What is the best treatment approach for a patient with patellar maltracking and bone-on-bone contact?

Treatment Approach for Patellar Maltracking with Bone-on-Bone Contact

For patients with patellar maltracking and bone-on-bone contact, the optimal treatment approach consists of a phased rehabilitation program with eccentric quadriceps strengthening, NSAIDs for pain relief, and a patellofemoral brace, with surgical intervention reserved only for cases that fail conservative management after 3-6 months. 1

Initial Assessment and Diagnosis

• Weight-bearing axial radiographs are the first-line imaging study to assess patellofemoral kinematics and demonstrate the degree of patellar tilt or subluxation 2
• CT is recommended when detailed assessment of component rotation and patellar alignment is needed 2
• Key findings to identify:
  • Lateral displacement of patella
  • Patellar tilt
  • Degree of articular cartilage damage (bone-on-bone contact)

Conservative Management (First-Line Approach)

Phase 1: Pain Control and Protected Range of Motion (0-4 weeks)

1. Medication Management:

   • NSAIDs (naproxen 500mg twice daily or ibuprofen 1.2g daily) for short-term pain relief 1
   • Acetaminophen as an alternative if NSAIDs are contraindicated 2

2. Bracing and Support:

   • Patellofemoral brace to resist lateral displacement of the patella 1
   • Medially directed patellar taping to improve patellar tracking 2
   • Consider medially wedged insoles for lateral compartment OA or laterally wedged subtalar strapped insoles for medial compartment OA 2

3. Initial Exercise Therapy:

   • Low-load quadriceps exercises that don't exacerbate symptoms 1
   • Gentle range of motion exercises
   • Isometric quadriceps contractions

Phase 2: Progressive Strengthening (4-8 weeks)

1. Exercise Progression:

   • Eccentric strengthening of the quadriceps 1
   • Hip strengthening exercises (particularly external rotators and abductors) 1
   • Aquatic exercises for patients who are aerobically deconditioned 2

2. Manual Therapy:

   • Combined with supervised exercise 2
   • Focus on improving lateral retinacular mobility 3

3. Weight Management:

   • Weight loss counseling for overweight patients 2

Phase 3: Advanced Rehabilitation (8-12 weeks)

1. Functional Training:

   • Occupation-specific training 1
   • Progressive functional exercises
   • Balance and proprioceptive training

2. Activity Modification:

   • Gradual return to activity based on symptom response
   • Avoidance of activities that exacerbate symptoms

Monitoring and Follow-up

• Regular assessment at 2,6, and 12 weeks to evaluate:

  • Pain levels
  • Range of motion
  • Functional improvement
  • Signs of recurrent instability 1

• Consider referral to specialist if no improvement after 6-8 weeks of conservative treatment 1

Indications for Surgical Intervention

Surgery should only be considered when:

1. Conservative measures fail after 3-6 months of well-managed treatment 1
2. Significant functional limitation persists 1
3. Specific conditions are present:
   • Osteochondral fracture
   • Substantial disruption of the medial patellar stabilizers
   • Laterally subluxated patella with normal alignment of the contralateral knee
   • Large loose bodies requiring removal 4

Return to Activity Criteria

Full activity is permitted when the patient demonstrates:

1. Complete resolution of pain
2. Full range of motion
3. Strength symmetry >90% compared to the uninjured side
4. Successful completion of occupation-specific functional tests 1

Special Considerations

• Iliotibial Band Influence: Consider assessment and treatment of iliotibial tract contracture, as it can significantly affect patellar tracking and dominate lateral patellar supporting structures 5

• Bone-on-Bone Contact: In cases with severe cartilage loss (bone-on-bone), pain management becomes more important while still focusing on improving patellar tracking to minimize further damage

• Recurrent Dislocation: Patients with history of recurrent patellar dislocation may benefit from surgical stabilization if conservative management fails 6, 4

The evidence strongly supports initial conservative management for most patients with patellar maltracking, with surgical intervention reserved for specific cases that fail to respond to comprehensive rehabilitation.