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  • Guideline Summary
  • NGC:010314
  • 2014 Mar 18

Evidence-based care guideline for conservative management of lateral patellar dislocations and instability in children and young adults aged 8-25 years.

Cincinnati Children's Hospital Medical Center. Evidence-based care guideline for conservative management of lateral patellar dislocations and instability in children and young adults aged 8-25 years. Cincinnati (OH): Cincinnati Children's Hospital Medical Center; 2014 Mar 18. 30 p. [100 references]

View the original guideline documentation External Web Site Policy

This is the current release of the guideline.

Age Group

UMLS Concepts (what is this?)

SNOMEDCT_US
Activity of daily living (129025006), Ambulation therapy (229595009), Ambulation therapy (370871008), Analgesic (373265006), Analgesic (53009005), Balance exercises (386293009), Closed kinetic chain exercises (229076008), Cold therapy (182660006), Cold therapy (257786008), Cold therapy (26782000), Conservative therapy (281131004), Dislocation of patellofemoral joint (263029007), Edema (20741006), Edema (267038008), Edema (79654002), Education of family (460616007), Examination of knee joint (284401004), Exercise (183301007), Exercise (256235009), Exercise (61686008), Gait training on stairs (229608007), Gait training procedure (74914000), Isometric exercise (64838004), Isotonic exercise (16709005), Knee joint hypermobility (298197005), Lateral dislocation (125174000), Manual therapy (229315006), Open kinetic chain exercises (229077004), Pain assessment (225399009), Pain management (278414003), Patellar instability (429696002), Patient discharge (58000006), Patient education (311401005), Physical therapy procedure (91251008), Range of joint movement (364564000), Rehabilitation therapy (52052004), Self-care interventions (384758001), Subluxation of knee joint (263058005), Therapeutic application of vasopneumatic device (85825007), Therapeutic electrical stimulation (169430000), Therapeutic electrical stimulation (57942008), Transcutaneous electrical nerve stimulation (229559001), Transcutaneous electrical nerve stimulation (432061000124105)

Major Recommendations

The strength of the recommendation (strongly recommended, recommended, or no recommendation) and the quality of the evidence (1a‒5b) are defined at the end of the "Major Recommendations" field.

General Recommendations

  1. It is recommended that patients begin physical therapy upon diagnosis of primary patellar dislocation (PPD) or recurrent patellar instability (RPI) in order to minimize secondary impairments such as persistent gait abnormalities, range of motion (ROM) deficits, and muscle atrophy that can result from poor gait patterns, immobility and disuse (Local Consensus, 2013 [5]).
  2. It is recommended that throughout the diagnosis and rehabilitation process, physical therapists are in open communication with the referring physician and any other team members involved in order to promote the best, most efficient and optimally effective quality of care (Local Consensus, 2013 [5]; "American Physical Therapy Association," 2003 [5a]).
  3. It is recommended that the patient and family members receive thorough education regarding the nature of injury, the plan of care, and the risks for future injury (Local Consensus, 2013 [5]; "American Physical Therapy Association," 2003 [5a]).

    Note: When educating the patient and family, it may be necessary to provide additional education about any factors specific to the patient that could potentially affect the patient's rehabilitation process and long-term prognosis. For example, if the patient has any anatomical abnormalities (e.g., patella alta), the clinician may want to inform the patient and family about the increased likelihood for re-occurrence of the injury relative to someone with PPD or RPI who does not have any anatomical variations (Local Consensus, 2013 [5]).

  4. It is recommended that the referring physician is notified if any of the following red flags/precautions are present during the initial evaluation or at any other time during the rehabilitation process:
    • Signs of deep vein thrombosis (Local Consensus, 2013 [5])
    • Unchanging or increased irritability in the knee (Local Consensus, 2013 [5])
    • Persistent or recurrent effusion (Stefancin & Parker, 2007 [1b]; Local Consensus, 2013 [5])
    • Unexpected loss or minimal progression of ROM (Local Consensus, 2013 [5])
    • Catching, locking, or persistent pathological end feel with passive ROM (Stefancin & Parker, 2007 [1b]; Local Consensus, 2013 [5])

    Note: It is estimated that approximately 20% to 40% of the PPD patient population suffer concomitant symptomatic osteochondral injuries (Nietosvaara, Aalto, & Kallio, 1994 [3b]) and up to 95% of patients with RPI possess chondral lesions (Slabaugh et al., 2010 [5a]). Therefore, if at any point during the rehabilitation, a patient experiences catching, locking or a persistent pathological end feel with passive ROM, the physical therapist may need to consider the possibility that an underlying chondral lesion or loose body could be present (Local Consensus, 2013 [5]).

Initial Examination

  1. It is recommended that a thorough chart review is performed that includes review of general medical history and imaging studies (e.g., radiograph, computed tomography [CT] scan, magnetic resonance [MR] images) with an emphasis on identifying conditions or potential complications such as:
    • Trochlear dysplasia
    • Patellar dysplasia
    • Osteochondral defects
    • Soft tissue disruptions or abnormalities (e.g., medial patellofemoral ligament [MPFL] tear)
    • Bone bruises

    Note: See Appendix 1 in the original guideline document for descriptions for additional measures for radiographic images (Local Consensus, 2013 [5]; "American Physical Therapy Association," 2003 [5a]).

  2. It is recommended that pain is assessed and localized using an appropriate scale (Local Consensus, 2013 [5]).

    Note: The Oucher/Faces Pain Scale can be used with children 4 to 16 years of age (Beyer et al., 2005 [4a]) or the Numerical Rating Scale (NRS) can be used with children age 6 years and older and adults (von Baeyer et al., 2009 [4b]; Williamson & Hoggart, 2005 [5a]).

  3. It is recommended that a thorough history including the following information is obtained from the patient and/or family:
    • Age
    • Sex
    • Previous activity level
    • Prior history of other musculoskeletal injuries and health conditions
    • Patient and family history of patellar dislocation and hypermobility
    • Description of mechanism of injury
    • Description of prior/current treatment
    • Complaints of "giving way"/feeling of instability
    • Brace use
    • Medications
    • Weight-bearing status
    • Restrictions/precautions
    • Patient/family goals
    • Date of next follow up visit with referring physician

    (Stefancin & Parker, 2007 [1b]; Local Consensus, 2013 [5]; "American Physical Therapy Association," 2003 [5a]; Wilk et al., 1998 [5a]; Andrish, 2008 [5b])

  4. It is recommended that a comprehensive objective physical therapy examination be completed, including the components named in Table 2 in the original guideline document (Local Consensus, 2013 [5]; "American Physical Therapy Association," 2003 [5a]).
  5. It is recommended that a comprehensive knee screen is performed to evaluate for additional conditions or complications of other important bony and soft tissue structures such as:
    • Anterior cruciate ligament
    • Posterior cruciate ligament
    • Medial collateral ligament
    • Lateral collateral ligament
    • Menisci

    (Local Consensus, 2013 [5])

  6. It is recommended that joint hypermobility be assessed to determine potential ligamentous laxity as an associated risk factor (Local Consensus, 2013 [5]).

    Note: The Beighton Scale is commonly used and cited to quantify hypermobility (Smith et al., 2008 [1b]; Smits-Engelsman, Klerks, & Kirby, 2011 [3b]; Cameron et al., 2010 [3b]; van der Giessen et al., 2001 [4b]) (see Appendix 2 in the original guideline document).

  7. It is recommended that knee-specific scales in conjunction with general health instruments are used for a more thorough understanding of the patient's assessment of his or her own knee function and general function after RPI/PPD, which may include:
    • Knee specific instruments:
      • International Knee Documentation Committee (IKDC)/Pedi-IKDC
      • Kujala Patellofemoral Disorder Score
      • Lysholm
      • Tegner Activity Score
      • Fulkerson
    • General health instruments:
      • Short Form 36
      • Musculoskeletal Function Assessment
      • PedsQL

    (Smith et al., 2010 [1b]; Smith et al., 2008 [1b]; Paxton et al., 2003 [2a]; Briggs et al., 2009 [3b]; Local Consensus, 2013 [5]; Lysholm & Tegner, 2007 [5a])

    Note: There is conflicting evidence regarding whether specific outcome measures directly pertaining to patellar instability are clinically meaningful (Smith, Davies, & Donell, 2010 [1b]). Nonetheless, studies indicate that the IKDC, Kujala, Fulkerson, Lysholm, and Tegner scales have all been demonstrated to have acceptable test–retest reliability, with a coefficient ranging from 0.82 to 0.92. With respect to validity, the Fulkerson, Kujala, Lysholm and IKDC were all able to differentiate statistically between a first time dislocation group and that with a history of subluxation/dislocation (p<0.01). The Kujala and IKDC instruments had the highest internal consistencies of the knee-specific instruments (Cronbach alpha, >0.80). The test-retest coefficients of all knee-specific scales exceeded 0.80; yielding high reliability (Paxton et al., 2003 [2a]).

Patient and Family Centered Care

  1. It is recommended that self-management education and skill building include tailored health education based on individual patient/family needs, risks, and readiness to change.

    Note: Self-management is the ability of the client and family to collaborate on and adhere to individualized therapy treatment recommendations and appropriately handle signs/symptoms/difficulties associated with the therapy and diagnosis to maximize quality of life and participation in life roles (Local Consensus, 2013 [5]; Lorig & Holman, 2003 [5b]).

  2. It is recommended that the patient and family's ability to participate in the management of their condition is assessed with regard to:
    • Attitudes and beliefs, including confidence and importance (Williams et al., 2007 [3a])
    • Readiness to change (Local Consensus, 2013 [5])
  3. It is recommended that in order to develop an individualized and collaborative plan of care, the following things patient and family are considered:
    • Understanding of the condition
    • Self-efficacy, beliefs and stage of readiness to address the condition
    • Degree of goal alignment with the health care team's goals
    • Dynamics and access to resources to adhere to health care professionals' recommendations regarding the condition
    • Potential barriers to being able to optimally attend physical therapy sessions and perform a home exercise program (HEP)

    (Local Consensus, 2013 [5]; Ryan & Sawin, 2009 [5a]; Holman & Lorig, 2004 [5b])

Physical Therapy Assessment and Diagnosis

  1. It is recommended that clinicians synthesize subjective, objective and self-management information from the physical therapy examination to establish a physical therapy diagnosis and individualize a plan of care ("American Physical Therapy Association," 2003 [5a]).

Re-Assessment

  1. It is recommended that quantitative and qualitative measures be re-assessed approximately every two weeks and/or at any point the patient experiences a significant change in status (Local Consensus, 2013 [5]).

Management Recommendations

  1. It is recommended that physical therapy dosage be determined based upon the patients' needs, preferences and specific impairments and supplemented with a HEP (Friedrich, Cermak, & Maderbacher, 1996 [2b]; Local Consensus, 2013 [5]; Bailes, Reder, & Burch, 2008 [5a]).

    Note: Patients who participate in supervised clinical visits demonstrate greater gains in muscle strength, functional mobility, gait speed, and quality of exercise performance than those who receive a HEP alone or no instruction at all (Friedrich, Cermak, & Maderbacher, 1996 [2b]).

  2. It is recommended that a functional-based goal progression model of advancement through the phases of rehabilitation be followed rather than a time-based progression model (Local Consensus, 2013 [5]).

    Note 1: All recommended milestones/goals may not be appropriate for every individual; appropriate rehabilitation progression relies on sound clinical judgment, a good understanding of the patient's pre-injury level of function and personal activity goals (Local Consensus, 2013 [5]).

    Note 2: Appendix 3a-d in the original guideline document provides a general overview of exercise and rehabilitation intervention suggestions that may be appropriate for each phase (Local Consensus, 2013 [5]).

Phases of Rehabilitation

General Interventions for All Phases

  1. It is recommended that the following are performed for pain relief assistance as appropriate and necessary:
    • Cryotherapy (Rice, McNair, & Dalbeth, 2009 [2a]; Hopkins, 2006 [2a]; Singh et al., 2001 [2a]; Bolgla & Keskula, 2000 [5b])
    • Electrical stimulation and/or transcutaneous electrical nerve stimulation (TENS) per clinician discretion (Local Consensus, 2013 [5]; Palmieri-Smith, Thomas, & Wojtys, 2008 [5a])
    • Medications: Patients may be further encouraged to follow physician recommendations regarding taking pain-relieving medications (Local Consensus, 2013 [5])

Effusion

  1. It is recommended that the following are used as available and appropriate for edema management:
    • Cryotherapy (Rice, McNair, & Dalbeth, 2009 [2a]; Hopkins, 2006 [2a]; Singh et al., 2001 [2a]; Bolgla & Keskula, 2000 [5b])
    • Vasopneumatic device (Holwerda et al., 2013 [3b])
    • Elastic compression wrap before and after therapy sessions (Janwantanakul, 2006 [4b]; Local Consensus, 2013 [5])

Initial Phase

This phase is designed to help patients prepare to engage in activities that will restore their ability to perform basic tasks associated with normalizing ROM and gait. Table 3 in the original guideline document highlights the specific goals and expected outcomes for the Initial Phase. Appendix 3a in the original guideline document provides a list of example exercises that may be appropriate for the Initial Phase. Some patients may skip this phase all together if, upon presentation, the goals/criteria for progression to the next phase have already been met (Local Consensus, 2013 [5]).

Initial Phase—ROM/Flexibility

  1. It is recommended that passive static stretches for lower extremity musculature are utilized to assist with gains in ROM and flexibility (Moseley et al., 2005 [2a]; Bandy, Irion, & Briggler, 1998 [2a]; Davis et al., 2005 [2b]; Local Consensus, 2013 [5]).

    Note 1: Gradual progression of ROM will help minimize the negative side effects of pain elevation, muscle guarding, and joint inflammation (Local Consensus, 2013 [5]).

    Note 2: For patients with PPD, ROM may take longer to normalize secondary to the traumatic mechanism of injury (Local Consensus, 2013 [5]).

    Note 3: Dynamic ROM and active assistive ROM (AAROM) may be helpful if the patient is muscle guarding due to pain and unable to achieve end range motion with static stretch (Bandy, Irion, & Briggler, 1998 [2a]; Local Consensus, 2013 [5]).

  2. It is recommended that AROM and AAROM are performed following stretching to maintain new gains in motion (Depino, Webright, & Arnold, 2000 [2b]).

Initial Phase—Muscle Strength and Control

  1. It is recommended that strengthening exercises for this phase begin with isometric and isotonic exercises targeting hip and knee musculature in gravity-mitigated positions with progression to isotonic exercises against gravity as tolerated by patient (Local Consensus, 2013 [5]).

    Note 1: Isometric holds in varying degrees of hip flexion, hip abduction, and hip extension with the knee in full extension may help target key muscles while minimizing patellofemoral forces to limit pain (Local Consensus, 2013 [5]).

    Note 2: The addition of resistance to exercises and integration of eccentric-specific exercises may be appropriate for certain muscle groups and/or positions based on clinical judgment (Local Consensus, 2013 [5]).

    Note 3: Clinicians may want to avoid isokinetic exercises during this phase of treatment to minimize pain and risk for further injury (Local Consensus, 2013 [5]).

  2. It is recommended that exercises are initiated with 2 sets of 10 to 15 repetitions of exercises as appropriate, with progression to 3 sets of each exercise as tolerated (Rhea, Alvar, & Burkett, 2002 [2b]; Faigenbaum et al., 1996 [4b]; Local Consensus, 2013 [5]).

    Note: If the patient is unable to perform 2 sets of 10 repetitions of an exercise, the intensity of the exercise may be modified per clinical judgment (Local Consensus, 2013 [5]).

  3. It is recommended that visual, tactile and verbal feedback cues be provided as needed to ensure optimal performance for all exercises in every rehabilitation phase (Nikku et al., 2009 [4b]).

    Note: Individuals who receive regular positive feedback from a physical therapist are more likely to be adherent with a supplemental HEP (Sluijs, Kok, & van der Zee, 1993 [4b]).

  4. It is recommended that neuromuscular electrical stimulation (NMES) be used in conjunction with exercise to facilitate quadriceps activation and strength (Fithian et al., 2004 [2a]; Snyder-Mackler et al., 1995 [2a]; Local Consensus, 2013 [5]).
  5. It is recommended that additional isometric and isotonic strengthening exercises are implemented to target bilateral core and hip musculature (Powers, 2010 [5a]; Reinold et al., 2006 [5a]).

Initial Phase—Balance

  1. It is recommended that balance exercises begin with an emphasis on symmetrical weight bearing in double limb stance with minimal to no assist and progressed to good control with weight-shifting in Anterior-Posterior and Medial-Lateral directions (Local Consensus, 2013 [5]).

    Note: Weight shifting in the anterior-posterior and medial-lateral directions may help to prepare the patient to progress away from dependence on an assistive device and help the patient progress to single leg balance in the next rehabilitation phase (Local Consensus, 2013 [5]).

Initial Phase — Gait

  1. It is recommended that patient-specific ambulation exercises are implemented to improve the patient's ability to:
    • Weight bear as tolerated and appropriate per physician recommendation
    • Demonstrate adequate ROM in hip, knee and ankle at each phase of the gait cycle
    • Maintain good quadriceps control, particularly during stance phase
    • Decrease dependence on assistive device while maintaining good gait mechanics

    (Local Consensus, 2013 [5])

Initial Phase — Functional Tasks

  1. It recommended that the patient is provided training and education in bed mobility, transfers and safe stair navigation with progression toward minimal use of assistive device as appropriate (Local Consensus, 2013 [5]).

Restoring Basic Function Phase

The purpose of this phase is to ensure the patient is able to perform all basic functional tasks associated with typical activities of daily living (e.g., walking longer distances, stooping, and stair navigation) (Local Consensus, 2013 [5]). The specific goals and expected outcomes for the Restoring Basic Function Phase are listed in Table 4 in the original guideline document. Appendix 3b in the original guideline document provides a list of example exercises that may be appropriate for the Restoring Basic Function Phase.

Restoring Basic Function Phase—ROM/Flexibility

  1. It is recommended that passive static stretches for lower extremity musculature continue to be utilized to assist with gains in ROM and flexibility (Moseley et al., 2005 [2a]; Bandy, Irion, & Briggler, 1998 [2a]; Davis et al., 2005 [2b]; Local Consensus, 2013 [5]).

    Note: Dynamic ROM (Bandy, Irion, & Briggler, 1998 [2a]) may continue to be appropriate if the patient is muscle guarding due to pain and unable to achieve end range motion with static stretch (Local Consensus, 2013 [5]).

  2. It is recommended that AROM and AAROM continue to be performed following stretching to maintain new gains in motion (Depino, Webright, & Arnold, 2000 [2b]).

Restoring Basic Function Phase — Muscle Strength and Control

  1. It is recommended that strengthening exercises include resisted isometric and isotonic strengthening exercises (concentric and eccentric) specifically targeting the hip, knee and ankle musculature of the involved limb (Bolgla & Uhl, 2005 [4b]; Local Consensus, 2013 [5]; Powers, 2010 [5a]; Reinold et al., 2006 [5a]).

    Note 1: Isokinetic exercises may be appropriate to integrate in the later stages of this phase (Local Consensus, 2013 [5]).

    Note 2: It may be necessary to begin these exercises with lighter resistance (partial to body weight only) with progression to increased resistance per clinical judgment (Bolgla & Uhl, 2005 [4b]; Local Consensus, 2013 [5]).

  2. It is recommended that NMES continue to be used as needed in conjunction with exercise to facilitate quadriceps activation and strength (Fithian et al., 2004 [2a]; Snyder-Mackler et al., 1995 [2a]; Local Consensus, 2013 [5]).
  3. It is recommended that open kinetic chain exercises (OKCE) are incorporated into the strength training exercises for the involved limb (Escamilla et al., 1998 [4b]; Local Consensus, 2013 [5]).

    Note: For patients with patellofemoral pain and/or concomitant chondral lesions, it may be necessary to limit knee flexion ROM per clinical judgment to minimize pain or discomfort (Souza et al., 2010 [4b]; Local Consensus, 2013 [5]).

  4. It is recommended that isotonic OKCE for knee flexion/extension are initially performed from 90 to 40 degrees for the involved limb to allow for enhanced osseous stability with progressions working toward exercises throughout the entire ROM (Escamilla et al., 1998 [4b]; Local Consensus, 2013 [5]).
  5. It is recommended that isotonic closed kinetic chain Exercises (CKCE) are initiated using a double limb stance with a focus on neuromuscular control of the pelvis, femur, tibia, and patella during knee flexion ROM to encourage optimal alignment of all joints during movements (Local Consensus, 2013 [5]).

    Note 1: The initiation of single limb CKCE can begin per clinician discretion, with emphasis on patient's ability to demonstrate sufficient neuromuscular control to maintain good alignment of lower extremity throughout the activity (Local Consensus, 2013 [5]).

    Note 2: The following exercises can effectively target the quadriceps muscle group during the Restoring Basic Function Phase:

    • Forward step-ups
    • Lateral step-ups
    • Retro/reverse step-ups
    • Wall squats

    (Lubahn et al., 2011 [4a]; Ayotte et al., 2007 [4a]; Boren et al., 2011 [4b]; Mercer et al., 2009 [4b])

    Note 3: Exercises that can effectively target the gluteus medius during this phase of rehabilitation:

    • Double leg squat
    • Wall squat, forward step-u
    • Lateral step-up, side stepping
    • Side plank

    (Ayotte et al., 2007 [4a]; Boren et al., 2011 [4b]; Distefano et al., 2009 [4b]; Mercer et al., 2009 [4b]; Ekstrom, Donatelli, & Carp, 2007 [4b]; Local Consensus, 2013 [5])

    Note 4: Exercises that can be utilized to target the gluteus maximus:

    • Double leg squat
    • Forward step-up
    • Lateral step-up
    • Retro/reverse step-up
    • Quadruped alternating upper extremity/lower extremity extension
    • Forward lunges
    • Wall squat

    (Lubahn et al., 2011 [4a]; Ayotte et al., 2007 [4a]; Boren et al., 2011 [4b]; Mercer et al., 2009 [4b]; Ekstrom, Donatelli, & Carp, 2007 [4b])

  6. It is recommended that a continued emphasis is placed on targeting hip, knee and ankle musculature of the uninvolved limb and any other muscle groups (e.g., core and trunk musculature) where significant strength deficits remain present (Bolgla & Uhl, 2005 [4b]; Powers, 2010 [5a]; Reinold et al., 2006 [5a]).

    Note: Specific exercises that can effectively target core abdominal musculature include the following:

    • Swiss ball roll-outs
    • Swiss ball skier
    • Swiss ball knee-up

    (Escamilla et al., 1998 [4b])

Restoring Basic Function Phase—Balance

  1. It is recommended that balance exercises for this phase include double limb stance challenges on dynamic surfaces and other external perturbations with an emphasis on transitioning to the ability to safely balance independently on a single leg.

    Note: Patients at this stage may also be ready to begin more challenging single leg balance challenges that include unstable surfaces and external perturbations (Local Consensus, 2013 [5]).

Restoring Basic Function Phase—Gait

  1. It is recommended that the remaining deficits in the gait cycle (e.g., quadriceps avoidance) continue to be emphasized to progress the patient off any assistive devices and normalize gait patterns on even and uneven surfaces (Local Consensus, 2013 [5]).

Restoring Basic Function Phase—Functional Tasks

  1. It is recommended that for activities of daily living advanced training exercises such as the following be incorporated:
    • Repeated chair squats
    • Reciprocal stair climbing and single leg balance with floor touches or object pick-ups
    • Obstacle avoidance and quick changes/pivots in direction while ambulating

    (Local Consensus, 2013 [5])

Restoring Basic Function Phase—Cardiovascular

  1. It is recommended that minimal intensity cardiovascular exercise be performed at a rate of perceived exertion (RPE) of 9 to 11 on the 6 to 20 Borg Scale or 3 to 4 on the Pictorial Children's Effort Rating Table (PCERT) (Roemmich et al., 2006 [4a]; Dunbar et al., 1992 [4b]; Local Consensus, 2013 [5]; Groslambert & Mahon, 2006 [5a]).

    Note: RPE has been shown to be a valid and reliable measurement of exertion and correlated with heart rate produced during physical activity (Dunbar et al., 1992 [4b]; Groslambert & Mahon, 2006 [5a]).

Restoring Advanced Function Phase

The purpose of this phase is to fully restore the patient's ability to engage in pre-injury levels of function and build symmetry between involved and uninvolved limbs. See Table 5 in the original guideline document for a list of specific goals and expected outcomes for the Restoring Advanced Function Phase. Appendix 3c in the original guideline document provides a list of example exercises that may be appropriate for the Restoring Advanced Function Phase. By the end of this phase, patients should be able to meet the Centers for Disease Control recommended guidelines for physical activity with the ability to participate in all activities expected for healthy, typically-developing children such as full participation in physical activity classes and at least 60 minutes of activity of moderate intensity (e.g., brisk walking) and vigorous intensity (e.g., running) a day (Local Consensus, 2013 [5]; U.S. Department of Health and Human Services [DHHS], 2008 [5a]).

Restoring Advanced Function Phase—ROM/Flexibility

  1. It is recommended that passive static stretches for lower extremity musculature continue to be utilized to assist with gains and/or maintenance of good ROM and flexibility (Moseley et al., 2005 [2a]; Bandy, Irion, & Briggler, 1998 [2a]; Davis et al., 2005 [2b]; Local Consensus, 2013 [5]).
  2. It is recommended that manual therapy techniques such as more aggressive manual stretching and joint mobilizations are utilized if ROM deficits continue to be present in the involved knee (Local Consensus, 2013 [5]).

Restoring Advanced Function Phase—Muscle Strength and Control

  1. It is recommended that isotonic and isokinetic resistance exercises targeting the knee, hip and ankle musculature of the involved knee continue to be integrated into therapeutic exercises (Local Consensus, 2013 [5]).

    Note: Level of resistance may be increased and increased ROM may be utilized for both OKCE and CKCE as tolerated by the patient and within the patient's ability to maintain good core, hip, knee and foot alignment (Local Consensus, 2013 [5]).

  2. It is recommended that a continued emphasis is placed on good control, alignment and appropriate muscle recruitment for double leg and single leg activities with an increased number of repetitions and improved endurance with isometric holds (Local Consensus, 2013 [5]).

    Note 1: Exercises emphasizing full-body dynamic movements in multiple planes of motion that incorporate strength and endurance building for core musculature and trunk stability (Powers, 2010 [5a]; Reinold et al., 2006 [5a]; Greiwe et al., 2010 [5b]) and strengthening activities performed on both static and dynamic surfaces can be particularly useful during the Restoring Advanced Function Phase (Local Consensus, 2013 [5]; Reinold et al., 2006 [5a], Bolgla & Keskula, 2000 [5b]).

    Note 2: The following exercises can effectively target the gluteus medius:

    • Single leg squat
    • Single leg balance with hip abduction
    • Single leg bridges in supine
    • Single leg deadlifts
    • Side planks with hip abduction

    (Lubahn et al., 2011 [4a]; Boren et al., 2011 [4b]; Distefano et al., 2009 [4b]; Ekstrom, Donatelli, & Carp, 2007 [4b]; Bolgla & Uhl, 2005 [4b])

    Note 3: The following exercises can effectively target the gluteus maximus:

    • Single leg squat
    • Single leg bridge
    • Side plank with hip abduction
    • Front plank with hip extension
    • Single leg deadlift
    • Transverse lunges

    (Lubahn et al., 2011 [4a]; Boren et al., 2011 [4b]; Distefano et al., 2009 [4b]; Ekstrom, Donatelli, & Carp, 2007 [4b])

    Note 4: The following exercises can effectively target the core abdominal muscles:

    • Swiss ball pike
    • Swiss ball roll-out with hip extension
    • Front plank with hip extension
    • Side plank with hip abduction

    (Boren et al., 2011 [4b]; Escamilla et al., 1998 [4b])

Restoring Advanced Function Phase—Balance

  1. It is recommended that balance training activities include more advanced activities for single leg balance with perturbations on unstable surfaces (Local Consensus, 2013 [5]).

Restoring Advanced Function Phase—Gait

  1. It is recommended that exercise interventions that emphasize good, symmetrical and safe gait patterns for jogging and running are integrated into this phase (Local Consensus, 2013 [5]).

    Note: Even if a patient did not engage in running activities regularly prior to injury, it is likely they may be expected to participate in at least low-level running activities for physical education classes or for participation at recess with classmates. Therefore, it is important to ensure the patient is able to run at least short distances safely using good form (Local Consensus, 2013 [5]).

Restoring Advanced Function Phase—Functional Tasks

  1. It is recommended that exercises are integrated that emphasize:
    • Quick changes in direction on stable and unstable surfaces and even and uneven step-heights
    • That increase intensity and dynamic motions associated with activities of daily living (ADLs) or work/play related tasks (e.g. squatting or lunging quickly with heavier weight to replicate lifting heavier boxes/object from the floor) with emphasis on mechanics
    • Age-appropriate activities such as skipping, double leg hopping, single leg hopping, skipping and jogging per patient and family goals and to return to desired physical activity

    (Local Consensus, 2013 [5])

    Note: These exercises emphasize improving the patient's ability to fully participate in physical education class and/or in recreational activities and are task or sport-specific such as being able to navigate the playground, participate in physical education classes or engage in the work environment safely (Local Consensus, 2013 [5]).

Restoring Advanced Function Phase—Cardiovascular

  1. It is recommended that moderate intensity cardiovascular exercises are integrated with a RPE of 12 to 14 on the 6 to 20 Borg Scale or 5 to 6 on the PCERT and vigorous intensity exercise be performed with a RPE of 15 to 17 or 7 to 8 on the PCERT (Roemmich et al., 2006 [4a]; Dunbar et al., 1992 [4b]; Local Consensus, 2013 [5]; Groslambert & Mahon, 2006 [5a]).

Return-to-Activity Phase

Successful attainment of the goals for the Restoring Advanced Function Phase is used as indication of the individual's readiness to reintegrate into higher level activities. If the patient's highest level of personal functional goals have been met at this time, and clinical judgment dictates the patient is able to perform all age-appropriate types of activities (e.g., full participation in physical education classes), it may appropriate to discharge patient at this time. Appendix 3d in the original guideline document provides a list of example exercises that may be useful for the Return-to-Activity Phase.

  1. It is recommended that progressive reintegration into activities be conducted according to the Cincinnati Children's Hospital Medical Center (CCHMC) guideline Evidence-based care guideline for return to activity after lower extremity injury in children and young adults ages 5 through 22 years.

Discharge Criteria

  1. It is recommended that discharge from therapy be based on clinical judgment, attainment of goals, and successful participation in desired activities (Local Consensus, 2013 [5]).

Definitions:

Table of Evidence Levels

Quality Level Definition
1a† or 1b† Systematic review, meta-analysis, or meta-synthesis of multiple studies
2a or 2b Best study design for domain
3a or 3b Fair study design for domain
4a or 4b Weak study design for domain
5a or 5b General review, expert opinion, case report, consensus report, or guideline
5 Local Consensus

†a = good quality study; b = lesser quality study.

Table of Recommendation Strength

Strength Definition
"Strongly recommended" There is consensus that benefits clearly outweigh risks and burdens (or vice-versa for negative recommendations).
"Recommended" There is consensus that benefits are closely balanced with risks and burdens.
No recommendation made There is lack of consensus to direct development of a recommendation.

Note: See the original guideline document for the dimensions used for judging the strength of the recommendation.

Clinical Algorithm(s)

None provided

Disease/Condition(s)

  • Lateral patellar dislocations/subluxations
  • Lateral patellar instability

Guideline Category

Evaluation

Management

Treatment

Clinical Specialty

Family Practice

Pediatrics

Physical Medicine and Rehabilitation

Intended Users

Advanced Practice Nurses

Nurses

Other

Patients

Physical Therapists

Physician Assistants

Physicians

Guideline Objective(s)

  • To provide a comprehensive description of evaluation and intervention strategies for conservative management of lateral patellar instability
  • To guide and promote consistency in the delivery of optimal evidence-based physical therapy services for non-surgical, conservative management of primary patellar dislocation (PPD) and recurrent patellar instability (RPI)
  • To promote long-term joint integrity and maximize healing
  • To reduce impairment
  • To enhance function
  • To maintain and improve patient and family satisfaction and quality of life
  • To minimize risk for re-injury

Target Population

Children or young adults, ages 8-25 years, with history of lateral patellar dislocation, subluxation or general patellar instability in one or both knees who are going to be conservatively managed

Note: Children or young adults following surgical patellar stabilization techniques or with neuro-developmental conditions associated with patellar instability or dislocation (e.g., cerebral palsy, Down Syndrome) are excluded from this guideline.

Interventions and Practices Considered

Assessment

  1. Review of general medical history and imaging studies
  2. Assessment and localization of pain using appropriate scale
  3. Comprehensive objective physical therapy exam
  4. Comprehensive knee screen
  5. Assessment of joint hypermobility
  6. Assessment of knee function using knee-specific scales in conjunction with general health instruments

Management/Treatment

  1. Self-management education and skill building
  2. Patient/family education about condition management
  3. Pain relief assistance
    • Cryotherapy
    • Electrical stimulation and/or transcutaneous electrical nerve stimulation (TENS)
    • Medication
  4. Edema management
    • Cryotherapy
    • Vasopneumatic device
    • Elastic compression wrap
  5. Physical therapy
    • Range of motion (ROM) and flexibility exercises (passive static stretches)
    • Muscle strength and control exercises
      • Isometric and isotonic strengthening exercises
      • Provision of visual, tactile and verbal feedback cues
      • Neuromuscular electrical stimulation (NMES)
      • Resisted isometric, isotonic and isokinetic strengthening exercises (open kinetic chain exercises [OKCE], closed kinetic chain exercises [CKCE])
      • Emphasis on good control, alignment and appropriate muscle recruitment for double leg and single leg activities
    • Balance exercises and advanced balance training activities
    • Patient-specific ambulation exercises
    • Training and education in bed mobility, transfers and safe stair navigation
    • Exercise interventions emphasizing good, symmetrical and safe gait patterns
    • Activities of daily living advanced training exercises
    • Minimal intensity and moderate intensity cardiovascular exercise
    • Manual therapy techniques
    • Advanced functional task exercises
  6. Progressive reintegration into activities
  7. Discharge criteria

Major Outcomes Considered

  • Ability to participate with self-report of pain
  • Range of motion/flexibility
  • Muscle strength and control
  • Balance
  • Gait
  • Ability to perform functional tasks

Methods Used to Collect/Select the Evidence

Hand-searches of Published Literature (Primary Sources)

Hand-searches of Published Literature (Secondary Sources)

Searches of Electronic Databases

Description of Methods Used to Collect/Select the Evidence

To select evidence for critical appraisal by the group for this guideline, the MEDLINE, EMBASE and the Cochrane databases were searched for dates of October 23, 2013 to generate an unrefined, "combined evidence" database using a search strategy focused on answering clinical questions relevant to patellar instability and employing a combination of Boolean searching on human-indexed thesaurus terms (medical subject headings [MeSH] headings using an OVID MEDLINE interface) and "natural language" searching on words in the title, abstract, and indexing terms. The key words used were: "Patellar Instability," "Patellar instability," "Patellar Dislocation," "Patella Dislocation," "Medial Patellofemoral Ligament," "MPFL," "Patellar Subluxation", and "Patellar Subluxation".

The citations were reduced by: eliminating duplicates, review articles, non-English articles, and adult articles. The resulting abstracts were reviewed by team members to eliminate low quality and irrelevant citations. During the course of the guideline development, additional clinical questions were generated and subjected to the search process, and some relevant review articles were identified. September 18, 2013 was the last date for which literature was reviewed for the previous version of this guideline. The details of that review strategy are not documented. However, all previous citations were reviewed for appropriateness to this revision.

Number of Source Documents

Not stated

Methods Used to Assess the Quality and Strength of the Evidence

Weighting According to a Rating Scheme (Scheme Given)

Rating Scheme for the Strength of the Evidence

Table of Evidence Levels

Quality Level Definition
1a† or 1b† Systematic review, meta-analysis, or meta-synthesis of multiple studies
2a or 2b Best study design for domain
3a or 3b Fair study design for domain
4a or 4b Weak study design for domain
5a or 5b General review, expert opinion, case report, consensus report, or guideline
5 Local Consensus

†a = good quality study; b = lesser quality study.

Methods Used to Analyze the Evidence

Review of Published Meta-Analyses

Systematic Review

Description of the Methods Used to Analyze the Evidence

Not stated

Methods Used to Formulate the Recommendations

Expert Consensus

Description of Methods Used to Formulate the Recommendations

The process by which this guideline was developed is documented in the Guideline Development Process Manual (see the "Availability of Companion Documents" field); relevant development materials are kept electronically. The recommendations contained in this guideline were formulated by an interdisciplinary working group which performed systematic search and critical appraisal of the literature, using the Table of Evidence Levels (see the "Rating Scheme for the Strength of the Evidence" field), and examined current local clinical practices.

Recommendations have been formulated by a consensus process directed by best evidence, patient and family preference and clinical expertise. During formulation of these recommendations, the team members have remained cognizant of controversies and disagreements over the management of these patients. They have tried to resolve controversial issues by consensus where possible and, when not possible, to offer optional approaches to care in the form of information that includes best supporting evidence of efficacy for alternative choices.

Rating Scheme for the Strength of the Recommendations

Table of Recommendation Strength

Strength Definition
"Strongly recommended" There is consensus that benefits clearly outweigh risks and burdens (or vice-versa for negative recommendations).
"Recommended" There is consensus that benefits are closely balanced with risks and burdens.
No recommendation made There is lack of consensus to direct development of a recommendation.

Note: See the original guideline document for the dimensions used for judging the strength of the recommendation.

Cost Analysis

A formal cost analysis was not performed and published cost analyses were not reviewed.

Method of Guideline Validation

External Peer Review

Internal Peer Review

Description of Method of Guideline Validation

  • The recommendation statements were formally reviewed by other physical therapists, physicians and athletic trainers. In addition, specific feedback regarding patient and family needs and preferences were obtained through a review process with former patients and family members who have undergone conservative management of lateral patellar instability.
  • The guideline has been reviewed and approved by clinical experts not involved in the development process, distributed to senior management, and other parties as appropriate to their intended purposes.

References Supporting the Recommendations

American Physical Therapy Association: guide to physical therapist practice. Rev to Second Edition. American Physical Therapy Association; 2003. 9-746 p.

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Briggs KK, Steadman JR, Hay CJ, Hines SL. Lysholm score and Tegner activity level in individuals with normal knees. Am J Sports Med. 2009 May;37(5):898-901. PubMed External Web Site Policy

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Davis DS, Ashby PE, McCale KL, McQuain JA, Wine JM. The effectiveness of 3 stretching techniques on hamstring flexibility using consistent stretching parameters. J Strength Cond Res. 2005 Feb;19(1):27-32. PubMed External Web Site Policy

Depino GM, Webright WG, Arnold BL. Duration of maintained hamstring flexibility after cessation of an acute static stretching protocol. J Athl Train. 2000 Jan;35(1):56-9. PubMed External Web Site Policy

Distefano LJ, Blackburn JT, Marshall SW, Padua DA. Gluteal muscle activation during common therapeutic exercises. J Orthop Sports Phys Ther. 2009 Jul;39(7):532-40. PubMed External Web Site Policy

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Escamilla RF, Fleisig GS, Zheng N, Barrentine SW, Wilk KE, Andrews JR. Biomechanics of the knee during closed kinetic chain and open kinetic chain exercises. Med Sci Sports Exerc. 1998 Apr;30(4):556-69. PubMed External Web Site Policy

Faigenbaum AD, Westcott WL, Micheli LJ, Outerbridge AR, Long CJ, LaRosa-Loud R, Zaichkowsky LD. The effects of strength training and detraining on children. J Strength Cond Res. 1996;10(2):110-14.

Fithian DC, Paxton EW, Stone ML, Silva P, Davis DK, Elias DA, White LM. Epidemiology and natural history of acute patellar dislocation. Am J Sports Med. 2004 Jul-Aug;32(5):1114-21. PubMed External Web Site Policy

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Type of Evidence Supporting the Recommendations

The type of supporting evidence is identified and graded for each recommendation (see the "Major Recommendations" field).

Potential Benefits

Appropriate evidence-based care for conservative management of lateral patellar dislocations and instability in children and young adults aged 8-25 years

Potential Harms

  • Underlying concomitant tissue damage such as chondral lesions that can lead to long-term pain or loose bodies in the joint may lead to limitations or difficulties with full implementation of these guidelines.
  • Pre-disposing anatomical abnormalities may reduce a patient's chances for long-term success of the implementation of these guidelines to reduce lateral patellar instability.

Qualifying Statements

These recommendations result from review of literature and practices current at the time of their formulations. This guideline does not preclude using care modalities proven efficacious in studies published subsequent to the current revision of this document. This document is not intended to impose standards of care preventing selective variances from the recommendations to meet the specific and unique requirements of individual patients. Adherence to this guideline is voluntary. The clinician in light of the individual circumstances presented by the patient must make the ultimate judgment regarding the priority of any specific procedure.

Description of Implementation Strategy

An implementation strategy was not provided.

IOM Care Need

Getting Better

IOM Domain

Effectiveness

Patient-centeredness

Bibliographic Source(s)

Cincinnati Children's Hospital Medical Center. Evidence-based care guideline for conservative management of lateral patellar dislocations and instability in children and young adults aged 8-25 years. Cincinnati (OH): Cincinnati Children's Hospital Medical Center; 2014 Mar 18. 30 p. [100 references]

Adaptation

Not applicable: The guideline was not adapted from another source.

Date Released

2014 Mar 18

Guideline Developer(s)

Cincinnati Children's Hospital Medical Center - Hospital/Medical Center

Source(s) of Funding

Cincinnati Children's Hospital Medical Center

The guideline was developed without external funding

Guideline Committee

Division of Occupational Therapy and Physical Therapy Guideline Development Team

Composition of Group That Authored the Guideline

Team Members: Catherine C. Quatman-Yates, PT, DPT, PhD, Team Leader, Division of Occupational Therapy and Physical Therapy and Department of Pediatrics Division of Sports; Amber Boyd, PT, DPT, SCS, CSCS, Division of Occupational Therapy and Physical Therapy; Jason Hugentobler, PT, DPT, SCS, CSCS, Division of Occupational Therapy and Physical Therapy; Kathleen Hugentobler PT, DPT, CSCS, Division of Occupational Therapy and Physical Therapy; Jeffery A. Taylor-Haas, PT, DPT, OCS, CSCS, Division of Occupational Therapy and Physical Therapy; Meredith Sheaffer, PT, DPT, CSCS, Division of Occupational Therapy and Physical Therapy

Senior Clinical Director: Rebecca D. Reder, OTD, OTR/L, Division of Occupational Therapy and Physical Therapy

Ad Hoc Assistants: Jamie Curley, PT, DPT, CSCS; Christopher Wall, PT, DPT, CSCS; Ashley Hemm, SPT; Alison Roell, SPT Laura Neal, PT, DPT; Marti Bradbury, PT, DPT; Kadi Carmisino, SPT

Internal Advisors: Chad Cherny, PT, DPT, MS, SCS, CSCS, Division of Occupational Therapy and Physical Therapy; Julie Lee, PT, DPT, Division of Occupational Therapy and Physical Therapy; Robyn McHugh, PT, OCS, Division of Occupational Therapy and Physical Therapy

Ad Hoc Advisors: Michelle Kiger, MHS, OTR/L, Division of Occupational Therapy and Physical Therapy; Mark Paterno, PT, PhD, MBA, SCS, ATC Division of Occupational Therapy and Physical Therapy; Karen Vonderhaar, Anderson Center

Support: Mary Gilene, MBA, Division of Occupational Therapy and Physical Therapy; Karen Vonderhaar, Anderson Center

Financial Disclosures/Conflicts of Interest

All Team Members and Anderson Center support staff listed have declared whether they have any conflict of interest and none were identified.

Guideline Status

This is the current release of the guideline.

Guideline Availability

Availability of Companion Documents

The following are available:

Patient Resources

None available

NGC Status

This NGC summary was completed by ECRI Institute on June 18, 2014.

Copyright Statement

This NGC summary is based on the original full-text guideline, which is subject to the following copyright restrictions:

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