Assessment of knee flexor muscles strength in patients with patellar instability and its clinical implications for the non-surgical treatment of patients after first patellar dislocation - pilot study

Krzysztof Małecki, Jarosław Fabiś, Paweł Flont, Anna Fabiś-Strobin, Kryspin Niedzielski, Krzysztof Małecki, Jarosław Fabiś, Paweł Flont, Anna Fabiś-Strobin, Kryspin Niedzielski

Abstract

Background: Biomechanical studies indicate that during outward rotation of the tibia and the valgus knee joint position, the patella is shifted in the lateral direction. After first-time patellar dislocation, the dynamic position of the femur in relation to the tibia plays an important role in joint stability, because the medial stabilizer of the patella (mostly the MPFL) is damaged or inefficient. The most important factor in controlling the rotational movement of the tibia in relation to the thigh are the hamstring muscles. The aim of the study therefore is to determine whether patients with patellar instability have a significant weakness in the knee flexor muscles, which can predispose to recurrent dislocations. This is an important consideration when planning the rehabilitation of patients with first-time patellar dislocation.

Methods: The study enrolled 33 patients with confirmed recurrent patellar dislocation, including six patients with bilateral involvement. In the study group, the hamstring muscles (both sides) were evaluated at velocities of 60 and 180 deg/s for the following parameters: peak torque, torque at 30 degrees of knee flexion, angle of peak torque and peak torque hamstring to quadriceps ratio (H/Q ratio).

Results: In the recurrent patellar dislocation group, a statistically significant weakness in knee flexors was observed for both angular velocities compared to age and gender normative data. No such relationship was observed in the control group of heathy subjects. In patients with one-sided dislocation, no differences were found in knee flexors peak torque, torque at 30 degrees of knee flexion, angle of peak torque or H/Q ratio between the healthy and affected limbs for either angular velocity.

Conclusions: In patients with recurrent patellar dislocation, knee flexors strength is decreased significantly in both the unaffected and affected limbs. This may indicate a constitutional weakening of these muscles which can predispose to recurrent dislocations.

Trial registration: The study was retrospectively registered on ClinicalTrials.gov ( NCT04838158 ), date of registration; 22/03/2021.

Keywords: Children; Hamstring strength; Isokinetic assessment; patella dislocation.

Conflict of interest statement

The authors declare that they have no competing interests.

© 2021. The Author(s).

References

    1. Zimmerer A, Sobau C, Balcarek P. Recent developments in evaluation and treatment of lateral patellar instability. J Exp Orthop. 2018;5(1):3. doi: 10.1186/s40634-017-0119-z.
    1. Nwachukwu BU, So C, Schairer WW, Green DW, Dodwell ER. Surgical versus conservative management of acute patellar dislocation in children and adolescents: a systematic review. Knee Surg Sports Traumatol Arthrosc. 2016;24(3):760–767. doi: 10.1007/s00167-015-3948-2.
    1. Erickson BJ, Mascarenhas R, Sayegh ET, Saltzman B, Verma NN, Bush-Joseph CA, Cole BJ, Bach BR., Jr Does operative treatment of first-time patellar dislocations Lead to increased patellofemoral stability? A systematic review of overlapping Meta-analyses. Arthroscopy. 2015;31(6):1207–1215. doi: 10.1016/j.arthro.2014.11.040.
    1. Bitar AC, Demange MK, D'Elia CO, Camanho GL. Traumatic patellar dislocation: nonoperative treatment compared with MPFL reconstruction using patellar tendon. Am J Sports Med. 2012;40(1):114–122. doi: 10.1177/0363546511423742.
    1. Saccomanno MF, Sircana G, Fodale M, Donati F, Milano G. Surgical versus conservative treatment of primary patellar dislocation. A systematic review and meta-analysis. Int Orthop. 2016;40(11):2277–2287. doi: 10.1007/s00264-015-2856-x.
    1. Khan M, Miller BS. Cochrane in CORR ®: surgical versus non-surgical interventions for treating patellar dislocation (review) Clin Orthop Relat Res. 2016;474(11):2337–2343. doi: 10.1007/s11999-016-5014-x.
    1. Liebensteiner MC, Dirisamer F, Balcarek P, Schoettle P. Guidelines for treatment of lateral Patella dislocations in skeletally mature patients. Am J Orthop (Belle Mead NJ) 2017;46(2):E86–E96.
    1. Jaquith BP, Parikh SN. Predictors of recurrent patellar instability in children and adolescents after first-time dislocation. J Pediatr Orthop. 2017;37(7):484–490. doi: 10.1097/BPO.0000000000000674.
    1. Balcarek P, Oberthür S, Hopfensitz S, Frosch S, Walde TA, Wachowski MM, Schüttrumpf JP, Stürmer KM. Which patellae are likely to redislocate? Knee Surg Sports Traumatol Arthrosc. 2014;22(10):2308–2314. doi: 10.1007/s00167-013-2650-5.
    1. Magnussen RA, Verlage M, Stock E, Zurek L, Flanigan DC, Tompkins M, Agel J, Arendt EA. Primary patellar dislocations without surgical stabilization or recurrence: how well are these patients really doing? Knee Surg Sports Traumatol Arthrosc. 2017;25(8):2352–2356. doi: 10.1007/s00167-015-3716-3.
    1. Zhang GY, Ding HY, Li EM, Zheng L, Bai ZW, Shi H, Fan FJ, Guo D. Incidence of second-time lateral patellar dislocation is associated with anatomic factors, age and injury patterns of medial patellofemoral ligament in first-time lateral patellar dislocation: a prospective magnetic resonance imaging study with 5-year follow-up. Knee Surg Sports Traumatol Arthrosc. 2019;27(1):197–205. doi: 10.1007/s00167-018-5062-8.
    1. Krych AJ, O'Malley MP, Johnson NR, et al. Functional testing and return to sport following stabilization surgery for recurrent lateral patellar instability in competitive athletes. Knee Surg Sports Traumatol Arthrosc. 2018;26(3):711–718. doi: 10.1007/s00167-016-4409-2.
    1. Rauschning W, Nordesjö LO, Nordgren B. Isokinetic knee extension strength and pain before and after correction of recurrent patellar dislocation. Arch Orthop Trauma Surg. 1983;102(2):102–106. doi: 10.1007/BF02498724.
    1. Oliva F, Ronga M, Longo UG, Testa V, Capasso G, Maffulli N. The 3-in-1 procedure for recurrent dislocation of the patella in skeletally immature children and adolescents. Am J Sports Med. 2009;37(9):1814–1820. doi: 10.1177/0363546509333480.
    1. Ronga M, Oliva F, Longo UG, Testa V, Capasso G, Maffulli N. Isolated medial patellofemoral ligament reconstruction for recurrent patellar dislocation. Am J Sports Med. 2009;37(9):1735–1742. doi: 10.1177/0363546509333482.
    1. Małecki K, Niedzielski K, Flont P, Fabis-Strobin A, Fabis J. Bilateral Hidden Isokinetic Quadriceps Performance before and after MPFL Reconstruction in Pediatric Patients [published online ahead of print, 2020 Jan 6]. J Knee Surg. 2020. 10.1055/s-0039-3402031.
    1. Dewan V, Webb MSL, Prakash D, Malik A, Gella S, Kipps C. When does the patella dislocate? A systematic review of biomechanical & kinematic studies. J Orthop. 2019;20:70–77. doi: 10.1016/j.jor.2019.11.018.
    1. Wiggin MM, Jackson R. Quadricep and hamstring peak torque norms in children 6 through 13 years. Pediatr Phys Ther. 2005;17(1):65.
    1. Freedson PS, Gilliam TB, Mahoney T, Maliszewski AF, Kastango K. Industrial torque levels by age group and gender. Isokinet Exerc Sci. 1993;3(1):34–42. doi: 10.3233/IES-1993-3105.
    1. LaPrade MD, Kennedy MI, Wijdicks CA, LaPrade RF. Anatomy and biomechanics of the medial side of the knee and their surgical implications. Sports Med Arthrosc Rev. 2015;23(2):63–70. doi: 10.1097/JSA.0000000000000054.
    1. Flaxman TE, Alkjær T, Simonsen EB, Krogsgaard MR, Benoit DL. Predicting the functional roles of knee joint muscles from internal joint moments. Med Sci Sports Exerc. 2017;49(3):527–537. doi: 10.1249/MSS.0000000000001125.
    1. Cleather DJ. An important role of the biarticular hamstrings is to exert internal/external rotation moments on the tibia during vertical jumping. J Theor Biol. 2018;455:101–108. doi: 10.1016/j.jtbi.2018.07.013.
    1. Kittl C, Becker DK, Raschke MJ, Müller M, Wierer G, Domnick C, Glasbrenner J, Michel P, Herbort M. Dynamic restraints of the medial side of the knee: the semimembranosus corner revisited. Am J Sports Med. 2019;47(4):863–869. doi: 10.1177/0363546519829384.
    1. Toor AS, Limpisvasti O, Ihn HE, McGarry MH, Banffy M, Lee TQ. The significant effect of the medial hamstrings on dynamic knee stability. Knee Surg Sports Traumatol Arthrosc. 2019;27(8):2608–2616. doi: 10.1007/s00167-018-5283-x.
    1. Wu R, Delahunt E, Ditroilo M, Lowery MM, DE Vito G. Effect of knee joint angle and contraction intensity on hamstrings Coactivation. Med Sci Sports Exerc. 2017;49(8):1668–1676. doi: 10.1249/MSS.0000000000001273.
    1. Morgan KD, Donnelly CJ, Reinbolt JA. Empirical based modeling for the assessment of dynamic knee stability: implications for anterior cruciate ligament injury risk. Conf Proc IEEE Eng Med Biol Soc. 2018;2018:1676–1679. doi: 10.1109/EMBC.2018.8512631.
    1. Gormeli G, Gormeli CA, Karakaplan M, Gurbuz S, Ozdemir Z, Ozer M. Acute patellar dislocation with multiple ligament injuries after knee dislocation and single session reconstruction. J Pak Med Assoc. 2016;66(6):757–760.
    1. Askenberger M, Ekström W, Finnbogason T, Janarv PM. Occult intra-articular knee injuries in children with Hemarthrosis. Am J Sports Med. 2014;42(7):1600–1606. doi: 10.1177/0363546514529639.
    1. Luhmann SJ, Schoenecker PL, Dobbs MB, Gordon JE. Arthroscopic findings at the time of patellar realignment surgery in adolescents. J Pediatr Orthop. 2007;27(5):493–498. doi: 10.1097/BPO.0b013e318093f4d8.
    1. Askenberger M, Bengtsson Moström E, Ekström W, Arendt EA, Hellsten A, Mikkelsen C, Janarv PM. Operative repair of medial patellofemoral ligament injury versus knee brace in children with an acute first-time traumatic patellar dislocation: a randomized controlled trial. Am J Sports Med. 2018;46(10):2328–2340. doi: 10.1177/0363546518770616.

Source: PubMed

Sponsors and Collaborators

Medical Conditions

Drug Interventions

3
Subscribe