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IntroductionAlthough open fractures of the patella arefrequently seen in patients with multipleinjuries, there are no clinical series reported.In a study by Torchia and LeWallen (1996),nearly all the fractures they examinedresulted from high-energy vehicular trauma.Patella fractures were among the first to betreated with open reduction and internalfixation to maximise functional outcome(Catalano et al, 1995). As a result of directcompressive and indirect forces on thepatellofemoral articulation, this open injuryoften involves soft tissue, bone and articularcartilage. In open injuries comminution,displacement and contamination canpresent a more difficult treatment problemthan the isolated closed patella fracture(Catalano et al, 1995; Koval and Kim, 1997;Torchia and LeWallen, 1996).

In the literature, treatment of openfractures for the knee has received littleattention (Torchia and LeWallen, 1996).Although there is agreement about the needfor rigid fixation and early joint motion,rehabilitation after surgical fixation for openpatella fractures is not well documented(Chapman, 1980).

Koval and Kim (1997) have documentedthat with a stable fixation, passive range ofmotion (ROM) exercises can begin 48 hoursafter surgery. Patients may then progress toactive ROM and isometric exercises. Oncethere is radiographic evidence of healing,then progressive resistance exercises areadded.

Despite these efforts, loss of knee motionis common following patella fractures and isusually due to fibrosis (Koval and Kim, 1997;Torchia and LeWallen, 1996).

Treatment of post-operative fibrosis or scartissue by cross friction massage has beenadvocated by Cyriax and is currently beingapplied extensively in clinical practice. Anexpanded form of soft tissue mobilisationknown as ASTM™ has been observed to beclinically successful in treating post-operativefibrosis (Melham et al, 1998; Davidson et al,1997). ASTM is a process that uses speciallydesigned instruments (Performance Dyn-amics, Muncie, USA) to help clinicians tomobilise soft tissue fibrosis.

ASTM is a descriptive name for atreatment which originates from andexpands upon the concepts of cross frictionmassage (Cantu and Grodin, 1992).Theoretically, ASTM works by allowingclinicians to introduce more effectively acontrolled amount of microtrauma into theaffected area (Buckley et al, 1991; Harrelson,1991; Stauber, 1990). This controlledmicrotrauma causes microvascular traumaand capillary haemorrhage that induces alocalised inflammatory response (Stauber,1990).

The inflammatory response is the first step in the body's healing cascade andimmune/reparative system (Leadbetter,1992; Stauber, 1990). This process appearsto stimulate connective tissue remodellingthrough resorption of excessive fibrosis,along with inducing repair and regenerationof collagen secondary to fibroblastrecruitment (Stauber, 1990; Gross, 1992).Essentially, ASTM induces resorption of scar tissue and stimulates an adaptiveremodelling of the affected area.

This case report identifies many of thedifficult aspects of treating a post-operativepatella fracture. In addition, the purpose ofthis case report was to determine whetherthis rehabilitation process could decreasepost-operative fibrosis, allowing increasedROM and function.

Rehabilitation of a Post-surgical Patella Fracture Case report

Summary A patient with an open knee fracture made littleprogress during a three-month course of conventionalphysiotherapy. After a further course of controlled microtrauma(ASTM) treatment for six weeks, however, his range of motionincreased, he walked without a limp, and he was pain free.

Key WordsPatella fracture, physical therapy, ASTM™.

by Paula Henry Beth PanwitzJulie K Wilson

Henry, P, Panwitz, B andWilson, J K (2000).‘Rehabilitation of a post-surgical patellafracture: Case report’,Physiotherapy, 86, 3, 139-142.

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The PatientA 20-year-old man ‘Tom’ was involved in amotor vehicle accident on April 29, 1997, inwhich he sustained an open patella fracturewhich was surgically repaired the same day.The surgeon placed him in a post-operativebrace locked at 30° of flexion for six weeks.He was then referred to our clinic forphysical therapy on June 25, 1997, with adiagnosis of post-operative right openpatella fracture.

Subjectively, Tom reported pain rangingfrom 4/10 at rest which intensified to 8/10with activity that lasted for minutes to severalhours. He was taking a prescribed narcotic(hydrocodone) for pain control andcomplained of constant pain, limited ROMand restricted activities of daily living. Hehad a decreased stance on the affected limb,with circumduction during the swing phase.Active and passive knee joint ROM meas-urements were taken (see table opposite).

Despite limited knee joint ROM, patellarmobility was good. The incision was wellhealed and mildly adhered. Quadricepsmass was significantly atrophied comparedto the left lower limb, and visually thepatient had poor quadriceps recruitment.

Tom’s family and personal medical history were negative with no knownrheumatological problems. His review ofsystems, other than musculoskeletalcomplaints, was negative, and social historywas unremarkable. He sustained noinfection from his injury or following thesurgery.

InterventionUpon completion of the evaluation, physicaltherapy was started, with a programmedesigned to increase ROM and function andto decrease his pain. ROM exercisesincluded:

� Passive ROM. � Heel slides (on the table and supine

against the wall). � Contract-relax exercises for the

quadriceps and hamstrings. � PNF exercises D1, D2 flexion and

extension for the lower extremity. � Stationary bike, using the unaffected leg

to control the speed and ROM.

Manual and active stretching exerciseswere included to address the hamstrings,quadriceps, gastrocnemius/soleus, andpiriformis.

Open kinetic chain isometric and isotonicstrengthening exercises were performedinitially and included:

� Quadriceps setting. � Straight leg raises. � Short arc quadriceps sets. � Hip abduction.

Functional electric stimulation was used inconjunction with straight leg raises forquadriceps recruitment. The electricstimulation was provided through a BMRNeuroTech 2000 using programme 0 (presetparameters at 50 Hz, 250 µ seconds) forseven seconds of contraction and 21 secondsof relaxation. All strengthening exerciseswere per formed with three sets of 10repetitions within the patient’s pain-freeROM. Tom then progressed to closed kineticchain strengthening exercises after the firstthree weeks which included:

� Wall squats for 20 to 60 seconds. � Single leg stance for balance. � Stationary bike. � Heel raises. � Lunges.� Single leg squats.� Leg press (single and double). � Hamstring curls.� Stairmaster. � BAPS (Balance and Ankle Proprioception

System) board seated and standing. � Power bands for both lateral and forward

motion.

Ultrasound at 3 MHz 1.0 W/cm2 pulsed at50% for six minutes was started in order toreduce patellar soreness. Ultrasound wasused for a total of seven treatments over thepatellar tendon. Once Tom began to regainsome knee joint ROM, joint mobilisationand cross friction massage were added to hisprogramme.

Tom was given this therapy at threesessions a week for 12 weeks. On September19, 1997, he was discharged on the ortho-paedic surgeon’s orders, with pain reportedat 2/10 at rest and 6/10 with activity. At thattime, he had 0° knee joint extension and 95°knee joint flexion.

On October 3, 1997, Tom returned underreferral of a different orthopaedic surgeon,who requested a continuation of physical

Authors and Addresses forCorrespondence

Paula Henry PT is thestaff physical therapist atBall Memorial HospitalHealth Strategies, whichis an outpatientrehabilitation cliniclocated at 113A SouthMemorial Drive, NewCastle, Indiana, USA47362.

Beth Panwitz ATC is thestaff certified athletictrainer at Ball MemorialHospital HealthStrategies.

Julie K Wilson MS ATC ispart of the researchdepartment at BallMemorial Hospital, whichis located at 3713 SouthMadison Street, Muncie,Indiana, USA 47302.

This article was receivedon March 19, 1999, andaccepted on November16, 1999.

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therapy with the addition of ASTM. His painand knee joint ROM remained the same asdocumented at discharge on September 19.

ASTM involves the use of speciallydesigned instruments that augment aclinician’s ability to perform soft tissuemobilisation (see figure). The instrumentsare solid specially made polyurethane hand-held devices with an angled edge, which areguided in a stroking motion along the skin.To reduce the coefficient of friction andprevent trauma to the overlying skin, cocoabutter is used as a lubricant between theinstruments and the skin during treatment.The instruments are moved with primarilylongitudinal strokes along the musculo-tendinous structures, and are used in multi-directional strokes around the bonyprominences of a joint. During eachtreatment session, the clinician goes througha progression of tools, from instruments with a larger area of contact, to those withprogressively smaller areas of contact. As theinstruments are passed over the skin, theclinician and patient can detect changes in the soft tissue texture through thereverberation of the instruments as theycontact the underlying tissue. Pressure isfirm enough to locate areas of change,presumably fibrosis, and to ‘catch’ on thoseareas to trigger an inflammatory response.

Tom was treated in this way while seatedand prone. This allowed the physicaltherapist to address the anterior, medial,and lateral aspects of the quadriceps,anterior and posterior tibialis, gastro-cnemius and soleus muscle structures, pesanserinus, and the knee joint regionincluding around the bony prominences.Marked fibrosis was noted along thequadriceps proximally at the rectus, distallyin the vastus medialis obliquus, and over thequadriceps tendon insertion at the superiorpatella.

Tom’s treatment session began with anactive warm-up on a stationary bike, followedby ASTM as described above for about five to10 minutes. He then performed stretchingexercises to lengthen the remodeling tissues.He was instructed to perform one repetitionof each stretch for 45 seconds. The closedkinetic chain strengthening exercises werethen performed, which stressed the affectedareas in order to influence the structuralalignment of the remodelling collagen fibresand soft tissue matrix.

Upon completion of treatment, an ice bagwas applied to the areas of fibrosis for five to10 minutes to limit post-treatment soreness.

Tom was instructed in a home stretchingprogramme consisting of the stretchesdescribed above to be per formed aminimum of four times daily, with one 45-second repetition of each exerciseperformed. He was encouraged to performas much activity as possible at home andwork, increasing his activity level as he wasable. He was advised to use ice as needed fordiscomfort.

After his first ASTM session, Tom’s kneejoint flexion increased to 113° whichenabled him to progress through thefunctional strengthening programme. Theexercises included resisted sports cord(forward/backward, lateral) and carioca(side-to-side motion with cross-over in themiddle of the body), jogging, agility andproprioceptive manoeuvres. The sports cordis attached to a harness and the wall andprovides resistance while the patient is in afully functional standing position.

Upon final discharge (November 16,1997), Tom had completed six weeks oftherapy, which included eight sessions ofASTM. He reported that pain at rest andwith activity was 0/10. His knee joint anglewas 0° extension and had increased to 121°flexion. He showed no limp and hadreturned to full functional daily activities,which included walking, jogging, going up

Pain, function, active and passive range of motion

First course of therapy Second course of therapy

Start Discharge Start DischargeJune 25 Sept 19 Oct 3 Oct 10 Nov 16

Pain with activity 8/10 6/10 6/10 2/10 0/10

Function Limp Limp Limp No limp No limp

Active knee flexion (°) 48 95 95 113 121

Passive knee flexion (°) 53 100 101 118 121

Active knee extension (°) 0 0 0 0 0

An ASTM instrument in use

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and down stairs, squatting, kneeling, etc. He was instructed to continue his homestretching programme as previouslydescribed, and was discharged.

Implications for PracticeIn physical therapy, treatment of patientsinvolves the selection of different techniquesto address patients’ specific needs for theirreturn to optimal function. In Tom’s case,ASTM was added to other techniques toaddress the specific problem of fibrosiswithin the quadriceps and knee joint.Although previous efforts in therapy hadprovided some relief, the patient continuedto report significant tightness, discomfort,and limitation in function. It was felt thatASTM could decrease the fibrosis present inthe area and enhance the other componentsof his therapy programme.

Tom experienced a significant increase inknee joint flexion and a decrease in painduring the first ASTM treatment, despite theduration of the injury and his previouscompliance with a thorough therapyprogramme. It appears that ASTM played acritical role in Tom’s improvement byinitiating the healing process to allow fortissue remodelling. The initiation of thishealing process through ASTM may have

been responsible for the rapid gain in ROMthat Tom experienced. The stretching andclosed chain activities provided essentialforces necessary to lay the blueprint for theremodelling collagen. Although each ofthese components was initiated beforeASTM, Tom gained minimal improvement atthat stage, while after the introduction ofASTM he demonstrated better objective andfunctional improvement.

ASTM, in our clinical experience, hasbeen very useful in increasing theeffectiveness of treatment for many types of soft tissue fibrosis. This case reportprovides clinical support for the conceptthat controlled microtrauma can lead tosubsequent regression of fibrosis in varioussoft tissue structures. The authors feel thatASTM, when added as a treatment option,alleviated Tom’s knee joint pain andstiffness. This improvement facilitated hisreturn to normal physical activities. Theauthors believe that various therapeuticinterventions such as stretching and closedchain exercises provide the forces necessaryfor appropriate remodelling of the tissue.ASTM may provide an effective treatmentoption for the frustrating problem of patellafracture.

Key Messages

� The table indicatesdata for passive andactive measurements ofknee joint ROM, painratings at rest and withactivity, and functionalstatus.

� Upon completion ofthe patient’s firstcourse of therapy (June25 to September 19,1997), the patient stillcomplained of pain atrest and with activity,and his knee jointROM was limited,causing him functionalrestrictions.

� Once the patientcompleted his secondcourse of therapy(October 3 toNovember 16, 1997)which included ASTM,his pain at rest andwith activity hadceased, and his kneejoint ROM increased,which allowed him toexpand his activities ofdaily living.

� Specifically, kneejoint flexion increasedfrom 95° to 121° (anincrease of 26°) withonly eight treatmentsessions.

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Melham, T J, Sevier, T L, Malnofski, M J, Wilson,J K and Helfst, R H (1998). ‘Chronic ankle painand fibrosis successfully treated with a new non-invasive augmented soft tissue mobilisationtechnique (ASTM): A case report’, Medicine andScience in Sports and Exercise, 30, 6, 801-804.

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