What is the treatment for lateral patellar tilt?

Treatment of Lateral Patellar Tilt

First-line treatment for lateral patellar tilt consists of patellofemoral bracing combined with progressive quadriceps strengthening exercises, with patellar taping added for short-term pain relief. 1

Initial Conservative Management

The treatment approach should begin with mechanical correction and muscle rebalancing:

Patellofemoral Bracing

• Apply a patellofemoral brace that resists lateral displacement through a medially directed force to maintain proper patellar alignment and decrease knee pain. 1
• Most patients can be successfully fitted with an off-the-shelf brace without requiring customization. 1
• More active individuals benefit from a patellofemoral brace with a lateral hinge and adjustable patellar buttress for enhanced control. 1
• Periodically inspect the brace for migration, strap loosening, or material fatigue to ensure continued effectiveness. 1
• Most patients report significant subjective improvements in pain and disability with brace wear. 1

Quadriceps Strengthening Program

• Implement progressive 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. 1, 2
• Allow at least 48 hours rest between training sessions for the same muscle group. 2
• Complete 2-4 sets for optimal strength gains, with 2-3 minutes rest between sets. 2
• The rationale is strong: reducing vastus medialis muscle tension increases lateral patellar tilt by 2.8° and lateral translation by 4mm, while elevating lateral joint contact pressures and reducing medial pressures. 3
• Quadriceps strengthening has been shown effective for pain reduction and functional improvement in knee pathology. 4

Important clinical predictor: Female patients whose quadriceps contraction reduces lateral patellar tilt (rather than worsening it) are more likely to experience pain relief with strengthening exercises. 5 Check dynamic patellar tilt characteristics before treatment—if quadriceps contraction worsens the tilt by more than 1.5°, the odds of unsuccessful outcome increase by 19% per degree. 5

Patellar Taping

• Apply medial patellar taping for short-term relief of pain and improvement in function (Grade B recommendation). 4, 1
• Medial taping produces statistically significant and possibly clinically important effects on pain reduction immediately and within 4 days of application. 4, 1
• Use taping particularly during rehabilitation exercises or activities that provoke symptoms. 2

Adjunctive Interventions

Foot Orthoses

• Consider shoe orthoses in addition to bracing for patients with recalcitrant patellofemoral pain syndrome. 1
• Prefabricated foot orthoses may benefit patients who respond favorably to treatment direction tests. 1

Activity Modification

• Avoid activities that increase patellofemoral joint loading during the acute phase. 1
• Implement relative rest by reducing high-impact activities that reproduce pain. 2
• Allow low-impact aerobic activities like cycling or swimming to maintain cardiovascular fitness. 2

Pain Management

• Use topical NSAIDs preferentially over oral NSAIDs to eliminate gastrointestinal hemorrhage risk while providing pain relief. 2
• Apply cryotherapy (ice through wet towel for 10-minute periods) for acute pain relief after activity. 2

What NOT to Do

• Do not prescribe lateral heel wedges—there is limited evidence for their effectiveness and they may worsen symptoms. 4, 1
• Never inject corticosteroids into patellar structures, as this inhibits healing, reduces tensile strength, and predisposes to spontaneous rupture. 2

Diagnostic Imaging Considerations

• Axial radiographs demonstrate the degree of patellar tilt or subluxation. 1
• Weight-bearing axial radiographs are recommended to better assess patellofemoral kinematics. 1
• Radiographs are usually satisfactory for assessment of patellar complications. 1

Treatment Timeline and Expectations

• Inform patients that recovery may take several months (typically 3-6 months) with appropriate conservative treatment. 1, 2
• Initial focus should be on pain reduction and improving patellar tracking through bracing and taping. 1
• Approximately 80% of patients with patellofemoral pathology recover completely within 3-6 months with appropriate conservative treatment. 2

Surgical Considerations

If conservative management fails after 3-6 months and symptoms significantly impair quality of life, surgical options may be considered. 2 Lateral patellar retinacular release has shown 78% survivorship at 15 years in adolescents with patellar tilt, with the majority of patients satisfied 5-22 years post-operatively. 6 However, surgery should only be pursued after exhausting conservative measures. 2

Common Pitfall

The lateral pull test and patellar tilt test have only fair intrarater reliability (kappa 0.39-0.50) and poor interrater reliability (kappa 0.20-0.35). 7 Do not rely solely on these physical examination findings for diagnosis—use imaging confirmation when clinical decisions are uncertain.