What is the best treatment for patellar alta with enthesopathy of the knee?

Treatment for Patellar Alta with Knee Enthesopathy

The best treatment is individualized knee-targeted exercise therapy with patellar taping as the primary intervention, supported by education and load management, with hip strengthening added if the patient cannot tolerate loaded knee flexion. 1

Primary Treatment Approach

Exercise Therapy (Core Intervention)

• Knee-targeted exercise therapy demonstrates high certainty evidence for pain reduction (SMD 1.16) and moderate certainty evidence for functional improvement (SMD 1.19) in patellofemoral conditions including patellar alta 1, 2

• Progressive quadriceps strengthening should be prescribed in both open and closed chain exercises, with parameters modified based on symptom severity and irritability 1

• Hip-and-knee combined exercise therapy should be prioritized when the patient demonstrates poor tolerance to loaded knee flexion, as this allows tissue adaptation while maintaining therapeutic benefit 1

• Eccentric exercises are specifically recommended for patellar tendon enthesopathy (tendinopathy) to reduce symptoms, increase strength, and promote tendon healing 1, 3, 4

Patellar Taping (Essential Adjunct for Patellar Alta)

• Patellar taping is particularly effective for patellar alta as it corrects patella alignment and provides immediate symptom relief during functional activities 5

• Taping should be applied when rehabilitation is hindered by elevated symptom severity and irritability, which is common with the combination of patellar alta and enthesopathy 1

• Teach the patient self-application of tape after confirming favorable response during functional testing (e.g., improved squat mechanics or reduced pain) 5

• Taping provides a safe, conservative, and cost-efficient measure to manage symptoms and improve activity tolerance 5

Supporting Interventions

Education (Mandatory Foundation)

• Education must underpin all interventions and should address: 1
  • The diagnosis and expected recovery timeline (several months) 2
  • Pain does not equal tissue damage, particularly important for chronic presentations 1
  • Load management strategies specific to their activities 1
  • Building confidence and reducing fear of movement 1

Prefabricated Foot Orthoses (Conditional)

• Prescribe prefabricated foot orthoses only if the patient responds favorably to treatment direction tests (e.g., symptom improvement during single leg squat with orthoses in place) 1, 2

• Customize for comfort by modifying density and geometry 1

• These are most beneficial in the short term and may not be needed long-term 1

Additional Modalities for Enthesopathy

• Deep transverse friction massage is recommended specifically for patellar tendon pain reduction 1

• Corticosteroid iontophoresis is effective for patellar tendinopathy pain and function, though this is specific to the enthesopathy component 1

• Injection therapies (platelet-rich plasma, perineural dextrose) show promise but have variable evidence quality; consider only after conservative measures fail 6, 3

Assessment-Driven Decision Making

Key Objective Findings to Guide Treatment

• Assess tissue tolerance to load through pain provocation tests and presence of effusion 1

• Evaluate quadriceps and hip strength using hand-held dynamometry to determine exercise prescription 1

• Observe movement patterns during single leg squat to identify biomechanical contributors 1

• Confirm patellar alta as a structural factor requiring specific attention to patella alignment strategies 1

Treatment Modification Algorithm

• If the patient tolerates loaded knee flexion: Begin with knee-targeted quadriceps exercises and progress intensity 1

• If the patient cannot tolerate loaded knee flexion: Emphasize hip strengthening initially, then gradually introduce knee loading as tolerance improves 1

• If symptoms persist after 6 weeks: Revisit assessment findings to ensure interventions align with impairments and verify patient engagement 1

Critical Pitfalls to Avoid

• Do not use lateral heel wedges as they have limited evidence and may worsen symptoms 2

• Avoid the term "tendinitis" as the pathophysiology is tendinosis (degenerative) rather than inflammatory 4

• Do not rely solely on NSAIDs for enthesopathy; while they may provide short-term relief, they do not change long-term outcomes and exercise therapy is superior 1

• Do not abandon taping prematurely in patellar alta cases, as alignment correction is crucial for this specific structural abnormality 5

Expected Timeline

• Recovery typically requires several months of consistent conservative management 2

• Reassess at minimum 6 weeks if favorable outcomes are not observed 1

• Surgery is reserved only for cases refractory to comprehensive conservative treatment and is not first-line for either patellar alta or enthesopathy 4