Key Words 139

Patella fracture,
physical therapy,
ASTM™.

by Paula Henry
Beth Panwitz
Rehabilitation of a Julie K Wilson
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
Treatment of post-operative fibrosis or scar
(ASTM) treatment for six weeks, however, his range of motion tissue by cross friction massage has been
increased, he walked without a limp, and he was pain free. advocated by Cyriax and is currently being
applied extensively in clinical practice. An
Introduction expanded form of soft tissue mobilisation
Although open fractures of the patella are known as ASTM™ has been observed to be
frequently seen in patients with multiple clinically successful in treating post-operative
injuries, there are no clinical series reported. fibrosis (Melham et al, 1998; Davidson et al,
In a study by Torchia and LeWallen (1996), 1997). ASTM is a process that uses specially
nearly all the fractures they examined designed instruments (Performance Dyn-
resulted from high-energy vehicular trauma. amics, Muncie, USA) to help clinicians to
Patella fractures were among the first to be mobilise soft tissue fibrosis.
treated with open reduction and internal ASTM is a descriptive name for a
fixation to maximise functional outcome treatment which originates from and
(Catalano et al, 1995). As a result of direct expands upon the concepts of cross friction
compressive and indirect forces on the massage (Cantu and Grodin, 1992).
patellofemoral articulation, this open injury Theoretically, ASTM works by allowing
often involves soft tissue, bone and articular clinicians to introduce more effectively a
cartilage. In open injuries comminution, controlled amount of microtrauma into the
displacement and contamination can affected area (Buckley et al, 1991; Harrelson,
present a more difficult treatment problem 1991; Stauber, 1990). This controlled
than the isolated closed patella fracture microtrauma causes microvascular trauma
(Catalano et al, 1995; Koval and Kim, 1997; and capillary haemorrhage that induces a
Torchia and LeWallen, 1996). localised inflammatory response (Stauber,
In the literature, treatment of open 1990).
fractures for the knee has received little The inflammatory response is the first
attention (Torchia and LeWallen, 1996). step in the body's healing cascade and
Although there is agreement about the need immune/reparative system (Leadbetter,
for rigid fixation and early joint motion, 1992; Stauber, 1990). This process appears
rehabilitation after surgical fixation for open to stimulate connective tissue remodelling
patella fractures is not well documented through resorption of excessive fibrosis,
(Chapman, 1980). along with inducing repair and regeneration
Koval and Kim (1997) have documented of collagen secondary to fibroblast
that with a stable fixation, passive range of recruitment (Stauber, 1990; Gross, 1992).
motion (ROM) exercises can begin 48 hours Essentially, ASTM induces resorption of
after surgery. Patients may then progress to scar tissue and stimulates an adaptive
active ROM and isometric exercises. Once remodelling of the affected area.
there is radiographic evidence of healing, This case report identifies many of the
Henry, P, Panwitz, B and
Wilson, J K (2000).
then progressive resistance exercises are difficult aspects of treating a post-operative
‘Rehabilitation of a added. patella fracture. In addition, the purpose of
post-surgical patella Despite these efforts, loss of knee motion this case report was to determine whether
fracture: Case report’, is common following patella fractures and is this rehabilitation process could decrease
Physiotherapy, 86, 3, usually due to fibrosis (Koval and Kim, 1997; post-operative fibrosis, allowing increased
139-142. Torchia and LeWallen, 1996). ROM and function.

Physiotherapy March 2000/vol 86/no 3

 140

Authors and The Patient Open kinetic chain isometric and isotonic
Addresses for A 20-year-old man ‘Tom’ was involved in a strengthening exercises were performed
Correspondence motor vehicle accident on April 29, 1997, in initially and included:
Paula Henry PT is the which he sustained an open patella fracture
staff physical therapist at which was surgically repaired the same day. ■ Quadriceps setting.
Ball Memorial Hospital The surgeon placed him in a post-operative
Health Strategies, which ■ Straight leg raises.
brace locked at 30° of flexion for six weeks.
is an outpatient ■ Short arc quadriceps sets.
He was then referred to our clinic for
rehabilitation clinic ■ Hip abduction.
physical therapy on June 25, 1997, with a
located at 113A South
Memorial Drive, New diagnosis of post-operative right open
Castle, Indiana, USA patella fracture. Functional electric stimulation was used in
47362. Subjectively, Tom reported pain ranging conjunction with straight leg raises for
from 4/10 at rest which intensified to 8/10 quadriceps recruitment. The electric
Beth Panwitz ATC is the stimulation was provided through a BMR
with activity that lasted for minutes to several
staff certified athletic
hours. He was taking a prescribed narcotic NeuroTech 2000 using programme 0 (preset
trainer at Ball Memorial
Hospital Health (hydrocodone) for pain control and parameters at 50 Hz, 250 µ seconds) for
Strategies. complained of constant pain, limited ROM seven seconds of contraction and 21 seconds
and restricted activities of daily living. He of relaxation. All strengthening exercises
Julie K Wilson MS ATC is had a decreased stance on the affected limb, were per formed with three sets of 10
part of the research with circumduction during the swing phase. repetitions within the patient’s pain-free
department at Ball Active and passive knee joint ROM meas- ROM. Tom then progressed to closed kinetic
Memorial Hospital, which urements were taken (see table opposite). chain strengthening exercises after the first
is located at 3713 South Despite limited knee joint ROM, patellar three weeks which included:
Madison Street, Muncie,
mobility was good. The incision was well
Indiana, USA 47302.
healed and mildly adhered. Quadriceps ■ Wall squats for 20 to 60 seconds.
mass was significantly atrophied compared
This article was received ■ Single leg stance for balance.
on March 19, 1999, and to the left lower limb, and visually the
patient had poor quadriceps recruitment. ■ Stationary bike.
accepted on November
16, 1999. Tom’s family and personal medical ■ Heel raises.
history were negative with no known ■ Lunges.
rheumatological problems. His review of
■ Single leg squats.
systems, other than musculoskeletal
complaints, was negative, and social history ■ Leg press (single and double).
was unremarkable. He sustained no ■ Hamstring curls.
infection from his injury or following the ■ Stairmaster.
surgery.
■ BAPS (Balance and Ankle Proprioception
System) board seated and standing.
Intervention ■ Power bands for both lateral and forward
Upon completion of the evaluation, physical motion.
therapy was started, with a programme
designed to increase ROM and function and Ultrasound at 3 MHz 1.0 W/cm2 pulsed at
to decrease his pain. ROM exercises 50% for six minutes was started in order to
included: reduce patellar soreness. Ultrasound was
■ Passive ROM.
used for a total of seven treatments over the
patellar tendon. Once Tom began to regain
■ Heel slides (on the table and supine some knee joint ROM, joint mobilisation
against the wall). and cross friction massage were added to his
■ Contract-relax exercises for the programme.
quadriceps and hamstrings. Tom was given this therapy at three
■ PNF exercises D1, D2 flexion and sessions a week for 12 weeks. On September
extension for the lower extremity. 19, 1997, he was discharged on the ortho-
■ Stationary bike, using the unaffected leg paedic surgeon’s orders, with pain reported
at 2/10 at rest and 6/10 with activity. At that
to control the speed and ROM.
time, he had 0° knee joint extension and 95°
Manual and active stretching exercises knee joint flexion.
were included to address the hamstrings, On October 3, 1997, Tom returned under
quadriceps, gastrocnemius/soleus, and referral of a different orthopaedic surgeon,
piriformis. who requested a continuation of physical

Physiotherapy March 2000/vol 86/no 3

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.

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and down stairs, squatting, kneeling, etc. been responsible for the rapid gain in ROM
Key Messages He was instructed to continue his home that Tom experienced. The stretching and
■ The table indicates stretching programme as previously closed chain activities provided essential
data for passive and described, and was discharged. forces necessary to lay the blueprint for the
active measurements of remodelling collagen. Although each of
knee joint ROM, pain Implications for Practice these components was initiated before
ratings at rest and with In physical therapy, treatment of patients ASTM, Tom gained minimal improvement at
activity, and functional involves the selection of different techniques that stage, while after the introduction of
status. to address patients’ specific needs for their ASTM he demonstrated better objective and
return to optimal function. In Tom’s case, functional improvement.
■ Upon completion of ASTM was added to other techniques to ASTM, in our clinical experience, has
the patient’s first
address the specific problem of fibrosis been very useful in increasing the
course of therapy (June
25 to September 19,
within the quadriceps and knee joint. effectiveness of treatment for many types
1997), the patient still Although previous efforts in therapy had of soft tissue fibrosis. This case report
complained of pain at provided some relief, the patient continued provides clinical support for the concept
rest and with activity, to report significant tightness, discomfort, that controlled microtrauma can lead to
and his knee joint and limitation in function. It was felt that subsequent regression of fibrosis in various
ROM was limited, ASTM could decrease the fibrosis present in soft tissue structures. The authors feel that
causing him functional the area and enhance the other components ASTM, when added as a treatment option,
restrictions. of his therapy programme. alleviated Tom’s knee joint pain and
Tom experienced a significant increase in stiffness. This improvement facilitated his
■ Once the patient knee joint flexion and a decrease in pain return to normal physical activities. The
completed his second
during the first ASTM treatment, despite the authors believe that various therapeutic
course of therapy
(October 3 to
duration of the injury and his previous interventions such as stretching and closed
November 16, 1997) compliance with a thorough therapy chain exercises provide the forces necessary
which included ASTM, programme. It appears that ASTM played a for appropriate remodelling of the tissue.
his pain at rest and critical role in Tom’s improvement by ASTM may provide an effective treatment
with activity had initiating the healing process to allow for option for the frustrating problem of patella
ceased, and his knee tissue remodelling. The initiation of this fracture.
joint ROM increased, healing process through ASTM may have
which allowed him to
expand his activities of
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