I received an email from a reader, Lisa, who had a total knee replacement about three months ago (thank you for reading Lisa and for buying The Little Book of Sparks!). All was well until she slipped and fell in her kitchen and ruptured the Vastus Medialis Oblique muscle (VMO - red area in the picture) and since then she has had a number of problems. Because the VMO helps stabilize your knee cap, when you rupture it, it's like cutting loose a mooring line on a ship on a windy day. Things get whacked around pretty good. She had to have the muscle surgically repaired to help re-align the patella.
Here's how she described it:
"The surgeon did a medial plication where he divided the medial retinaculum as it inserts into the patella. Then he reattached it more medially onto the patella itself in a pants over vest fashion. At the same time, he did a lateral retinacular release. Apparently, all of this is done in order to carefully balance my patella in the trochlear groove."
But, here's what has happened since.
"..... I'm still having trouble with the lateral part of the quad pulling my kneecap to the left. Also, the x-rays show that the patella is tilted and not sitting neatly in the groove as it was right after surgery. Repeat x-rays show that the patella has remained the same and is not any worse but it is certainly not in the groove. My orthopedist says that it could take up to a year for everything to stabilize with the patella, IF it does. I knew going in that the surgery may not work and that the VMO is a very hard muscle to rehab. Also, it seems that my muscle wants to stretch easily. In other words, the surgeon tightened the VMO because the initial injury and subsequent healing had resulted in extensive stretching of the muscle to the point that if any stress were put on my knee it would give way and I would fall. It looks as though it is probably stretching again....
She went on to say that she has good motion in her knee and can manage going up stairs but when she tries to step down, her kneecap shifts to the outside.
Do you have any suggestions? Would electrical stimulation help at all? Will I ever be able to get the left quad to act anywhere near like the right quad? Any help with this would be greatly appreciated."
First, here's my standard disclaimer. It's a lot easier to see, feel, and watch what a person is complaining about than it is to decipher over email. Video helps. Telephone helps. But, I'm an Intuitive so ideas just sort of appear in my head in the moment from the interaction. And I don't know your entire story, the surgeon, your therapist nor you. But you asked for suggestions and after reading your email I thought of a few things. So, here we go.
The issue, as you pointed out, is your
VMO is likely too loose or long as well as weak. So, repeatedly bending and straightening the knee is probably
not a great idea right now. And it's not just your muscle you have to be concerned about but the fascial connections within it and to the patella. All of that tissue has to tighten up. And you have to get your muscle to work again.
But I think first you need joint stability. Here are the ideas I had to address the instability.
- Prolotherapy followed by immobilzation. Prolotherapy is a series of injections that uses a mixture of saline and dextrose (sugar water) to jump start a healing response in the tissues. The prolotherapy will help the fascia, ligaments and muscle heal and tighten up and if this is done with the knee then held in extension in a brace, it may provide enough tightening to counter the lateral pull of the outside muscles. Usually after a surgical procedure like you had,
your knee would be immobilized in full extension for a month and then in
a hinged, locking brace at specific angles for another month and then
rehab might start. Here's a reference on that (click here ).
I don't know if this happened or not but it might not be too late to
start over.
- Slowly increase the range of motion after a month of immobilization. The down side to the immobilization is a loss of muscle strength, which will be considerable, and motion. Everything will feel stiff and getting it back will be slow.
- If you don't want to go that route or think it's too radical, then you might get some benefit from a brace - not the kind you tried before - but one that helps control rotation of the femur. Click here for a description. We all tend to think of the patella sliding out but that's if you look at it from the femur being fixed. And you describe the problem when you step down which involves femoral rotation. So, it's possible that some of the slipping of the patella is from too much inward rotation of the femur underneath it. The brace might help keep the femur from rotating too much.
- You didn't mention if you had tried taping techniques. There's some controversy over whether taping the patella actually moves it. If it does, it does so a small amount (about 1 millimeter*). But, it might be enough to alter the timing of the other musculature and provide you with some feedback. You can also use tape to act as a sort of external fascial support system. I've done this with a few clients who sustained fascial tears of the hamstring and it worked quite well. And, along those lines, a special type of compression garment also works fairly well for this too (click here for examples).
- And speaking of feedback....biofeedback might be worth trying to help you get the VMO going again. You can't isolate the VMO really from the other muscles of the quadriceps since it shares the same nerve supply but biofeedback can help you achieve maximal contraction.
- You asked about electrical stimulation. Normally, it's not too helpful but I think in your case, especially if you choose #1, having a unit on to keep your muscle firing makes sense. And, here's a case report (click here for it) of it being used on a patient with a chronically dislocating patella. But, it was several hours per day. So, you would have to buy or rent the unit. And, I think an even better application, is to get a heel switch placed in your shoe that would trigger the electrical stimulation. So, when you heel hits the ground, the unit would fire (of course, going down stairs would be a bit awkward).
- You'll have to work really hard at being patient. I know. You've already had a long haul. But whatever you choose to do, the road will likely be long and bumpy. So, keep some short term goals in sight and find a story in my book that lifts you up. That's why I wrote it.
- You asked if your left quad will ever be anywhere near your right (strength, size, etc). Well, the human body is amazingly adaptive and capable so that's on your side. But, your recovery of strength will depend on how well you can stabilize the patella-femoral joint. And the size of your muscle comes from training - months of it. Most people have a slightly smaller leg (in terms of circumference) after surgery. So, there's a chance that you could regain a lot of strength but be left with some degree of difference in size.
I hope these things will be helpful to you. I know that some of my suggestions may be one or two standard deviations away from the typical. But, you have an atypical problem.
* Herrington, L. (2006). "The effect of corrective taping of the patella on patella position as defined by MRI." Res Sports Med 14(3): 215-23.
Follow my
recovery from a meniscus tear here. New to the View? Consider
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Sparks"? You can order it here .
I received an email from a reader, Lisa, who had a total knee replacement about three months ago (thank you for reading Lisa and for buying The Little Book of Sparks!). All was well until she slipped and fell in her kitchen and ruptured the Vastus Medialis Oblique muscle (VMO - red area in the picture) and since then she has had a number of problems. Because the VMO helps stabilize your knee cap, when you rupture it, it's like cutting loose a mooring line on a ship on a windy day. Things get whacked around pretty good. She had to have the muscle surgically repaired to help re-align the patella.
Here's how she described it:
"The surgeon did a medial plication where he divided the medial retinaculum as it inserts into the patella. Then he reattached it more medially onto the patella itself in a pants over vest fashion. At the same time, he did a lateral retinacular release. Apparently, all of this is done in order to carefully balance my patella in the trochlear groove."
But, here's what has happened since.
"..... I'm still having trouble with the lateral part of the quad pulling my kneecap to the left. Also, the x-rays show that the patella is tilted and not sitting neatly in the groove as it was right after surgery. Repeat x-rays show that the patella has remained the same and is not any worse but it is certainly not in the groove. My orthopedist says that it could take up to a year for everything to stabilize with the patella, IF it does. I knew going in that the surgery may not work and that the VMO is a very hard muscle to rehab. Also, it seems that my muscle wants to stretch easily. In other words, the surgeon tightened the VMO because the initial injury and subsequent healing had resulted in extensive stretching of the muscle to the point that if any stress were put on my knee it would give way and I would fall. It looks as though it is probably stretching again....
She went on to say that she has good motion in her knee and can manage going up stairs but when she tries to step down, her kneecap shifts to the outside.
Do you have any suggestions? Would electrical stimulation help at all? Will I ever be able to get the left quad to act anywhere near like the right quad? Any help with this would be greatly appreciated."
First, here's my standard disclaimer. It's a lot easier to see, feel, and watch what a person is complaining about than it is to decipher over email. Video helps. Telephone helps. But, I'm an Intuitive so ideas just sort of appear in my head in the moment from the interaction. And I don't know your entire story, the surgeon, your therapist nor you. But you asked for suggestions and after reading your email I thought of a few things. So, here we go.
The issue, as you pointed out, is your VMO is likely too loose or long as well as weak. So, repeatedly bending and straightening the knee is probably not a great idea right now. And it's not just your muscle you have to be concerned about but the fascial connections within it and to the patella. All of that tissue has to tighten up. And you have to get your muscle to work again.
But I think first you need joint stability. Here are the ideas I had to address the instability.
I hope these things will be helpful to you. I know that some of my suggestions may be one or two standard deviations away from the typical. But, you have an atypical problem.
* Herrington, L. (2006). "The effect of corrective taping of the patella on patella position as defined by MRI." Res Sports Med 14(3): 215-23.
Follow my recovery from a meniscus tear here.
New to the View? Consider subscribing to my RSS feed: Subscribe to this blog's feed . Or sign up to get email updates in the box at the top right hand corner of my blog and then share this blog with your friends.
Do you have a copy of my book, "The Little Book of Sparks"? You can order it here .