Recovery After Primary Patellar. Dislocation in Adolescent Dancers

Transcription

1 Recovery After Primary Patellar Dislocation in Adolescent Dancers Anna Lamonica October 11, 2018 Los Angeles, CA Aug-Dec 2017

2 Abstract Following a primary patellar dislocation, my 16-year-old dance student was struggling to accept her newfound bodily limitations, yet wanted to avoid knee surgery. I began working with her after her physical therapy ended and she had experienced a subsequent patellar subluxation. We focused on increasing core strength and stability, activating her vastus medialis oblique (VMO), correct patellar tracking in both parallel and external rotation, and strengthening her gluteal muscles. The goals for this specific case were to strengthen the muscles supporting the knee joint so she could return to her previous competitive dance agenda as well as to maintain proper control and alignment throughout the body to prevent future dislocations and other potential knee problems. While she has improved her overall alignment and knee function, she continues to wear a supportive brace while dancing to help prevent excessive lateral movement of her patella. 2

3 Table of Contents Basic Anatomy of the Knee 4 Case Study 6 Conditioning Program 7 Conclusion 9 Works Cited 10 Works Consulted 11 3

4 Basic Anatomy of the Knee The knee is a very unique joint in the body because while it is a hinge joint, the kneecap, or patella, is free-floating. The patella is encased in the tendon of the quadriceps muscles and rides anterior to the knee joint, fitting into the patellar surface of the femur (Fitt 46). The anterior structure of the knee joint can be seen below: (Fig. 1) As you can see here, there are six main ligaments that help hold the patella in place. When the quadriceps femoris muscle contracts along the front of the thigh, the patella is pulled out of its normal bony groove at the end of the femur, known as the trochlear groove, via the quadriceps tendon. This groove, along with the stabilizing ligaments on 4

5 either side of the patella, play an enormous role in maintaining proper knee stability (Kaar). However, when the knee is dislocated, which normally occurs laterally, the medial patellofemoral ligament (MPFL) is stretched or torn. The MPFL, which lies within the medial patellar retinaculum, is therefore unable to guide the patella along the trochlear groove, resulting in full or partial dislocation (Kaar). Partial dislocation is known as subluxation and is a common recurrence following initial dislocation. A basic image of normal knee alignment, subluxation and full dislocation can be seen here: (Fig. 2) Following a full patellar dislocation, there is often swelling and tenderness surrounding the knee joint. There is also a feeling of instability which makes many people hesitant to continue the normal physical demands of their life, particularly pertaining to sports or fitness regimes. 5

6 Case Study The subject of this case study was a 16-year-old female dancer named Gemma. Nearly one year prior to our sessions in October 2017, Gemma experienced a full dislocation of her right knee. It was determined by her doctors that surgery was not the proper course of action at the time as there were no full ligament tears. In the pediatric and adolescent population, patellar dislocation usually occurs during sports activities in which the leg internally rotates relative to a fixed foot, often including simultaneous quadriceps contraction (Khormaee et al. 4). While dislocation usually occurs due to a twisting motion, as it did with Gemma, there are often other factors at play. Gemma, like many dancers, also has hyperextended knees. In ballet, external rotation is often forced and over time, puts a lot of stress on the ligaments of the knee. This forced rotation combined with hyperextension made Gemma extremely vulnerable to a knee injury. Hyperextended knees often initiate a chain reaction of postural misalignments and are particularly dangerous on landings from jumps or leaps (Fitt 51). Following knee dislocations in adolescents, there is not always a clear course of action. In most cases, a period of immobilization occurs followed by regimented physical therapy to strengthen and retrain the muscles, ligaments and tendons surrounding the knee. Depending on the severity of the damage, surgery may be recommended. While each case is different, there is agreement on some of the basic principles. Rehabilitation needs to be directed toward recovery from injury as well as restoring potential pre-existing muscle imbalances, including strength and flexibility. Particular attention should be directed at core strength, targeting proximal control of 6

7 limb rotation and balance (Sillanpaa 2-3). These principles helped guide me in the conditioning program I created for Gemma, which focused on core stability, hamstring strengthening, quadriceps control and patellar tracking. Luckily for Gemma, she had a great physical therapist who was well aware of the physical demands of a dancer. She returned to a partial dance schedule after just three months with the assistance of a knee brace. While there is great controversy over the effectiveness of knee braces, the overall goal is to restore proper alignment by mechanical inhibition of lateral patella motion (Malanga et al.) However, sometimes patients may become reliant on their brace instead of focusing on their physical rehabilitation. In Gemma s case, this was what led to the subluxation of her knee in June After taking the summer off from dance, Gemma returned in August 2018 and we began our Pilates program to focus on increased strength, stability and confidence in her knee joint s ability to support her. BASI-Inspired Conditioning Program Over the course of our sessions, I worked with Gemma exclusively on the reformer and without wearing her knee brace. We worked first to identify her weaknesses and imbalances and then sought to strengthen the entire body to better support the daily demands of her knee. We primarily focused on activating her VMO, strengthening her abdominals, gluteal muscles and hamstrings and releasing her IT bands. Below is the progression of work, following the BASI block system, though not all of the techniques employed were strictly BASI. 7

8 BASI BLOCK EXERCICES COMMENTS Warm Up Footwork Abdominals Hip Work Spinal Articulation Stretches Full Body Integration *roll down *pelvic curl *chest lift & w/ rotation *standard footwork not including prehensile *modified ab work w/o spinal flexion *short box series (no climb-atree) *hundred prep *hip extension, Ferris wheel circles & reverse, leg presses *bottom lift on heels *pelvic curls on mat *shoulder bridge prep *standing lunge *figure 4 for glutes *hip stretch off edge of Cadillac *moving forearm plank on reformer 8 -looked for leg weight favoring in roll down -at first only in parallel -no single leg -ball in ankles/knee to help with tracking -pressed arms down, small circles w/ arms -leg toe taps, single & double leg stretch -at first only in parallel w/ ball between ankles/knees -with ball between knees for maintaining adduction & alignment -very tight hip flexors & glutes -watched hyperextension in hamstring stretch -added shoulder extension in later sessions Arm Work *arm work sitting on box -varied sets including serve a platter & bow and arrow Leg Work Lateral Flexion/Rotation *side lying leg work w/ feet on bar or foot/leg in straps *adduction w/ magic circle *single leg skating *jump board *mermaid-like stretches *incorporated rotation into arm work -clams, bent & straight leg circles, dips, angled leg presses -jump: parallel, v, single leg & changes, v (out-in) land -tilt on short box & bow and arrow in arm work -lateral stretching Back Extension *back extension on mat -also holding magic circle Additional Work *rolled IT bands *dips on a step one-legged to asses patellar tracking *VMO activation/contraction -dips on Cadillac as time progressed -used several different techniques for VMO

9 Conclusion Using a combination of resources including physical therapists, online research and my knowledge of dance kinesiology, I sought to get Gemma s knee back on track, literally. Since most patellar dislocations occur laterally, there is normally a resulting stretch or tear in the medial ligaments which causes instability in the lower limbs. This recovery can be an uphill battle, especially for a teenager. We focused mainly on gluteal and leg musculature to aid in patellar tracking and as we progressed, began working in external rotation to simulate many of the positions used in ballet. We also focused on abdominal work. Following her dislocation and subsequent immobility, Gemma gained weight that altered her core control. This made the rehabilitation process even trickier. She was eager to return to competitive dance however her body would not comply. The first and foremost application for students of dance is heightening awareness of one s own capacities and limitations (Fitt 458). While Gemma continues to wear a knee brace for dance, she knows these physical struggles are not over. She has been given tools to manage her knee instability, and I hope she continues to use them to improve in strength, steadiness and her passion for movement. 9

10 Works Cited Fig. 1. Knee Pain - Causes, Exercises, Remedies, Medication & Treatment. Health Jade, 4 May 2018, healthjade.com/knee-pain/. Fig. 2. Miller, Craig. Patellar Subluxation (Partially Dislocated Kneecap). BraceAbility, 21 May 2016, Fitt, Sally Sevey. Dance Kinesiology. 2nd ed., Schirmer Books, Kaar, Scott. Patellar Dislocation. Sports Injuries, Treatment and Performance Information, Sports MD, 7 Mar. 2018, Khormaee, Sariah, et al. Evaluation and Management of Patellar Instability in Pediatric and Adolescent Athletes. Sports Health: A Multidisciplinary Approach, vol. 7, no. 2, 2014, doi: / Malanga, Gerard A, et al. Patellar Injury and Dislocation Treatment & Management. Patellar Injury and Dislocation Treatment & Management: Acute Phase, Recovery Phase, Maintenance Phase, Medscape, 25 July 2017, reference.medscape.com/article/ treatment. Sillanpää, Petri. Treatment of Patellar Dislocation in Children

11 Works Consulted Acute Patellar Dislocation Protocol. Seacoast Orthopedics and Sports Medicine, Miller, Kat. Vastus Medialis Exercises to Stabilize the Knee Joint. Healthline, Healthline, 11