Physical Therapy Interventions for Recurrent Patellar Instability and Tibial Tuberosity

Transfer Surgery Rehabilitation

Jack Lougeay

Portland Community College

FT 280B - Internship II

Alma Eaton

September 04, 2023

Goal of this Project

To conduct research and engage in discussion with physical therapists to better

understand a DPT’s process and guidelines for exercise therapy prescription (post-evaluation).

Case Study - Patient Profile

The patient is a 20 year old male who suffered from recurrent patellar subluxation (i.e.,

patellar instability), and a peripheral tear of his left medial meniscus was also discovered after

having an MRI. The injury occured whilst wrestling in January 2019. The patient just had a tibial

tuberosity transfer surgery done in June 2023. They now experience some pain and tenderness at

the left knee.

Defining the Diagnosis

● Peripheral Tear of Medial Meniscus

○ Peripheral = located on the outside (of the

meniscus) (https://www.verywellhealth.com/types-of-
meniscus-tears-3862073)

○ “The most common mechanism of menisci

injury is a twisting injury with the foot

anchor on the ground, often by another

player's body. A slow twisting force

may also cause the tear. Damage to the meniscus is due to rotational forces

directed to a flexed knee (as may occur with twisting sports) is the usual

underlying mechanism of injury.” (https://www.physio-pedia.com/Medial_meniscus)

● Recurrent Left Patella Subluxation

 ○ Recurrent = occurring often or repeatedly

○ Patellar Subluxation = the kneecap has briefly slid out of its normal place in the

groove at the center of the bottom end of the thigh bone

(https://www.nationwidechildrens.org/conditions/patellar-subluxation)

■ What Causes Patellar Subluxation?

● “The most common cause is weakness and/or tightness of certain

muscles in the hip and thigh, which can make the knee move

differently than it should.”

OR

● “A direct blow to the front or side of the knee that pushes the

kneecap out of its groove.” (https://www.nationwidechildrens.org/conditions/patellar-

subluxation)

● Tibial Tubercle Transfer Surgery

○ Tibial Tubercle = “The tibial tuberosity, or tibial tubercle, is an elevation on the

proximal, anterior aspect of the tibia, just below

where the anterior surfaces of the lateral and

medial tibial condyles end.”

(https://en.wikipedia.org/wiki/Tuberosity_of_the_tibia)

○ Anterior Tibial Tuberosity Transfer* - Patella

Realignment = this operation involves cutting off

the Anterior Tibial Tuberosity (ATT), and then reattaching it in a new position

(usually lower and more medial) to be more alligned with the patella and help

stabilize it. (https://www.dr-meyer-

orthopaedics.com)
 ■ *also known as a Tibial Tubercle Osteotomy

● Osteotomy = the surgical cutting of a bone or removal of a piece

of bone. (Oxford Languages/Google)

Patient Evaluation - Results

Range of Motion (ROM) - Knee Evaluation

Active ROM (AROM) Passive ROM (PROM)

Flexion Extension Flexion Extension

Normal = 135°-145° Normal = 0° n/a Normal = 0°

LEFT 95° 0° n/a 5°

RIGHT 132° 0° n/a 5°

Girth Measurements (cm)

Right Left

Joint Line 41.0 cm 41.5 cm

Quadriceps/Hamstring 53.5 cm 52.0 cm

Girth

Gastrocnemius/Soleus Girth 44.0 cm 41.5 cm

● Assessment Notes from the PT

○ “The patient demonstrated impairments in ROM, strength, weight bearing and

pain level affecting their ability to perform squatting and walking.”

Post-Operation - Exercise Therapy

After many hours of reading through databases of articles, I have found that much of the

research surrounding the treatment of this specific injury is in regard to the efficacy of tibial

tuberosity transfer surgery versus medial patellofemoral ligament (MPFL) reconstruction.

However, some of these studies do address varying amounts of postoperative management as a

factor in comparing the effectiveness of those different surgical treatments for patellar instability.

One systematic review paper from the Orthopaedic Journal of Sports Medicine (Chatterji,

2020) looked at thirty nine studies, and they evaluated the guidelines of postoperative

rehabilitation after patients have undergone surgeries for recurrent patellar instability. Of these

thirty nine studies, only sixteen of them “explicitly identified objective and subjective criteria for

return to play.” And of those sixteen, only three studies discussed a protocol of specified

physical therapy. It is also relevant to address that non-physical therapy rehabliation

interventions were mentioned across the large majority of the thirty nine studies. The studies

referenced implementation of a brace, weightbearing guidelines, range-of-motion goals, and

quadriceps-strengthening exercises as some of the key components of rehabiliation and return-to-

play after having this surgery.

Next, I dug deeper into the three studies cited in the Chatterji (2020) review paper that

discussed formal physical therapy interventions. What I determined to be useful towards the goal

of this project I found in just two of those three papers. In one study from The American Journal

of Sports Medicine, they cited active flexion exercises to be appropriate as early as one day

postoperativley (Damasena, 2017). In the other study, from the Journal of Orthopaedic Science,

they encouraged the patients to do straight leg raising and quadriceps setting exercises, again, as

early as one day following their surgery (Watanabe, 2008). However, it is important to include
that in both studies the patients did not begin range-of-motion or weightbearing exercises until a

few more days following surgery (Damasena, 2017; Watanabe, 2008).

Aside from my time spent reading the scientific research around this particular knee

surgery and the associated rehabiliation guidelines, I had a lot of hands-on experience with

patients at North Lake PT that also were recovering from other knee injuries and surgeries. I

noticed many patterns and similiarites between the patient exercise programs, even if they were

rehabilitating for different reasons. Additionally, I was fortunate to be granted access to one of

the North Lake PT’s Limber Health account. Limber Health is a digital platform designed for

providers that has outlined specific exercise therapy protocols based on different physical

ailments and injuries. On the website, they have a protocol that is designed for someone who

experiences patellar instability, which I reviewed.

The combination of my research, my hands-on clinical experience, plus outside resources

such as Limber Health, gave me a strong foundation to work with in my approach to designing

an appropriate exercise therapy program for the client in this case study. Below is a table

outlining the exercises that I selected:

Sample Exercise Therapy Program

Gastrocnemius Stretch Supine Straight Leg Raises

Supine Quad Set Clamshell

Heel Slide Side Lying Hip Abduction

Short Arc Quad Sit to Stand

TKE (terminal knee extension) Prone Hip Extension

Hamstring Stretch w/ strap Bridge

Heel Raises Supported Squat

 My rationale for choosing these exercises was based on deeming if it was ultimately

appropriate for the area that we are trying to get the client stronger in. I mainly selected

quadricep-strengthening exercises plus some other lower extremity exercises. A lot of these I had

seen real patients do in the North Lake clinic and I assisted those patients with many of them. I

excluded any specification of volume (sets and repetitions), as I did not believe it was relevant

for this case study since I have learned from my time at North Lake that volume varies greatly

depending on the patient and where that individual is at in their recovery.

Concluding Thoughts

After putting together my exercise program for this case study client, I had the chance to

sit down and meet with two of my worksite supervisors, North Lake PT’s Jenny and Brian. They

shared some of their thoughts and notes with me, and we talked about some of the criteria that

they consider when prescribing exercise to clients, progressing or regressing them, and areas to

focus on in order to gauge their progress.

Reflecting back on this project and how it turned out, I am very pleased with what I was

able to come up with. As I outlined in the goals section of this project, my main pursuit was to

better understand the process of prescribing exercise in a clinical physical therapy setting. I do

not (yet) have the level of education required to effectively choose and prescibe specific

interventions for real patients with real injuries. However, I do feel I now have a better picture of

the process as a whole and have learned about many of the things that PT’s consider during this

process. Additionally, as a result of my research efforts, I also got some great practice diving into

different scientific journals and working on my reading and comprehension of the literature.
 References

Chatterji, R., White, A. E., Hadley, C. J., Cohen, S. B., Freedman, K. B., & Dodson, C. C.

(2020). Return-to-Play Guidelines After Patellar Instability Surgery Requiring Bony

Realignment: A Systematic Review. Orthopaedic journal of sports medicine, 8(12),

2325967120966134. https://doi.org/10.1177/2325967120966134

Damasena I, Blythe M, Wysocki D, Kelly D, Annear P. Medial Patellofemoral Ligament

Reconstruction Combined With Distal Realignment for Recurrent Dislocations of the

Patella: 5-Year Results of a Randomized Controlled Trial. The American Journal of

Sports Medicine. 2017;45(2):369-376. doi:10.1177/0363546516666352

Limber Health. https://www.limberhealth.com/

Watanabe, T., Muneta, T., Ikeda, H. et al. Visual analog scale assessment after medial

patellofemoral ligament reconstruction: with or without tibial tubercle transfer. J Orthop

Sci 13, 32–38 (2008). https://doi-org.proxy.lib.pdx.edu/10.1007/s00776-007-1196-0