What is the initial treatment for recurrent patella subluxation?

Initial Treatment of Recurrent Patellar Subluxation

Conservative management with structured physical therapy focusing on quadriceps strengthening, patellar bracing, and activity modification should be the initial treatment for recurrent patellar subluxation, as surgery is reserved for patients who fail conservative treatment.

Diagnostic Confirmation

Before initiating treatment, confirm the diagnosis and assess severity:

• Obtain weight-bearing axial radiographs to evaluate patellofemoral kinematics and demonstrate the degree of patellar subluxation 1
• Consider CT imaging when more detailed assessment of axial malrotation is needed, particularly if there are concerns about anatomic predisposing factors 1
• Physical examination should assess for medial subluxation (which can occur iatrogenically after previous surgery) versus the more common lateral subluxation 2

Conservative Treatment Protocol

Physical Therapy Program

The cornerstone of initial management is structured rehabilitation:

• Quadriceps strengthening exercises with emphasis on vastus medialis obliquus (VMO) activation 3
• Neuromuscular exercises to improve proprioception and dynamic patellar stability 3
• Stretching exercises for the lower extremity, particularly addressing any tightness that may contribute to maltracking 3
• Note that unstructured lower limb physical therapy programs show similar outcomes to specific exercise protocols, but structured programs are still recommended 3

Bracing and Orthotic Support

• Knee brace with limited range of motion during the acute phase to prevent recurrent episodes 3
• Patellofemoral stabilizing brace for ongoing support during activities 2
• Orthotic devices may be beneficial if foot pronation or pes planus contributes to malalignment 1

Expected Outcomes with Conservative Management

Conservative treatment produces good functional results in the majority of patients:

• 85% of patients achieve excellent or good functional outcomes (Lysholm score) with conservative management 4
• 71% report good subjective results at long-term follow-up 4
• However, the recurrence rate remains approximately 26% even with appropriate treatment 4
• Conservative management shows no significant difference in redislocation rates, reoperation rates, or functional outcomes compared to surgical intervention for most patients 4

When to Consider Surgical Referral

Surgery should be reserved for specific indications after failed conservative treatment:

• Recurrent instability episodes despite adequate conservative management (typically 3-6 months) 5
• Osteochondral fragments requiring fixation 4
• Major defects of the parapatellar ligament complex 4
• Patients with multiple anatomic risk factors (patella alta, trochlear dysplasia, increased TT-TG distance) who continue to have instability 6

Important Caveats

• Age matters: Patients younger than 20 years have significantly greater tendency to redislocation compared to those older than 20 years 6
• Activity level: Patients typically cannot completely regain their pre-injury high activity level even with successful treatment 4
• Avoid premature surgery: Surgical management is associated with lower redislocation rates but does not clearly produce superior functional outcomes compared to conservative management 3
• Prevention focus: If surgery becomes necessary, proper technique is critical to avoid iatrogenic medial subluxation from excessive lateral release or MPFL overcorrection 2