Joined: September 13, 2004
I'm looking for some advice. Short case summary is a patient who has had three lateral releases and proximal realignments. All initially worked well but only for a limited period of time. Isokinetic eccentric testing at 30 dps and 60 dps shows marked break point at approx 30 deg of knee flexion. Does anyone have any suggestions for eccentric quads exercises in the 0-30 deg flex range? Thanks for any help.
Joined: March 12, 2004
Agree with Shill. Also, try repetitive step downs from a small step or standing quad sets with Theraband. If you have a Shuttle, Total Gym, or a Wallclimber, you can easily focus on the 0-30 degree ROM as well.
Don?t forget about single leg standing with medicine ball lifted high above their head. Keep the knee bent have them rock the upper body on the lower. So they will look like an upside down pendulum. Have them use a 3-10# medicine ball. This would resemble carrying groceries or something in your arms. Also i don?t think isokinetic machines carry over to function but that might be my own ignorance. When you sit in a machine you rule out core muscles balance, proprioception, gluts... so many important things that we use in function. What do you see when she does single leg step down as described by Chris. Does she look unstable?
Joined: September 13, 2004
Thanks for the helpful advice. In answer to your question Ragempt yes she does look unstable on a single leg step down. We've been working on intro bridging work and glut med/min recruitment and control plus soft tissue release work on ITB alongside the eccentric quads. I agree that there is an issue regarding the functional carry over of isokinetic machines but the patient is reporting the same pain and a feeling of knee giving way going down stairs although at a lesser intensity than the isokinetic test.
I have a question though. It is a bit 'chicken and egg' - are the rotational lower limb changes and poor core muscle balance creating the excessive pressure in the lateral PF compartment OR could it be that because of the excessive pressure in the lateral PF compartment the patient has adopted these compensatory things? How to find out and what influence would that have on treatment plan? Thinking out loud really but would welcome comments/thoughts.
Joined: March 15, 2006
integrate, don't isolate. single leg stance, squats are excellent but don't isolate the quads, they will fail. be sure to have the butt back and the knee behind the toes to integrate the hamstrings and gluteals and spread the work out away from the quads.
He who is wise in the ways of science The Omniscient One
ergo, to complicated for my brain. even if you had the answer i dont know if it would help your situation. really challenge her with decelrating. get her off her back. do everything in standing if she can tolerate.
Joined: October 24, 2006
From: New York
Your chicken or egg question is certainly a good one, but difficult to consider without more history on the patient. My guess is that the patient is dealing with far more than abnormal PF forces at this point, though. It sounds like she may now be experiencing the sequelae of multiple surgeries. How old was she for the first release? How close were the surgeries together? My experience with them is that they first happen to young girls (teens) who are athletic/active. In my opinion, supported only by my personal observations and patient experiences, many of these girls who get released were destined to "grow out" of the PFPS. I've just seen this phenomenon too many times in non-surgical cases to think otherwise. It may take years, until college or perhaps activity/sport change (usually by patient choice and not because of the pain), but it happens. Typically they continue with athletics or anything else they want to do with their legs. Once the knee is cut (for a release), however, it NEVER gets better (again my personal obs). There may very well be a small percentage of severe cases that need a release, but the majority don't and do not benefit.
If your patient began her surgery sequence as a young girl, she may very well be experiencing surgically perpetuated, joint position and/or soft tissue length/tension induced inhibition of the quads. Think about the quads atrophy some patients get after ACL or even arthroscopic procedures - some of it lasts up to 18 months, some longer, despite them working their tails off. Maybe her knee has been hit so many times too close together - it may never have had a chance to recover neurologically.
Lynn Snyder-Mackler from the U. of Delaware has pioneered a protocol utilizing high intensity muscle stimulation for the quads that works extremely well with post-op ACL and TKR patients. I am not aware of it's documented use for lat release cases, but it seems reasonable that it could by applied as an "off label" use. I have used it for athletes with PFPS who I felt were quads-inhibited and were non-surgical with good results. There are studies dating back to at least 1995 showing improved EMG, gait, strength vs. controls with use of the techniqe. Your isokinetic unit is a key peice of instrumentation for performing the technique, you can do it and protect the PFJ. If you buy into my speculation about the neuro inhibition, the evidenced-based case for the stim is in the motor unit activation size principle and reverse-activation. She may have motor units that have been "sleeping" since her first surgery. Perhaps activating them can help re-modulate and strengthen things.
Apologies for the general references. I can forward you the U. of Delaware Protocol and some copies of journal articles if you like - just PM me.