What is the initial treatment for a patient with Patella Alta?

Initial Treatment for Patella Alta

The initial treatment for patella alta should include individualized knee-targeted exercise therapy, focusing on quadriceps strengthening, combined with education and patellar taping for symptom relief. 1

Assessment and Diagnosis

Before initiating treatment, a thorough evaluation should include:

• Objective assessment of physical impairments including:
  • Muscle strength (hip and knee)
  • Movement patterns of the lower extremity
  • Tissue tolerance to load
  • PFJ structure/function specific to patella alta 1
• Evaluation of functional limitations and pain patterns during activities

Treatment Algorithm

First-Line Treatment

1. Knee-targeted exercise therapy:

   • Focus on eccentric strengthening of the quadriceps 1, 2
   • Begin with low-load exercises that don't exacerbate symptoms
   • Gradually progress intensity as tolerated
   • For patients with poor tolerance to loaded knee flexion, initially focus more on hip exercises 1

2. Patellar taping:

   • Apply medially directed patellar taping to improve patellar tracking 1, 2
   • Taping provides statistically significant and possibly clinically important effects on pain reduction 1
   • Can be used for short-term relief of pain and improvement in function 1, 3

3. Education:

   • Provide education about the condition, recovery expectations, and pain management 1
   • Challenge inaccurate beliefs about the condition
   • Explain that pain doesn't necessarily correlate with damage
   • Develop insight into recovery journey and expected timeframes 1

Supporting Interventions

1. Prefabricated foot orthoses:

   • Consider for patients who respond favorably to treatment direction tests 1
   • Customize for comfort by modifying density and geometry
   • Note: Lateral heel wedges are not recommended for medial compartmental OA 1

2. Bracing:

   • A patellofemoral brace can help resist lateral displacement of the patella 2
   • Provides symptomatic relief but should support rather than replace active rehabilitation 2

3. Manual therapy:

   • Consider when rehabilitation is hindered by elevated symptom severity and irritability 1
   • Can be combined with supervised exercise to improve outcomes 2

4. Movement retraining:

   • Consider when symptoms are associated with task-specific biomechanics 1

Phased Rehabilitation Approach

Implement a structured rehabilitation program:

1. Initial phase (0-4 weeks):

   • Focus on pain control and protected range of motion 2
   • Begin gentle quadriceps strengthening
   • Apply patellar taping for symptom relief

2. Intermediate phase (4-8 weeks):

   • Progressive strengthening exercises and eccentric training 2
   • Increase load as tolerated
   • Continue with taping as needed

3. Advanced phase (8-12 weeks):

   • Occupation-specific training and functional exercises 2
   • Gradual return to activities

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 2

• If no improvement occurs after 6-8 weeks of conservative treatment, consider referral to a specialist 2

Special Considerations

• For patients with recurrent patellar dislocations associated with patella alta, surgical intervention may eventually be necessary if conservative measures fail 4, 5
• Surgical techniques may include transposing the patellar tendon insertion distally 4 or patellar tendon imbrication 6
• Young patients (particularly under 16 years) with patella alta have a higher risk of recurrent dislocation 5

Return to Activity

Return to full activity is permitted when the patient demonstrates:

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

By following this structured approach to treating patella alta, clinicians can effectively manage symptoms and improve functional outcomes while reducing the risk of recurrent issues.