What is the treatment for patellar tilt and subluxation?

Treatment for Patellar Tilt and Subluxation

The primary treatment for patellar tilt and subluxation should begin with conservative management including quadriceps strengthening exercises, hamstring stretching, and bracing, with surgical intervention reserved for cases that fail to respond to non-operative measures. 1

Diagnostic Evaluation

• Initial assessment should include weight-bearing axial radiographs to evaluate patellofemoral kinematics and demonstrate the degree of patellar tilt or subluxation 2
• CT is the most commonly used modality for measuring axial malrotation when more detailed assessment is needed, especially when evaluating component rotation in post-total knee arthroplasty patients 2
• MRI with metal artifact reduction techniques may be used to detect patellar complications when radiographs are inconclusive 2

Conservative Management

Exercise Therapy

• Quadriceps strengthening exercises, particularly quadricep sets and straight leg raises, form the cornerstone of treatment with approximately 80% success rate 3
• Hip abductor and adductor strengthening to improve patellar tracking 3
• Hamstring stretching is essential as tight hamstrings can contribute to patellofemoral problems 3
• Avoid flexion-extension activities like stair climbing during the acute phase 3
• Proprioceptive training and hip external rotator strengthening to improve patellar stability 4

Bracing and Support

• Knee bracing with limited range of motion is one of the most commonly recommended interventions 1
• Patellar taping techniques can help improve patellar alignment and reduce pain 4
• Orthotic devices may be beneficial, particularly for patients with foot pronation or pes planus that contributes to malalignment 2

Surgical Management

Surgical intervention should be considered when conservative treatment fails after an appropriate trial period (typically 3-6 months):

• Lateral release is appropriate specifically for patellar tilt (abnormal rotation) 4
• Proximal patellar realignment using arthroscopic or combined arthroscopic/mini-open approaches for patellar subluxation 4
• Medial retinacular release for medial patellar subluxation 5
• Lateral retinacular imbrication or reconstruction of the lateral patellofemoral ligament for medial subluxation 5
• Tibial tubercle transfer (medial or anteromedial) for more profound malalignments or symptomatic articular lesions 4

Treatment Outcomes

• Conservative management results in good outcomes in approximately 80% of patients 3
• Surgical management is associated with a lower rate of re-dislocation compared to conservative treatment 1
• Post-surgical CT evaluation shows significant improvement in lateral shift measurements compared to pre-operative values 6
• Successful surgical outcomes correlate with improvement in lateral shift when the quadriceps is contracted 6

Special Considerations

• Be alert for symptoms of medial subluxation in postoperative patients, which may require lateral patellar tenodesis 4
• Complications of conservative treatment may include low back pain, iliopsoas tendinitis, and muscle soreness 3
• Tight iliotibial band can put abnormal stress on the lateral aspect of the patella and should be addressed in the treatment plan 3
• For patients with total knee arthroplasty, patellofemoral instability (1-12% incidence) is often due to internal malrotation of the femoral and/or tibial components 2