From the Guidelines
Management of patella lateral subluxation should prioritize conservative measures, including physical therapy targeting quadriceps strengthening, hamstring stretching, and proprioceptive training, as supported by recent evidence 1. The goal of treatment is to reduce pain, improve function, and prevent further subluxation. Key components of conservative management include:
- Quadriceps strengthening, particularly the vastus medialis obliquus, to improve dynamic stabilization of the patella
- Hamstring stretching to reduce tension on the patella
- Proprioceptive training to enhance knee joint stability and awareness
- Bracing with a patellofemoral stabilizing brace or taping techniques to provide immediate stability during activities
- Anti-inflammatory medications, such as ibuprofen (400-600mg three times daily) or naproxen (500mg twice daily), for 1-2 weeks to manage pain and inflammation
- Activity modification, avoiding deep squats, prolonged sitting, and high-impact activities during the acute phase
According to recent studies 1, patient education and tailored care are essential for successful management of patellofemoral pain. Patients should be educated on the importance of strengthening the whole leg to reduce pressure on the joint, as well as the role of quadriceps and hip strengthening in managing patellofemoral pain.
For recurrent or severe cases unresponsive to 3-6 months of conservative management, surgical interventions may be necessary, including lateral release, medial patellofemoral ligament reconstruction, or tibial tubercle osteotomy 1. These procedures aim to correct anatomical factors contributing to lateral tracking, such as increased Q-angle, patella alta, trochlear dysplasia, or ligamentous laxity.
The underlying pathophysiology involves imbalances in the dynamic and static stabilizers of the patella, which is why targeted strengthening of the medial stabilizers is crucial for successful management 1. By prioritizing conservative measures and considering surgical interventions when necessary, patients with patella lateral subluxation can achieve improved outcomes in terms of morbidity, mortality, and quality of life.
From the Research
Management of Patellar Lateral Subluxation
The management of patellar lateral subluxation, also known as patellofemoral instability, can be approached through both conservative and surgical methods.
- Conservative treatment, as described by 2, involves an exercise program that includes quadricep sets, straight leg raises, hip abductors, hip adductors, hip flexors, and hamstring stretches, with a reported success rate of approximately 80%.
- The prevention of flexion extension activity and the importance of stretching the hamstring muscles are also emphasized in the conservative treatment approach 2.
- In cases where conservative treatment fails, surgical intervention may be necessary, particularly for patients with recurrent dislocations, as discussed in 3 and 4.
Surgical Intervention
Surgical techniques for managing patellar lateral subluxation include:
- Medial patellofemoral ligament (MPFL) reconstruction, which is an effective treatment for preventing recurrent dislocations in patients with normal anatomy and kinematics 3.
- Lateral retinacular lengthening, which is recommended over lateral release due to the potential risk of iatrogenic medial instability 5.
- Lateral patellofemoral ligament reconstruction, which can be performed to effectively treat medial instability 5.
- The use of a quadriceps tendon graft for lateral patellofemoral ligament reconstruction, as described in 6, provides an alternative technique for addressing patellar instability.
Rehabilitation
Rehabilitation after MPFL reconstruction is crucial for restoring normal kinematics and preventing recurrent dislocations, as discussed in 4. The rehabilitation protocol typically involves phase-specific guidelines for progression, including exercises and interventions tailored to the patient's needs.