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Knee Subluxation
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Knee Subluxation
Patellar subluxation syndrome is also referred to as patellar instability. Patella subluxation and dislocation is a disorder that can hinder any and all movement in a person’s knee. This is injury that occurs on the knee cap. In this type of condition, the patella repetitively subluxate and thus puts strain on the patellofemoral joint. It feels like the knee cap keeps shifting from one location to another It can occur during forced straightening of the leg, with kneecap moving from the grove to the outer side of the knee. The cause is also kind of an abnormality according to how our legs were built. There can be under development in inner thigh muscles or overdevelopment in the outer thigh muscles.
Kneecap can occur in a higher place than the usual one may also be knocked-knee or also have underdevelopment of femoral condyle. It is quite key to understand the difference between acute primary patellar and habitual dislocation CITATION Wal08 l 1033 (Walsh, 2008). Acute primary patellar accounts for 2-3% of all cases. Primary or first-time patellar subluxation is the clinical condition that often causes physical disruptions to medial peripatellar structures that were not injure. A common finding between acute, primary and traumatic patellar is leading of the joints space often referred to as hemarthrosis of knee which results from the traumatic damage on medial restraints of patellar.
The patellofemoral joint is where the knee is joined by the femoral condyles and the patella join. Articulation of the patellofemoral function is dependent on the functions of the quadriceps. Its main role is to increase the surface angle that the patellar tendon pulls and thus improving the mechanical functions of the quadriceps in the knee area. The articular surfaces are made up of the patella and the trochlear surface of femoral condyles. The articular cartilage that is located in the medial facet is usually thick when compared to one on lateral facet. However, the articular cartilage on lateral facet is often bigger than one located in the medial facet (Frederick, 2008).
Femoral condyles always tend to project are located just in front of the shaft found in the femur but extends a huge posteriorly. Patellar articular surface is quite small on the medial femoral condyle and larger on the lateral femoral condyle. There is an interior groove which projects from lateral femoral condyle all the way to the patellar groove. This forms the bony surface in the skeletal tissue that we often even feel with our hands. Its role is to prevent lateral subluxation of the patella. In the knee region, we also have the trochlea on the distal end, anterior part of the femur. On the other hand, is the groove which is posteriorly located together with the intercondylar notch of femur. Lastly, there are the lateral faces have greater radius an is more prominent. The movement as well as suspension of the patella is often through active and the passive stabilizers. The passive stabilizers include: capsule of the knee, fascia lata and ligamentum patellae, ligamentum meniscopatia are lateral and medial, ligamentum patellofemoral lateral and medial. Active stabilizers in the other hand include retinaculum, ligamentum patellae, and four heads of the quadriceps.
People who play sports or athletics are associated with patellar dislocation often. It is also quite likely to occur to females in their 20s CITATION DrE05 l 1033 (Dr. Ellison, 2005). Women are more susceptible because of the lax ligaments and genu valgum. Patellar dislocation often come about as a result of a traumatic incident on your knee area including a direct blow to the knee. There are factors however that predisposes an individual into getting patella subluxation including a shallow femoral groove, if one has quadriceps muscles that are weak and if one’s lateral retinaculum or biceps femoris muscles are weak. A dominant predisposing factor will need less trauma for dislocation. The etiology is viewed as a multi-factorial as it is often associated with: imbalance between stronger tissues such as vast lateralis, they are able to overcome weak medial structure such as distal vastus medialis and medial patellofemoral ligament. and lateral reticannulum, reduced osseous constraint from the lateral femoral condyle. Also, etiology is associated with the biomechanical functions such a rotation of tibia and femur and planus and pes.
There are top for causes however that have been known to cause patellar subluxation: the first one is the bone structure, a patellofemoral grove that is rotated or abnormally shallow does not provide a resting location for the stability of the kneecap. Another cause is muscle weakness. Weak muscles especially ones surrounding both the knee and the hip will often control the position of the leg properly. This leads to instability of kneecap. Soft tee malfunction also results in patella subluxation. Tendons and ligaments found in the knee region ought to hold thee kneecap in place. If an individual is flexible such as an athlete or has previously had patellar tracking issues, then their tissue silkily to stretch. They lose the ability to hold the kneecap in place and it thus eventually dislocates. Soft tissue outside the nee is quite too tight, it thus can pull the kneecap from the patellofemoral groove. Finally, poor movement patterns increase likelihood of getting patella subluxation. These movements include jumping or running. They make the knee cap easily susceptible to subluxation CITATION Nel08 l 1033 (D., 2008).
Patella subluxation affects the skeletal system, nervous system, and muscular system. In order to understand how patella dislocation affects the skeletal system, the anatomy is quite important. Knee is considered largest joint in the body. There are ligaments and tendons in place that connect the femur to the skeletal bones on the lower part of the leg. The four main ligaments that are found in the bone act like ropes that hold bones together. The tendons are what connect the bones to the muscles. Quadriceps tendons are what connect the muscles in the thighs to the patella. There are quadriceps tendons that are referred to as patellar retinacula which connects to the tibia and are also important in stabilizing the patella. The patellar tendon is the tendon that gets to stretch from the patella to the tibia.
Patella subluxation almost affect skeletal and the muscular system in a similar way because the bones surrounding the knee are connected to the various muscles including quadriceps muscles. In the skeletal system, the knee is quite important in offering of support to the body. Patella serves two main roles in the body the first is protecting the knee from injuries and secondly it enhances leverage where quadriceps tendons are able to exert on the femur thus improving efficiency. When the patella, which is a skeletal bone gets dislocated the tendons and ligaments that attach from the bone to the muscles are also affected thus causing difficulty in movement. Doing tasks such as kneeling which utilizes muscles become quite impossible.
For the nervous system, palatal subluxation causes effect in terms of the pain it causes. There is a term that has been coined for this pain and it is the Patellofemoral pain syndrome that tend to occur on the anterior part of the knee. The pain may because after the dislocation, the ligaments tear. If one is not able to seek medical attention immediately it may result in the loss of their leg. The role of the nervous system is to transmit impulses including pain from the affected part of the brain to the central nervous system. When one is injured including pain from the knee dislocation, pain gets to stimulate the sympathetic nervous system which in turns leads to an increase in the heart rate resulting in peripheral vasoconstriction happening. The pain is usually intense after the dislocation has occurred but can still persist during the recovery period and thus doctors need to give advice to the patients on the best way they could deal with the pain.
A radiography is often quite important in order to eliminate avulsion and osteochondral fractures. Patellar apprehension test is also usually used whereby the patella ought to provide resistance. Fulkerson and Lysholm scales can differentiate patients with and without recurrent subluxations. MRI test would only be necessary to establish if tendons were torn and in cases of a complete tear, X-Ray is used due to luxation of patella CITATION Non05 l 1033 (JC, 2005). Through X-Ray, MRI and topography, Patella subluxation can be identified by measurement of trochlea groove-tuberosities tibiae distance.
Patella Subluxation is accompanied by various signs and symptoms. Depending on how severe the subluxation is symptoms will vary. Improper tracking of kneecap may not cause any symptoms however, in serious cases, it leads to complete dislocation of the knee cap. Patellar subluxation will always feel like the knee cap is shifting or jamming from its normal location. It causes discomfort when taking part in any activity, there is pain both at the sides of the kneecap and the front. The pain is commonly referred to as patellofemoral pain syndrome. This kind of pain may be the most indicating factor that an individual is suffering from subluxation of the knee. Besides sliding of the kneecap other common symptoms include CITATION Cou17 l 1033 (Cade, 2017)Stiffness that may be felt on the entire leg
Squeaking especially on the patellar area
Pain on the knee which intensifies when in an activity that is as simple as walking. Pain may even be felt when siting down CITATION Cro16 l 1033 (Crossley Kay, 2016)Knees tend to buckle up and they can no longer hold your weigh. This makes it hard to stand or even walk
Cracking sounds or creaking that are felt on the knee. you may hear them while standing up or walking.
When one is diagnosed with patella subluxation the next is to treat it which is the management. Management can be operative or non-operative depending on the severity of the subluxation CITATION Hin111 l 1033 (Hing CB, 2011). In acute lateral patellar dislocation Non-operative management encompasses a multimodal approach which includes use of braces that offer support to knee, pain medication, behavioral education to the patient especially on the do’s and don’ts while on recovery and weight reduction.
Physical therapy revolves around strengthening of the already weakened muscles as well as proprioceptive exercises. In physiotherapy there may be conservative treatment such as the manual therapy. This includes knee and knee mobilization j in order to improve RO of the knee. It may also incorporate combination therapy. This form of therapy focusses on strengthening exercises for hamstrings, quadriceps, muscles of both lower abdomen and hip, adductors and other muscles of the leg [9]. Nit is quite important to use closed kinetic chains as they have great number of advantages when compared to other forms of exercises. Stretching and flexibility aid in the training of hamstrings and quadriceps.
Distal Vastus Medals is another form of muscle strengthening that has been proved to significantly improve functionality of muscles. This form of therapy however has been proved to show little improvement in quadriceps muscle especially to individuals with first-time patellar dislocation. Another important form of management is bracing and reduction. Bracing involves use knee braces that provide knee support, they are often referred to as patellar stabilizers or patellar tracking brace. These braces help in proper movement of the knee and also prevents subluxation. Re-education provides important information to individual and thus a great way of ensuring prevention of patellar subluxation. Behavioral modification and reassurance is applied in order to prepare one of the exercises while in therapy as well as prevent re-dislocation of the patella again.
There are instances where surgery may be necessary in order for a patient to recover. These forms of surgery often involve reconstructing as well as repairing of the lateral stabilizers. In cases where the tendon and ligaments that hold the kneecap in place are torn, reconstructive surgery comes in quite handy. Open lateral repair is a surgical procedure that was first suggested as a possible medical solution by Hughston and Brinker. When there is good amount of tissue, side-to-side anastomosis technique is used in the re-appropriation of the tissue. When vastus laterais is retracted or released it ought to be repaired and mobilized. It is important to understand that there should be presence of good tissue in order for this type of surgery to be successful
At times, tissue quality is not sufficient and thus open lateral repair is not an option, in such cases Open Lateral reconstruction is often considered. Techniques such as utilization of Iliotibial band, patellar tendon or the tensor fascia can be used in the reconstruction. In this techniques the surgeon makes a dissection of about 3-4 cm in length on the affected knee. Lateral aspect of Gerdy’s tubercle is conferred to the distal aspect of IT band, the strip is then utilized in closing of the lateral deficit through joining of lateral patella. Iliotibial band can be attached to the soft tissue or another option may be lacing it through the patellar tunnel. Patellar tendon is often utilized in the reconstruction of the lateral restraints by attaching the patella tendons distally from tibia tubercle and then left without interruption proximally and may include a bone attachment. Patellar tendon can also be reconstructed to the tibia by using suture anchors, or utilizing bone tunnels.
Arthroscopic medal release is another medical procedure that has proved to be useful in treatment of the subluxation of the patella. The first step encompasses diagnostic arthroscopy and then medial release by use of an acrioplasty electrode. Medial retinaculum was divided into two phases, first one involves the pole of patella located superiorly and would transverse distally all the way to anteromedial portal. After the procedure, the patella needs to be shifted laterally at an angle of 50 to 70 degrees of its lateral edge, ensuring any reticular tissue that remains is divided. A final reconstruction is then done over the medial undersurface of the knee as a way of confirming if there is a complete release. Fulkerson procedure is another surgical procedure that involves osteotomy as well as anteremodialization of tibial tubercle with aim of elevating distal pole of patella. This in turn reduces contact of patella with knee during flexion. Its aim is to reduce anterior knee pain as well as reduce degenerative process
Patellar dislocation is quite common in athletes. They can result in direct trauma or low energy twisting mechanisms. They are likely to occur in second decade of life. When ne is brought in doctor’s conduct examinations physically and with the use of radiographs to determine best method to treat patella dislocation It is important to prevent oneself from getting subluxation through use of braces when exercising. Patellar dislocation are awful injuries that result in a lot of discomfort and will disrupts individual’s daily activities. Reoccurrence of patellar dislocation is high once it occurs. An athlete may be unable to go back to sporting once a patella dislocation occurs. Through management however, ne may improve and the chronic pain usually felt is completely reduced.
References
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Callaghan MJ, S. J. (2012). “Patellar taping for patellofemoral pain syndrome in adults”. Cochrane Database, 18(4).
Crossley Kay, M. C. (2016). Patellofemoral Pain. BR J Sports Med Journal, 5, 247-250.
Dr. Ellison, A. E. (2005). Athletic Training and Sports Medicine. New York: American Academy of Orthopedic Surgeons.
Frederick Michels, N. P. (2008). Locked patellar dislocation: a case report. Journal of Medical Case Reports, 5, 752-947.
Hing CB, S. T. (2011). Surgical versus non-surgical interventions for treating patellar dislocation. Cochrane Database, 11(9).
Hing CB, S. T. (2011). Surgical versus non-surgical interventions for treating patellar dislocation”.
JC, N. D. (2005). The diagnosis and treatment of medial subluxation of the patella after lateral retinacular release. AM Sports Med Journal, IV (22), 680-686.
Nelitz M, D. D. (2011). The relationship of the distal femoral physics and the medial patellofemoral ligament. Knee Surg Sports Traumatol Arthrosc, 19, 2067-71.
Walsh, J. H. (2008). Patellar Subluxation and Dislocation. Sanders Publisher.
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