Patellarectomy and Exercise

Question:

I have a client that seems to require a special exercise/fitness routine. He has been released by his physicians (he has several) to exercise. He has been advised he has no physical limitations. This individual has been sedentary and has the following issues:

He is 40 years old, 260 pounds and is under 6 feet tall. He has had four knee operations over the past several years. His patellas have been removed by a procedure called bilateral patella rectomy. At 32, he had blockage in a heart valve and had a cath. His medical history revealed an excessive heart rate. He can walk, but walking up stairs causes him pain. He completed physical therapy over four years ago. He takes pain medication, but his neurologist has determined no nerve damage and does not know what is causing the pain. He has slight arthritis. In addition to a lack of inactivity, he has a poor diet habits (excessive soft drinks, sugar, fatty foods).

We would like to help this gentleman begin an exercise program. What types of exercises do you suggest he perform? We’re looking for an integrated program design for him for both cardiovascular and muscle development.

Answer:

Although bilateral patellarectomys were once thought of as an option to rectify patellofemoral dysfunctions, there are very few (if any) physicians who still perform this procedure. To have an idea of what needs to be modified and included in the exercise program, one must understand some basic functions of the patella and its relationship to the knee joint. They include:

1. Enhances mechanical efficiency of the quadriceps by providing a larger moment arm.
2. Prevent friction of the patellar tendon against the intercondyler groove.
3. Decreases compression forces of the patellar tendon on the intercondylar groove

By removing the patella, the moment arm has obviously decreased. This creates less of a mechanical advantage for the quadriceps with it’s relationship to the tibia, thus weaker quadriceps. Due to the friction and compression forces created on the intercondylar joint via the patellar tendon, the risk of fraying the patellar tendon also increases. These abnormal stresses can affect the mechanics of the knee, leading to excessive wear on the tibiofemoral joint and knee pain. Due to these structural and mechanical abnormalities, there are some specifics you should be aware of to decrease the chance of injury.

1. Strengthen his core (hips, abs and low back). Because the quadriceps will become mechanically weakened through this procedure in addition to your client’s large frame, there are extreme forces being placed on his structure that must be controlled. Having a strong core will allow for his structure to accept, produce and distribute forces more efficiently, potentially placing less stress to his knee joints. Exercises to strengthen his abdominals, low back and hip musculature will be important to incorporate into the routine.
2. When performing movements that involve knee flexion (i.e., squats), the range of motion will have to be limited. This is due to the increased frictional and compression forces being placed on the intercondylar groove by the patellar tendon in a flexed position. Knee extension machines would not the preferred exercise in this situation and should be avoided.
3. Strengthen all musculature surrounding the knee (gastrocnemius, soleus and hamstrings). Once again, due to the weakness of the quadriceps, it will be important to strengthen other muscles associated with the joint to enhance stabilization and dynamic control of the joint.
4. Stretch commonly tight muscles that may affect the mechanics of the knee joint (gastrocnemius/soleus, adductors, hip flexors and lats).

Without performing a thorough assessment, exact exercise protocol cannot be determined. However, below are some stretching and strengthening exercises that can help accomplish the above criteria.

FLEXIBILITY 

STABILIZATION

* Perform with slight knee and hip flexion and emphasize contract of glutes throughout the entire motion
**Limit range of eccentric motion (lowering portion of movement) and emphasize contract of glutes throughout the entire motion
***E= eccentric, I= isometric, C= concentric

NOTE: For all flexibility, stabilization and strength exercises, cue your client to draw their navel in towards their spine and squeeze their glutes. This program does not have to be performed all in one session!

To ensure safety and effectiveness of the above exercises, follow the below checklist to monitor your client’s form while performing these movements:

• Feet: pointed straight ahead
• Knees: in line with the toes
• Hips: remain level
• Shoulders: avoid elevation (shrugging)
• Head: chin tucked and head level