Physiotherapy 96 (2010) 269281

Systematic review

Clinical outcomes of rehabilitation for patients following lateral patellar dislocation: a systematic review
Toby O. Smith a,c, , Leigh Davies b , Rachel Chester b,c , Allan Clark c , Simon T. Donell c
a b

Institute of Orthopaedics, Norfolk and Norwich University Hospital, Norwich, UK Physiotherapy Department, Norfolk and Norwich University Hospital, Norwich, UK c Faculty of Health, University of East Anglia, Norwich, UK

Abstract Objectives Little has been published about which physiotherapy interventions are used to treat patients with instability of the patella. The purpose of this study was to review the literature systematically to determine the clinical outcomes of rehabilitation for patients following a lateral patellar dislocation. Data sources AMED, CINHAL, Cochrane Library, EMBASE, MEDLINE, PEDro and Scopus database searches were performed from their inception to August 2009. A search of unpublished and grey literature databases was undertaken, in addition to contacting all authors of included publications. Review methods All publications presenting the outcomes of patients following a conservatively managed lateral patellar dislocation were included. All eligible articles were appraised critically using the Critical Appraisal Skills Programme appraisal tool. Data on interventions, cohort characteristics, outcome measures and results were extracted. A narrative research synthesis method approach was adopted. Results In total, 29 publications were eligible for inclusion in this review. Although a proportion of patients experienced recurrent instability and dislocation episodes after rehabilitation, a large proportion of patients reported acceptable outcomes following physiotherapy. No randomised controlled clinical trials were identied assessing different physiotherapy interventions. The evidence base included a number of under-powered studies which poorly described the specic physiotherapy interventions prescribed. Conclusions Further, well-designed randomised controlled trials assessing different conservative management strategies with specic patient groups, to provide pre-intervention as well as follow-up data, are required to determine the optimal clinical outcomes of physiotherapy for patients following a lateral patellar dislocation. 2010 Chartered Society of Physiotherapy. Published by Elsevier Ltd. All rights reserved.
Keywords: Patellar dislocation; Physiotherapy; Rehabilitation; Conservative treatment; Systematic review

Introduction Patellar dislocation and associated recurrent instability is a complex musculoskeletal complaint. It commonly presents in young and physically active people [1,2]. Observational studies have estimated the incidence of patellar instability to be 43 per 100,000 [3], with a greater incidence in females than males [4]. Although not fully understood, the principal theory for a lateral patellar dislocation is based around the assump Corresponding author at: Institute of Orthopaedics, Norfolk & Norwich University Hospital, Colney Lane, Norwich NR2 7UY, UK. Tel.: +44 01603 286990; fax: +44 01603 287369. E-mail address: toby.smith@nnuh.nhs.uk (T.O. Smith).

tion that the patella disengages from the trochlear groove due to poor osseous constraint from the lateral femoral condyle [58]; or because the lateral tissues, such as the lateral retinaculum and vastus lateralis, are able to overcome weaker medial structures, especially the medial patellofemoral ligament and the distal vastus medialis or vastus medialis obliquus (VMO). In the latter case, patellar stability is primarily dependent on a patients soft tissue balance between the contractile and non-contractile medial and lateral structures. Historically, patients following a primary patellar dislocation have been managed conservatively. Such regimes have included a period of immobilisation and rest, followed by formal physiotherapy [8]. The aims of physiotherapy are to restore knee range of motion, and to strengthen the quadri-

0031-9406/$ see front matter 2010 Chartered Society of Physiotherapy. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.physio.2010.02.006

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T.O. Smith et al. / Physiotherapy 96 (2010) 269281 Table 1 Search strategy. 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. patella/ dislocations/ 1 OR 2 physical therapy (specialty)/ rehabilitation/ physiotherapy.tw. brac$.tw. immobili$.tw. splint$.tw. exercis$.tw. manual therapy.tw. mobilisation.tw. mobilization.tw. tape.tw. taping.tw. electrotherap$.tw. biofeedback.tw. ultrasound.tw. muscle stimulation.tw. electronic stimulation.tw. OR/4 20 3 AND 21 limit 22 to humans

ceps muscles with the aim of restoring soft tissue balance and patellar stability. However, recurrent patellar dislocation following a conservatively managed primary dislocation may occur in up to 44% of patients [9]. Recurrent patellar instability can have a considerable impact on a patients occupational and social pursuits, with a detrimental effect on their quality of life. In such cases, patients nd it difcult to engage in sporting activities and strenuous tasks, since they are unable to trust that their knee will be able to cope with relatively normal tasks undertaken in everyday life. Although physiotherapy has been advocated for decades to patients following a lateral patellar dislocation [9,10], there remains little consensus about the optimal method of rehabilitating this patient group. Physiotherapists and orthopaedic surgeons have principally associated any rehabilitation programme with the prescription of quadriceps exercises. However, over the past 20 years, clinicians have suggested that the VMO should be preferentially strengthened to improve the patellas medial contractile stability [1113]. This is based on the premise that the vastus medialis is assumed to be weaker or present with an abnormal onset timing compared with the vastus lateralis [14]. However, a previous systematic review indicated that it remains unclear whether the VMO can actually be preferentially targeted in patients following patellar dislocation, and there remains no evidence to demonstrate that a difference exists in onset timing between the vastus medialis and vastus lateralis in this patient group [14,15]. As a result, a considerable degree of confusion remains surrounding the optimal rehabilitation of patients following a patellar dislocation. Due to these uncertainties, the objective of this literature review was to determine the clinical outcomes following rehabilitation for patients following a lateral patellar dislocation.

Eligibility criteria This review included all full-text, randomised and non-randomised clinical trials and observational studies, published in any language, which presented the outcomes of patients who were conservatively managed following a lateral patellar dislocation. Publications assessing patients who reported primary patellar dislocation and recurrent dislocations were included. Papers where subjects presented with patellofemoral pain syndrome, patellar subluxation or generalised patellar instability symptoms, and did not report a convincing patellar dislocation, were excluded. In addition, where it was not possible to differentiate between clinical results following conservative compared with surgical procedures, papers were excluded. Finally, editorials, comments and letters, and cadaver and animal studies were also excluded. Study identication Two reviewers (TS, LD) independently reviewed all titles and abstracts that were identied from the search strategy. Full-text manuscripts for all potentially eligible studies were ordered. These were independently reviewed by each of the reviewers a second time in respect of the predened eligibility criteria. Data extraction Data extraction for each eligible paper was performed independently by two reviewers (TS, LD) using a predened spreadsheet. The reviewers spreadsheets were amalgamated to create an agreed extraction form. Data extracted included:

Materials and methods Data source The following electronic databases were searched: AMED (1985 to August 2009), British Nursing Index (1985 to August 2009), CINHAL (1982 to August 2009), EMBASE (1974 to August 2009), MEDLINE (1950 to August 2009) and PsycINFO (1806 to August 2009) via Ovid. Scopus and the Cochrane Library were also searched. The MeSH terms and keywords with the Boolean operators adopted are presented in Table 1. Unpublished literature was also assessed using SIGLE (System for Information on Grey Literature in Europe), the National Technical Information Service, the National Research Register (UK) and Current Controlled Trials databases with the search term patellar dislocation. The reference list from each pertinent full-text manuscript was scrutinised for any omitted studies. Attempts were made to contact all corresponding authors for each included paper in order to identify any additional publications which had not been highlighted through the search strategy.

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study design, sample size, duration from dislocation to rehabilitation, treatment strategies, clinical outcomes (recurrent dislocation, recurrent instability, functional outcomes, pain, range of motion, strength, apprehension, maltracking) and the follow-up period. In cases where insufcient data were provided within the publication, attempts were made to contact all corresponding authors to identify such data. Critical appraisal Each reviewer (TS, LD) appraised the included studies critically using the Critical Appraisal Skills Programme (CASP) critical appraisal tool [16]. The CASP tool is comprised of three appraisal sections: an assessment of study validity, an evaluation of methodological quality and presentation of results, and an assessment of external validity. If any disagreements arose regarding study selection, data extraction or appraisal score, these were resolved through discussion between the two reviewers. If agreement could not be reached, this would have been resolved through a third reviewer (RC). However, this was not required in this study.

Data analysis All analyses were initially undertaken by one reviewer (TS) and veried by another reviewer (LD). A narrative review was undertaken of all included literature. An assessment of the efcacy of different physiotherapy treatments through a meta-analysis was planned. However, it was not possible to conduct such an analysis since there was considerable methodological heterogeneity, particularly with the information provided about treatment intervention, whilst no studies had compared two different rehabilitation or physiotherapy strategies. Accordingly, there were insufcient data to conduct a meta-analysis.

Results Search strategy The results of the search strategy are presented in a PRISMA ow chart (Fig. 1) [17]. As Fig. 1 demonstrates, a total of 254 citations were identied through the search strategy. Twenty-nine papers satised the eligibility criteria and were therefore included in the review. This included 15

Fig. 1. PRISMA ow chart.

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Table 2 Summary of the studies reviewed.

Study Arnbjrnsson et al. [26] Atkins et al. [50] Numbers Patients 29 74 Knees 29 74 Mean age (years) SD (range) 25 (13 to 54) 19.9 (11 to 56) Gender (male/female) 7/22 37/37 Diagnosis and how made Two or more complete patellar dislocations Convincing history of primary patellar dislocation with haematosis/effusion; medial retinaculum tenderness; positive apprehension test Reported recurrent patellar dislocation Reported primary patellar dislocation; knee effusion; positive apprehension test; tenderness on medial retinaculum Primary patellar dislocation requiring manipulation for reduction Presented as a primary patellar dislocation to the hospital Locked dislocation of history of knee trauma, intra-articular haematoma, tenderness of the medial epicondyle and positive apprehension test Convincing history of patellar dislocation Positive apprehension test Evident or suspected patellar dislocation Convincing history of patellar dislocation on magnetic resonance imaging. Positive apprehension test N/S N/S Convincing history of patellar dislocation Convincing history of primary patellar dislocation with positive clinical diagnosis on evaluation N/S N/S Reported recurrent patellar dislocation Patellar dislocation on examination with convincing history and signs of patellar dislocation Observed locked primary patellar dislocation or dislocatable on examination under anaesthetic Unreduced patellar dislocation reported or observed in clinic Convincing history of patellar dislocation Clinically evident or suspected patellar dislocation Primary patellar dislocation with convincing history and clinical signs Reported primary patellar dislocation Primary patellar dislocation with convincing history and presentation Reported or observed traumatic primary patellar dislocation Primary patellar dislocation conrmed by physical examination and magnetic resonance imaging Reported primary patellar dislocation and evidence of physical examination Mean duration prior to commencing rehabilitation N/S <4 weeks Mean follow-up period (range) 14 years (11 to 19 years) 24 weeks

Bohannon [22] Buchner et al. [1]

1 63

1 63

29 21.1 (10 to 52)

1/0 35/28

21 years N/S

6 weeks 8.2 years (2 to 15 years)

Camanho et al. [34] Cash and Hughston [10] Christiansen et al. [35]

16 100 35

16 103 35

26.8 (12 to 74) N/S 19.9 (13 to 39)

7/9 N/S 18/17

3 to 4 weeks 14 days N/S

36.3 months 2 years (minimum) 2 years

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Coeld and Bryan [9] Garth et al. [54] Hawkins et al. [27] Helgeson and Smith [44] Hvass et al. [46] Kiviluoto et al. [2] Larsen and Lauridsen [40] Menp and Lehto [30] Menp et al. [49] Menp et al. [18] Marcacci et al. [19] McManus et al. [21] Nikku et al. [25] Nikku et al. [37] Osterhues [23] Palmu et al. [29] Pedersen and Pedersen [48] Racouillat [24] Savarese and Lunghi [20] Sillanp et al. [32] Sillanp et al. [33] Sillanp et al. [31]

45 68 20 1 37 77 71 100 82 75 16 33 57 55 1 28 26 1 17 22 53 76

48 79 20 1 37 77 79 100 82 75 16 33 57 55 1 28 26 1 17 22 53 76

17.6 (10 to 54) 16.4 (7 to 35) 19 (13 to 39) 23 18 (8 to 32) 23 18.7 (6 to 52) 23 (10 to 64) 36 (11) N/S N/S N/S 20 (8) 19.1 (7.5) 49 13 (2) 22 (11 to 74) 16 N/S 20.0 (19 to 21) 20.0 (19 to 23) 20.0 (19 to 22)

19/26 49/18 11/9 0/1 15/22 29/48 27/44 37/63 32/50 N/S 6/10 N/S 27/30 25/30 0/1 9/19 16/8 0/1 N/S 21/2 53/0 72/4

N/S 0 Approximately 4 to 5 days 4 weeks N/S N/S N/S N/S N/S N/S N/S N/S <14 days 14 days 3 days <2 weeks N/S 10 days N/S 1 day (0 to 7 days) <21 days Day 1

5 years (minimum) 2 years (minimum) 40 months (6 to 174 months) 12 weeks 31 months (15 to 64 months) 1 year 5.9 years (1 to 31 years) 13 years (6 to 26 years) 13 years (SD 5 years) 11 years (6 to 24 years) 30 years (20 to 45 years) 31 months (6 to 61 months) 7.2 years (5.7 to 9.1 years) 25 months (20 to 45 months) 5 weeks 14 years (11 to 15 years) 35 months (17 to 54 months) 9 weeks 3 years (11 months to 6 years) 7 years (6 to 9 years) 6.9 years (4 to 10 years) 7.5 years (6 to 11 years)

SD, standard deviation; N/S, not stated.

Table 3 Summary of the Critical Appraisal Skills Programme results.

Study design Focused question Appropriate design Population dened Recruitment methods acknowledged Sample size dened by power Study setting described Interventions described Physiotherapy treatment reproducible Outcome measures dened Observers dened Statistical methods described Variance described Inferential statistics employed Condence intervals presented Appropriate interpretation Generalisability Relevance to present evidence base Clinical relevance discussed Total Arnbjrnsson et al. [26] CC Yes Yes No No No No No No Yes No Yes Yes Yes No Yes No Yes Yes 9 Menp et al. [18] Obs No Yes No No No No No No Yes No Yes Yes Yes No Yes No Yes Yes 8 Atkins et al. [50] Obs Yes Yes Yes Yes Yes Yes Yes No Yes No Yes Yes Yes No Yes Yes Yes Yes 15 Menp and Lehto [30] Obs Yes Yes No No No Yes Yes No Yes No Yes Yes Yes No Yes No Yes Yes 11 Bohannon [22] CS Yes Yes Yes No No No Yes Yes Yes No No No No No Yes Yes Yes Yes 10 Marcacci et al. [19] CC No Yes No No No Yes No No Yes No No No No No Yes No Yes Yes 6 Buchner et al. [1] Retro No Yes No No No Yes No No Yes No Yes Yes Yes No Yes No Yes Yes 9 Camanho et al. [34] Obs Yes Yes Yes No No Yes No No Yes No Yes No Yes No Yes Yes Yes Yes 11 McManus et al. [21] Obs No No Yes Yes No Yes Yes No Yes No No No No No No Yes Yes Yes 8 Cash and Hughston [10] Retro No Yes Yes No No Yes Yes No Yes No Yes No No No Yes Yes Yes Yes 10 Nikku et al. [25] RCT No Yes Yes No No Yes Yes No Yes No Yes Yes Yes Yes Yes Yes Yes Yes 13 Christiansen et al. [35] RCT Yes Yes No No Yes Yes Yes No Yes No Yes Yes Yes No Yes No Yes Yes 12 Nikku et al. [37] RCT No Yes Yes Yes No Yes Yes No Yes No Yes Yes Yes Yes Yes Yes Yes Yes 14 Coeld and Bryan [9] Obs Yes Yes No No No Yes No No Yes No No No No No Yes No Yes Yes 7 Osterhues [23] CS No Yes Yes No No No Yes Yes Yes No No No No No Yes No Yes Yes 8 Garth et al. [54] Obs Yes Yes Yes No No No Yes Yes Yes No Yes No Yes No Yes Yes Yes Yes 12 Palmu et al. [29] RCT Yes Yes Yes No Yes Yes Yes No Yes Yes Yes Yes Yes No Yes Yes Yes Yes 15 Hawkins et al. [27] Obs No Yes Yes No No No No No Yes No No No No No Yes Yes Yes Yes 7 Pedersen and Pedersen [48] Obs Yes Yes No Yes No Yes Yes No Yes No Yes Yes Yes No Yes Yes Yes Yes 13 Hvass et al. [46] Obs No Yes Yes No No No No No No No No No Yes No Yes No No Yes 5 Racouillat [24] CS Yes Yes Yes No No No Yes Yes Yes No No No No No Yes Yes Yes Yes 10 Helgeson and Smith [44] CS Yes Yes Yes No No No Yes Yes Yes No No No No No Yes Yes No Yes 9 Savarese and Lunghi [20] Obs Yes Yes No No No No Yes No Yes No No No No No Yes Yes Yes Yes 8 Larsen and Lauridsen [40] Obs No Yes No No No Yes Yes No Yes No Yes No Yes No Yes No Yes Yes 9 Sillanp et al. [32] RCT Yes Yes Yes No Yes Yes Yes No Yes Yes Yes Yes Yes No Yes Yes Yes Yes 15 Kiviluoto et al. [2] Obs Yes Yes No No No Yes Yes No Yes No Yes No Yes No Yes No Yes Yes 10 Sillanp et al. [33] RCT Yes Yes Yes Yes No Yes No No Yes No Yes Yes Yes No Yes Yes Yes Yes 13 Menp et al. [49] Obs No Yes No No No No No No Yes No Yes Yes Yes No Yes No Yes Yes 8 Sillanp et al. [31] Obs Yes Yes Yes No No Yes Yes No Yes Yes Yes Yes Yes No Yes Yes Yes Yes 14

T.O. Smith et al. / Physiotherapy 96 (2010) 269281

Study design Focused question Appropriate design Population dened Recruitment methods acknowledged Sample size dened by power Study setting described Interventions described Physiotherapy treatment reproducible Outcome measures dened Observers dened Statistical methods described Variance described Inferential statistics employed Condence intervals presented Appropriate interpretation Generalisability Relevance to present evidence base Clinical relevance discussed Total

CC, casecontrol study; Obs, observational (prospective) study; CS, case study; Retro, retrospective study; RCT, randomised controlled trial. 273

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prospective observational studies, six randomised controlled trials of operative compared with non-operative management, four case studies, two casecontrolled studies and two retrospective studies. These are summarised in Table 2. Critical appraisal The ndings of the critical appraisal are summarised in Table 3. On analysis, the literature presented with a number of methodological limitations. Twelve studies did not dene their populations clearly in terms of diagnosis, duration since injury or past musculoskeletal history. Only four studies identied how subjects were recruited, whilst only four papers justied their sample sizes based on power calculations. Eighteen papers clearly described the interventions undertaken. Whilst the general management strategies undertaken were clearly described in these papers, only ve publications presented sufcient information to reproduce their methodologies for physiotherapy treatments. Furthermore, whilst all studies reviewed used appropriate outcome measures to evaluate their cohorts, only three studies detailed the number or types of assessors employed. No studies blinded their assessors or patients to the treatments prescribed. Whilst inferential statistics were presented in 19 publications, condence intervals were only provided in two papers. However, all authors interpreted their ndings appropriately and related these results suitably to clinical practice and the existing evidence base. Population characteristics The population characteristics of patients included in the review are summarised in Table 2, whilst Table 3 summarises the rehabilitation strategies adopted in each paper. A total of 1210 patients and 1218 knees were included. Mean reported patient age was 21.4 years [standard deviation (SD) 7.2]. In ve papers, the average age was not detailed [10,1821]. Four hundred and ninety-three males and 490 females were recruited within 25 studies. Patient numbers were not documented in four studies [10,18,20,21]. The most commonly used criterion to diagnose the occurrence of a lateral patellar dislocation was the patients ability to provide a convincing report of a patellar dislocation, such as visualisation of the dislocated patella and then, in some cases, its spontaneous reduction or the necessity for its manual reduction. This was applied in 15 studies. In addition, a positive apprehension test and tenderness on medial retinaculum palpation were also used in the diagnosis of ve and three cohorts, respectively. Nine studies diagnosed a lateral patellar dislocation through the requirement of the patella being reduced under anaesthesia or through radiological evidence of a locked patella. Three studies did not state what criteria were used to identify their sample of patients following patellar dislocation. Twenty-two studies described that their cohorts were primary patellar dislocations, whereas two studies described that their cohorts had sustained recur-

rent dislocations. The remaining ve studies did not state whether their patients had experienced a primary or recurrent dislocation (Table 4 ). The mean duration from primary dislocation to intervention was 7.6 days (SD 9.5), stated in seven studies. Three studies reported that rehabilitation began within 14 days of the primary patellar dislocation, one reported that rehabilitation commenced less than 28 days after injury, and one study stated that the reported rehabilitation programme began 21 years since the patients primary dislocation [21]. The mean follow-up duration of the reviewed cohorts was 6.1 years (SD 6.8), ranging from 5 weeks [22] to 45 years [18]. Clinical outcomes A variety of different clinical outcomes have been reported in patients following physiotherapy management after a lateral patellar dislocation. These will be assessed individually below. Functional assessment A number of different assessment methods were used to determine the functional outcomes of patients following rehabilitation of a patellar dislocation. These methods included the Kujala score [28], assessed in nine studies [17,25,2935]; the Lysholm knee score [36], assessed in three studies [1,26,37]; the Hughston visual analogue scale knee score [38], assessed in three studies [25,29,37]; and the Tegner level of activity score [39], assessed in six studies [1,25,29,31,33,37]. In addition, two studies [19,40] presented their functional outcomes using the Crosby and Insall assessment tool [41,42], one study assessed their cohort with the Lower Extremity Functional Scale [43,44], Savarese and Lunghi [20] assessed the functional outcomes of their cohort using the Hall assessment [45], and Hvass et al. [46] assessed outcomes using the Cox rating system. Although they did not state the specic tool used, Christiansen et al. [35] assessed patellar instability using a patellar instability score, in addition to using the Knee Injury and Osteoarthritis Scores [47]. The results of these tests indicated that, after a patellar dislocation, patients regain acceptable to excellent function following rehabilitation. There was no substantial difference in the individual outcomes between the studies. Only the result of the Tegner activity score presented a difference between studies. For this outcome measure, patients reported a mean post-rehabilitation Tegner score of 6.2, ranging from 4.6 [1] to 6 [29]. Two studies reported a decrease in activity level after dislocation by 0.7 [37] and 2.2 [1], whilst one study reported an increase in Tegner score after physiotherapy by 1 point [29]. Whilst there was no substantial difference in the treatment strategies adopted between the groups, as acknowledged earlier, this may be attributed to a difference between the cohorts, where Palmu et al.s [29] sample consisted solely of young patients, whilst Nikku et al.s [37] and Buchner et al.s [1] studies included adult patients.

T.O. Smith et al. / Physiotherapy 96 (2010) 269281 Table 4 Conservative treatment strategies used.

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276 Table 4 (Continued )

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Fig. 3. Frequency of recurrent instability (not dislocation) symptoms after rehabilitation.

Fig. 2. Frequency of recurrent patellar dislocation after rehabilitation.

Recurrent dislocation and instability Twenty-two studies assessed the frequency of recurrent patellar dislocation. These indicated that 33% (range 6% to 100%) of patients reported repeated patellar dislocation after rehabilitation. As Fig. 2 demonstrates, two studies presented with a considerably higher percentage of recurrent dislocation than the other studies [22,29]. Bohannons [22] study was a short follow-up, single case study assessing the treatment effects of electronic stimulation alone. Palmu et al.s [29] study was the only research which solely recruited people under 16 years of age. A recurrent dislocation rate of less than 10% was reported in one study [21]. In this paper, only two cases (6%) experienced recurrent patellar dislocation. The treatment strategies used in this study (a period of immobilisation followed by quadriceps strengthening exercises) were comparable to those documented by all eight studies which reported a recurrent dislocation rate of less than 20% [20,2932,37,48]. Twelve papers presented data assessing the frequency of instability or subluxation symptoms in the absence of frank dislocation events after an initial lateral patellar dislocation. These reported that 27% (range 15% to 70%) of cohorts reported recurrent instability following rehabilitation. As Fig. 3 demonstrates, this trend was consistent between the studies, with the exception of Nikku et al.s [25] ndings which reported that 70% of their cohort presented with recurrent patellar instability following rehabilitation. Unfortunately, Nikku et al. [25] did not state what treatments were included in their rehabilitation programme to assess whether this difference in recurrent instability or subluxation was attributable to the interventions provided. Furthermore, this studys follow-up period was considerable longer (mean 7.2 years) compared with others reviewed [20,21,34,46,48], which may have contributed to this higher recurrent instability rate (Fig. 4).

Pain Five studies assessed knee pain at 2.5 to 3 years following rehabilitation [20,27,46,48]; one study assessed knee pain at 8 years follow-up [1]. All studies reported that pain remained in a proportion of their cohort on follow-up. There was considerable variation in the method of assessing this outcome. Hawkins et al. [27] stated that ve patients (25%) reported mild pain, six patients (30%) reported moderate pain and four patients (20%) reported severe pain. Pedersen and Pedersen [48] stated that nine subjects (35%) reported pain at rest. Savarese and Lunghi [20] indicated that seven patients (41%) reported pain, whilst Hvass et al. [46] stated that eight patients (22%) reported pain. Buchner et al. [1] assessed pain using a visual analogue scale with a mean follow-up period of 8 years. They reported a mean score of 3 in their cohort at this longer-term measure. Due to the variation in the methodology of assessing pain between these studies, it was not possible to gain a consensus about whether the different interventions used in managing this patient group substantially inuenced perceived pain.

Fig. 4. Need for surgical intervention after rehabilitation.

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Range of knee motion Knee range of motion was assessed through a variety of different methods in eight studies [20,23,29,30,32,44,49,50]. There was some variation in the reported results. Osterhues [23] reported that knee range of motion was equal between the dislocated and contralateral limb at 5 weeks, whilst Helgeson and Smith [44] reported that full range of motion was obtained following 12 weeks of rehabilitation. Whilst not stating the extent, Savarese and Lunghi [20] reported that knee range of motion was limited in 12% of cases at nal follow-up. When analysing the treatment strategies adopted, Osterhues [23], Helgeson and Smith [44] and Atkins et al. [50] incorporated range of motion exercises into their rehabilitation programmes, whereas Savarese and Lunghi [20], Palmu et al. [29], Menp and Lehto [30] and Sillanp et al. [32] solely prescribed muscle strengthening exercises. This may have accounted for this difference in outcome. Using a more objective description of range of motion, Sillanp et al. [32] assessed total range of motion. They reported a mean range of 140 degrees, ranging from 130 to 150 degrees. Atkins et al. [50] presented extension and exion range of motion values in their observational cohort study. They reported a mean extension of 0 degrees (5 to 5 degrees), whilst exion was measured as 132 degrees ranging from 75 to 155 degrees. Menp et al. [49] and Menp and Lehto [30] reported that a exion decit was evident in 23% and 21% of their cohorts, respectively. An extension decit was also exhibited in 15% and 13% of patients in these studies [30,49]. Since there was limited information on the rehabilitation protocols of Menp et al.s [49] and Menp and Lehtos [30] studies, it was not possible to determine whether the difference between these studies and those of Atkins et al. [50] and Sillanp et al. [32] were associated with the interventions prescribed. Muscle strength and power Muscle strength and power was assessed through the Medical Research Councils (MRC) muscle rating system, isokinetic strength and observational assessment. All studies suggested that after rehabilitation, muscle strength remained reduced in a proportion of patients. One study assessed muscle strength using the MRC observational grading system [51]. This case report showed an improvement in quadriceps strength from 2+/5 to 4+/5 over a 9-week period [24]. Three studies presented the results of isokinetic lower limb strength and power following rehabilitation [18,49,50]. Atkins et al. [50] reported that isokinetic knee extension torque was greater than 80% of the contralateral limb in 60 out of 74 patients by 24 weeks. Menp et al. [18] demonstrated that there was a 10% decit in quadriceps muscle testing at a mean of 11 years follow-up when assessed at 60 degrees knee range, whereas there was no signicant decit at full extension. Although Menp et al. [49] did not comment on isokinetic decit following a rehabilitation programme, they reported that at nal follow-up, there was a signicant

difference in quadriceps torque, with less torque measured in recurrent compared with non-recurrent dislocation patients, but no signicant difference in hamstring torque between these groups (P < 0.05) [49]. On comparing these results, as Table 2 demonstrates, only Atkins et al. [50] presented details on which physiotherapy interventions and exercises were taught to these patients, whilst Menp et al. [18,49] neglected to provide this important information. Three studies evaluated quadriceps atrophy [20,23,27]. Osterhues [23] reported minimal quadriceps atrophy in their single case study at nal (5 weeks) follow-up. However, Hawkins et al. [27] reported that 20% of patients presented with observable quadriceps atrophy at a mean 40 months follow-up, and Savarese and Lunghi [20] reported that 76% of patients exhibited quadriceps atrophy at 3 years. The difference in outcomes may be attributed to the structured exercises prescribed to Osterhuess [23] case, whilst Hawkins et al.s [27] patients did not receive physiotherapy exercises as part of their intervention. Furthermore, Savarese and Lunghis [20] cohort, who presented with a high incidence of quadriceps atrophy, were prescribed isometric quadriceps exercises. Since these exercises have been shown to have a limited effect on muscle hypertrophy [52], this may have accounted for these ndings. Apprehension The apprehension test was assessed in ve studies after rehabilitation [20,21,27,37,40]. A positive apprehension test was recorded in a mean of 47.9% (SD 19.5) of these cohorts, ranging from 29% [37] to 82% [21]. Whilst there was a considerable range in apprehension test results, the treatment strategies were broadly similar between the studies, consisting of immobilisation followed by various forms of quadriceps exercises. The only exception was Hawkins et al.s [27] study, where patients did not receive any exercises; this study reported a positive apprehension test in 10 patients (50%). Maltracking Patellar maltracking was assessed clinically in two studies after rehabilitation [27,50]. Hawkins et al. [27] reported that eight out of 20 patients still presented with maltracking on review at 40 months. Conversely, only 12 patients in Atkins et al.s [50] cohort of 74 patients presented with lateral patellar tracking at an earlier 12-week review. This difference in maltracking may be related to the interventions prescribed, since subjects in Hawkins et al.s [27] study were solely immobilised and did not receive exercises, whereas Atkins et al. [50] prescribed passive and closed chain strengthening exercises to their cohort.

Discussion This study has identied that although recurrent instability and dislocation appeared to continue for a number of patients, a large proportion of cohorts have reported accept-

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able outcomes following rehabilitation. It was not possible to determine the efcacy of different physiotherapy treatments used for patients following a lateral patellar dislocation, since no studies used a control group or compared two or more physiotherapy interventions using well-designed randomised controlled trials. This review identied that the methodological quality of the present evidence base exhibits a number of limitations. The most pressing was that the efcacy of different physiotherapy treatments used in the management of patients following patellar dislocation cannot be determined, since no randomised controlled trials have been conducted. Without this, it is not possible to determine treatment efcacy. Similarly, the cohort and rehabilitation programmes were heterogeneous between studies. Therefore, it is not possible to state whether outcomes should be attributed to a specic modality, or whether any differences were a consequence of population variance. In general, the papers poorly described the physiotherapy interventions utilised. For instance, the specic positioning, frequency, duration or progression of exercise programmes was only detailed sufciently in two papers [23,24], thereby limiting clinical interpretation. In addition, sample sizes were not based on power calculations. Accordingly, the samples recruited may not necessarily have been large enough to detect a difference in outcome following a rehabilitation programme, irrespective of whether or not a difference existed [53]. The method of recruitment of patients was not clearly stated. It was therefore unclear whether allocation bias impacted on ndings or whether some patients were excluded from presented series due to poor outcomes. The papers poorly described who assessed the subjects. Accordingly, it was not possible to determine whether measurement error inuenced the results obtained, or whether the experiences or training of the assessors was a variable which may have accounted for any between-study differences. Finally, pre-physiotherapy baseline data were only presented for Tegner scores in three studies. Consequently, it was not possible to determine the effect of physiotherapy on each patients recovery for all other outcome measures. These limitations should be considered when designing future longitudinal cohort studies and randomised controlled trials. There is considerable variation in clinical presentation and anatomical abnormalities within the patellar dislocation population [29,31,37]. For example, patients can be hypermobile, exhibit trochlear dysplasia, patella alta, rupture of the medial patellofemoral joint, or various proximal or distal biomechanical variances such as poor glutei muscle control or femoral, tibial or forefoot rotational abnormalities. Studies have not categorised patients by their principal anatomical presentation (e.g. osseous, soft tissue or biomechanical abnormality) to differentiate their aetiological features. The ability to dene the patient population under study would produce greater external validity for clinicians and improve generalisability. This is of considerable importance since such anatomical abnormalities are considered prognostic indicators [18,30,50,54]. This should be considered further when

reviewing literature, and when adopting such ndings into clinical practice. The literature poorly differentiated between the assessment of recurrent and primary patellar dislocation. As well as potentially presenting with anatomical differences [18,30], patients who sustain recurrent patellar dislocations frequently receive physiotherapy a number of times over a period of years as this is considered the mainstay treatment following a patellar dislocation [8,55]. Attitudes to physiotherapy may differ between patients who experience a single isolated patellar dislocation and patients who have suffered recurrent dislocations. It is suggested that health beliefs and patientphysiotherapist interactions may be an important variable, despite being complex, which could be associated with differences in outcomes between primary and recurrent patellar dislocation rehabilitation. There was considerable between-study variability for the initial management of patients following a patellar dislocation. As Table 2 demonstrates, the methods for immobilisation varied widely between studies, from no immobilisation to immobilisation using a cylinder cast. Furthermore, the duration of immobilisation also varied from 0 days [54] to 6 weeks [9,31]. Whilst it remains unclear whether the type of immobilisation inuences outcomes, Menp et al. [49] suggested that the duration of immobilisation had a substantial effect on outcome, citing that immobilisation causes atrophy of type I and type II muscle bres, in addition to degenerative changes of bone, cartilage and ligaments [30,49,56,57]. It is therefore recommended that the efcacy of immobilisation and its potential impact on physiotherapy rehabilitation should be considered and standardised when designing future research, to prevent these factors acting as confounding variables. Although used in two studies [34,54], the literature did not indicate overall that specic VMO exercises are widely used in practice. Neither of these studies stated the outcome of VMO exercises on muscle power, recurrent dislocation or instability. This is important given that there remains particular controversy over the prescription of specic VMO exercises in this patient group. Previous authors have suggested that an abnormality in VMO onset timing or activity may be an aetiological factor in the development of patellar dislocation and instability symptoms [11,12,58,59]. Nonetheless, it still remains uncertain whether there is a difference in VMO onset timing or activity in patients following patellar dislocation [15], or whether the VMO can be preferentially strengthened in this patient group [14]. However, textbook and academic papers have widely suggested that VMO exercises should be included in the rehabilitation of patients following patellar dislocation [6,13,60].

Conclusions This review indicated that a variety of different physiotherapy strategies have been reported for the rehabilitation

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T.O. Smith et al. / Physiotherapy 96 (2010) 269281 [16] CASP (Critical Skills Appraisal Programme) homepage. Oxford: Learning & Development Public Health Resource Unit, 2007. Available at: http://www.phru.nhs.uk/casp/critical.appraisal-tools.htm (last accessed 01/08/2009). [17] Moher D, Liberati A, Tetzlaff J, Altman DG, the PRISMA Group. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. BMJ 2009;339:3326. [18] Menp H, Huhtala H, Lehto MUK. Recurrence after patellar dislocation. Redislocation in 37/75 patients followed for 624 years. Acta Orthop Scand 1997;68:4246. [19] Marcacci M, Zaffagnini S, Iacono F, Visani A, Petitto A, Neri NP. Results in the treatment of recurrent dislocation of the patella after 30 years follow-up. Knee Surg Sports Traumatol Arthrosc 1995;3:1636. [20] Savarese A, Lunghi E. Traumatic dislocations of the patella: problems related to treatment. Chir Organi Mov 1990;75:517. [21] McManus F, Rang M, Heslin DJ. Acute dislocation of the patella in children. Clin Orthop 1979;139:8891. [22] Bohannon RW. Effect of electrical stimulation to the vastus medialis muscle in a patient with chronically dislocating patellae. A case report. Phys Ther 1983;63:14457. [23] Osterhues DJ. The use of Kinesio Taping in the management of traumatic patella dislocation. A case study. Physiother Theory Pract 2004;20:26770. [24] Racouillat M. Use of plyometrics in the rehabilitation of a female lacrosse player following patellar dislocation. Orthop Pract 2007;19:18994. [25] Nikku R, Nietosvaara Y, Aalto K, Kallio PE. Operative treatment of primary patellar dislocation does not improve medium-term outcome. A 7-year follow-up report and risk analysis of 127 randomized patients. Acta Orthop 2005;76:699704. [26] Arnbjrnsson A, Egund N, Rydling O, Stockerup R, Ryd L. The natural history of recurrent dislocation of the patella. Long-term results of conservative and operative treatment. J Bone Joint Surg 1992;74B:1403. [27] Hawkins RJ, Bell RH, Anisette G. Acute patellar dislocations. The natural history. Am J Sports Med 1986;14:11720. [28] Kujala UM, Jaakkola LH, Koskinen SK, Taimela S, Hurme M, Nelimarkka O. Scoring of patellofemoral disorders. Arthroscopy 1993;9:15963. [29] Palmu S, Kallio PE, Donell ST, Helenius I, Nietosvaara Y. Acute patellar dislocation in children and adolescents: a randomized clinical trial. J Bone Joint Surg 2008;90-A:46370. [30] Menp H, Lehto MUK. Patellar dislocation. The long-term results of nonoperative management in 100 patients. Am J Sport Med 1997;25:2137. [31] Sillanp PJ, Menp HM, Mattila VM, Visuri T, Pihlajamki H. Arthroscopic surgery for primary traumatic patellar dislocation. A prospective, nonrandomized study comparing patients treated with and without acute arthroscopic stabilization with a median 7-year followup. Am J Sport Med 2008;36:23019. [32] Sillanp PJ, Mattila VM, Menp H, Kiuru M, Visuri T, Pihlajamki H. Treatment with and without initial stabilizing surgery for primary traumatic patellar dislocation. J Bone Joint Surg 2009;91-A:26373. [33] Sillanp PJ, Peltola E, Mattila VM, Kiuru M, Visuri T, Pihlajamki H. Femoral avulsion of the medial patellofemoral ligament after primary traumatic patellar dislocation predicts subsequent instability in men: a mean 7-year nonoperative follow-up study. Am J Sports Med 2009;37:151321. [34] Camanho GL, Viegas AdC, Bitar AC, Demange MK, Hernandez AJ. Conservative versus surgical treatment for repair of the medial patellofemoral ligament in acute dislocations of the patella. Arthroscopy 2009;25:6205. [35] Christiansen SE, Jakobsen BW, Lund B, Lind M. Isolated repair of the medial patellofemoral ligament in primary dislocation of the patella: a prospective randomised study. Arthroscopy 2008;24:8817. [36] Lysholm J, Gillquist J. Evaluation of knee ligament surgery results with special emphasis on use of a scoring scale. Am J Sport Med 1982;10:1504.

of patients following lateral patellar dislocation. The optimal strategy is not yet known. Accordingly, a well-designed randomised controlled trial is required to determine how best to manage patients following a lateral patellar dislocation to improve the management of this complex musculoskeletal condition.

Acknowledgements The authors wish to thank the library staff at the Norfolk and Norwich University Hospitals Sir Thomas Browne Library for their assistance in gathering the papers required for this study. Ethical approval: None required. Funding: This study forms part of a PhD undertaken at the University of East Anglia by Toby Smith, which has been partly funded by Action Arthritis. Conict of interest: None declared.

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