What is the management of patellar subluxation?

From the Guidelines

The management of patellar subluxation should prioritize conservative treatment, focusing on knee-targeted exercise therapy, including quadriceps strengthening, hamstring stretching, and hip abductor strengthening, as supported by the most recent and highest quality study 1. The goal of treatment is to restore normal patellar tracking and prevent recurrent subluxation by addressing underlying biomechanical issues and muscle imbalances.

• Initial management includes rest, ice, compression, and elevation (RICE protocol) to reduce pain and swelling.
• Physical therapy is essential and should be individualized based on a robust assessment of symptom severity and irritability, with exercise parameters modified accordingly, as recommended by 1.
• Patients should perform exercises regularly, typically 3-4 times per week for at least 6-8 weeks.
• Bracing or taping techniques can provide additional support during activities.
• Over-the-counter NSAIDs like ibuprofen (400-600mg three times daily) or naproxen (500mg twice daily) can help manage pain and inflammation.
• For recurrent or severe cases unresponsive to conservative measures, surgical interventions may be considered, including lateral release, medial patellofemoral ligament reconstruction, or tibial tubercle osteotomy, as mentioned in 1.
• Activity modification is also important, with patients advised to temporarily avoid activities that involve deep knee bending, pivoting, or jumping until symptoms improve and strength is restored.
• The use of prefabricated foot orthoses, taping, and manual therapy should be considered when rehabilitation and/or quality of life is hindered by elevated symptom severity and irritability, or high fear of movement, as suggested by 1.

From the Research

Management of Patellar Subluxation

The management of patellar subluxation can be divided into conservative and surgical approaches.

• Conservative management includes physiotherapeutic interventions such as a knee brace with a limited range of motion, stretching, and neuromuscular exercises 2.
• The use of a structured lower limb physical therapy program has been shown to have similar outcomes to specific exercises 2.
• Surgical management is associated with a lower rate of re-dislocation, but it is unclear whether surgery produces greater functional outcomes than conservative management 2.

Surgical Management

Surgical management of patellar subluxation often involves reconstruction of the medial patellofemoral ligament (MPFL), which is the most important medial structure providing restraint to lateral subluxation of the patella 3.

• MPFL reconstruction is an effective treatment for preventing recurrent dislocations in patients with normal anatomy and kinematics 3.
• Various surgical techniques have been described, with differences in fixation and graft selection 3.

Conservative Treatment

Conservative treatment of patellofemoral subluxation has been shown to be effective in approximately 80% of cases 4.

• The classic exercises used in conservative treatment include quadricep sets, straight leg raises, hip abductors, hip adductors, hip flexors, and hamstring stretches 4.
• Prevention of flexion extension activity and stretching of the hamstring muscles are also important components of conservative treatment 4.

Physical Therapy Intervention

Physical therapy intervention after MPFL reconstruction is crucial for a successful return to sport or functional activity 5.

• A staged physical therapy intervention, including proprioceptive-focused and dynamic rehabilitation, along with a home exercise program, has been shown to be effective in achieving excellent results for return to activity/sport 5.
• The use of the Modified Cincinnati Knee Outcome Measure (MCKOM) can be used to assess outcomes and guide treatment progression 5.