What are the treatment options for a full thickness tear of the lateral patella facet?

Treatment Options for Full Thickness Tear of Lateral Patella Facet

A full-thickness tear of the lateral patellar facet should be initially managed with conservative treatment including relative rest, eccentric exercises, NSAIDs, and physical therapy, with surgical options such as partial lateral facetectomy reserved for cases failing conservative management after 3-6 months.

Initial Conservative Management

First-Line Interventions

• Begin with relative rest by reducing activities that involve repetitive loading of the patellofemoral joint, while avoiding complete immobilization to prevent muscular atrophy 1
• Eccentric exercise programs are specifically recommended to reduce symptoms, increase strength, and promote tendon healing in patellar pathology 1
• NSAIDs should be administered as initial pain management, with moderate evidence supporting their use for rotator cuff and tendon pathology 2
• Paracetamol can be used concurrently with NSAIDs for more effective pain control 2

Physical Therapy Components

• Deep transverse friction massage is recommended to reduce pain in patellar tendinopathy 1
• Stretching exercises are widely accepted and thought to be helpful 1
• Tensile loading of damaged tissue stimulates collagen production and guides normal alignment of newly formed collagen fibers 1

Second-Line Conservative Options

• A single corticosteroid injection with local anesthetic may provide short-term improvement in both pain and function, though this should be limited to avoid overuse 2
• Corticosteroid iontophoresis has shown effectiveness for patellar tendon pain and function 1
• Opioids should be reserved only for rescue analgesia when other methods fail 2

Diagnostic Imaging Considerations

When to Image

• MRI or ultrasonography should be obtained when diagnosis remains unclear after history and physical examination, or when pain is recalcitrant despite adequate conservative management 1
• MRI is useful for showing tendon thickening, chronic degenerative changes, and detailed anatomic information with moderate sensitivity (78%) and specificity (86%) 1
• Ultrasonography is more specific (94%) than sensitive (58%) for patellar tendinopathy, better at ruling in the condition when positive 1

Surgical Management

Indications for Surgery

• Failure of conservative treatment after 3-6 months of appropriate therapy 1
• Persistent pain and functional limitation despite optimal nonsurgical management 3, 4

Surgical Options

Partial Lateral Facetectomy (PLFE)

• PLFE with patella thickness resection is a minimally invasive option that aims to decrease high pressure in the lateral facet and improve patellar congruence 4
• This procedure showed considerable improvement in pain scores (2.34 points on WOMAC) and function scores (1.63 points) at mean 24-month follow-up 4
• 78% of patients experienced improvement in Knee Society Scores after PLFE 4
• Long-term outcomes show Kaplan-Meier survival rates of 85% at 5 years, 67.2% at 10 years, and 46.7% at 20 years, with approximately half of patients having satisfactory outcomes at 10-year follow-up 3
• Average time to reoperation in the failure group was 8.0 years 3

Surgical Technique Considerations

• The procedure maintains a width/thickness ratio of 1.8:1.0 after surgery 4
• PLFE is relatively simple, minimally invasive, and can be a valid early alternative to more complex operations in selected patients 4

Common Pitfalls to Avoid

• Do not overuse corticosteroid injections - limit to single injections for short-term relief rather than repeated injections 2
• Avoid complete immobilization as it leads to muscular atrophy and deconditioning 1
• Do not use opioids as first-line treatment - reserve them strictly for rescue analgesia 2
• Do not rush to surgery - ensure adequate trial of conservative management for at least 3-6 months before considering surgical intervention 1
• Recognize that older age is associated with higher failure rates and poorer outcomes, which should influence treatment decisions 2

Treatment Algorithm

1. Weeks 0-4: Relative rest, NSAIDs/paracetamol, ice application, begin gentle ROM exercises
2. Weeks 4-12: Progress to eccentric strengthening exercises, deep friction massage, continue NSAIDs as needed
3. Months 3-6: If inadequate response, consider single corticosteroid injection; continue physical therapy
4. After 6 months: If conservative management fails, obtain MRI for surgical planning and consider partial lateral facetectomy in appropriate candidates