Management of Patella Dislocation
The management of patella dislocation should follow a staged approach beginning with closed reduction, followed by 3-4 weeks of immobilization using a posterior splint, knee brace, or cylinder cast, with posterior splints showing the best balance between preventing redislocation and maintaining joint mobility. 1
Initial Management
Acute Phase
- Closed reduction should be performed promptly
Radiographic Evaluation
- Obtain anteroposterior and lateral knee radiographs to:
- Rule out fractures
- Assess for osteochondral fragments 1
- Consider MRI without contrast if:
- Osteochondral injury is suspected
- Substantial disruption of medial patellar stabilizers is suspected 1
Conservative Treatment
Immobilization (0-4 weeks)
- Posterior splint is likely the optimal choice for immobilization as it provides:
- Low redislocation rate (0.08 per follow-up year)
- Less knee joint movement restriction compared to cylinder cast 4
- Alternative options include:
- Cylinder cast (redislocation rate 0.12 per follow-up year)
- Knee brace (higher redislocation rate of 0.29 per follow-up year) 4
- Duration: 3-4 weeks of immobilization 1
Early Rehabilitation Phase (0-4 weeks)
- Begin quadriceps isometric exercises
- Gentle range of motion exercises as tolerated within brace limitations
- Weight-bearing as tolerated is recommended by 49% of surgeons 1
Intermediate Rehabilitation Phase (4-8 weeks)
- Progressive range of motion exercises
- Strengthening of quadriceps and hip abductors
- Proprioceptive training 1
Advanced Rehabilitation Phase (8-12 weeks)
- Sport-specific exercises
- Return to activity when full range of motion and strength are restored 1
Exercise Therapy Approach
- Individualized knee-targeted exercise therapy should be delivered following assessment of symptom severity and irritability
- Education should underpin all interventions to:
- Build confidence and understanding of the diagnosis
- Explore the concept of pain not correlating with tissue damage
- Develop insight into recovery journey and expected timeframes
- Promote autonomy and reduce fear 5
Supporting Approaches
- Patellofemoral braces can be used as an adjunct to rehabilitation
- Patients report significant subjective improvements in pain and disability with brace wear
- Braces help resist lateral displacement of the patella 5
- Foot orthoses should be prescribed when patients respond favorably to treatment direction tests
- Can be customized for comfort by modifying density and geometry 5
- Taping should be considered when rehabilitation is hindered by elevated symptom severity or high fear of movement 5
Surgical vs. Non-Surgical Management
- Current evidence comparing surgical vs. non-surgical management is of very low certainty 6
- Consider surgical management for:
- Osteochondral fracture
- Substantial disruption of medial patellar stabilizers
- Laterally subluxated patella with normal alignment of contralateral knee
- Second dislocation
- Failure to improve with appropriate rehabilitation
- Young patients (<35 years) participating in contact sports
- Significant anatomic risk factors 1
Risk Factors for Recurrence
- Young age
- Female gender
- Anatomic abnormalities (trochlear dysplasia, patella alta)
- Participation in high-risk sports
- Recurrence rates after conservative treatment range from 15-44% 1
Clinical Pearls and Pitfalls
Pitfall: Using knee braces alone without comprehensive rehabilitation program
- Solution: Patellofemoral braces should be used in conjunction with a comprehensive knee rehabilitation program that includes strengthening, flexibility, and technique improvements 5
Pitfall: Excessive immobilization leading to joint stiffness
- Solution: Balance between immobilization to prevent redislocation and early mobilization to prevent stiffness; posterior splints appear to offer the best balance 4
Pitfall: Failing to identify patients who might benefit from surgical intervention
- Solution: Carefully assess for risk factors for recurrence and consider early surgical referral for high-risk patients 1