Dislocated Kneecap, torn medial Patellar Retinaculum Ligament, Cartilage, etc

[whisky]

Ok, Dr. Mark, what are the downsides or risks associated with a manipulation since that is seeming more likely. Would like your opinion before the procedure rather than after it...

Google "knee manipulation" and you will see many examples of others having this done. Granted, most of them have had total knee replacements but it will give you an idea.

Best of luck to you!

[drmark]

I have seen more than one femur fracture associated with aggressive and forceful manipulation.

Beware of butt heads with medical licenses.

For that reason, I do the releases first, and then can do the rest with only two fingers of force.

[Lacy Underalls]

Please, please, please listen to Dr Mark on this one and don't ever let anyone perform a manipulation without having had an arthroscopy first!! What Dr Mark says is so true - the scar tissue can be just as strong if not stronger than the bones it is attached to and the forces required to break up the scar tissue can indeed be bone breaking. Why take a chance at big time damage to your joint by having this barbaric procedure performed. Granted, there've been umpteen successful manipulations performed over the years and yes the downtime is less than a scope but the risks just so outweigh the possible benefits. It's just not worth it.

And I would seriously question the knowledge of any OS who suggests performing this procedure nowadays without an accompanying scope as it's been proven time and time again not to be worth the risk of further damage unless performed within a few weeks of the initial procedure. As I recall you're at least a couple months out from surgery. You may want to ask your OS what his success rate is for manipulations this far out. Something else to consider - wouldn't you rather have the scar tissue removed rather than just broken up but still in there?

Correct me if I'm wrong Dr Mark but aren't manipulations performed initially more often on TKR patients because of the increased danger of infection with surgery? My brother had a TKR a year ago and he is supposed to take antibiotics even before having dental work done because of the risk of infection.

[drmark]

The prevailing though on manipulations of the knee is that they may be done no later than three weeks after TKA (because after that the scar tissue may be stronger than the femur) and only two fingers should be used.

Also I can't remember any manipulation is this circumstance that worked anyway. So the downtime after such a misadventure (even if the guy doesn't break the femur or tibia) is infinity.

I don't think fear of infection comes into the mix.


I agree with you. This fellow needs to find a better educated doc.

[whisky]

April 28 will be the 8 week anniversary.

New PT guy asks about history of injury and current home exercise program. Explained to him that I was doing just as the current PT people wanted me to be doing. Straight leg raises, quad sets, heel slides, stretching until pain, and ice when swollen.

His body language tells me he's not impressed and informs me that I need to get the leg moving. Gives me a list and shows me how to do the following.

1. Lift leg to step and apply pressure just to the point of pain. Gradually moving a step higher. Idea is to train your leg to go up a stair again and also stretch the medial retinacular. This is a good warm-up exercise and have noticed it becoming easier.

2. Lying on stomach, lift up on toe and tighten thigh to strenghten quad. Yes I can feel it but I honestly don't believe I'm going to get much out of this. I just have a hard time believeing you can strenghthen you thigh to where it needs to be without bending it.

2a. Lift leg upwards using hamstring. Assist with other leg until point of pain. Remove other leg and slowly decline. Repeat. This is difficult for me and speaks volumes as to how weak my leg is. Also, lying on your stomach makes bending you knee much more difficult.

3. Using a rocker or glider rocker, rock back and forth to point of pain. This exercise just isn't doing it for me.

4. Ride bike. Of course I can't bend my leg nearly enough to ride so he has me standing on the side of my Schwinn Air Dyne. Supported by my good leg and holding onto a chair I push down with my bad leg on the side of the bike so that the bike pedals backwards. Knee raises up and bends at top of motion. Starts out stiff but after 5-6 minutes it loosens up nicely and feels good. You need to really pay attention to your hips so that you aren't cheating the circular motion your leg should be making. Proper form is key to any exercise. This has been by far the best exercise for me. Knee feels good and loose following.

5. Practice walking properly. Heel to toe forcing your knee to bend. Again, another exercise you must concentrate on not allowing your hips to cheat or your leg to swing out. Easier said than done when it pains you to do so. Also, the longer you're on your legs the stiffer they become making this almost impossible for me by days end. I try and keep trying in hopes that each day it becomes a little easier.

I'm contantly lifting my knee upwards and massaging in an attempt to stretch and loosen the retinacular. I just cannot believe it is this difficult.

Follow up with Ortho April 30. We shall see what he makes of my progress, or lack of.

[comish]

2 weeks and 1 visit into new PT#2 and 12 weeks post-op. We seem to be making some progress here. I was up to 68 or 69 degrees last night. Combination of ultrasound, lots more direct deep massage of area surrounding knee cap, and continued work on bending while massaging knee cap and surrounding area, biking (or attempted biking although I can now get it around on PT bike w/ short crankarms), seems to be loosening it up. I was around 35 to 37 degrees when I went into PT#2 and seem to making a few degrees every visit. Soo, veeeerrrry slowly maybe we are getting somewhere. Walking is really nice as well, although Mrs. Comish says I look drunk even when I haven't had a drink, although in the last couple days I'm getting much closer to a "normal" walk.

This dynasplint must be a really rare specimen because they still haven't conjured up one. Will go back to Ortho after next week's PT which will be 4 weeks with PT#2 to see what he thinks.

[whisky]

Comish- You and I are relatively close as far as injury and flexion. I have to tell ya, standing alongside a Schwinn Air Dyne and peddeling it backwards is doing me wonders. Each week it seems I get to stand a bit farther forward towards the bike and make a more circular motion with my leg. The next best exercise for me has been laying on my stomach and trying to bring my heel to my azz. Of course I can't do it but using my other leg to help raise it once stuck gives me a good stretch. I can already attest to the fact that working your hamstring is under-rated in the recovery process.

Braces/sleeves. I am anti brace when you have a strong and healthy body part. I'm of the opinion that they take away flexability and will flat out make you weeker. However, during a recovery period such as ours they can be very useful. Currently I am using just a plain black sleeve with a little extra support stitched into the knee part. It is made of two different types of materials and cost a whopping $15! (Walgreens brand) I can move about the house much better in it than without a brace. It actually helps me with flexion, compression, and the heat kept inside helps keep me feeling loose as well. Best thing about it is that I can wear it ALL DAY without ANY moisture build up. Something you might want to look into.

Ride that bike of yours BACKWARDS 4-5 times a day for 5-6 minutes each time. Goal is to make one revolution per second. Not an easy task, but attainable....

[SponsoredByDuctTape]

Good to hear you're making some progress. I seem to have hit a bit of a wall between 80 and 90 degrees. PT can flex my knee to 88 degrees, but that's pretty painful.

I think I'm having the same issue as you - quad and quad tendons above the patella are too tight. They've got me doing half pedal rotations on a recumbant where I pedal forward till my knee is bent on the up stroke, and then go backward till it's bent on the downstroke. This seems to be working pretty well as the stretch you get is controlled by how much downward pressure you use on the "good" pedal. Much better than the heel slides.

Edit: You going to be in Mammoth this weekend?

[comish]

Nope, going to Vegas. Would have gone to Mammoth, but booked this weekend months ago, long before the Mini date was chosen. Kinda bummed as I would have liked to have had a marg at the Mill...

Some good ideas here, thanks for sharing everyone on what is working. My knee cap seems to have come unstuck and now moves a bit where as before it was just totally stuck and had no movement or flotation when the leg is fully extended / relaxed. That gives me hope we are moving in the right direction.

now my IT band is tight as a mutha which is making it harder to wail on the knee cap... good times.

[whisky]

Think back to when we were healthy. In order to get a good stretch your muscles needed to be warmed up. It's impossible to get a good stretch without first loosening/warming up.

The first PT group had me focused on stetching. Nothing really about warming/loosening it up. This new guy has me focuse on 'movement'. While he's told me it would be best to be sitting on the bike, he would rather have me continue to stand on the side and focus on two things. Repetitions and the stetch. By peddeling backwards the stetch is felt on the way up. I've tried it both ways and backwards is the way to go. As you get better you can stand closer to the bike and focus on not cheating with your hips swinging back. I know stand with my azz against a support beam in the basement preventing me from cheating.

Two weeks ago I was at 68 degrees max. I'd ride the bike for 5 minutes and then stretch for 5 minutes. Back and forth...repeating as often as I could. First thing I did in the morning, last thing before bed. Nice to go to bed with a loose knee. I figured I got the knee to about 80 degrees.

PT on Wednesday. After warming up, doing some stretches, and more warming up I measured 83 degrees. Currently the PT guy is focused on the scar tissue on the medial side of my leg. MCL, retinacular...you name it. He is trying to desensitize the area. Vibrating tool for a five minutes, more stretching. What finally worked best was him grinding his knuckles into the side of my knee. I mean GRIND them. After doing this several times I was able to get to 93 degrees.

He reminded me that it's two steps forward and one back. Here at home on my own I've been able to get close to 90. Still a long way to go but it's progress.

You'll love this. Since I maxed out just above 90 degrees he gave me another exercise to work on as well. He wants me to get up on my bed...on all fours! Putting some pressure on the knee will hopefully rid me of that over sensitive feeling and also give me a good stretch.

Warm up those knees, and give yourself some aggressive deep tissue massage. Seems to have worked for me at this time.

[whisky]

Well for me I'm stuck at 95 degrees. Doesn't look like I'm going to be making anymore progress on my own. I see the OS June 3rd and am expecting him to tell me that a knee manipulation is needed. With that in mind, along with continuing to try and gain as much flexion as I can I'm going to be working on some light leg extensions in an attempt to strenghten my leg. I sure as hell can't make it any siffer.

Dr. Mark... My OS previously told me that he believes he can manipulate my knee under Anesthesia fairly easily. He said he'd go slow. I do know at this point he's against any type of surgery into a knee as banged up as mine. Said it would only set me back further. Any comments???

Comish...how you doing?

[drmark]

Ahhhhhh!

He is right your knee is damaged. The bones have become osteoporotic from disuse. One strong orthopaedic surgeon, and snap, your problem will first begin.

A knife, or arthroscopic blade, cause less trauma than a brutal manipulation, and any manipulation that is done with more than two fingers is dangerous-and I can't imagine that a two finger manipulation will be sucessful.

Find a new doctor as soon as possible, or wait it out longer.

I though that the 1950s were over, I guess they aren't.

[comish]

I'm at 74 degrees. Prolly gained about 4 degrees last week. Finally got this dynasplint last week. Sleeping in it all night. It seems to put gently pressure so I don't loose the range during sleeping. Seeing my Doc on Thursday. I'm still making progress, although painfully slow...

[comish]

Dr. Mark,
I know you are into the scientific study of various methods of treatment and looking at results from a numerical/statistical perspective. You have any studies you can link to or post that discuss knee manipulations and their results i.e. percentage of successful/unsuccessful manipulations, risks, studies that discuss the risk of breaking bones etc.

Thanks

[drmark]

Perhaps this helps. Also google Manipulation of the knee under anesthesia. I don't know how one can ethically do a prospective study on a devastating complication. Even prisoners would sign on for that, even to shorten their sentence.

I am sure that the patient I have inherited with the femur fracture after a knee manipulation will be delighted (he needs the practice before his malpractice depositon) to tell you has story. If you pm me your email, I will, after I get permission of course, put you two together.

Arthrofibrosis is a serious condition that can afflict knee joints that have either been recently injured, operated upon, or both. The process begins when the traumatic stimulus of an injury and/or surgery leads the knee to form extensive, internal scar tissue. This is followed by shrinkage and tightening of the knee's joint capsule (surrounding envelope ligament). Sometimes even nearby tendons outside of the joint stiffen up. This internal and external tightening process may continue to the point where motion between the femur (thigh bone) and tibia (shin bone) is severely restricted. Afflicted patients may permanently lose the ability to fully straighten and/or bend their knee.

In general, the likelihood of developing arthrofibrosis increases with the severity of a knee joint injury, the extensiveness of related surgery, and the length of time that the knee is subsequently immobilized. However, not everyone who sustains a major knee injury or who undergoes major surgery will develop arthrofibrosis. Some people are more prone to developing this problem than others. Genetic factors apparently predispose some patients to develop arthrofibrosis by way of an inherited tendency to form hypertrophic (excessive) internal joint scar tissue in response to injury and/or surgery. Such individuals often heal surgical ligament repairs and grafts quite solidly, but go on to heal "excessively", forming an overabundance of unwanted fibrous scar in their knee. This essentially makes their knee too stable, to the point of being stiff and lacking proper joint motion. Such "heavy scar-formers" can literally fill up their entire knee joint cavity with thick, tough scar tissue. This obliterates all of the normal open spaces within the joint, adhering everything together and effectively "freezing" the joint (hence the traditional term "frozen joint").

Patients with "sensitive" knees or low pain thresholds are also more likely to develop this problem, as they find it more difficult than most to use and move their knee after injury or surgery. Lack of joint motion and use leads the knee to form more abundant and less compliant scar tissue than it otherwise would, and allows the relatively unused (and thus unstretched) surrounding knee capsule to contract down and tighten up, almost like "shrink-wrap" does. A stiff, arthrofibrotic knee is a very difficult problem for the orthopedic surgeon and physical therapist to handle. It usually requires a specially planned, intensive protocol of surgical treatment and post-operative management.

The traditional treatment approach for arthrofibrotic knees that did not loosen up with aggressive stretching and exercise in physical therapy has been to place the patient under anesthesia and then literally break up and tear the restrictive, internal scar tissue within the joint by forcing the knee to fully bend and straighten. The surgeon accomplishes this by way of strenuous, manual joint manipulation. The procedure therefore came to be known as a manipulation under anesthesia, or "M.U.A.", and is still in common use. In cases of severely frozen knees, extremely stressful manipulation forces may be required to break up the scar tissue and get the joint moving again. This poses a risk to a patient who has not been able to bear much weight on their leg for quite some time, because the femur and tibia may have lost a considerable amount of bone mineral (calcium phosphate), thus weakening them. This increases the chance of an inadvertent femoral or tibial fracture occurring at the time of the joint manipulation. My preference over the years has been to perform an arthroscopic, internal surgical scar resection to remove as much restrictive scar tissue as possible, prior to manipulating the knee. This approach not only leaves very little scar within the joint to re-organize and solidify once again, but it also reduces the manipulation force required to get the knee moving, thus reducing (but not eliminating) the chance of femoral or tibial fracture.

[comish]

Just for accuracy, the last 4 paragraphs of Dr. Mark's post above is from an article written by Alexander Sapega M.D., http://www.kneeandshoulder.md/arthro_01.html

Not sure why I'm citing this but there it is...

Whisky, Lets definitely compare research notes when you get more info. I'm going back Thursday, but plan on speaking to a few different friends and friends of friends about this. Gotta say, homie don't want a busted femur...

[drmark]

I didn't say that I wrote it, although I complete agree with the writer.

[whisky]

Thanks for the replies.

Comish...I'll keep in touch. The OS hand picked my PT guy for me and I will be talking with him Tuesday hopefully.

Funny thing about my leg. After I pedal the bike backwards for five minutes or so I walk pretty darn good. The longer I stand though, the tighter it gets. I've been full weight bearing for quite some time now and on my leg quite a bit. Seems to stiffen up as I go, but at the same time it recovers quickly as well.

On a side note, this has been frustrating enough for me that on several occassions I've thought about wrapping my hands around my ankle and just YANKING the thing back!

[whisky]

Ahhhhhh!

He is right your knee is damaged. The bones have become osteoporotic from disuse. One strong orthopaedic surgeon, and snap, your problem will first begin.

A knife, or arthroscopic blade, cause less trauma than a brutal manipulation, and any manipulation that is done with more than two fingers is dangerous-and I can't imagine that a two finger manipulation will be sucessful.

Find a new doctor as soon as possible, or wait it out longer.

I though that the 1950s were over, I guess they aren't.

My Orthopedic surgeon is from the University of Wisconsin. He has, and continues to take care of many of it's athletes. He is one of two that I have consulted thus far. In my particular case, both have said to me that introducing an arthroscope to my knee would only cause the knee more trauma, inflamation, and have it want to lay down even more scar tissue, making it even more stiff post-op.

My PT guy was hand picked by this man. His specialty so to speak is knees. At this particular time he thinks I am a good candidate for a MUA. While laying on my back he said the only obstacle he feels when bending my knee is ME! He feels if I were asleep, it would continue to go back further, either all the way or till they felt a 'leathery band' of scar tissue. Depending upon what point that occurs determines how they proceed.

I wish I could allow them to bend it back further but the pain is just too intense. I've had a similar injury which required surgery on my left knee. I've had my left shoulder reconstructed and neither caused this type of stiffness.

My course of action at this point till June 3rd is to bear down and continue to try and make gains while strenghthening it along the way.

Any other comments or suggestions are appreciated by all.

[drmark]

Cant argue with that. Have it done and tell us how it works.

[comish]

So looks like I'm going in for surgery #2. Dr's plan is arthroscopic investigation, cutting of scar tissue, potential lateral release depending on whats going on. Goal is to get somewhere north of 120 degrees during the surgery and then go hard on PT afterwards.

I expressed my concerns on just doing a MUA after he presented his plan so I feel pretty good that his conclusion was what I was thinking going in if that makes any sense.

Hopefully this will get this thing moving...

Dr. Mark, would you mind commenting on what your post surgery regime would be in a situation like this (mpfl reconstruction 3.5 months ago, 74ish degrees ROM before arthroscopic surgery)? I want to make sure I'm doing everything possible to keep and increase my ROM after this surgery and I think this is where I potentially went wrong or was guided a little conservatively last time.

I did speak with your patient who sounds like he has had quite the ordeal (not at Dr. Mark's hand I will add). I think he said he was up to surgery #13 or something crazy like that. Woof. Thanks for connecting us, its definitely appreciated.

Don't know when its scheduled for, but they are aiming to get it done asap, potentially next week pending scheduling/insurance BS.

[drmark]

At surgery, I would be absolutely certain that your heel came to your a$$ before I finished. And, I wouldn't think twice about cutting the medial patellofemoral ligament or lengthening the quadriceps tendon, both harmless procedures. I would keep you in the hospital for several days on a morphine drip, allowing you to get to that positon at least once per hour. Morphine works better than the nerve blocks that are popular today.

After you go home from the hospital in three days, you will not have much trouble in maintining your flexion.

The problem as I see it is that your doctor made the MPFL too tight and it captured the knee. As far as I know, there is only one thing in the human conditon that (we guys, at least) never think is tight enough. AND THE KNEE ISN'T IT.

The damm thing is that most docs don't know that sewing up the knee is not the same as sewing up thier best buddy's wife afte a vaginal delivery. Most of the docs out there just don't get it.

I am interested in hearing how it comes out.

[SponsoredByDuctTape]

So looks like I'm going in for surgery #2. Dr's plan is arthroscopic investigation, cutting of scar tissue, potential lateral release depending on whats going on. Goal is to get somewhere north of 120 degrees during the surgery and then go hard on PT afterwards.

I expressed my concerns on just doing a MUA after he presented his plan so I feel pretty good that his conclusion was what I was thinking going in if that makes any sense.

Hopefully this will get this thing moving...

Dr. Mark, would you mind commenting on what your post surgery regime would be in a situation like this (mpfl reconstruction 3.5 months ago, 74ish degrees ROM before arthroscopic surgery)? I want to make sure I'm doing everything possible to keep and increase my ROM after this surgery and I think this is where I potentially went wrong or was guided a little conservatively last time.

I did speak with your patient who sounds like he has had quite the ordeal (not at Dr. Mark's hand I will add). I think he said he was up to surgery #13 or something crazy like that. Woof. Thanks for connecting us, its definitely appreciated.

Don't know when its scheduled for, but they are aiming to get it done asap, potentially next week pending scheduling/insurance BS.

Good luck with everything. If it all works out, you'll probably be on skis before me. Is this a new doc?

[comish]

Nope same doc. Thanks man. I'm still targeting early next year...

[whisky]

I'm beginning to see a pattern. I make a gain, and then for about two weeks I maintain that gain until I make another. Seems like it's been that way now for the past six weeks. Measuring the degree of flexion yourself is not the easiest of tasks, but to the best of my ability I believe I've made it to 105-110. It is most defineately farther than the 95 degrees I was two weeks ago.

After a fair amount of warming up and stretching I'm also now able to sit on the Airdyne and peddle it backwards. Something I could not do even 10 days ago.

Dr. Mark... Can a guy continue to make progress, albeit this slow, all the way to full flexion or is there a point and time when you say you just aren't going to do it without some other sort of intervention?

Trying to make it back to 150 degrees or so sure seems like a long way, but if it can be done, I'm willing to put in the time.