Background and Purpose

The patella is known to be the largest sesamoid bone in the human body located at the

anterior surface of the tibiofemoral joint.1 A sesamoid bone is one that is imbedded within a

muscle or tendon near joint surfaces, with the patella having attachment points with the

quadriceps tendon and patellar tendon.2 The patella allows the knee joint to absorb ground

reaction forces (GRF) through a larger surface area, dissipating shock absorption between the

lower and upper segments of the lower extremity. Due to this bone having to react to GRFs

during ambulation and weight-bearing activities, it has an increased susceptibility to dislocation

compared to other lower extremity bones. Dislocation of the patella accounts for approximately

2-3% of all injuries of the knee, largely affecting young and active individuals most commonly.3

According to Jain et al,4 “Incidence is reported as 5.8 per 100,000 but could be as high as 29 per

100,000 in the adolescent population.”(p1) Dislocations of the patella most often occur in the

lateral direction due to the direction of pull from the quadriceps muscles compared to the

mechanical axis of the limb, but can dislocate in other anatomical directions.3

There are multiple factors that can contribute to dislocation(s) of the patella. Acute

dislocations of the patella typically result from a traumatic event such as a non-contact twisting

of the knee with the foot fixated to the ground or from an external force driving the knee into a

varus/valgus position.3 This mechanism of injury is most commonly observed, with other factors

including ligamentous laxity, anatomical variations, and congenital abnormalities being less

common.3 There are many static and dynamic stabilizers within the knee joint that act to prevent

this bone from deviating from its anatomical location, including the medial patellofemoral

ligament (MPFL) and the vastus medialis obliquus (VMO) muscle. The primary static restraint to

lateral patellar instability is the MPFL, while the primary dynamic stabilizer of the patella is the

1
VMO muscle which provides a medially directed force to allow for movement of the patella

during knee flexion and extension.3 Excessive laxity or weakness of these static and dynamic

stabilizers predisposes the individual to a higher risk of dislocation of the patella.3 Individuals

that have obtained an acute dislocation of the patella are at an increased risk of recurrent

dislocations throughout their life with a 70-80% increase of dislocation after two incidents of

patellar dislocations reported by Stover et al.5

Common signs and symptoms reported with patellar dislocations are inflammation and

swelling, pain in and around the patella, knee instability, and fear avoidance due to the feeling

that it may dislocate a subsequent time.5 Individuals that obtain a patellar dislocation for the first

or second time typically are treated conservatively with protection, ice, bracing for compression,

rest, and physical therapy interventions.5 Individuals that report recurrent patellar dislocations are

typically treated with surgical interventions. According to Jeffery Housner,6 a Doctor of

Medicine at the University of Michigan, procedures used to stabilize the patella include MPFL

reconstruction, medial retinacular repair, and tibial tubercle osteotomy.

Currently, there are no clinical practice guidelines in place for conservative management

of lateral patellar dislocations and instability, and there are varying protocols that surgeons use

for patients that experience this type of injury. A protocol conducted by Sanford Orthopedics

Sports Medicine7 refers to a guideline to follow for non-operative patellar dislocations within the

scope of physical therapy. This guideline starts with diminishing pain and inflammation while

improving active range of motion/passive range of motion (AROM/PROM) of the knee through

isometric and active strengthening exercises before progressing to sport-specific activities

requiring cutting, twisting, and hopping prior to return to sport. The general healing timeline for

utilizing this protocol is 10-16 weeks, considering the immobilization period after sustaining the

2
injury. Another protocol conducted by Fowler Kennedy8 refers to a guideline to utilize after

surgical intervention for a patient that suffered a lateral patellar dislocation. This guideline is

similar to the one described earlier by Sanford Orthopedics Sports Medicine, but differs by

having a longer acute period of immobilization due to the surgical procedure. This protocol

focuses on joint protection and joint range of motion (ROM) for a longer period before

progressing to sport-specific interventions. While varying protocols exist for rehabilitation

following a patellar dislocation, it is difficult to provide task-specific interventions at this time by

evidence due to the absence/paucity of current literature.

Smith et al9 examined whether distal VMO muscle strengthening improved functional

outcomes when compared to generalized quadriceps muscle strengthening following an

individual's patellar dislocation for the first time. This study included 55 patients, with a mean

age of 23 years, which were randomized into a specific VMO exercise and rehabilitation

program (n=25) or a generalized quadriceps muscle strengthening program (n=25). Primary

outcomes used were the Lysholm Knee Score, Tegner Level of Activity score, Norwich Patellar

Instability (NPI) score, and isometric knee extension strength at varying degrees of knee flexion.

These outcomes were assessed and recorded at baseline, 6 weeks, 6 months, and 12 months post

patellar dislocation. The VMO specific group were prescribed four exercises that were confirmed

through electromyographic (EMG) data to specifically bias the distal VMO muscle.10 These

exercises included a modified wall slide exercise, isometric quadriceps and tibial/femoral

internal rotation, isometric quadriceps with hip rotation in semi-squatting position, and leg dips

in internal tibial/femoral rotation. The generalized quadriceps strengthening exercise group were

prescribed interventions including a wall slide exercise, straight leg raises, leg dips, and

isometric quadriceps exercises. Both groups completed each of these 4 exercises for 7

3
repetitions, 3 times daily. These two groups received similar co-interventions on top of these

exercises that focused on knee range of motion (ROM) exercises, modalities such as ice to

reduce inflammation, and other functional activities to increase lower extremity musculature

recruitment. Findings of this study concluded that there was a statistically significant difference

in activity levels and functional outcomes with the Lysholm Knee Score and Tegner Level of

Activity score outcomes in the VMO-specific exercise group, but they did not reach a clinically

important difference at 12-months post dislocation between the two groups. Other findings of

this study concluded that there was no statistically significant difference for NPI scores and

isometric strength when comparing the VMO-specific exercise group to the generalized

quadriceps muscle strengthening group at any of the follow up intervals.

Honkonen et al11 conducted a randomized control trial (RCT) comparing outcomes of

use with a patella-stabilizing knee brace versus a neoprene non-hinged knee brace in patients that

suffered a traumatic lateral patellar dislocation. This study investigated whether restricting knee

mobility within the patella-stabilizing knee brace resulted in improved outcomes compared to its

counterpart that allowed for full range of motion (ROM) of the knee joint. This study included

64 patients that were divided into group A (n=32) with the patellar-stabilizing knee brace; and

group B (n=32) with the neoprene non hinged brace. The primary outcome used in this study was

dislocation rate with other outcomes used including knee active range of motion (AROM),

quadriceps muscle atrophy, and functional outcomes utilizing their Kujala score. Both groups

received similar physical therapy interventions for 4 weeks, including closed kinetic chain

(CKC) lower limb and muscle strengthening exercises to improve quadriceps muscle strength.

The participants were advised to wear their respective knee brace continuously for 4 weeks after

suffering a patellar dislocation. There were no weight bearing restrictions associated with either

4
group throughout the duration of physical therapy and follow up appointments for this study

were at 4 weeks, 3 months, 6 months, and 3 years post-patellar dislocation. Authors concluded

that the dislocation rate in group A was 34.4% and 37.5% in group B, with group A exhibiting

less knee flexion AROM compared to group B at 4 weeks and 3 months. Participants in group A

exhibited greater quadriceps muscle atrophy at 4 week and 3-month follow-up appointments

compared to group B, while group B displayed better functional outcomes through their Kujala

Score at the 6-month follow-up period. In summary, the use of a patella-stabilizing knee brace

for 4 weeks after a traumatic lateral patellar dislocation did not result in a statistically significant

reduction in dislocations when compared to its counterpart, the neoprene non-hinged knee brace.

The authors of this study concluded that immobilization of the knee joint was associated with

less knee AROM, greater quadriceps muscle atrophy, and worse functional outcomes in the first

6 months after sustaining the injury.

A prospective RCT conducted by Straume-Næsheim et al12 compared outcomes between

two groups suffering from recurrent lateral patellar dislocations. Group A received MPFL

reconstruction surgery with active rehabilitation and group B received active rehabilitation only

after suffering from recurrent lateral patellar dislocations. This study included 61 participants,

with group A (n=30) and group B (n=31) falling within the age group of 12-30 years old. Group

A underwent an open MPFL reconstruction surgery utilizing their distal semitendinosus tendon

as the autograft and were instructed to perform passive range of motion (PROM) exercises,

straight leg raises, and isometric quadriceps contractions for 8 weeks. The primary outcome

observed in this study was the presence of a re-dislocation of the patella, as well as PROM of the

knee and pain scores utilizing the visual analogue scale (VAS). These outcomes were assessed at

12 months status post-lateral patellar dislocation between the 2 groups. Results of this study

5
showed that 6.7% (2/30) of group A participants reported patellar instability compared to 41.9%

(13/31) of group B participants at the 12-month follow up period. Other findings included no

statistically significant difference in activity levels between the two groups, as well as no

differences in PROM of the knee. The authors of this study concluded that participants have a 6-

fold increased risk of persistent patellar instability if only treated with active rehabilitation alone

compared to MPFL reconstruction with active rehabilitation. The authors of this study also

concluded that active rehabilitation in the absence of MPFL reconstruction improved patient

reported knee function after 12 months, but that it did not protect against persistent instability of

the patella.

Adolescents are the typical age group that experience dislocations of the patella due to

this population maintaining activity in sports activities.13 The first occurrence of a patellar

dislocation is most often observed during sporting activities (72%), and rarely because of direct

trauma (7%).14 Instability of the patella has been linked to have a hereditary association in 15%

of cases, but the patterns of inheritance have not yet been identified.15 Subsequently, an article

conducted by Buchner et al16 found that individuals younger than 15 years of age had a 52%

recurrence rate of a lateral patellar dislocation after the initial injury and a 10% increase in risk

of contralateral patellar dislocation. General risk factors for patellar dislocations include age,

gender, prior dislocation, and family history. Females are at an increased risk of obtaining a

patellar dislocation due to having a higher Q-angle from wider hips, which puts an abnormal

lateral stress on the patella.17 A dislocation of the patella has the potential to lead to secondary

impairments in terms of strength and ROM of the knee, potentially delaying their return to sport

or daily activities requiring use of the lower extremity.

6
 Currently, there are no clinical practice guidelines in place for conservative management

of lateral patellar dislocations and instability, as well as varying protocols that surgeons use for

patients that experience this type of injury. The reason for varying protocols within this

population is due to whether or not the individual underwent a surgical procedure to correct the

deviation, or whether they chose to participate in conservative treatment through physical

therapy intervention alone. The studies reviewed have shown the importance of physical therapy

interventions and their impact on improving quadriceps strength to prevent recurrence of a lateral

patellar dislocation in the adolescent population. The purpose of this case report was to describe

physical therapy interventions to improve strength and stability of the lower extremity in an

adolescent with a history of recurrent patellar dislocations and to describe intentional

rehabilitation efforts to prevent further recurrent lateral patellar dislocations.

Prior to preparing this report, consent was obtained from the patient to proceed. All

information contained in this case report meets the Health Insurance Portability Accountability

Act (HIPAA) requirements of the clinical agency for disclosure of protected health information.

This case report was completed under the direction of the Department of Physical Therapy and

with the oversight of the College of Graduate Studies at Central Michigan University.

Case Description

Patient History and Review of Systems

The patient was a 14-year-old male who sustained a right lateral patellar dislocation

secondary to a high-energy impact with another player during basketball practice. The impact

created a lateral to medial stress at the knee joint, forcing the right knee into a valgus position, a

position that typically results in a lateral patellar dislocation. The patient stated that they have a

history of lateral patellar dislocations bilaterally, and that the process of relocation of the patella

7
was completed by his father, a registered physician, shortly after the mechanism of injury. This

process involves passively extending the knee while maintaining a medial stress on the lateral

border of the patella.18 The patient was then sidelined from basketball practice and game activity

for the rest of the week until they were able to schedule an appointment with a physical therapist.

The patient was scheduled for an initial evaluation 3 days after sustaining the injury with a

physical therapist.

During the initial examination, the patient was alert and oriented to person, place, and

situation, as well as able to answer all subjective information. The patient stated that they lived

with their parents and that they were in the middle of their high school basketball season when

the injury occurred. The patient reported that they played tight end in football in the summer/fall

and power forward in basketball in the winter. The patient and their father reported that this was

not the first occurrence of a lateral patellar dislocation, and that they have a history of this injury

occurring bilaterally. The patient was able to state that they have obtained this injury twice on

the left lower extremity (LLE), and that this was the second time this has occurred on the right

lower extremity (RLE). The patient and their father were unable to recall when each of these

dislocations occurred, but stated that it had been over 12 months since the last incident and that

this was the second dislocation resulting from a contact injury. Prior to sustaining this injury, the

patient reported being pain-free during ambulation and sport specific activities requiring

jumping, pivoting, and squatting, as well as being independent with all activities of daily living

(ADLs).

Upon initial examination, the patient’s main complaint was discomfort in the right medial

and lateral knee joint. Other patient complaints included lower extremity weakness, decreased

confidence, and whether he would be able to return to basketball practice shortly. The patient did

8
not have any restrictions from his primary care provider in terms of weight-bearing, ROM,

strength training, or length of return to play. The patient reported that icing the right knee helped

decrease symptoms of discomfort, and that passive movements of the patella slightly reproduced

symptoms of discomfort but that was the only aggravating factor.

The patient’s past medical history included bilateral recurrent patellae dislocations, but

there were no other significant past medical history conditions the patient reported. The patient

did report that his mother has a history of the same pathology, with this mechanism also

occurring bilaterally. The patient’s mother was a 3-sport athlete in high school and reported that

her injuries were a result of non-contact injuries. The patient’s mother reported it had been 8

years since her last lateral patellar dislocation and relates this to her bilateral knee braces she

uses while participating in higher level activities. The patient reports no history of smoking, no

past surgical history, and that he is not currently on any medications other than the occasional

Ibuprofen to help combat his symptoms of right knee discomfort.

The patient reported that he lived with both of his parents in a 3-level house with 3 steps

to enter and 2 sets of 12 steps within the household. The patient reported that he enjoyed playing

sports with his friends, as well as spending time outside hiking trails in the wilderness and

maintaining activity outside of sports. The patient was accompanied by his father during the

initial evaluation, helping provide information regarding his past medical history and any other

pertinent information. The patient stated their goals with physical therapy were to decrease

discomfort around the medial and lateral aspects of his right patella, improve strength of his

bilateral lower extremities, and to be able to play basketball without fear of further dislocation.

The patient’s father, a physician, reported that he had ordered plain radiographic imaging

(x-ray) and a magnetic resonance image (MRI) of the adolescent’s right knee the following day

9
after the patellar dislocation. His father relayed that the x-ray did not reveal any evidence of a

fracture in either the patella, proximal tibia, proximal fibula, or distal femur. The patient’s father

also relayed that the MRI did not show any evidence of musculoskeletal, ligamentous, or soft

tissue damage to the surrounding areas of the knee joint. The patient’s father stated that there

was no evidence of vascular involvement other than mild subcutaneous edema in the right distal

anterior thigh. If there had been evidence of any fractures/ligamentous injuries, it would have the

potential to delay return to sport due to bone and tissue healing factors playing a role.

Clinical Impression #1

Given these findings from the information relayed from the x-ray, MRI, and chronic

history of the same injury, it was expected that the patient would have a decrease in strength of

his right lower extremity compared to the left, as well as have increased levels of pain with

passive joint play (PJP) of the right patella. These will be assessed with objective measurements

of strength through manual muscle testing (MMT), pain through the Numeric Pain Rating Scale

(NPRS), and PJP through the 6-point scale of mobility. It was also expected that sport specific

activities that require jumping, pivoting, and landing would be decreased in terms of distance

compared to their premorbid status. These distances will be assessed with objective

measurements through the single hop for distance test and the triple hop for distance test, which

also helps give the clinician a guide to lower extremity strength and power. Due to the patient

having decreased confidence with this recurrent injury, the Banff Patellofemoral Instability

Instrument (BPII)19 was used to assess the patient’s quality of life and confidence level. A Kujala

Score and a Norwich Patellar Instability (NPI) score was not utilized due to the BPII having

statistically significant correlations between the two outcome measures (P < 0.001).20

10
 The patient’s diagnosis of a lateral patellar dislocation with no further structural damage,

combined with the patient’s history and family history of this injury, makes this patient an

interesting case report subject. Patellar instability has been linked to have a hereditary

association in 15% of cases, and individuals younger than 15 years old had a 52% recurrence

rate after the first injury, with a 10% increase in risk of contralateral patellar dislocation.15,16 This

is a unique case report when compared to the average patient with a first time lateral patellar

dislocation, on top of the patient being in the middle of his sports season, which had the potential

to vary the plan of care in terms of intensity and ability to participate in therapy sessions.

Examination

Strength testing. Formal manual muscle testing (MMT) of the RLE and LLE was completed at

the initial examination for baseline measurements. Strength of the lower extremities was

assessed through MMT by following procedures and testing protocols identified by Reese.21

Research regarding MMT has been shown to have moderate to excellent overall interrater

reliability of lower extremity muscles (ICC = 0.66-1.00),22 with moderate construct validity (r =

0.768, P < 0.001).23 All lower extremity MMT were assessed utilizing a break test. A “break” test

involves having the patient move their extremity into its mid-range with the examiner applying a

force that counteracts the patient's desired movement.24 This force starts as minimal resistance

applied by the therapist and progresses to maximal resistance to assess the strength of a muscle

or group of muscles. The grading scale for strength is based on a 5-point scale defined by

Reese.21 A score of 0 indicates the inability of the patient to contract a muscle in a gravity-

eliminated position, while a score of 5 indicates the ability of the patient to withstand maximal

resistance applied by the examiner in a gravity-resisted position. Standardized positions stated by

Reese21 were utilized for all hip and knee MMT strength recordings. Ankle plantarflexion and

11
dorsiflexion strength were assessed at the edge of the table with the knee fully extended, while

resistance was applied by the examiner at the distal aspect of the metatarsals. Ankle eversion

strength was assessed at the edge of the table with the knee flexed to 90°, and a medially directed

force was applied to the lateral calcaneus by the examiner. Ankle MMT procedures differed from

Reese21 and; therefore, reliability and validity measures are not applied to these modified

strength ratings. Although there are no established MDC or MCID for MMT, a systematic

review concluded by Cuthbert et al25 concluded that a MMT score must change by at least a full

grade in order to be considered a statistically significant difference. Overall, the patient

demonstrated a slight decrease in strength of hip internal and external rotation, as well as knee

flexion and extension when comparing the RLE to the LLE at the initial examination. See Table

1 for lower extremity strength grades and an analysis of each strength grade.

Active Range of Motion. RLE AROM was assessed utilizing the parallel lines method with a

universal goniometer, with ranges shown below in Table 2.26 Currently, there is no research

examining the reliability and validity of ROM measurements of the lower extremity utilizing a

standard goniometer and the parallel lines method. The parallel lines method utilizes a standard

goniometer, lining up the reference and indicator segments with the respective bony segments

that are being measured in a parallel manner. The axis of rotation of the goniometer is placed at

the joint line, also known as the point at which an object rotates. This differs from the standard

protocol of measuring ROM because it utilizes body segments rather than anatomical landmarks

and was used due to differences in anatomical variability in patients. RLE hip flexion, hip

abduction, hip internal and external rotation, knee flexion, knee extension, ankle plantarflexion,

ankle dorsiflexion, and ankle eversion were measured at the initial examination and at discharge

6 weeks after the examination. AROM measurements for the hip, knee, and ankle were taken

12
with the patient lying supine on the treatment table with exception for hip internal and external

rotation. Hip flexion AROM was assessed by asking the patient to bring their knee towards their

chest, while hip abduction AROM was assessed by asking the patient to bring their lower

extremity out to the side. Hip internal and external rotation AROM was assessed with the patient

in the prone position and knee flexed to 90°. Knee flexion AROM was assessed by asking the

patient to perform a heel slide while in supine, and then to activate his quadriceps muscles to

perform knee extension for the measurement. Ankle dorsiflexion and plantarflexion were

assessed by asking the patient to perform an ankle pump in supine, while ankle eversion was

assessed by asking the patient to bring his toe out laterally. AROM of the RLE was recorded at

the initial examination and at the 6-week discharge session. The minimal detectable change

(MDC) for knee goniometric measurements utilizing a goniometer and the standard protocol for

measurement was found to be 10°, while MDC for the parallel lines method has not been

established in current literature.27 Overall, the patient demonstrated a slight decrease in RLE knee

flexion AROM, but all other AROM measurements did not show a deficiency. See Table 2 for

RLE AROM measurements. The left lower extremity (LLE) was noted as within normal limits

(WNL) at the initial examination.

Passive Joint Play and Pain. Passive joint play (PJP) was recorded for the patella at the initial

examination based on subjective complaints from the patient regarding discomfort with passive

movement. The available joint play was graded using a 7-point scale that was initially introduced

by Stanley Paris.28 The scale ranges from 0, or ankylosed, to 6, unstable. This scale has been

found to be a valid and reliable tool with a very high intra-rater reliability (ICC = 0.88-0.95)29

and has been found useful for detecting prognosis in treatment. There is no data regarding MDC

or minimally clinically important difference (MCID) with this objective measurement. Passive

13
translatoric gliding of the patella was assessed with medial gliding, lateral gliding, superior

gliding, and inferior gliding of the patella with the patient’s knee in full extension while supine.

Overall, the patient demonstrated slightly increased movement (grade of 4) with passive lateral

gliding of the right patella, indicating slight hypermobility compared to the contralateral lower

extremity. During PJP examination of the patella bilaterally, pain was assessed utilizing the

Numeric Pain Rating Scale (NPRS).30 The NPRS is an outcome measurement used to assess the

patient’s progression of pain for a wide range of patient populations it can be applied to. This

measurement is an 11-point scale that requires the administrator to ask the patient to numerically

assess their current level of pain on a scale of 0, meaning no pain at all, to 10, meaning

emergency room level of pain. The NPRS has been found to be a valid and reliable tool for

assessing adolescents and children's pain rating over time.31 For patients with chronic

musculoskeletal pain, the NPRS has been found to have an MCID of 1.0 points.32 Overall, the

patient demonstrated a moderate pain level (NPRS = 4) score utilizing the NPRS with PJP of the

patella as is reported in Table 3.

Stability. Stability of the patient’s lower extremities were assessed utilizing the single limp hop

test and triple hop test for distance. These were also utilized to assess when the patient would be

cleared to return to sport specific activities. Testing protocols for the single limb hop test and the

triple limb hop tests were followed by guidelines modified by Physiopedia Contributors.33 The

single limb hop test for distance was assessed by having the patient perform a single leg hop and

maintaining the landing position for a minimum of 2 seconds. This was performed for 3 trials for

measurement purposes and averaged, comparing it to the non-injured limb. The triple hop test for

distance was assessed by having the patient perform 3 consecutive hops while on a single limb

and was also performed for 3 trials by the patient. Each test started with two preliminary trials

14
(one on each lower extremity) before data was recorded for the patient to gain an understanding

of the movement required. The goal for these tests is to have less than a 10% difference in

distance between the uninjured and injured lower extremity. Single limb hop tests have

demonstrated a strong intrarater reliability (ICC = 0.85) and have also shown to have a much

lower risk of reinjury when criteria is met compared to a timeline.34,35 The MDC for the non-

specific patient population in males has been found to be 21.81 cm for the single limb hop for

distance test and 47.59 cm for the triple hop test for distance.36 Overall, the patient demonstrated

greater than a 10% deficit in distance when comparing the injured limb to the uninjured limb

during the single limb hop test and the triple hop test at the second physical therapy session.

Further statistical analysis of these hop tests are reported in Figure 1.

Quality of Life and Confidence. The Banff Patellofemoral Instability Instrument (BPII)19 was

used to assess the patient’s quality of life and confidence level. The BPII has been found to be a

relevant clinical tool in terms of assessing quality of life (QoL) and confidence levels when

compared to its counterparts of the Kujala score and NPI score.20 The BPII consists of 23

questions with 5 separate domains, assessing symptoms and physical complaints, work-related

concerts, sport/recreation concerts, as well as social and emotional factors that affect lifestyle.

Each question is scored from 0 to 100, with lower scores correlating to a lower QoL. The sum of

each question answered is totaled and divided by the number of questions answered, requiring a

minimum of 19 out of the 23 questions be answered. The MCID for the BPII in patients with

patellofemoral instability has been found to be 6.2 points37 in a population of adolescents/adults

older than 10 years of age. The reliability for this instrument has been graded as high (Cronbach

alpha coefficient > 0.95), while the validity of this outcome measure has been graded as

15
moderate (r = 0.50, P < 0.001).20 Overall, the patient demonstrated a moderate score in terms of

QoL with the BPII at the initial examination, with further analysis shown below in Figure 2.

Clinical Impression #2

The patient presented with deficiencies in strength of the RLE, pain with PJP of the

patella in a position of full knee extension, and ability to participate in sport specific activities

requiring jumping, pivoting, and cutting. Objective measurements of the single limb hop test and

triple hop test for distance were not measured at the initial examination due to these motions

sustaining a large increase in GRFs through the lower extremity. The patient was educated on

purchasing a knee brace that would not completely restrict patellar motion, but one that would

limit it slightly by providing compression to the knee. These measurements were taken at the

second physical therapy session once the patient had brought in a Breg Bledsoe crossover knee

brace (AG060050, Breg, Carlsbad, CA) (Figure 3). The knee brace was introduced to the patient

due to having a history of bilateral patellar dislocations, a past family history of the same

pathology, and to increase patient confidence with movements that require higher levels of

activity. This information of the recurrent issue of patellar dislocation helped influence the

decision of purchasing a brace, with literature supporting its use within this population for

improved outcomes.11 Despite the list of patient impairments and their past medical history, the

patient had good rehabilitation potential. Positive factors such as family and friend support, as

well as increased patient motivation to return to sport with greater confidence, were potential

indicators that the patient was a good candidate for improved outcomes observed. The patient’s

initial barriers to recovery and return to sport activity were pain with PJP of the right patella,

difficulty performing sport specific activities requiring jumping/pivoting, decreased confidence,

and a decrease in strength of the injured limb compared to the uninjured limb.

16
 Given these deficits and the patient’s goals, a plan of care was developed. The first

physical therapy goal was to increase strength of the injured right lower limb to decrease the

subsequent chances of obtaining another patellar dislocation. The second physical therapy goal

was to have the patient perform sport-specific activities requiring jumping and cutting with

evidence of no excessive dynamic knee valgus. The third goal was to increase the patient’s

confidence with performing these sport specific activities. The patient’s stated goals were to

decrease discomfort around the medial and lateral aspects of his right patella, improve strength

of his bilateral lower extremities, and to be able to play basketball without fear of further

dislocation. To meet the patient’s goals and address their deficits, the patient would participate in

outpatient physical therapy services 2 times per week for an anticipated length of 6 weeks.

The range and extent of the patient’s deficiencies in pain, strength, stability, and

confidence make them an interesting case report subject. These deficiencies, combined with their

past medical history, past family history, and that they were currently in season for a sport, also

make this patient an interesting case report subject. Lateral patellar dislocations are a common

injury with sporting activities requiring jumping and cutting, with different interventions being

utilized to decrease a subsequent dislocation, and varying rehabilitation guidelines based on the

extent of injury and tissue healing factors that impact the plan of care.

Interventions

The physical therapy interventions implemented to address his impairments and strive

towards increased patient confidence with performing sport-specific activities included

neuromuscular re-education, therapeutic exercise, and therapeutic activities. Given the patient’s

initial complaints of increased pain with passive mobilization of the right patella, pain rating was

assessed at the beginning of each therapy session with PJP of the patella in all anatomical

17
directions. The interventions performed were designed to replicate the sporting environment they

would be returning to, involving jumping, cutting, pivoting, and landing. There were no

restrictions in the plan of care in terms of activity or strengthening, with pain rating being the

guiding factor for treatment.

Neuromuscular re-education. Foss et al38 examined whether a neuromuscular training (NMT)

program on sport-related injury incidence for high school and middle school aged adolescents

reduced the rate for knee and ankle injuries. The authors concluded that participation in the NMT

program resulted in a lower injury incidence rate in knee injuries relative to participation in their

sham protocol which included running using elastic bands for resistance. The NMT program

included jumping in the sagittal, frontal, and transverse planes, as well as strengthening of the

lower extremities and core musculature. Given the research regarding neuromuscular re-

education and its ability to reduce further injury rate, neuromuscular re-education in multiple

planes was a focus for the patient during the rehabilitation process. The first neuromuscular re-

education exercise (Figure 7) that was introduced was to increase hamstring mobility in 2 planes

of motion. This involved the patient flexing the hip while keeping the knee extended and neutral

ankle position with the contralateral lower extremity in a weight bearing position. The patient

then leaned forward with their upper torso in a neutral position to increase tension in the

hamstring muscle group, leaning into and out of resistance in the sagittal plane for 15 repetitions.

The patient would then use a top-down driver, meaning they would use their contralateral upper

extremity to reach across their body laterally, causing internal rotation of the ipsilateral hip. This

was introduced to increase extensibility of the hamstring muscle group in the transverse plane

and was performed for another 15 repetitions. These were completed at the beginning of each

therapy session bilaterally as a warmup prior to higher intensity activity.

18
 Hip flexor mobility was also introduced as a warmup prior to higher intensity activity at

each therapy session. This neuromuscular re-education activity (Figure 8) was performed in a

TRUEStretch™ cage (800SSCLUB, TRUE, St. Louis, MO), a piece of equipment designed to

promote safe stretching with a reduced risk of injury (Figure 4). The activity required the patient

to stand on a plantarflexed wedge with a toe-in position to better bias the hip flexor compared to

the distal lower extremity musculature groups. The contralateral lower extremity was placed in a

hip flexion and knee flexion position, with the patient leaning into and out of the stretch in the

sagittal plane to start. After 15 repetitions in the sagittal plane, the patient was instructed to lean

forward and laterally move their hips to lengthen the hip flexor muscle group in the frontal plane

for 15 repetitions. The last component of this activity involved moving further into knee flexion

and extension in a clockwise/counterclockwise position to lengthen the hip flexor muscle group

in the transverse plane for 15 repetitions. This neuromuscular re-education activity was

performed bilaterally.

Posterior chain stability, or strength of the posterior aspect of the injured lower extremity,

was a target of many neuromuscular re-education activities implemented. This exercise focused

on increasing strength and stability of the posterior chain musculature of the lower extremity in 3

planes of movement. Patel,39 an orthopedic surgeon with a specialty in sports medicine, wrote an

article on how strengthening of the posterior chain musculature (i.e., gluteals, hamstrings,

gastrocnemius) helps reduce the loading force in the knee and contributes to less evidence of

excessive valgus during higher intensity activities requiring jumping. Bell et al40 stated how

excessive knee valgus during jumping activities contributes to increased tension on the anterior

longitudinal ligament (ACL), increasing susceptibility to injuring this passive structure. Posterior

chain stability was included for this reason in the intervention plan for this patient. The first

19
posterior chain stability neuromuscular re-education exercise introduced involved increasing

stability of the posterior lower extremity musculature. This involved the patient placing the

injured limb on a slider device to decrease friction between its surface and the ground (Figure 9).

The patient would then slide the lower extremity in a postero-lateral direction to increase their

base of support (BOS), a directly posterior direction, and a postero-medial direction to narrow

their BOS. This intervention focused on the weight bearing lower extremity, requiring the

posterior musculature group to adapt to these altered bases of support in multiple planes of

motion. Each direction was completed for 20 repetitions and was completed bilaterally. This

neuromuscular re-education activity was completed at each therapy session to increase strength

of the lower extremities, as well as increase proprioception.

Porrati-Paladino et al41 examined whether plyometric and eccentric exercises helped

improve jumping and stability in female soccer players. One of the exercises included in this

study was lunging in multiple planes. The authors concluded that eccentric exercises helped

improve lower extremity stability, despite no detectable change in jump height with the

exercises. Based on this work, a lunge matrix was introduced to the patient and tweaked to

involve multiple plane stability. Tweakology™ refers to nomenclature created by Gary Grey and

David Tiberio,42 and refers to altering an intervention or exercise to the patient for a desired

outcome, or “tweaking” it. The common lunge matrix utilized for the patient included an anterior

lunge, a same side lateral lunge, and a same side rotational lunge to hit all 3 planes of motion

(Figure 10). The exercise initiated in the second therapy session involved the patient completing

these lunges with no external resistance, with 20 repetitions in each of the 3 directions. This

exercise was then progressed to include the patient utilizing a 10-pound weighted ball with a

reach to the ipsilateral lunging knee, further incorporating whole body movement and

20
challenging the patient’s core while altering their center of mass. The patient completed this

exercise for the following 4 sessions with 20 repetitions in each direction. This exercise was then

progressed further to increase proprioception and decrease valgus forces at the knee. The

progression included the patient performing a lunge onto the round side of a BOSU Balance

Trainer (BOSU, Ashland, OH) ball with a 10-pound weighted ball, incorporating an uneven

surface to further increase lower extremity stability and proprioception. The weighted ball

reaches were performed to the lateral aspect of the knee to promote a varus position and were

completed for a total of 20 repetitions in each direction. This exercise was completed by the

patient for the final 6 sessions in physical therapy and were completed bilaterally to increase

stability and proprioception of the contralateral lower extremity.

A BOSU Balance Trainer ball was utilized for different neuromuscular re-education

activities as well to further increase lower extremity proprioception. Panagoulis et al43 examined

whether 8 weeks of integrative neuromuscular training utilizing a BOSU Balance Trainer ball

and stability balls helped improve performance in early adolescent soccer athletes. The authors

concluded that the 8-week integrative neuromuscular training program helped promote positive

adaptations in terms of performance in this population of athletes while in their season. Due to

this research supporting interventions utilizing a BOSU Balance Trainer ball and altered surfaces

while in-season training, similar activities with the BOSU Balance Trainer were implemented

into the plan of care. The first neuromuscular re-education activity including a BOSU Balance

Trainer ball was a single leg stance (SLS) with 5° of knee flexion in the weight bearing lower

extremity to further increase lower extremity muscle activation compared to a fully extended

knee joint (Figure 11). The patient completed this activity for 3 repetitions of 20 second holds in

a SLS position bilaterally on the third physical therapy session. This neuromuscular re-education

21
activity was then progressed the following session to incorporate dual tasking. This involved the

same criteria stated before with the SLS position, but now the patient had to catch a tennis ball in

varying locations to further challenge the patient’s proprioception and strength with altering their

BOS. The patient was able to complete 3 repetitions of 30 second holds in a SLS position while

catching and throwing a tennis ball before lower extremity fatigue prevented further participation

and was completed bilaterally. The final progression of this exercise included the same criteria of

a SLS position on a BOSU Balance Trainer, but now external perturbations in all directions were

applied to the patient’s upper torso. The perturbations were added to challenge and increase the

patient’s reactive balance, making these interventions more task specific to the environment they

would be playing in. The patient was able to complete the final progression of this

neuromuscular re-education activity for 3 reps of 30 seconds bilaterally.

A 12-inch step was utilized for another neuromuscular re-education activity to challenge

verticality and proprioception while also increasing strength and stability of the lower

extremities. This exercise focused on the sagittal plane of motion in the anterior direction,

challenging hip and knee musculature to maintain isometric contraction of the stepping leg,

while promoting concentric and eccentric contraction of lower extremity musculature of the

stationary leg. The activity introduced on a 12-inch step was an anterior step down (Figure 12).

This involved the patient standing on the 12-inch step, performing a single leg squat on one

extremity while the other extremity maintained a neutral hip and knee position to tap the heel

onto the floor. The patient completed 3 sets of 20 repetitions in the anterior direction bilaterally

before lower extremity fatigue prevented further participation. This neuromuscular re-education

activity was completed for 4 sessions before progressions and tweaks were made to further

increase proprioception activation. The progression that was made to this neuromuscular re-

22
education activity involved the patient holding an 8-pound weighted ball overhead while

completing the anterior step down. This tweak altered the patient’s center of mass, moving it

superiorly to further challenge strength and proprioception of the lower extremities, as well as

coordination of completing this motion. The patient completed 1 set of 20 repetitions with the

weighted ball directly overhead, 1 set of 20 repetitions with the weighted ball placed overhead

but biased towards the ipsilateral lower extremity completing the step down, and 1 set of 20

repetitions with the weighted ball overhead biased towards the contralateral lower extremity.

Tweaking the position of the ball overhead altered the patient’s center of mass outside of the

midline of the body, further challenging proprioception and stability of the patient’s lower

extremities to adapt to these changes.

Therapeutic exercise. Rio et al44 examined isometric contractions of the quadriceps muscles and

the influence of those contractions on reduction of patellar tendinopathy pain in volleyball

players. These authors concluded that a single bout of resistance training of isometric

contractions of the patellar tendon reduced patellar related pain and increased maximal voluntary

isometric contraction (MVIC) of the quadriceps muscle group. The MVIC increased significantly

by 18.7±7.8% following the isometric contraction and was significantly higher than baseline (P <

0.001) within this population.44 Given the research and patient reported pain levels located at the

patella, isometric contractions of the patellar tendon were introduced. The patient was instructed

to perform a wall sit with a therapy ball against the wall, with the hips and knees flexed to 90°.

The patient performed this exercise for 30 second isometric holds with the feet in a neutral

position for 4 repetitions at the second physical therapy session. The patient completed the wall

sits with isometric holds with this dosage for the following 4 sessions and was able to complete 4

repetitions with 60 second holds for the remaining 6 sessions.

23
 Hip abductor muscle strengthening was also addressed via an exercise that required the

patient to perform isometric activation into a therapy ball against the wall with one lower

extremity, while performing active hip abduction with banded resistance on the contralateral

lower extremity, all in a semi-squatted position of 45° of hip flexion and 60° of knee flexion

(Figure 13). The patient performed this exercise for 15 repetitions bilaterally for 3 sets during the

final 6 therapy sessions. This exercise was introduced to increase strength of the hip abductor

muscles to reduce tension at the patellofemoral and tibiofemoral joints. The resistance bands

utilized throughout the plan of care were designed by Val-U-Band® (Fabrication enterprises,

Akron, OH), a latex-free exercise band. See Figure 6 below for a chart describing these bands

and the increase of resistance that correlates to each color design. A green resistance band was

utilized for the first 3 sessions that this exercise was introduced before progressing to a blue

resistance band. The increase in resistance allowed for a progression of load into hip abduction,

increasing glute activation and optimizing further strength output. A second therapeutic exercise

to target the hip abductor musculature was lateral stepping with banded resistance applied at the

superior aspect of the patient’s bilateral patellae. This involved the patient assuming a crouched

position, with slight flexion at the bilateral hips and knees, with a blue resistance band being

utilized. The patient performed 6 laps of lateral stepping for 30 feet before lower extremity

fatigue limited further participation. A third therapeutic exercise to target hip abductor

musculature included active hip abduction with a velocity tweak (Figure 14). This exercise

involved the patient to perform hip abduction in a straight leg position against banded resistance,

with the contralateral lower extremity in weight-bearing. A purple banded resistance was used,

and the patient performed 2 sets of 30 seconds of hip abduction against resistance bilaterally. The

patient was encouraged to complete repetitions in a quick manner, with the weight-bearing lower

24
extremity having to account for these rapid changes in their center of mass to maintain standing.

This exercise was a progression to increase strength of the patient’s hip abductor musculature to

reduce valgus stress at the knee joint and was completed for the final 2 physical therapy sessions.

The last therapeutic exercise implemented into the plan of care was focused on increasing

hip flexor strength, as well as contralateral lower extremity stability. This exercise utilized the

KEISER® Functional Trainer (3020, KEISER, Fresno, CA) for resistance, which was applied

around the distal aspect of the patient’s lower extremity but not crossing the ankle mortise. The

KEISER® Functional Trainer is a versatile piece of cable equipment that utilizes compressive air

for resistance (Figure 5). The patient was instructed to perform a posterior toe tap with 6 pounds

of resistance applied to that lower extremity and then to explode into a SLS with the resisted

lower extremity in 90° of hip flexion and knee flexion (Figure 15). The patient was encouraged

to maintain this SLS position for a 3 second count to further increase stability of the stance leg.

The patient was able to complete this exercise for 3 sets of 12 repetitions bilaterally before lower

extremity fatigue prevented further participation. This exercise was then progressed after the 6th

session to include a verticality component, further challenging the patient’s lower extremity to

move through a larger ROM. This involved the patient completing this exercise on a 12-inch step

with the same dosage, with the patient completing this for 3 sets of 12 repetitions.

Therapeutic activities. Ardakani et al45 examined whether jump-landing biomechanics were

altered after a hop stabilization intervention period of 6 weeks in male collegiate basketball

players with chronic ankle instability. These authors concluded that the hop stabilization

program resulted in larger hip and knee flexion angles in the sagittal plane, greater ankle

dorsiflexion, and improved self-reported function (P < 0.05) when comparing it to the control

group. Due to this research and the demands of the sport the patient was participating in, jump

25
and hop training were introduced into the plan of care. The first therapeutic activity that was

introduced to the patient included double leg jump training with an emphasis on the landing

phase. This started out with no resistance to better focus on the biomechanics of loading into the

pre-jump and exploding into the phase of jumping and landing with unlocked knee joints. The

emphasis on landing with “soft knees,” meaning slightly flexed, was to reduce anterior patellar

ground reactions forces and reduce the risk of knee hyperextension. The patient was able to

complete 3 sets of 8 double leg jumps in the sagittal plane with no evidence of excessive

dynamic knee valgus at the third physical therapy session. After this activity, single leg jumping

with an emphasis on landing was incorporated to bias each lower extremity. The patient was able

to complete 3 sets of 8 single leg jumps bilaterally within the same session. This therapeutic

activity was completed each session after initiation and was tweaked at the 6th physical therapy

session to add resistance once the patient was able to complete this activity with no excessive

knee valgus. A KEISER® Functional Trainer was utilized for resistance, which provided a cable

column with an attachment to place around the patient’s lower trunk. This device utilizes air

compression instead of weights for resistance, allowing the user to either increase or decrease the

amount of resistance with a single press of a button. The cable attachment was placed inferior to

the umbilical region and superior to the anterior superior iliac spine (ASIS), with the line of pull

being parallel to the KEISER® Functional Trainer. For sessions 6-9, 8 pounds of resistance were

used during double leg jump training (Figure 16) while 6 pounds of resistance were used for

single leg jump training. The patient was able to complete 6 sets of 4 repetitions in both

scenarios. Two pounds of resistance were added to each scenario for the remaining 3 sessions of

physical therapy, with the patient being able to complete these jumping activities with no

evidence of excessive knee valgus upon landing with the same dosage.

26
 Since the demands of basketball require lateral shuffling, resistance was applied around

the patient’s lower torso through a cable from the KEISER® Functional Trainer. The patient was

able to perform lateral shuffling with 8 pounds of resistance for 6 reps across 15 feet of distance

for 3 sets and was able to complete this bilaterally. This activity was then progressed at the 6th

physical therapy session to include 10 pounds of resistance, further increasing muscular

activation in bilateral lower extremities.

Hop training was utilized as a therapeutic activity for a warmup each session after the

warmups utilized in the TRUEStretch™ cage. This included the patient hopping in all 3 planes

of motion with a small diameter to prepare their body for task specific and therapy interventions

for the session. The patient started off hopping both anteriorly and posteriorly over a line, then

laterally, and finally rotationally to be able to hit all 3 planes of motion with pivoting (Figure

17). The patient completed each plane for 60 seconds total before transitioning into the next

plane of movement, and only 1 set for each plane was completed due to this acting as a warmup

prior to activity. A progression of this exercise included the patient performing a 36-360 jump

matrix (Figure 18). This therapeutic activity was termed by Gary Grey and was designed to

challenge the 3-dimensional needs of the knee during sports specific activity.46 This activity was

a progression due to the patient covering a larger area of distance, requiring greater lower

extremity strength and control to complete in a successful manner. This activity requires 2

double leg jumps forward before rotating 90° to the left and completing 2 lateral jumps, 2

backwards jumps, 2 lateral jumps to the right, 2 forward jumps, and then completing these jumps

in reverse order to finish with 18 jumps in a linear direction. These jumps are then repeated back

to the starting position to finish with 36 total jumps and 360° of whole-body rotation. The patient

was able to complete this therapeutic activity for 2 sets at the final 2 physical therapy sessions.

27
This is a progression from hop training due to the lower extremities, in particular the knees,

having to react to the different motions of the body while creating a larger force for propulsion

into a jump.

Beato et al47 examined the effects of a complex change of direction and plyometric

protocol compared to an isolated change of direction protocol and if it resulted in a positive

impact on jumping and speed parameters in youth soccer players. The authors concluded that the

complex change of direction and plyometric protocol resulted in greater results of the long jump

test compared to the isolated change of direction protocol. Due to this research and the demands

of acceleration/deceleration in basketball, a plyometric therapeutic activity was incorporated into

the patient’s plan of care. This activity included the patient jumping off one leg to assume the

position of 90° of hip and knee flexion of the contralateral lower extremity, landing with

eccentric control of the quadriceps muscle groups, and exploding of the lower extremity into

another jump. The patient was able to complete 3 sets of 15 plyometric single leg jumps at the

3rd to last physical therapy session, with no evidence of excessive dynamic knee valgus upon

landing. This activity was not introduced into the plan of care until the end due to plyometrics

requiring great force and speed of lower extremity musculature and tendon lengthening

properties. The final 3 sessions included this therapeutic activity to increase the patient’s

confidence in performing these higher levels of activity, as well as increasing strength and power

of the lower extremities.

All the interventions completed by the patient throughout the plan of care were done so

without the Breg Bledsoe crossover knee brace applied to the RLE. This was because the

examiners were adamant about examining the amount of dynamic knee valgus during exercise,

which would be tough to examine with the external compression device applied. While recording

28
measures of the single limb hop and triple hop for distance tests, the Breg Bledsoe crossover

knee brace was applied at initial examination and at discharge for reproducibility and reliability

purposes.

Outcomes

The patient was able to meet all physical therapy and personal goals upon discharge from

outpatient physical therapy. The patient stated that they were feeling more confident during

basketball practice and in games with the Breg Bledsoe crossover knee brace applied to the RLE.

The patient participated in 12 physical therapy sessions over 6 weeks of outpatient physical

therapy.

Strength

Overall, the patient exhibited increases in strength of the RLE from initial examination

compared to discharge. See Table 1 for RLE and LLE strength measurements throughout the

plan of care. By discharge, improvements were made in right hip flexion and hip abduction to

5/5, right hip internal and external rotation to 4/5, and right knee flexion and extension to 5/5.

Although there are no established MDC or MCID for MMT, a systematic review concluded by

Cuthbert et al25 concluded that a MMT score must change by at least a full grade to be

considered a statistically significant difference.

Active range of motion

The AROM of the RLE demonstrated improvements from initial examination compared

to at discharge. See Table 2 for further AROM measurements of the RLE throughout the plan of

care. By discharge, the patient was able to flex their right knee through 15° more of a range

compared to initial examination, with less discomfort felt at the end range of knee flexion.

Currently, there is no research examining the reliability and validity of ROM measurements of

29
the lower extremity utilizing a standard goniometer and the parallel lines method. The MDC for

knee goniometric measurements utilizing a goniometer and the standard protocol for

measurement was found to be 10°.27 Due to not having MDC or MCID statistics for the parallel

line method of measuring ROM, it is unclear if this patient had a truly significant difference in

measurements at discharge compared to initial examination. However, an increase of 15° was

observed in knee flexion AROM throughout the plan of care with this patient.

Passive joint play and pain

Passive joint play (PJP) and pain were assessed at the start of each session over the 12

total visits in outpatient physical therapy. See Table 3 for PJP of the right patella and pain ratings

throughout each session in the plan of care. By discharge, the patient’s patella demonstrated

normal movement (grade of 3) compared to the contralateral patella, with the patient

experiencing no pain (0/10 NPRS) during mobilization. Although there is no MDC or MCID

data for the Stanley Paris Joint Play Scale, the MCID for the NPRS has been shown to be 1.0

points.32 The patient scored 4 points lower utilizing the NPRS when comparing discharge to

initial examination.

Stability

The patient demonstrated improvements in the single leg hop test and triple hop test for

distance bilaterally throughout the plan of care. See Figure 1 for distance recordings during the

single leg hop test and triple hop test from initial examination to discharge. By discharge, the

patient had a 1.82% difference in single leg hop distance when comparing bilateral lower

extremities, and a 0.15% difference in triple hop distance. The minimal detectable change

(MDC) for the non-specific patient population in males has been found to be 21.81 cm for the

single limb hop for distance test, and 47.59 cm for the triple hop test for distance.36 The patient

30
was able to jump 37.41 cm farther during the single leg hop test of the RLE compared to the

initial examination, and 55.99 cm farther during the triple hop test of the RLE compared to the

initial examination.

Quality of life and confidence

The patient’s initial examination score of the Banff Patellofemoral Instability Instrument

(BPII) was recorded at 78.7 points, indicating a moderate score of QoL and confidence. At the

12th physical therapy session, the patient was recorded at 96.8 points, indicating a near maximal

score of QoL and confidence. The MCID for the BPII in patients with patellofemoral instability

has been found to be 6.2 points, with this patient scoring 18.1 points higher when comparing the

two sessions.37 The patient was able to participate in sport activities with increased confidence,

which also led to an improvement in terms of QoL. The greatest improvements within this

outcome measure were within section C, the recreation/sport/activity section that pertained to the

individual. See Figure 2 for further information regarding the patient’s BPII score at initial

examination and at discharge.

Discussion

The purpose of this case report was to describe physical therapy interventions to improve

strength and stability of the lower extremity in an adolescent with a history of recurrent patellar

dislocations and to describe intentional rehabilitation efforts to prevent further recurrent lateral

patellar dislocations. During the plan of the care, the patient purchased a Breg Bledsoe crossover

knee brace to increase their confidence with sport specific activities requiring 3-dimensional

movement of the lower extremity, as well as provide compression to the patella during

movement. Physical therapy interventions included neuromuscular re-education, therapeutic

exercise, and therapeutic activities.

31
 The patient’s improvements in lower extremity strength are consistent with many

research studies that have been conducted with the adolescent population that has suffered a

patellar dislocation. In a randomized control trial conducted by Askenberger et al,48 the

examiners compared patients that utilized a surgical MPFL repair compared to non-surgical

treatment post lateral patellar dislocation. The group studied included participants aged 9-14

years of age that had no weight bearing restrictions, but were in a knee splint during lower

extremity strengthening exercises. The results of this study at 2 years post-rehabilitation stated

that there was no statistically significant difference in isokinetic knee flexion or extension

strength between either group. Similarly, a retrospective study conducted by Moström et al49

examined skeletally immature patients that were treated surgically and non-surgically after an

acute first-time patellar dislocation. This study investigated a different surgical approach than the

MPFL repair, utilizing an osteochondral fragment fixation and proximal soft tissue realignment.

At the 7.5 year follow up, the authors concluded that isokinetic knee flexion and extension

strength scores improved similarly in both groups. These studies help provide support to a non-

surgical rehabilitation treatment compared to a surgical treatment for patients that have suffered

a lateral patellar dislocation in terms of improving lower extremity strength. The non-surgical

option was chosen by the patient and their family due to the risks and complications of patellar

realignment surgical intervention. These include an increased risk of infection, exacerbated

inflammatory reactions that can lead to algodystrophy or complex regional pain syndrome, and

even arterial or nerve damage.50 These factors, combined with the improvements seen in this case

report patient’s lower extremity strength, help show that non-surgical rehabilitation intervention

programs can be just as beneficial at improving lower extremity strength as surgical

interventions with less risks involved. These findings suggest that therapeutic exercise, combined

32
with neuromuscular re-education and therapeutic activity, may be beneficial to incorporate into a

plan of care to increase strength of the lower extremities. Improving strength of the lower

extremity, with an emphasis on knee flexion and knee extension musculature, helped improve

the patient’s ability to perform sport specific activities that require 3-dimensional movement of

the knee with less fear of suffering a patellar dislocation.

Although the patient demonstrated improvements in lower extremity strength through

MMT procedures, this objective measure has been shown to have moderate to excellent

reliability (ICC = 0.66-1.00), with moderate construct validity (r = 0.768, P < 0.001).22,23 Kubo

et al51 examined the time course of changes in muscle and tendon properties during strength

training and detraining. The authors concluded that within the first 2 months of strength training,

improvements in strength are largely attributed to improved neuromuscular activation compared

to hypertrophy. They correlated this change to an increase in circulation and inflammation from

the muscle repair/regeneration process. This process starts during the first 4-5 days after injury

and gradually diminishes 3-4 weeks after the initial injury, requiring multiple steps including

repair and maturation of damaged muscle fibers and connective tissue formation, as well as

activation/proliferation of the spinal cord.52 Due to this research supporting a longer timeline to

see true statistical changes in muscular strength, it is likely that the increase in MMT score was

largely attributed to improvements in neuromuscular activation of their lower extremity

musculature.

Return to sport criteria for the single limb hop test and triple hop test for distance has not

been identified for the population of patellar instability. Thus, data used for establishing these

criteria was paralleled to patients’ status-post ACL reconstruction. Based upon literature

conducted by Bizzini et al53 that examined patient’s status-post ACL reconstruction, Ménétrey et

33
al54 established 6 criteria for patients to return to sport following a patellar dislocation. These

criteria are as follows: “(1) no pain; (2) no effusion; (3) no patellofemoral instability; (4) a full

range of motion; (5) nearly symmetrical strength (85-90%); and (6) excellent dynamic

stability.”54(p3) For assessing dynamic stability with this research study, the single leg squat and

the star excursion balance test (SEBT) were utilized. Although these tests have been shown to

have good reliability and validity,55 they do not account for sport specific activities that require

motion throughout all 3 planes of motion with momentum and GRFs playing a role.

Neuromuscular re-education and therapeutic activities were all implemented to increase

proprioception within the lower extremities to prepare for sport-specific activity. Sport specific

movements require different reactions in multiple planes, which is why with each activity, an

exercise was tweaked to include movement throughout these different planes of motion. In a

study conducted by Chang et al,56 they concluded that “persons with medial knee osteoarthritis

(OA) had decreased proprioceptive acuity in the varus direction, diminished body-weight

normalized knee varus and valgus muscle strength, and impaired ability to actively stabilize the

knee in the varus-valgus direction.”(p1) This solidifies the importance of knee frontal plane

proprioceptive control in combating the forces transmitted through the knee, and is why these

neuromuscular re-education activities were tweaked to involve motion in multiple planes to

decrease the risk of further dislocation. This case report patient was able to meet all 6 previous

criteria upon discharge from physical therapy intervention, with a 1.82% difference in single leg

hop distance and a 0.15% difference in triple hop distance when compared bilaterally. These two

tests that examine stability of the lower extremity allowed the practitioner to simulate the

environment they would be returning to, increasing specificity of the interventions implemented.

These findings suggest that therapeutic activities requiring jumping and hopping, as well as

34
plyometric training and therapeutic exercise, may help increase hopping distance and stability of

the lower extremity while in-season training.

Surgeon rehabilitation protocols for conservative management of lateral patellar

dislocations and instability mainly focus on improving lower extremity strength and AROM of

the knee joint.7,8 These are important for patients that want to return to their prior level of

function, but these guidelines and protocols do not take into account proprioception in multiple

planes. Proprioception is “the sense that lets us perceive the location, movement, and action of

parts of the body.”57(p1) Proprioceptors are the body’s organizers of coordinated movement;

different types of these cells respond to different levels of movement. For example, pacinian

corpuscles are proprioceptors located in joint capsules that respond to high velocity changes in

position, accounting for acceleration and deceleration of movements.58 Other proprioceptors, like

golgi ligament endings, are activated by tension or stress on ligaments that help monitor the

position of body segments.58 Different types of proprioceptors respond to different types of

movements in multiple planes, with some requiring greater velocity and speed for true activation.

Although the varying protocols for lateral patellar dislocations take into account higher levels of

activity in the sagittal plane, they disregard the importance of frontal and transverse plane

motions. For this reason, with this case report patient, interventions were altered to provide

movement in all 3 planes, as well as transitioning into and out of the 3 planes with a relatively

high velocity. It can be inferred that with motions in multiple planes, there may have been more

potential to increase the patient’s confidence with performing sport-specific movements that

require activation of a greater density of proprioceptors. These findings suggest that therapeutic

exercise, neuromuscular re-education, and therapeutic activities may be beneficial to incorporate

into a plan of care when attempting to increase AROM of a joint. Improvements in AROM of the

35
knee joint allows the patella to glide throughout its full range of motion, increasing congruence

between the patella and femur during flexion of the knee. This allows forces at this joint to be

dispersed through a larger surface area, resulting in decreased stress at the patella throughout the

knee and its osteokinematic movement.59

Improvements noted in pain and confidence are consistent with current research

regarding utilizing a knee brace. Cudejko et al60 observed large differences in pain and

confidence levels in patients with knee osteoarthritis (OA) when wearing a soft knee brace

versus not wearing a brace. Although this study included patients with knee OA compared to this

case report patient that suffered a patellar dislocation, it can be inferred that similar outcomes

may be observed due to the compression benefits of a knee brace. In this study, wearing a soft

knee brace significantly reduced pain levels during ambulation, reduced self-reported knee

instability during ambulation, and reduced lack of confidence in bilateral knees during

ambulation compared to not wearing a brace. Using the NPRS for pain and the BPII for QoL and

confidence, this case report patient had an increase of 18.1 points in the BPII with a pain level of

0 through the NPRS. The MCID for the BPII in patients with patellofemoral instability has been

found to be 6.2 points, with this patient scoring 18.1 points higher when comparing the two

sessions.37 This increase in confidence with decreased levels of pain allowed the patient to

perform sport-specific motions with less guarding from fear of further dislocation, possibly a

result of the Breg Bledsoe crossover knee brace the patient utilized during higher intensity

activity. When compared to the study conducted by Cudejko et al,60 this case report patient was

participating in a higher intensity activity, a potential limitation to comparing it to this

population. Although this limitation exists, one would infer that the results of this case report

patient further solidified the impact of a knee brace and its effects at improving confidence while

36
decreasing pain during a wider range of activity. With these findings, it suggests that

neuromuscular re-education, combined with therapeutic exercise designed to increase strength of

the lower extremity and the additional use of a knee brace, may help decrease levels of pain with

PJP of the patella after suffering a patellar dislocation, and may be beneficial for improving

confidence and QoL in patients with patellofemoral instability.

The patient’s motivation to return to participating in sport specific activity with less pain

was a factor that contributed to the patient’s progress in physical therapy throughout outpatient

services. Other positive factors that contributed to the patient’s success in therapy were his

family and teammates support, support from the intradisciplinary team, and previous experience

with this same pathology bilaterally. The patient had previously participated in physical therapy

interventions for the same condition, and he was able to provide subjective feedback regarding

his current level of function at each session, drawing comparisons to his previous experiences.

The patient had family members that transported him to physical therapy sessions, as well as

supportive family members and friends that wanted to see him finish out the remainder of his

basketball season. Piat et al61 stated how family members and friends are primary support

networks for an individual and the impact they play on someone’s mental and physical health.

The authors concluded that having positive support networks led to overall greater improvements

in mental and physical health compared to individuals that did not.

This case report subject is different from populations studied by previous research due to

multiple factors. The patient did not have a period of immobilization after suffering the lateral

patellar dislocation and did not purchase a knee brace until after recommendation from physical

therapy. According to the University of Connecticut Orthopedics and Sports Medicine18

department, an immobilization period of 7-10 days is recommended after suffering a patellar

37
dislocation to reduce swelling. The patient did not present with excessive swelling or pain with

palpation, but the patient did experience pain with lateral patellar joint play, which is why the

knee brace was recommended compared to strict immobilization. The patient still participated in

basketball practice and games during their 6-week physical therapy plan of care with the Breg

Bledsoe crossover knee brace, which had the potential to affect healing rates of the structures

that surround and attach to the patella. This subject also had a previous history of bilateral

patellar dislocation, combined with his family history of this condition, made this patient an

interesting case report subject. The previous history and hereditary component were possible

barriers to seeing improvements noted in physical therapy in regard to strength and confidence

improvements. A prospective study completed in 2006 stated that “previous injury was the

greatest risk factor for future injury secondary to changes along the kinematic chain, i.e.

proprioceptive deficits, reduced ROM, excessive flexibility, and scar tissue accumulation.”62(p1)

With this patient having four total lateral patellar dislocations in their life, two for each patella, it

had the potential to affect their confidence with performing sport specific activities that require

higher levels of activity/intensity. These factors, as well as ones stated previously, may have

been potential barriers to achieving further improved patient outcomes.

One limitation of this case report is that the parallel lines method was utilized to

objectively measure AROM. Currently, there are no research articles examining the reliability or

validity of AROM assessment utilizing this technique, making it difficult to compare to other

studies of this population. Another limitation of this case report is that there were no formal

objective measures used to measure the patient’s knee proprioception before and after the plan of

care was initiated. A third limitation to this case report is that the environment utilized during the

single limb hop and triple hop for distance tests was altered from initial examination to

38
discharge. During the initial examination, the patient had a smaller surface area to utilize due to

having other patients in the treatment area, while at discharge, the treatment area was empty.

Future research should look at patients that present with no effusion or pain upon

palpation after a lateral patellar dislocation. Many surgeons or physicians use different

rehabilitation protocols after a lateral patellar dislocation,7,8 with variability based on the

clinician’s clinical reasoning behind what protocol to put in place. Having an advanced protocol

put in place for patients that have less structural and functional damage to the joint may allow

clinicians to improve upon their ability to implement research supported interventions at an

advanced rate. Based on results shown with this case report subject, it is recommended to

implement sport-specific activities that require jumping and pivoting in multiple planes early on

in rehabilitation at a decreased intensity compared to implementing them further into their plan

of care. The effects of bracing the knee joint after a lateral patellar dislocation have been studied

in previous research, but this study did not conclude with what brace leads to the best outcomes

in terms of strength and confidence.11 Having a recommended brace with supporting research on

how it can decrease the likelihood of a subsequent injury may help improve patient confidence

with wearing it. Finally, future studies should look at an objective method to measure knee joint

proprioception while in the beginning stages of rehabilitation compared to the end of the plan of

care. The joint position reproduction (JPR) method involves the clinician passively moving a

joint into a position for the patient to understand the target. They then flex or extend the joint to a

different position and ask the patient to actively try and reach the target with their eyes closed.

The degree of difference is noted from the target position to the position the subject was able to

obtain, giving the clinician an objective measure of proprioception. Currently, there are no

research articles examining the effects of this JPR method at the knee joint after a patellar

39
dislocation. Proprioception of the knee is important for prevention of excessive knee valgus, a

position that increases the likelihood of obtaining a dislocation of the patella and should be

further studied in regard to return to sport criteria. It is important for each clinician to design a

plan of care that is specific to the individual and their impairments, taking into account what

level of activity the patient will be returning to, as well as what their prior level of activity was.

With protocols and guidelines that only utilize static and sagittal plane movements for improving

strength and confidence, it is difficult to provide research supported interventions that take all

planes of motion and velocity into account to further improve return to sport potential.

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