What is the recommended treatment for a 25-year-old male with a high riding patella, painful knee when playing basketball, and MRI findings of partial loss of medial and lateral articulating patellar facets?

Treatment Recommendation for High-Riding Patella with Patellar Facet Cartilage Loss

This 25-year-old active male with patella alta and partial loss of medial and lateral patellar facets should begin with a structured 3-6 month trial of conservative management centered on eccentric quadriceps strengthening exercises, activity modification, and patellar taping, with surgical correction (tibial tubercle distalization combined with lateral release and possible patelloplasty) reserved only if conservative treatment fails and symptoms significantly impair quality of life. 1, 2, 3

Initial Conservative Management (3-6 Month Trial)

Exercise Therapy - Primary Treatment

• Implement eccentric quadriceps strengthening as the cornerstone intervention, training 2-3 days per week at 60-70% of one-repetition maximum for 8-12 repetitions across 2-4 sets, with at least 48 hours rest between sessions 1, 3
• Progress to heavy slow resistance training (≥80% of 1RM) as strength improves and tolerance increases 3
• Include both hip and knee-targeted exercises, with the balance determined by tolerance to loaded knee flexion 1
• Incorporate complementary hamstring and quadriceps stretching 2-3 days per week, holding static stretches for 10-30 seconds after warming up muscles 3

Activity Modification

• Implement relative rest by reducing basketball and other jumping/pivoting activities that reproduce pain, particularly avoiding repetitive loading that aggravates symptoms 1, 3
• Critical pitfall: Avoid complete immobilization, as this causes muscular atrophy and deconditioning 3
• Allow low-impact aerobic activities like cycling or swimming to maintain cardiovascular fitness 3

Adjunctive Interventions

• Apply medially directed patellar taping for short-term pain relief and improved function, particularly during rehabilitation exercises or activities that provoke symptoms 1
• The taping provides statistically significant and possibly clinically important effects on pain immediately and up to 4 days after application 1
• Consider manual therapy (deep transverse friction massage) in combination with supervised exercise for additional pain reduction 1, 3

Pain Management

• Use topical NSAIDs preferentially over oral NSAIDs to eliminate gastrointestinal hemorrhage risk while providing pain relief 1, 3
• Apply cryotherapy (ice through wet towel for 10-minute periods) for acute pain relief after activity 3
• Critical pitfall: Never inject corticosteroids into the patellar tendon or articular surfaces, as this inhibits healing, reduces tensile strength, and predisposes to spontaneous rupture 3

Assessment of Underlying Anatomic Risk Factors

Key Structural Abnormalities to Evaluate

• Patella alta is a significant predisposing factor for patellofemoral instability and must be considered when planning treatment 4
• The high-riding patella results in decreased bony stability and altered patellofemoral contact mechanics 4
• Evaluate for additional risk factors including trochlear dysplasia, increased tibial tubercle-trochlear groove distance (TT-TG), and lateral patellar tilt 5, 6
• The partial loss of medial and lateral patellar facets suggests chronic abnormal loading patterns and possible previous subluxation episodes 7, 6

Clinical Examination Findings to Monitor

• Assess lateral patellar glide with knee in extension or 20° flexion; displacement >50% of patellar width is abnormal 5
• Check for tenderness at the lateral patellofemoral joint line and resistance to medial patellar displacement at 30° flexion 8
• Perform decline squat test to assess patellar tendon tolerance to load 3
• Monitor for signs of instability including apprehension with lateral displacement and giving way episodes 8, 5

Surgical Indications and Approach

When to Consider Surgery

Surgery should be reserved exclusively for patients who have failed a well-executed 3-6 month conservative treatment program and continue to experience:

• Significant pain affecting quality of life and preventing return to desired basketball activity 2, 3
• Recurrent instability episodes or persistent apprehension despite optimal rehabilitation 5, 4
• Progressive cartilage damage or mechanical symptoms 7

Surgical Strategy for Patella Alta with Facet Damage

The surgical approach must address multiple anatomic abnormalities simultaneously ("à la carte surgery"):

• Tibial tubercle distalization to correct the patella alta and improve patellar engagement in the trochlear groove 7, 4
• Lateral retinacular release to address lateral restraint and improve patellar tracking, with sequential division of the vastus lateralis obliquus, lateral retinaculum, and anterior iliotibial tract fibers as needed 8, 7
• Medial facet patelloplasty if there is a bulge or protrusion of the distal medial facet hindering recentering, which can improve stability and lateral tilt 7
• Consider anteromedialization of tibial tubercle if TT-TG distance is increased 7

Surgical Outcomes

• In patients with patellofemoral dysplasia and patellar instability treated with combined procedures including patelloplasty, 86.5% achieved satisfactory or very satisfactory results at mean 7.5-year follow-up 7
• Recurrent dislocation rate was only 4.7% with comprehensive surgical correction 7
• For lateral facet syndrome treated with lateral release procedures, 87% had satisfactory pain relief and returned to normal activities at minimum 2-year follow-up 8

Critical Decision-Making Algorithm

1. Begin with 3-6 months of structured conservative management focusing on eccentric strengthening, activity modification, and patellar taping 1, 2, 3

2. Reassess at 6 weeks: If no favorable outcomes observed, revisit assessment findings to ensure interventions align with clinical reasoning and verify patient engagement 1

3. At 3-6 months: If patient continues to have significant pain preventing basketball participation despite optimal conservative care, proceed with surgical consultation 2, 3

4. Surgical planning must address all anatomic abnormalities: patella alta correction (distalization), lateral restraint release, and consideration of medial facet patelloplasty based on imaging findings 7, 4

Important Caveats

• The partial cartilage loss indicates chronic abnormal mechanics that may not fully resolve with conservative treatment alone, but surgery should still be delayed until conservative measures have been exhausted 7, 6
• Patella alta significantly impacts other risk factors for instability and must be corrected if surgical intervention becomes necessary 4
• Education is essential: Explain that pain doesn't necessarily correlate with tissue damage, set realistic expectations for recovery timeline (most patients recover in 3-6 months with conservative care), and promote autonomy to reduce fear of movement 1, 3
• For overweight patients, weight loss counseling should be included as part of the comprehensive treatment plan 1, 9