What is the recommended treatment for a 19-year-old female with mild lateral patellar maltracking?

Treatment of Mild Lateral Patellar Maltracking in a 19-Year-Old Female

Conservative management with patellofemoral bracing combined with a comprehensive rehabilitation program focused on eccentric strengthening exercises is the recommended first-line treatment for this patient with mild lateral patellar maltracking. 1

Initial Conservative Management Approach

Patellofemoral Bracing

• Patellofemoral braces should be used as an inexpensive, subjectively helpful component of anterior knee pain therapy, applied to resist lateral displacement of the patella and maintain proper patellar alignment. 1
• The brace mechanism works through a medially directed force to improve patellar tracking, though changes in regional temperature, neurosensory feedback, or circulation may also contribute to therapeutic effects. 1
• Patients consistently report significant subjective improvements in pain and disability with brace wear, even though objective evidence of efficacy remains mixed in the literature. 1
• An off-the-shelf patellofemoral brace with neoprene material and lateral buttress support is typically sufficient for most patients, though more active individuals may benefit from a brace with a lateral hinge and adjustable patellar buttress. 1

Rehabilitation Program Components

Eccentric strengthening exercises are the cornerstone of treatment, reducing symptoms, increasing strength, and promoting proper patellar tracking by stimulating collagen production and guiding normal alignment of newly formed collagen fibers. 2

Exercise Protocol:

• Implement eccentric quadriceps strengthening as the primary therapeutic intervention. 2, 3
• Progressive stretching of quadriceps and hamstrings to improve lateral retinacular mobility and muscular flexibility, which enhances patellar tracking. 3, 4
• Sport-specific exercises with gradual progression back to full participation as symptoms improve. 3

Activity Modification:

• Relative rest by reducing repetitive loading activities that reproduce pain, particularly jumping and stair navigation, while avoiding complete immobilization. 2, 3
• Complete cessation of all activity should be avoided to prevent muscular atrophy and deconditioning. 2, 3
• Maintain activities that do not reproduce pain to prevent deconditioning. 3

Adjunctive Pain Management

• Deep transverse friction massage may provide additional pain relief and benefit. 2, 3
• Cryotherapy through a wet towel for 10-minute periods provides effective acute pain relief. 2, 3
• NSAIDs (oral or topical) can be used for short-term pain control if needed, though they do not affect long-term outcomes, with topical formulations being preferable due to elimination of gastrointestinal hemorrhage risk. 2, 3

Expected Outcomes and Timeline

Approximately 80% of patients recover completely within 3-6 months with appropriate conservative treatment. 2, 3

Critical Pitfalls to Avoid

• Never inject corticosteroids into or near the patellar tendon, as this inhibits healing, reduces tensile strength, and predisposes to spontaneous rupture. 2, 3
• Avoid complete immobilization or casting, as this causes muscular atrophy and deconditioning. 2, 3
• Do not proceed to surgical intervention without an adequate 3-6 month trial of conservative treatment. 2, 5

Surgical Considerations

Surgery should only be considered if conservative management fails after 3-6 months of well-managed treatment and the patient continues to experience significant pain affecting quality of life or inability to return to desired activity level. 2, 5

Anatomical Considerations for This Patient

The 25 mm measurement of lateral patellar maltracking in this young patient suggests mild maltracking that should respond well to conservative management. 6 In patients with patellar instability, lateral patellar maltracking with the knee extended can be largely attributed to either a shallow trochlear groove or a combination of patella alta and lateral position of the tibial tuberosity. 7 However, given the mild nature of this patient's maltracking and absence of acute instability, conservative treatment remains the appropriate initial approach. 8, 9