Patella Baja: The Most Common Knee Condition Nobody Knows About

by Mike McClellan

Constant pain in the front and center of your knee. The inability to bend your knee into a crouched position. Not enough leg strength to stand up from a crouched position. Does this sound familiar? If so, there’s a chance you may have Patella Baja.

Patella Baja

Patella Baja is a condition where the knee cap is positioned too low. It can make bending your leg past 90 degrees difficult to impossible. As if this lack of mobility isn’t bad enough, it will also usually lead to weak leg muscles. More specifically, weak quadriceps muscles.

Quadriceps Weakness

With your knee cap sitting so low, the tendon above your knee is constantly being stretched more than it should, just to reach your knee cap. When you bend your leg farther and farther, it continues to stretch that tendon even more, and eventually it just refuses to stretch any more, usually around 90 degrees.  If your leg can’t bend past 90 degrees, then any leg exercise you might do is only going to be strengthening over a limited range of motion. This may allow you to fairly comfortably sit up from a high seated-chair, but crouching down to pick something up isn’t an activity you would attempt in your wildest dreams.

Total Knee Arthroplasty (Knee Replacement) Patients

People who have had previous knee injuries, from bone fractures to tendon/ligament tears, are at an increased risk of developing Patella Baja. You may think you’re out-of-the-woods if you’ve had a TKA (Total Knee Arthroplasty), but that’s far from the truth. Surprisingly enough, people who have had a total knee replacement have a higher increased risk of developing Patella Baja. Studies have found that the prevalence of the condition occurs in anywhere from 25-34% of TKA patients. This typically starts a month after surgery, and progressively worsens for up to four (4) years post-surgery.

Patella Fracture Articles

ORIF Knee Recovery on X10 (with Professor Jik Chin)People talk about self-driving cars. That's all part of robotics and is incredibly interesting. It’s important work that Elon Musk and others are doing in that area. This knee robot, unlike self-driving cars, which is really technology for the future, it's already there.November 12, 2019The $300,000 Knee (Lois and the knee replacement nightmare)Lois' left knee has added up to more than $300,000, at least. And this knee has occupied more than 10 months of her life so far. Listen to Lois' story here.October 16, 2019Tibial Plateau Fracture Recovery (Gina’s X10 Intervention)We share an interview with Gina who had a tibial plateau fracture recovery with the X10. She started on the X10 ten weeks after the surgery when she was very disappointed with her recovery. Within two weeks she solved her knee surgery recovery problem.July 22, 2019

What often happens is after an individual has a TKA, they go through at home and clinical physical therapy. Once that is complete, after typically 4-8 weeks, they return to a mostly sedentary lifestyle. The longer they are inactive, the weaker their quadriceps muscles become. And the farther their knee cap will continue to drop. After a while the knee cap drops so far that the quadriceps t...

What happens after knee replacement when there is a lack of full knee extension? We explore this question in this installment of our series entitled 'Threats to a Proper Knee Replacement Recovery'.

Threats to a Proper Knee Replacement Recovery (Lack of Full Knee Extension)

by PJ Ewing

This is Part 3 of a series of articles on threats to a proper knee surgery recovery. In this installment we discuss achieving full knee extension after knee replacement. I encourage you to explore the other articles in the series which you can find by clicking on the link below.

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Deep Vein Thrombosis and Knee Replacement

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Infection and Knee Replacement

Getting to 0º: Achieving Full Extension

Physical therapists, surgeons, exercise physiologists, personal trainers all emphasize full terminal knee extension for their knee patients after surgery. Why?

Let's start with defining our terms. Terminal Knee Extension is achieved when the angle of your leg is 0º when extending it out in front of you. 0º means it is perfectly straight. PTA Yvonne LaCrosse defines extension and flexion in this short video.

The Immediate Impact of Extension Loss

Loss of knee extension has a dramatic impact on gait, muscle activity, and normal tibiofemoral and patellofemoral arthrokinematics (the connectivity and function of your knee cap in relation to both the tibia and femur).

Imagine not being able to straighten your knee out. You can’t lock out your knee for stability. You naturally will shift your weight to the other extremity and overload your other knee, hip, and probably even your back. Your quadriceps and hamstring muscles never get to turn off and relax. Your patellar tendon will probably be on fire. And your patella (knee cap) will always be in use and engaged, taking stress. (5)

Lack of Full Knee Extension (1)

Here are five key results of the lack of proper knee straightening. Lack of a straight knee:

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Leads to worse patient outcomes and statistical success scores

*

"The most statistically significant factor related to lower subjective scores was lack of normal knee extension. Normal knee straightening is considered to be within 2° of extension, including hyperextension." (3)

*

Increases the risk for developing arthritis

*

Multiple studies have shown that people with limited knee extension have a higher prevalence of arthritis (even in as little as a 3° loss). For example:

*

"Less than normal knee extension ROM at discharge was a predictive factor for developing Osteoarthritis after ACL surgery" (3)

*

"Loss of normal knee ROM at final follow-up was associated with a higher prevalence of Osteoarthritis" (4)

*

Causes an abnormal walking pattern or gait

*

If you're lacking knee extension motion, you can't achieve TKE during terminal stance (fully straighten your leg, stand erect). Therefore this puts more strain/stress on other structures in the kinetic chain.

*

A slightly flexed position causes abnormal joint loading.

*

This abnormal joint loading makes it easier for you to fall by catching your foot as opposed to walking heel to toe

*

Higher demand on the patella tendon (what connects your kneecap to the tibia, the bone below your knee)

*

If your knee never gets fully straight (and into the closed-pack position) and is always slightly flexed,

Threats to a Proper Knee Replacement Recovery (Lack of Full Knee Extension)

by PJ Ewing

This is Part 3 of a series of articles on threats to a proper knee surgery recovery. In this installment we discuss achieving full knee extension after knee replacement. I encourage you to explore the other articles in the series which you can find by clicking on the link below.

*

Deep Vein Thrombosis and Knee Replacement

*

Infection and Knee Replacement

Getting to 0º: Achieving Full Extension

Physical therapists, surgeons, exercise physiologists, personal trainers all emphasize full terminal knee extension for their knee patients after surgery. Why?

Let's start with defining our terms. Terminal Knee Extension is achieved when the angle of your leg is 0º when extending it out in front of you. 0º means it is perfectly straight. PTA Yvonne LaCrosse defines extension and flexion in this short video.

The Immediate Impact of Extension Loss

Loss of knee extension has a dramatic impact on gait, muscle activity, and normal tibiofemoral and patellofemoral arthrokinematics (the connectivity and function of your knee cap in relation to both the tibia and femur).

Imagine not being able to straighten your knee out. You can’t lock out your knee for stability. You naturally will shift your weight to the other extremity and overload your other knee, hip, and probably even your back. Your quadriceps and hamstring muscles never get to turn off and relax. Your patellar tendon will probably be on fire. And your patella (knee cap) will always be in use and engaged, taking stress. (5)

Lack of Full Knee Extension (1)

Here are five key results of the lack of proper knee straightening. Lack of a straight knee:

*

Leads to worse patient outcomes and statistical success scores

*

"The most statistically significant factor related to lower subjective scores was lack of normal knee extension. Normal knee straightening is considered to be within 2° of extension, including hyperextension." (3)

*

Increases the risk for developing arthritis

*

Multiple studies have shown that people with limited knee extension have a higher prevalence of arthritis (even in as little as a 3° loss). For example:

*

"Less than normal knee extension ROM at discharge was a predictive factor for developing Osteoarthritis after ACL surgery" (3)

*

"Loss of normal knee ROM at final follow-up was associated with a higher prevalence of Osteoarthritis" (4)

*

Causes an abnormal walking pattern or gait

*

If you're lacking knee extension motion, you can't achieve TKE during terminal stance (fully straighten your leg, stand erect). Therefore this puts more strain/stress on other structures in the kinetic chain.

*

A slightly flexed position causes abnormal joint loading.

*

This abnormal joint loading makes it easier for you to fall by catching your foot as opposed to walking heel to toe

*

Higher demand on the patella tendon (what connects your kneecap to the tibia, the bone below your knee)

*

If your knee never gets fully straight (and into the closed-pack position) and is always slightly flexed,

Chris Nowacki spends time with us discussing her husband's bilateral knee replacement. Wallander (Wally) Nowacki was an Olympic cyclist early in his life. Finding himself in need of two new knees last age 65 he took the leap and did both knees at once.

Bilateral Knee Replacement for Olympic Cyclist

an interview with Chris Nowacki

Chris Nowacki spends time with us discussing her husband's bilateral knee replacement. Wallander (Wally) Nowacki was an Olympic cyclist for Team Poland early in his life. However, finding himself in need of two new knees at age 65, he took the leap and did both knees at once. Chris and Wally did extensive research on how to best prepare for knee replacement surgery. They examined how to best recover afterward. Click the Play button above to listen to the interview. And look for a special bonus at the end of the interview - a nice surprise there for you.

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Bilateral Knee Replacement for Olympic Cyclist

an interview with Chris Nowacki

Chris Nowacki spends time with us discussing her husband's bilateral knee replacement. Wallander (Wally) Nowacki was an Olympic cyclist for Team Poland early in his life. However, finding himself in need of two new knees at age 65, he took the leap and did both knees at once. Chris and Wally did extensive research on how to best prepare for knee replacement surgery. They examined how to best recover afterwards. Click the Play button above to listen to the interview. And look for a special bonus at the end of the interview - a nice surprise there for you.

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Why the CPM Machine Failed to Solve Knee Surgery Recovery

The Continuous Passive Motion machine (CPM) does not increase a patient's range of motion or strength. It does not or shorten recovery. It doesn’t help, and can even hurt a patient's knee.

The CPM machine is a story of failed early research and technology. If you are interested in the enormous body of research about the Continuous Passive Motion machine click here (as compiled by orthopedic surgeon, Dr. David Halley).

The Great Hope of the Late 1970's

Robert Salter (MD) and John Saringer (an engineer) commercialized the CPM in 1978. The original idea was to stimulate cartilage production in knees, at which the machine succeeded extremely well in rabbits, but not for humans. Human knee cartilage has no blood supply and consequently cannot grow back.

Range of Motion

Soon patients began using the Continuous Passive Motion machine to increase knee range of motion. Most research studies, before 2005, compared the range of motion of patients who used the CPM to patients who had only bed-rest. When that comparison was made it looked as though the CPM had a tremendous effect. However, after 2005, the experiments on the CPM evolved. These studies compared people who used the CPM to those who did not use the CPM, but who also were not confined to their beds. The non-CPM control group could move about.  None of these studies showed that the CPM could increase range of motion better than those who simply moved about. The results were remarkably clear: the Continuous Passive Motion machine failed to increase knee range of motion.

The CPM lost its allure in a single decade. Surgeons who took a close look at the research stopped using the device. The Continuous Passive Motion machine failed to do what was claimed.

Moving from a six-week cast to modern recovery

In the early 1970’s most civilian knee surgery patients had their knees in a cast for six weeks, and were largely confined to bed. The military not only did not cast injured knees, they immediately got patients up and moving. At that point in time the research showed that some movement was superior to no movement. Dr. Salter reasoned that if some movement was better, continuous movement would be better still, and hence the invention of the CPM.

What Continuous Passive Motion Does

Basically, the CPM flexed a patient’s leg through a prescribed arc. In order to work properly, the patient was to lay absolutely still for up to 20 hours a day. The purpose behind laying still was to preserve the alignment between the patient and machine. However, simply moving a patient’s head disrupted the alignment, and to make matters worse, the machine itself moved over the surface of the bed. Even bolting the machine down did not solve the alignment problem. Because of the alignment problem patient’s legs only experienced 68% of the prescribed arc. And the CPM was painful for most patients. Lastly they were not very compliant.

Surgeons who have kept abreast of the research, as a rule do not prescribe the CPM, though some will admit that they offer it if patients ask for it.

How the CPM failed (the research) - Read...

Why the CPM Machine Failed to Solve Knee Surgery Recovery

The Continuous Passive Motion machine (CPM) does not increase a patient's range of motion or strength. It does not or shorten recovery. It doesn’t help, and can even hurt a patient's knee.

The CPM machine is a story of failed early research and technology. If you are interested in the enormous body of research about the Continuous Passive Motion machine click here (as compiled by orthopedic surgeon, Dr. David Halley).

The Great Hope of the Late 1970's

Robert Salter (MD) and John Saringer (an engineer) commercialized the CPM in 1978. The original idea was to stimulate cartilage production in knees, at which the machine succeeded extremely well in rabbits, but not for humans. Human knee cartilage has no blood supply and consequently cannot grow back.

Range of Motion

Soon patients began using the Continuous Passive Motion machine to increase knee range of motion. Most research studies, before 2005, compared the range of motion of patients who used the CPM to patients who had only bed-rest. When that comparison was made it looked as though the CPM had a tremendous effect. However, after 2005, the experiments on the CPM evolved. These studies compared people who used the CPM to those who did not use the CPM, but who also were not confined to their beds. The non-CPM control group could move about.  None of these studies showed that the CPM could increase range of motion better than those who simply moved about. The results were remarkably clear: the Continuous Passive Motion machine failed to increase knee range of motion.

The CPM lost its allure in a single decade. Surgeons who took a close look at the research stopped using the device. The Continuous Passive Motion machine failed to do what was claimed.

Moving from a six-week cast to modern recovery

In the early 1970’s most civilian knee surgery patients had their knees in a cast for six weeks, and were largely confined to bed. The military not only did not cast injured knees, they immediately got patients up and moving. At that point in time the research showed that some movement was superior to no movement. Dr. Salter reasoned that if some movement was better, continuous movement would be better still, and hence the invention of the CPM.

What Continuous Passive Motion Does

Basically, the CPM flexed a patient’s leg through a prescribed arc. In order to work properly, the patient was to lay absolutely still for up to 20 hours a day. The purpose behind laying still was to preserve the alignment between the patient and machine. However, simply moving a patient’s head disrupted the alignment, and to make matters worse, the machine itself moved over the surface of the bed. Even bolting the machine down did not solve the alignment problem. Because of the alignment problem patient’s legs only experienced 68% of the prescribed arc. And the CPM was painful for most patients. Lastly they were not very compliant.

Surgeons who have kept abreast of the research, as a rule do not prescribe the CPM, though some will admit that they offer it if patients ask for it.

How the CPM failed (the research) - Read...

Five Months After Knee Replacement

Nan's "Never Say Die" Knee Recovery

Everyone else thought Nan's recovery was done. Her bend was "good enough", her pain was gone, she should "be happy" with the mobility with which she was left. Nan did not agree.

Nan's knee extension (straightening) was good at 0º which means her leg was perfectly straight. It was the 107º flexion that troubled her. For a life-long athlete this was far from what she expected. And then fate stepped in. It was as if the world simply conspired to help Nan when it was most needed. Fortuitously her friend, Alison, was just finished with the X10 in her home. She had done so well and was ready to let the machine move on to help the next person. They discussed it and Nan decided to take the X10 immediately and see what she could do.

The conventional wisdom, and most clinical literature, agree that at five months after knee replacement it is unlikely to see much gain in flexion (bending the knee back). It is understood that knee replacement patients have until three months to improve their flexion, and six months to finish off their knee extension. Scar tissue, swelling, quad tightness and other factors can inhibit or simply stop the opportunity for range of motion gains.

Many Athletic Pursuits

Nan has been an athlete all her life. Gymnastics (University of Washington, four years), rugby (Boston Women's Rugby Team), running, hiking, skiing, Tae Kwon Do and Tang Soo Do. At age 62 she was not about to let a knee surgery get in the way of her highly active lifestyle. She had arthroscopic knee surgery way back in college in 1978. At the time this was a really big deal. Over the past year it became really apparent that a knee replacement was needed. When she simply could not get back on her skis after falling she knew the time had come.

To listen to our interview with Nan click on the play button at the top of this page. The interview is part of our series of patient interviews that we present on The Bee's Knees Podcast (knee surgery recovery). And a special thanks to Nan for such generosity with her time in sharing her story.

The X10 Meta-Blog

We call it a "Meta-Blog." In these articles we step back and give you a broad perspective on all aspects of knee health. We explore surgery and recovery and such subjects as 'Five Months After Knee Replacement'.

This is a one-of-a-kind blog. We gather together great thinkers, doers, and writers. And it is all related to Knee Surgery, Recovery, Preparation, Care, Success and Failure. Meet physical therapists, coaches, surgeons, and patients. And as many smart people as we can gather to create useful articles for you. You may have a surgery upcoming. Or in the rear-view mirror. Maybe you just want to take care of your knees to avoid surgery. In all cases you should find some value here. Executive Editor: PJ Ewing ([email protected])

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