“Very frequently, it’s the knee that suffers”

An impact, an unfortunate turn, or excessive strain on the knee, and the kneecap can jump out of its natural path. In addition to trauma and anatomical predispositions, functional inappropriate mechanical stress is often a cause of dislocations, observes Physical Therapist Steffen Wiemann. The Manager at TRIMEDIC in Karlsruhe explains the complex interaction of possible aspects compromising a securely guided patella. The problem is rarely isolated and therefore usually requires a comprehensive treatment approach where supports, such as the new GenuTrain P3, can help.

Steffen Wiemann: I primarily see two patient groups with patellar dislocations. Young, physically active people in their twenties where acute trauma is usually the trigger. More often, however, it’s patients from the age of about 40 with function-related inappropriate mechanical stress being the cause.

Steffen Wiemann: Morphological risk factors, such as trochlear dysplasia or patella alta, an increased TT-TG distance¹ and the integrity of the medial patellofemoral ligament (MPFL) must be checked and taken into account. They increase the risk of recurrence and impact the physician’s treatment decisions as well as approaches. But in my experience, patellofemoral problems are primarily the manifestation of compromised neuromuscular joint guidance, not structural damage. They mainly represent a problem with regulation and guidance.

Steffen Wiemann: Even if nothing much stands out during the imaging, there can be significant problems. Analyzing movement, muscle activation, and strain management is therefore key.

Steffen Wiemann: I look at the patient’s gait: How does the patient walk when entering my office? This is followed by the medical history: What does the patient tell me? Symptoms are often protracted and the condition has become chronic. Then I’ll check statics with rapid tests: Can the patient squat down, for example? After that, I’ll look at the patient’s back. If the sacroiliac joint has a dysfunction, there may be tension in the quads and hamstrings, which, in turn, increases tension on the patella. I do all this to support the physician’s treatment decisions as effectively as possible and to base my approach on them. We work in close cooperation and coordinate if applicable.
I examine the knee with the patient lying down. What are the contours like? Is there any swelling? I check the mobility and gliding characteristics of the kneecap, always in comparison with the healthy side. This is followed by further rapid tests to identify whether the problem primarily relates to muscles, fasciae, tendons, or nerves. These are all factors that can impair the kneecap’s dynamic guidance and cause patellofemoral pain.

Steffen Wiemann: Yes, very frequently, it’s the knee that suffers but the cause is elsewhere. The patella is very sensitive to changes in neuromuscular control which impact functional interaction along the leg axis. Dysfunctions in the ankle always result in inappropriate mechanical stress in the knee joint. Imbalances in the back and hip muscles can affect the quads. A compressed femoral nerve can impair reflexes, leading to patellar instability. I therefore try to find the cause first.

Steffen Wiemann: Strength and coordination are important, but so is mobility. And being mobile means: having elasticity. The quadriceps muscle exerting its strength is dependent on its tendon. If the tendon loses elasticity, the lengthening-shortening cycle will be restricted. The contact pressure behind the kneecap will increase. If this is ignored, reactions caused by excessive strain will occur. If subjected to tension, the iliotibial tract can promote the knee’s valgus position via its myofascial connections and increase tension on the MPFL, which affects the patella’s movement in its natural path. The kneecap moves outward and opens up on the inside.

“Patella problems are harder to treat than you think.”

Steffen Wiemann

Steffen Wiemann: Every patient is different and requires an individual training program based on a differentiated analysis. But exercises for torso stabilization and improvement of elasticity in the anterior muscle chain are almost always a part of it. Evidence-based rehabilitation concepts highlight the significance of neuromuscular training strategies compared to isolated strengthening. Focus is therefore on targeted muscle activation, axis stabilization, and strain management. If dynamic guidance is optimized, problems can usually be reduced in the long term.

Steffen Wiemann: The early stage focuses on the reduction of joint-related muscle inhibition, mainly concerning the quads, for example, using isometric contraction in flexion angles that cause very little pain. At the same time, we’re activating the posterior muscle chain and the hip-stabilizing muscles. Proprioceptive exercises on something unstable or using disruptive stimuli are important to improve awareness of the joint position and response time reacting to unexpected strain. Exercises for valgus prevention, such as controlled step-down movements, promote dynamic axis control. As training progresses, reactive components will be added. Unexpected impulses, changes in direction, or landing mechanisms promote the anticipatory and reflexive stabilization of the joint system. For physically active patients, we integrate sports-specific patterns of strain at the end and gradually increase intensity.

Steffen Wiemann: I believe that knee supports which guide the patella are an excellent tool during transitions, for example, when returning to sports and the associated strain, or during phases of increased insecurity because they improve proprioceptive feedback. After a first dislocation or with pronounced feelings of instability, they can support medial patellar guidance, reduce pain, and improve subjective confidence when subjected to strain. They act as a functional amplifier of active treatment. They’re no substitute but a useful addition.

Steffen Wiemann: I think it’s cleverly designed. The support combines biomechanical precision with sensorimotor activation. The knee pad provides different types of stimulation, it prevents pressure peaks, and, together with the dynamic strap, centers the patella. I like how the strap is positioned laterally to help medializing tension during flexion. That means the patient can control the pressure caused by strain more effectively. The small grooved pad on the thigh can relax the pressure exerted on the iliotibial tract by the fascia, which reduces lateral tension on the kneecap. The support therefore helps with proprioception by increasing mechanical stimuli on ligaments and muscles, thus promoting neuromuscular control. For me, as a physical therapist, this offers welcome assistance because the patient needs to get involved at home and when the prescription has finished.

Steffen Wiemann: A current patient comes to mind straight away: a professional football player, early 20s, trauma during a match, patellar dislocation, two cartilage flakes behind the kneecap and in the area of the trochlea. He underwent surgery and we’ll be treating him for 12 weeks. Now, after seven weeks, is where the critical phase begins. He is no longer in pain and can be subjected to strain. In a half-squat, he can’t stretch the affected leg yet, he’s shaking, and activation doesn’t work. The surgeon specifically instructed not to use the stairs for three months because the contact pressure is too high. The patient is dependent on the correct guidance at the moment because the cartilage won’t attach otherwise. If the physician agrees, I’d like to use the GenuTrain P3, in addition to treatment. The patient will benefit from an improved feeling during movement as well as some protection.

“The new GenuTrain P3 combines biomechanical precision with sensorimotor activation. It acts as a functional amplifier of active treatment and is a useful addition.”

Steffen Wiemann

Steffen Wiemann: It’s generally good for patients suffering from dislocation. But also for patients with chronic problems. I’m currently treating a patient in his early 50s who suffers from patellar tip syndrome. He’s sporty but has had ongoing problems for a year now. The ultrasound shows an irritated, swollen patellar tendon insertion as well as irritation in Hoffa’s fat pad. When palpating the knee, I can feel clear crepitation, meaning the gliding characteristics aren’t very good. The tension test of the tendon and fascia structures shows that there is little elasticity and high contact pressure. The knee support could relieve the knee. The frictional nubs along the lower edge of the knee pad stimulate Hoffa’s fat pad. The thigh pad has an effect on the areas that we also include in osteopathic trigger point treatment to relax the fasciae and reduce tension on the kneecap. These are all important additional stimulations to help the body regulate itself more effectively.

Steffen Wiemann: Definitely. Patella problems are harder to treat than you think. So it’s handy that I can set up different levels with the GenuTrain P3. Functional stability and subjective confidence are improved in the long term. Patients can trust in their movement again.

¹ The Tuberositas-Tibiae-Trochlea-Groove distance is measured using MRI. A greater distance indicates an increased risk of patellar dislocation.

Improved patellar guidance with the new GenuTrain P3

The new GenuTrain P3 generation supports treatment of patellar dislocation and patellofemoral problems. The corrective strap now integrated in the knee pad surrounds the patella laterally, ensuring improved power transfer and noticeable relief, thanks to its special deflection.
Find out more.

Pictures: Andreas Wetzel, Bauerfeind AG