What are the treatment options for patellar alta?

Treatment of Patellar Alta

For patellar alta, initiate a structured 3-6 month conservative management program centered on eccentric quadriceps strengthening exercises, activity modification, and medially directed patellar taping, reserving surgical correction (tibial tubercle distalization) only for cases that fail conservative treatment and significantly impair quality of life. 1

Conservative Management Framework

Primary Intervention: Eccentric Quadriceps Strengthening

The foundation of treatment is progressive resistance training targeting the quadriceps and surrounding muscle groups 2, 3:

• Training frequency: 2-3 days per week with at least 48 hours rest between sessions 3, 1
• Initial intensity: 60-70% of one-repetition maximum for novice to intermediate patients 3, 1
• Volume: 8-12 repetitions across 2-4 sets, with 2-3 minutes rest between sets 3
• Progression: Advance to heavy slow resistance training (≥80% of 1RM) as strength and tolerance improve 3, 1

The evidence strongly supports eccentric training as having the strongest available evidence for patellar pathology treatment 3. Include both hip and knee-targeted exercises, with the balance determined by tolerance to loaded knee flexion 1.

Activity Modification and Load Management

Implement relative rest by reducing high-impact activities that reproduce pain, particularly repetitive loading and jumping activities 3, 1:

• Avoid: Complete immobilization, which causes muscular atrophy and deconditioning 3
• Allow: Low-impact aerobic activities like cycling or swimming to maintain cardiovascular fitness 1
• Goal: Prevent ongoing damage while permitting activities that don't worsen pain 2

Patellar Taping for Symptom Control

Apply medially directed patellar taping for short-term pain relief and improved function 4, 2, 1:

• Particularly beneficial during rehabilitation exercises or activities that provoke symptoms 1
• Provides immediate stability and relief while promoting muscle preservation 5
• Most effective when rehabilitation is hindered by elevated symptom severity and irritability 3

Pain Management Strategies

Pharmacologic Options

• First-line: Topical NSAIDs preferentially over oral NSAIDs to eliminate gastrointestinal hemorrhage risk 2, 3, 1
• Acute relief: Cryotherapy through wet towel for 10-minute periods after activity 2, 3, 1

Critical Pitfall to Avoid

Never inject corticosteroids into the patellar tendon or articular surfaces, as this inhibits healing, reduces tensile strength, and predisposes to spontaneous rupture 3, 1. While corticosteroid iontophoresis may be considered for pain relief, direct injection is contraindicated 3.

Complementary Interventions

Flexibility Training

Perform stretching exercises for quadriceps and hamstrings 2-3 days per week 3, 1:

• Hold static stretches for 10-30 seconds after warming muscles through light aerobic activity 3
• Complete 60 seconds of total stretching time per flexibility exercise, repeating 2-4 times 3
• Daily stretching provides the greatest gains 3

Manual Therapy

Deep transverse friction massage in combination with supervised exercise provides additional pain reduction 2, 3, 1.

Patient Education and Lifestyle Modifications

Education is essential and should underpin all interventions 2, 3:

• Explain that patellar alta represents a structural variant that may predispose to chronic tendinosis rather than acute inflammation 2, 3
• Emphasize that pain doesn't necessarily correlate with tissue damage 2, 3, 1
• Set realistic expectations: approximately 80% of patients recover completely within 3-6 months with appropriate conservative treatment 3, 1
• For overweight patients, include weight loss counseling as part of the comprehensive treatment plan 2, 1

Surgical Considerations

Surgery should be reserved only after 3-6 months of well-managed conservative treatment has failed 3, 1:

• Indications: Persistent significant pain affecting quality of life and inability to return to desired activity level despite appropriate non-surgical management 2
• Surgical options: Tibial tubercle distalization to correct the high-riding patella, with excision of abnormal tendon tissue and longitudinal tenotomies to release areas of scarring and fibrosis 2
• Open or arthroscopic approaches are comparable, though arthroscopic surgery results in faster recovery time 6

Common Pitfalls to Avoid

• Do not proceed to surgery without an adequate 3-6 month trial of conservative treatment 3, 1
• Avoid multiple corticosteroid injections as they weaken tendon structure despite short-term symptom relief 3
• Do not immobilize completely, as this causes muscular atrophy and deconditioning 3
• Reassess intervention strategy if favorable outcomes are not observed after a realistic trial period 3