What is the diagnosis and treatment for a patient with knee pain and an MRI showing lateral patellar tilt with elongated patellar tendon and mild chondromalacia in the lateral patellar facet?

Patellofemoral Pain Syndrome with Lateral Patellar Tilt and Chondromalacia

The MRI findings of lateral patellar tilt with elongated patellar tendon and mild chondromalacia in the lateral patellar facet are consistent with patellofemoral pain syndrome (PFPS), which requires targeted physical therapy focusing on quadriceps strengthening as first-line treatment. 1, 2

Diagnosis Explanation

The MRI findings reveal three key components:

1. Lateral patellar tilt - This indicates malalignment of the patella within the trochlear groove, causing abnormal tracking during knee flexion and extension
2. Elongated patellar tendon - This can contribute to patellar alta (high-riding patella), which increases the risk of lateral displacement
3. Mild chondromalacia in the lateral patellar facet - This represents early cartilage damage due to abnormal forces on the lateral aspect of the patella

These findings collectively represent patellofemoral malalignment, which is a common cause of anterior knee pain 2. The lateral patellar tilt creates abnormal contact forces between the lateral facet of the patella and the lateral femoral condyle, leading to chondromalacia (softening of the cartilage) 3, 4.

Clinical Correlation

Patients with these findings typically experience:

• Anterior knee pain, especially when climbing stairs or sitting for prolonged periods
• Pain that worsens with activities that increase patellofemoral compressive forces
• Possible crepitus with knee flexion and extension
• Tenderness at the lateral patellofemoral joint line 2, 5

Treatment Algorithm

First-Line Treatment:

1. Physical therapy with quadriceps strengthening

   • Focus on vastus medialis oblique (VMO) strengthening to improve patellar tracking
   • Stretching of tight lateral structures (vastus lateralis, iliotibial band)
   • Core and hip strengthening exercises 2

2. Patellar bracing or sleeve

   • Patellar-stabilizing braces are more effective than simple sleeves in reducing lateral translation and tilt 6
   • Braces help realign the patella within the trochlear groove during movement

3. Activity modification

   • Temporarily avoid activities that exacerbate symptoms (deep squats, prolonged sitting)
   • Gradually reintroduce activities as symptoms improve 2

4. Pain management

   • NSAIDs for pain and inflammation
   • Topical analgesics as needed 2

Second-Line Treatment (if first-line fails after 3-6 months):

1. Intra-articular corticosteroid injections for short-term relief 2

2. Consider additional imaging

   • CT scan to better evaluate patellofemoral anatomy and tibial tubercle-trochlear groove distance 1
   • Dynamic MRI to assess patellar tracking during movement 7

Third-Line Treatment (for refractory cases):

1. Surgical options
   • Lateral release of tight lateral retinacular structures
   • Tibial tubercle osteotomy (Fulkerson procedure) for significant malalignment
   • Patellofemoral arthroplasty for advanced chondromalacia not responding to conservative measures 2, 5

Monitoring and Prognosis

• Most patients improve with conservative management within 3-6 months
• Follow-up imaging may be necessary if symptoms persist despite appropriate therapy
• Early intervention is important to prevent progression of chondromalacia and development of patellofemoral osteoarthritis 2

Important Considerations

• Lateral patellar tilt with chondromalacia represents a biomechanical problem that requires correction of the underlying malalignment, not just pain management
• The American College of Radiology recommends MRI as the appropriate next step after radiographs for evaluating patellofemoral pain 1
• Sagittal plane malpositioning (as indicated by the elongated patellar tendon) contributes to abnormal patellofemoral loading and should be addressed in rehabilitation 4
• Avoid arthroscopic debridement alone for chondromalacia, as it provides limited benefit without addressing the underlying malalignment 2