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Ask Dr. Rick – September 2010

September 2, 2010

Knee Patella Instability

With the summer in full flow, knee injuries to both men and woman are on the rise. One of the more common problems that we see here at the U.S. Center for Sports Medicine in young athletes is instability of the patella. This can happen traumatically or atraumatically. In a traumatic dislocation or subluxation, the kneecap usually slides to the outside of the leg and stays dislocated for a period of time. A subluxation is when the kneecap slides out and then immediately reduces. Again, the kneecap can immediately reduce or remain dislocated and require a form of reduction, either by a coach, parent or an emergency room doctor. Transient instability is when the kneecap shifts and comes back. It can occur on a daily basis, can be painful and can also create damage in the knee joint surfaces.

Treatment for patellofemoral instability, which is a common problem in young athletes, is usually physical therapy. In cases where the instability cannot be cured by strengthening, physical therapy and bracing; surgical resolution to reconstruct in the inside ligaments of the knee
(the medial patellofemoral ligament) is required. If there is joint damage or the articular cartilage has been traumatized, pieces chipped off or floating in the knee joint, this needs to be addressed arthroscopically.

After one traumatic dislocation, the athlete should be treated conservatively in a brace with physical therapy and rest. If the athlete experiences multiple dislocations, this should be assessed for possible surgery. In patients that have atraumatic instability, meaning that the kneecap dislocates without any type of trauma or rotational stress to the knee, the first line of defense is physical therapy and prolonged efforts to strengthen the quadriceps mechanisms, the hip muscles and the core stabilizers is recommended prior to any type of surgical consideration. In short, get strong and try to avoid patellar shifting as well as joint damage, which can lead to arthritis in later years.

Ask Dr. Rick

“Dr. Rick: I very much enjoy reading your column and had an incident two months ago that I would like you to address. I slammed my finger in a car door and had a large amount of blood underneath my middle fingernail. My mother suggested I take a paper clip, heat it up with a match and make a hole on the top of my nail to get the blood out. I tried to do this and no blood came out. Now, I am wondering what the right thing is to do if in fact this happens again.”
– Steve R., Alton, Illinois

Steve: Unfortunately, this is a common problem and decompression of what is called a subungual hematoma should be undertaken by medical personnel. A primary care physician, a nurse, nurse practitioner, etc. are well-equipped to decompress your nail bed. I would not recommend trying this at home due to the possibility of infection, injuring the nail bed and possibly making the hematoma worse. This is actually a very good question and I appreciate you shouting out.

“Dr. Rick: I saw your segment on cosmetic plastic surgery of the feet and wonder what your true thoughts are. I am 26 years old and a triathlete. My feet look horrendous and I have been contemplating trying to get my bunion corrected and some of my corns addressed. I do not really have any pain but my toes look awful! Thank you.”
– Alyssa N., Ladue, Missouri

Alyssa: If you are a competing triathlete and are having no pain in your feet, I would not recommend that you consider any type of surgical resolution. There are conservative treatments to be done for the corns. A component of your bunions is most likely hereditary. If you are competing without difficulty and you are not experiencing pain in your feet with daily activities, I would not recommend surgical treatment. I would suggest alterations in your shoe wearing if appropriate. Many times, we only see the upside of surgery and do not really consider the down side.
Thank you very much for your question.

The tip of the month includes a multivitamin and one baby aspirin a day to maintain good health.

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