Key Words 139
Patella fracture,
Rehabilitation of a
Post-surgical Patella Fracture
Case report
Summary A patient with an open knee fracture made little
progress during a three-month course of conventional
physiotherapy. After a further course of controlled microtrauma
(ASTM) treatment for six weeks, however, his range of motion
increased, he walked without a limp, and he was pain free.
Introduction
Although open fractures of the patella are
frequently seen in patients with multiple
injuries, there are no clinical series reported.
In a study by Torchia and LeWallen (1996),
nearly all the fractures they examined
resulted from high-energy vehicular trauma.
Patella fractures were among the first to be
treated with open reduction and internal
fixation to maximise functional outcome
(Catalano et al, 1995). As a result of direct
compressive and indirect forces on the
patellofemoral articulation, this open injury
often involves soft tissue, bone and articular
cartilage. In open injuries comminution,
displacement and contamination can
present a more difficult treatment problem
than the isolated closed patella fracture
(Catalano et al, 1995; Koval and Kim, 1997;
Torchia and LeWallen, 1996).
In the literature, treatment of open
fractures for the knee has received little
attention (Torchia and LeWallen, 1996).
Although there is agreement about the need
for rigid fixation and early joint motion,
rehabilitation after surgical fixation for open
patella fractures is not well documented
(Chapman, 1980).
Koval and Kim (1997) have documented
that with a stable fixation, passive range of
motion (ROM) exercises can begin 48 hours
after surgery. Patients may then progress to
active ROM and isometric exercises. Once
there is radiographic evidence of healing,
Henry, P, Panwitz, B and
Wilson, J K (2000).
then progressive resistance exercises are
‘Rehabilitation of a added.
post-surgical patella Despite these efforts, loss of knee motion
fracture: Case report’, is common following patella fractures and is
Physiotherapy, 86, 3, usually due to fibrosis (Koval and Kim, 1997;
139-142. Torchia and LeWallen, 1996).
physical therapy,
ASTM™.
by Paula Henry
Beth Panwitz
Julie K Wilson
Treatment of post-operative fibrosis or scar
tissue by cross friction massage has been
advocated by Cyriax and is currently being
applied extensively in clinical practice. An
expanded form of soft tissue mobilisation
known as ASTM™ has been observed to be
clinically successful in treating post-operative
fibrosis (Melham et al, 1998; Davidson et al,
1997). ASTM is a process that uses specially
designed instruments (Performance Dyn-
amics, Muncie, USA) to help clinicians to
mobilise soft tissue fibrosis.
ASTM is a descriptive name for a
treatment which originates from and
expands upon the concepts of cross friction
massage (Cantu and Grodin, 1992).
Theoretically, ASTM works by allowing
clinicians to introduce more effectively a
controlled amount of microtrauma into the
affected area (Buckley et al, 1991; Harrelson,
1991; Stauber, 1990). This controlled
microtrauma causes microvascular trauma
and capillary haemorrhage that induces a
localised inflammatory response (Stauber,
1990).
The inflammatory response is the first
step in the body's healing cascade and
immune/reparative system (Leadbetter,
1992; Stauber, 1990). This process appears
to stimulate connective tissue remodelling
through resorption of excessive fibrosis,
along with inducing repair and regeneration
of collagen secondary to fibroblast
recruitment (Stauber, 1990; Gross, 1992).
Essentially, ASTM induces resorption of
scar tissue and stimulates an adaptive
remodelling of the affected area.
This case report identifies many of the
difficult aspects of treating a post-operative
patella fracture. In addition, the purpose of
this case report was to determine whether
this rehabilitation process could decrease
post-operative fibrosis, allowing increased
ROM and function.
Physiotherapy March 2000/vol 86/no 3
 140
Authors and
Addresses for
Correspondence
Paula Henry PT is the
staff physical therapist at
Ball Memorial Hospital
Health Strategies, which
is an outpatient
rehabilitation clinic
located at 113A South
Memorial Drive, New
Castle, Indiana, USA
47362.
Beth Panwitz ATC is the
staff certified athletic
trainer at Ball Memorial
Hospital Health
Strategies.
Julie K Wilson MS ATC is
part of the research
department at Ball
Memorial Hospital, which
is located at 3713 South
Madison Street, Muncie,
Indiana, USA 47302.
This article was received
on March 19, 1999, and
accepted on November
16, 1999.
Physiotherapy March 2000/vol 86/no 3
The Patient
A 20-year-old man ‘Tom’ was involved in a
motor vehicle accident on April 29, 1997, in
which he sustained an open patella fracture
which was surgically repaired the same day.
The surgeon placed him in a post-operative
brace locked at 30° of flexion for six weeks.
He was then referred to our clinic for
physical therapy on June 25, 1997, with a
diagnosis of post-operative right open
patella fracture.
Subjectively, Tom reported pain ranging
from 4/10 at rest which intensified to 8/10
with activity that lasted for minutes to several
hours. He was taking a prescribed narcotic
(hydrocodone) for pain control and
complained of constant pain, limited ROM
and restricted activities of daily living. He
had 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, patellar
mobility was good. The incision was well
healed and mildly adhered. Quadriceps
mass was significantly atrophied compared
to the left lower limb, and visually the
patient had poor quadriceps recruitment.
Tom’s family and personal medical
history were negative with no known
rheumatological problems. His review of
systems, other than musculoskeletal
complaints, was negative, and social history
was unremarkable. He sustained no
infection from his injury or following the
surgery.
Intervention
Upon completion of the evaluation, physical
therapy was started, with a programme
designed to increase ROM and function and
to decrease his pain. ROM exercises
included:
■ 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 exercises
were included to address the hamstrings,
quadriceps, gastrocnemius/soleus, and
piriformis.
Open kinetic chain isometric and isotonic
strengthening exercises were performed
initially and included:
■ Quadriceps setting.
■ Straight leg raises.
■ Short arc quadriceps sets.
■ Hip abduction.
Functional electric stimulation was used in
conjunction with straight leg raises for
quadriceps recruitment. The electric
stimulation was provided through a BMR
NeuroTech 2000 using programme 0 (preset
parameters at 50 Hz, 250 µ seconds) for
seven seconds of contraction and 21 seconds
of relaxation. All strengthening exercises
were per formed with three sets of 10
repetitions within the patient’s pain-free
ROM. Tom then progressed to closed kinetic
chain strengthening exercises after the first
three 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 at
50% for six minutes was started in order to
reduce patellar soreness. Ultrasound was
used for a total of seven treatments over the
patellar tendon. Once Tom began to regain
some knee joint ROM, joint mobilisation
and cross friction massage were added to his
programme.
Tom was given this therapy at three
sessions a week for 12 weeks. On September
19, 1997, he was discharged on the ortho-
paedic surgeon’s orders, with pain reported
at 2/10 at rest and 6/10 with activity. At that
time, he had 0° knee joint extension and 95°
knee joint flexion.
On October 3, 1997, Tom returned under
referral of a different orthopaedic surgeon,
who requested a continuation of physical
Professional articles 141

therapy with the addition of ASTM. His pain

and knee joint ROM remained the same as
documented at discharge on September 19.
ASTM involves the use of specially
designed instruments that augment a
clinician’s ability to per form soft tissue
mobilisation (see figure). The instruments
are solid specially made polyurethane hand-
held devices with an angled edge, which are
guided in a stroking motion along the skin.
To reduce the coefficient of friction and
prevent trauma to the overlying skin, cocoa
butter is used as a lubricant between the
instruments and the skin during treatment.
An ASTM instrument in use
The instruments are moved with primarily
longitudinal strokes along the musculo-
tendinous structures, and are used in multi- Tom was instructed in a home stretching
directional strokes around the bony programme consisting of the stretches
prominences of a joint. During each described above to be per formed a
treatment session, the clinician goes through minimum of four times daily, with one
a progression of tools, from instruments 45-second repetition of each exercise
with a larger area of contact, to those with performed. He was encouraged to perform
progressively smaller areas of contact. As the as much activity as possible at home and
instruments are passed over the skin, the work, increasing his activity level as he was
clinician and patient can detect changes able. He was advised to use ice as needed for
in the soft tissue texture through the discomfort.
reverberation of the instruments as they After his first ASTM session, Tom’s knee
contact the underlying tissue. Pressure is joint flexion increased to 113° which
firm enough to locate areas of change, enabled him to progress through the
presumably fibrosis, and to ‘catch’ on those functional strengthening programme. The
areas to trigger an inflammatory response. exercises included resisted sports cord
Tom was treated in this way while seated (forward/backward, lateral) and carioca
and prone. This allowed the physical (side-to-side motion with cross-over in the
therapist to address the anterior, medial, middle of the body), jogging, agility and
and lateral aspects of the quadriceps, proprioceptive manoeuvres. The sports cord
anterior and posterior tibialis, gastro- is attached to a harness and the wall and
cnemius and soleus muscle structures, pes provides resistance while the patient is in a
anserinus, and the knee joint region fully functional standing position.
including around the bony prominences. Upon final discharge (November 16,
Marked fibrosis was noted along the 1997), Tom had completed six weeks of
quadriceps proximally at the rectus, distally therapy, which included eight sessions of
in the vastus medialis obliquus, and over the ASTM. He reported that pain at rest and
quadriceps tendon insertion at the superior with activity was 0/10. His knee joint angle
patella. was 0° extension and had increased to 121°
Tom’s treatment session began with an flexion. He showed no limp and had
active warm-up on a stationary bike, followed returned to full functional daily activities,
by ASTM as described above for about five to which included walking, jogging, going up
10 minutes. He then performed stretching
exercises to lengthen the remodeling tissues. Pain, function, active and passive range of motion
He was instructed to perform one repetition
First course of therapy Second course of therapy
of each stretch for 45 seconds. The closed
kinetic chain strengthening exercises were Start Discharge Start Discharge
June 25 Sept 19 Oct 3 Oct 10 Nov 16
then performed, which stressed the affected
areas in order to influence the structural Pain with activity 8/10 6/10 6/10 2/10 0/10
alignment of the remodelling collagen fibres Function Limp Limp Limp No limp No limp
and soft tissue matrix. Active knee flexion (°) 48 95 95 113 121
Upon completion of treatment, an ice bag Passive knee flexion (°) 53 100 101 118 121
was applied to the areas of fibrosis for five to Active knee extension (°) 0 0 0 0 0
10 minutes to limit post-treatment soreness.

Physiotherapy March 2000/vol 86/no 3

 142
Key Messages
■ The table indicates
data for passive and
active measurements of
knee joint ROM, pain
ratings at rest and with
activity, and functional
status.
■ Upon completion of
the patient’s first
course of therapy (June
25 to September 19,
1997), the patient still
complained of pain at
rest and with activity,
and his knee joint
ROM was limited,
causing him functional
restrictions.
■ Once the patient
completed his second
course of therapy
(October 3 to
November 16, 1997)
which included ASTM,
his pain at rest and
with activity had
ceased, and his knee
joint ROM increased,
which allowed him to
expand his activities of
daily living.
■ Specifically, knee
joint flexion increased
from 95° to 121° (an
increase of 26°) with
only eight treatment
sessions.
Physiotherapy March 2000/vol 86/no 3
and down stairs, squatting, kneeling, etc.
He was instructed to continue his home
stretching programme as previously
described, and was discharged.
Implications for Practice
In physical therapy, treatment of patients
involves the selection of different techniques
to address patients’ specific needs for their
return to optimal function. In Tom’s case,
ASTM was added to other techniques to
address the specific problem of fibrosis
within the quadriceps and knee joint.
Although previous efforts in therapy had
provided some relief, the patient continued
to report significant tightness, discomfort,
and limitation in function. It was felt that
ASTM could decrease the fibrosis present in
the area and enhance the other components
of his therapy programme.
Tom experienced a significant increase in
knee joint flexion and a decrease in pain
during the first ASTM treatment, despite the
duration of the injury and his previous
compliance with a thorough therapy
programme. It appears that ASTM played a
critical role in Tom’s improvement by
initiating the healing process to allow for
tissue remodelling. The initiation of this
healing process through ASTM may have
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