What is the best course of treatment for a patient with no meniscus tear, intact cruciates (cruciate ligaments), mildly inflamed infrapatellar plica, and lateral patellar tilt?

Treatment for Mildly Inflamed Infrapatellar Plica and Lateral Patellar Tilt

Begin with knee-targeted exercise therapy focused on quadriceps strengthening combined with education, and address the lateral patellar tilt through specific interventions including prefabricated foot orthoses and patellar taping as needed. 1

Initial Conservative Management

Primary Intervention: Exercise Therapy

• Knee-targeted exercise therapy is the cornerstone of treatment, with high certainty evidence showing significant short-term pain reduction (SMD 1.16) and moderate certainty evidence for functional improvement (SMD 1.19). 1
• Progressive quadriceps strengthening should be delivered through both open and closed chain exercises, as the quadriceps play a critical role in patellar tracking and stability. 1
• Hip-targeted exercises can be added to knee-targeted therapy if assessment reveals hip weakness or dysfunction contributing to patellar maltracking. 1

Education Component

• Education must underpin all interventions and should be adjusted to reflect the patient's specific needs and understanding. 1
• Explain the relationship between muscle strength, patellar tracking, and symptom control to enhance treatment adherence. 1

Addressing Lateral Patellar Tilt

Patellar Taping

• Taping should be considered when rehabilitation is hindered by elevated symptom severity and irritability from the inflamed plica or patellar maltracking. 1
• McConnell-style patellar taping can help correct lateral tilt and reduce pain during exercise progression. 1
• Discontinue taping if no favorable outcomes are observed after a realistic trial period. 1

Prefabricated Foot Orthoses

• Individually modified prefabricated foot orthoses demonstrate primary efficacy and should be prescribed if assessment reveals foot mechanics contributing to patellar maltracking. 1
• Use treatment direction tests (e.g., squat with/without orthoses) to determine if orthoses improve symptoms before prescribing. 1
• Customize for comfort by modifying density and geometry as needed. 1

Management of Inflamed Plica

Conservative Approach First

• The mildly inflamed infrapatellar plica typically responds to conservative management with activity modification and the exercise therapy outlined above. 2
• NSAIDs can be used for symptomatic relief during the initial inflammatory phase. 3
• Physical therapy should include proprioceptive training and balanced strengthening to restore normal patellar mechanics. 2

When to Consider Surgical Intervention

• Surgical resection of a pathologic plica is reserved for cases that fail comprehensive conservative management. 2
• Surgery is NOT indicated initially for mild plica inflammation without mechanical symptoms or refractory pain. 2

Assessment-Guided Treatment Selection

Key Assessment Findings to Guide Intervention

• Evaluate patellar tracking during functional movements (squatting, stair climbing) to identify specific maltracking patterns. 2, 4
• Assess for lateral retinacular tightness using the patellar tilt test, as excessive tightness contributes to lateral patellar tilt. 4, 5
• Examine hip external rotator strength, as weakness can contribute to dynamic knee valgus and patellar maltracking. 1, 2
• Check for generalized hypermobility (Beighton score) which may influence treatment approach. 5

Critical Pitfalls to Avoid

• Do not proceed to lateral release surgery for lateral patellar tilt without an adequate trial (minimum 3-6 months) of comprehensive conservative management including exercise therapy and appropriate adjunctive interventions. 2, 4
• Avoid isolated hip strengthening without addressing quadriceps weakness, as knee-targeted exercise is the primary intervention. 1
• Do not prescribe foot orthoses without performing treatment direction tests to confirm they improve symptoms. 1
• Recognize that the intact cruciates and absence of meniscal pathology indicate this is primarily a patellofemoral tracking problem, not a ligamentous instability issue requiring surgical stabilization. 2, 4

Expected Timeline and Progression

• Most patients with patellofemoral pain respond to conservative management within 6-12 weeks if adherent to exercise therapy. 1
• If symptoms persist beyond 3-6 months of appropriate conservative management, reassess for contributing factors that may have been missed or consider referral to a specialist. 1, 2
• Surgical intervention for plica resection or lateral release should only be considered after documented failure of comprehensive conservative treatment. 2, 4