong, tight, and flexible, I work on making a program that will create balance between all the muscles involved. Remember the focus and the goal is extremely important in creating progress with a client. Teaching them how to move their body correctly in every day life will help in decreasing the chances of another injury.

11 Bibliography 1. Jarmey, Chris. The Concise Book of Muscles. Chichester, England : Lotus Publishing, Moore, Deith and Palley, Arthur. Clinically Oriented Anatomy. Baltimore, Maryland : Mark S. John, D.O. November 1, 1999.

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