9 Easy Patella Fracture Rehabilitation Exercise & Physiotherapy Protocol

Let me start with one of the case studies I treated in my physiotherapy centre.

An 18-year-old hockey player came for post-operative physiotherapy of a patella fracture. While playing a tournament, he sustained a direct blow over the right patella with the hockey stick of the opponent player. He was immediately rushed to the local hospital, where, after initial treatment, cylindrical support was given and referred to other hospitals for further management.

Surgery was indicated, and open reduction internal fixation with K-wire fixation was performed. After the operation, the knee was immobilized with a cylindrical plaster cast for one to five weeks. After removing the plaster cast, he was referred to physiotherapy for further management.

Patella fracture rehabilitation exercises simplified

Though I started this article with a case of a young hockey player, the study papers have a different story.

1. The study reveals that patella fractures are more common in females who are 65 years old or above.
2. The primary cause of these fractures is minor trauma, and around 70% of cases occur due to falling from a standing height¹.
3. Most patella fractures are treated without surgery, and only 24% of cases require surgical intervention².

The treatment for a knee cap bone fracture depends on the type of fracture that has occurred.

1. A simple hairline fracture can be treated with posterior slab immobilization for 2 to 3 weeks.
2. Surgical intervention is required if the broken segment is displaced due to quadriceps femoris traction.
3. ORIF (Open Reduction Internal Fixation) is necessary for fractures with displacements >3mm and articular incongruity of 2mm or more³.
4. Tension band wiring is the most common surgical procedure for this fracture type.

After surgery, the leg is immobilized with a cylindrical plaster cast for 3 to 4 weeks.

In both conditions, physiotherapy must start immediately after the leg is put under the cast. During this period of immobilisation, movement of the remaining joint has to be started as early as possible to prevent complications such as joint stiffness, swelling & oedema, and muscle weakness.

Physical therapy exercise for broken patella with plaster on

Whatever exercises I will demonstrate under this subheading are performed when the knee joint is still under the plaster cast. Though the model in the image does not have a knee plastered, we must follow the exercises’ gist.

So, let us start with ankle, foot, and toe movements.

1) Active movements of the ankle, foot, toe

This exercise is very important to maintain the blood circulation around the lower leg and prevent oedema. It also helps maintain the flexibility of the muscle and other soft tissues around the lower leg and foot. Here’s the step-by-step process for performing this exercise.

1. Sit comfortably in a long sitting posture.
2. Move your ankle, foot, and toe up and down.
3. Perform the movement as many times as possible and whenever possible.
4. Move both the ankle joint and toes.

2) Assisted straight leg raise exercise for broken knee cap

Our next exercise is an active-assisted straight leg raise. This exercise requires a partner to assist you in raising your leg straight up to 30 degrees of angle. It’s important to note that this exercise should not be entirely passive but rather an active movement with some assistance. It is an effective way to strengthen the muscles in your legs and improve flexibility. To perform this exercise:

1. You will need to lie down on your back with your partner standing next to you.
2. Your partner will then hold onto your leg just above your ankle.
3. Keep your leg straight and lift it up towards the ceiling, as high as you can go with some outside help.
4. It’s important to maintain the active movement of your leg while your partner assists you.
5. For maximum benefit, you should aim to repeat this exercise a minimum of 10 to 15 times per session.

3) Knee press exercise (static quadriceps exercise)

This exercise is designed to help strengthen the quadriceps muscle in the front of your thigh, which can be weakened after a knee cap fracture. To perform this exercise:

1. Sit on the bed with your legs extended in front of you.
2. Keep your back straight and your hands resting on your thighs.
3. Slowly squeeze your right knee and press it in a downward direction towards the floor.
4. Hold this position for 5 seconds.
5. Release the pressure. Repeat this for 15 to 20 repetitions of the exercise in each session.

Exercises 3 – 4 weeks after the removal of plaster cast

After 3 -4 weeks of plaster immobilisation of the knee, the sufferer finds that the knee has become stiff. Due to pain and stiffness, it becomes difficult to bend and straighten the knee. There is also a problem with walking.

So, immediately after the plaster removal, careful knee movement had to be started. So, here are the best exercises for fractured patella after removing plaster.

1) Knee flexion-extension on CPM exerciser (Continuous Passive Motion exerciser)

The Continuous Passive Motion (CPM) machine is used to regain knee movement when there is still a lot of pain around it. It is a device that fixes the knee in place, as shown in the figure, and has a graduated angle control that can be used to increase the angle of movement.

Once the knee is properly fixed, the machine is set to bend it passively within the pain-tolerable range. If knee bending is painful, the machine reduces the bending angle. This way, the angle is slowly increased day by day.

This device can be found at any well-equipped physical therapy centre, and it is always used under the supervision of a qualified physiotherapist.

2) Active knee flexion-extension physical therapy after patella surgery

For this exercise:

1. Lie flat on your back with your legs straight out in front of you.
2. Slowly bend your knee, bringing your heel towards your buttocks, until you feel a comfortable stretch in the back of your leg.
3. Hold this position for 5-10 seconds and then slowly straighten your leg back to the starting position.
4. Repeat this movement 10-15 times, ensuring that you are within your pain-free range of motion.
5. Gradually increase the range of motion daily, but do not push yourself too hard or fast.

3) Knee press using pillow or bedroll

The knee press exercise is a simple and effective way to strengthen the quadriceps muscle in the front of the thigh. Here are the detailed steps to perform this exercise:

1. Sit in a comfortable and long sitting position with your legs straight out in front of you.
2. Place a pillow or a bedsheet roll under the affected knee to elevate it slightly.
3. Now, contract the quadriceps muscle in the front of your thigh and press down on the pillow with your knee.
4. Hold this position for 5 seconds, making sure to keep the rest of your body relaxed.
5. Release the pressure on the pillow and relax your leg for 5 seconds.
6. Repeat the knee press procedure 30 to 50 times in a single session, depending on your comfort level. Take a break between sets if you feel fatigued, but aim to do as many sets as possible to increase the exercise’s effectiveness.

4) Straight leg raise exercises for fractured patella

The exercise described is a strengthening exercise for the quadriceps muscle and is called the straight leg raise. The following are the steps to perform this exercise:

1. Lie down on your back on a flat surface such as a yoga mat or carpet.
2. Bend one leg at the knee while keeping the other leg straight.
3. Push the back of your knee onto the mat to tighten the muscles in the straight leg. Slowly raise the straight leg to a height of no more than 30 degrees.
4. Hold the leg in the raised position for 5 seconds while pushing the back of your knee down onto the mat.
5. Slowly lower the leg back down to the starting position.
6. Repeat the exercise for a minimum of 10 repetitions on each leg.

5) Partial weight-bearing gait using a crutch or cane

In the first stage, the patient may need crutches or a wheelchair to move around. As the healing process progresses, the patient can begin to bear partial weight on the affected leg while walking with the help of a cane. This is an essential step towards regaining strength and mobility in the affected leg and can help accelerate the overall recovery.

However, it is essential to follow the guidance of a healthcare professional during the rehabilitation process to ensure a safe and effective recovery.

6) Full weight bearing

After a tibia bone fracture, a crucial part of the rehabilitation process is to start independent walking with full weight bearing on the affected leg. This typically begins around six weeks after the injury, once the bone has had time to heal and the patient has progressed through other rehabilitation exercises.

This step is essential for regaining strength, mobility, and range of motion in the affected leg.

What are the causes of knee cap fracture?

The knee cap or patella fracture can be due to:

1. The direct injury occurs with a direct blow on the patella while the knee is slightly flexed, like falling on the knee or a direct assault on the knee. The above-discussed case is one example of direct injury.
2. The indirect injury occurs when the knee is bent forcefully while the quadriceps muscle (in the front of the thigh) contracts strongly.

Classification patella fracture

The patella, also known as the knee cap, is a flat bone at the front of the knee. It has a triangular shape, and its edges are rounded, with the apex pointing downwards. The upper base of the patella is connected to the quadriceps tendon.

At the same time, the lower apex is attached to the ligamentum patella, which, in turn, is connected to the tibia bone of the leg. Traumatic fractures of the patella are classified as transverse, vertical, comminuted, marginal, or osteochondral according to the principle of practice.

1. Transverse fracture: This type of fracture occur horizontally across the patella and divides it into the upper and lower part. It is most often due to an indirect impact on the patella, like falls.
2. Vertical fractures: Vertical fractures run from the inferior to the superior pole and divide into left and right fractured parts. This type of fracture is generally stable and often treated conservatively without surgery.
3. Fractures to the margins of the patella: This fracture occurs at the perimeter of the patella. It commonly happens due to a direct force to the side of the patella.
4. Comminuted fractures: The patella, when fractured into multiple segments, is termed a comminuted fracture. It is frequently seen in multiple injured patients.

Clinical features of broken kneecap

1. Pain and swelling over the knee. In un-displaced fractures, pain and tenderness are localized to the knee. In a displaced fracture, one may feel the gap between the displaced fracture segments. Swelling is due to hemarthrosis.
2. There is a loss of active knee extension.
3. X-ray examination: X-ray examination indicates the patella fracture.

Further reading: Exercises for arthritis in knee for pain relief

Patella fracture FAQ

Sunit. S. Ekka

Dr Sunit Sanjay Ekka is a physiotherapist in practice for the last 15 years. He has done his BPT from one of the premium Central Government physiotherapy colleges, ie, SVNIRTAR. The patient is his best teacher and whatever he gets to learn he loves to share it on his Youtube channel and blog.