What is the most appropriate management for a patient who has undergone patellar repair and now presents with quadriceps weakness?

Management of Quadriceps Weakness After Patellar Repair

Begin isometric quadriceps exercises immediately in the first postoperative week if they can be performed without pain, progressing systematically through a structured 9-12 month rehabilitation program that prioritizes early motion, neuromuscular training, and objective progression criteria. 1, 2

Immediate Postoperative Phase (Week 1-2)

Pain and Inflammation Control

• Apply cryotherapy during the first postoperative week to reduce pain 3, 1
• Use NSAIDs for acute pain management, with caution in patients with renal dysfunction 1
• Consider nerve blocks (femoral/fascia iliaca) for severe pain when appropriate 1

Early Mobilization Strategy

• Initiate immediate weight-bearing only if the patient demonstrates a correct gait pattern (with crutches if necessary) and experiences no pain, effusion, or temperature increase during or after walking 3
• Avoid complete immobilization to prevent muscular atrophy and deconditioning 1, 2
• Use a hinged knee brace to protect the repair while allowing controlled motion 1

Quadriceps Reactivation

• Start isometric quadriceps exercises (quadsets) in full knee extension during the first week when they provoke no pain 3, 1, 4
• Full knee extension offers the best quadriceps rehabilitation, as 10 degrees of flexion reduces effective muscle effort to approximately 1/4 of that demonstrated in full extension 4
• Add electrostimulation to isometric training to re-educate voluntary contraction of the quadriceps muscles if significant weakness persists 3, 2

Progressive Strengthening Phase (Week 2-12)

Closed Kinetic Chain (CKC) Exercises

• Begin CKC exercises (mini squats, leg press) from week 2 postoperative when the quadriceps is reactivated, provided the knee does not react with effusion or increased pain 3, 2

Open Kinetic Chain (OKC) Exercises

• Start OKC exercises from week 4 postoperative in a restricted range of motion of 90-45° 3, 2
• Progress ROM systematically: 90-30° in week 5,90-20° in week 6,90-10° in week 7, and full ROM in week 8 3, 2
• Extra resistance (leg extension machine) can be added cautiously during this phase 3

Exercise Progression Sequence

• Replace isometric exercises with concentric exercises when quadriceps reactivation occurs 3, 2
• Subsequently introduce eccentric exercises as concentric exercises are well-tolerated 2
• Eccentric strengthening is crucial for tendon healing and functional recovery 2

Advanced Rehabilitation Phase (Week 12+)

Neuromuscular Training

• Add neuromuscular training to strength training to optimize functional outcomes and prevent compensatory movement patterns 3, 5, 2
• Focus on quality of movement rather than quantity to prevent reinjury 3, 5, 2
• Include balance and proprioception exercises for the lower extremity 5
• Incorporate closed-chain rhythmic stabilization exercises 5

Objective Progression Criteria

Progress based on objective criteria rather than time alone: 5, 2

• Absence of pain with current exercise level
• No increase in swelling, warmth, or effusion after activity
• Ability to perform exercises with proper form without compensation
• Functional testing at 12 weeks including manual muscle testing, grip strength assessment, and quality of movement evaluation 5

Duration and Return to Activity

Rehabilitation Timeline

• Continue rehabilitation for 9-12 months, depending on the final return-to-work or play goals 3
• This extended period is necessary because most patients cannot reach end-rehabilitation goals in shorter timeframes 3
• Early motion protocols (initiated at 7-10 days) with full weight-bearing and brace-free ambulation at 6 weeks have demonstrated excellent outcomes with Lysholm scores averaging 92 points at 4-year follow-up 6

Return to Activity Assessment

• Evaluate ability to perform functional movements without pain or compensation before returning to activity 2
• Address sport-specific movement patterns during rehabilitation for athletes or physically active individuals 1
• Consider psychological factors (self-efficacy, fear of reinjury) that may influence rehabilitation outcomes 3, 2

Critical Pitfalls to Avoid

• Do not neglect eccentric strengthening exercises, which are essential for tendon healing and functional recovery 2
• Avoid focusing solely on strength without addressing neuromuscular control and movement quality, as altered biomechanics increase risk of reinjury 3, 2
• Do not rely solely on passive interventions (massage, ultrasound, heat) as active interventions produce superior outcomes 1
• Avoid aggressive stretching or loading in the acute phase as this may compromise the repair 1
• Be aware that sequential extensor mechanism failures can occur; comprehensive patient education and structured follow-up are essential 7